Cosmetic Surgery

Melvin A. Shiffman Alberto Di Giuseppe

Editors

Cosmetic Surgery
Art and Techniques
Editors
Melvin A. Shiffman, M.D., J.D., FCLM Alberto Di Giuseppe, M.D.
Chair, Section of Surgery Institute of Plastic and Reconstructive
Newport Specialty Hospital Surgery, School of Medicine
Tustin, CA University of Ancona
USA Ancona
Italy

ISBN 978-3-642-21836-1 ISBN 978-3-642-21837-8 (eBook)

DOI 10.1007/978-3-642-21837-8
Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2011941191

Springer-Verlag Berlin Heidelberg 2013

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This book is dedicated to the memory of my parents, Albert and Eva
Shiffman, who made me what I am today with encouragement and
sacrifices to send me to college and medical school.
The book is dedicated to my sister, Vivian Sadin (now deceased),
and my brother-in-law, Stan Sadin, who have been my very dearest
friends. Also to my loving daughter-in-law, Kim Shiffman, R.N., who
is the epitome of excellence in nursing, being both caring and efficient
in her work with newborn infants and who, at one time, was my
Recovery Room nurse. My wife, Pearl, has withstood constant
clattering on my computer and travels with me internationally while
I teach cosmetic surgery through lectures and workshops. She is my
constant companion. And to my compatriot and colleague,
Sid Mirrafati, M.D., with whom friendship is more like family.
My students, nationally and internationally, have been an
inspiration to me by their dedication to learning and enthusiasm to be
better physicians. But, most of all, their friendship.
I have to include those international surgeons who I have worked
with in lecturing at meetings who have become my dear friends and
who are colleagues of exceptional talent. To name a few, these include
Alberto Di Giuseppe, Anthony Erian, Afshin Fatemi, Julio Ferreira,
Giorgio Fischer, Pierre Fournier, Justin Hao, Enrique Hernandez-
Perez, Toma Mugea, Angelo Rebelo, Lina Valero, Fernando Pedrosa,
and Tetsuo Shu (now deceased). There are more but the list would be
endless. Books that I have edited, in Cosmetic Surgery, have resulted
in e-mail friendships with many surgeons who almost never say no to
my request for a chapter. These names run in the hundreds.
What more can I wish for in my 55 years as a physician and
36 years as a medical legal consultant?

Melvin A. Shiffman
Foreword

With this book, Cosmetic Surgery: Art and Techniques, published by Melvin A.
Shiffman M.D., J.D. and Alberto Di Giuseppe M.D., Cosmetic Surgeons now have a
complete encyclopedia in our field: Human Beauty Surgery
Mel should be especially congratulated as he has accomplished what he decided
years ago: to give recognition to our specialty of pure Cosmetic Surgery thanks to the
publication of a large series of books about our daily work that is ours for many years.
In the numerous already published volumes, he gives the groundwork where our prac-
titioners, experienced or beginners, can find teaching resulting from many years of
practice by experienced Cosmetic Surgeons coming from all around the world. This
book is very special among all the other ones already published as it is all encompassing
and is the first one in the literature about General Cosmetic Surgery. In the present time
teaching is audiovisual. Words of course are indispensable but a visible representation
of what has been said is crucial. We all know how important a diagram or a slide is.
As Napoleon the First used to say when he had to summarize his tactic before a
battle to make his mind up: a little drawing is better than a long talk. An image
focuses, zooms our attention, and stimulates our mind. We know that it enhances our
understanding on the strategy of a future procedure. It is acting as an impact.
This book will satisfy the readers as in its 68 chapters they can find carefully
described all the conventional reliable techniques as well as the most recent advances
offered today to our patients. The different procedures described are on the head and
neck, breasts, abdomen, limbs, liposuction, lipofilling, peeling, and hair grafting.
Many other chapters are dedicated to the different lasers, radio frequency, facial
implants, fillers, threads, and the use of stem cells and growth factors. Also included
are chapters on buttocks lift and implants, intimate surgery in women and men, anat-
omy, and the History of Cosmetic Surgery.
This important iconography explaining fully all the procedures will allow Cosmetic
Surgeons to obtain the best possible results, to avoid or decrease the number of com-
plications, major or minor, and to have a satisfied patient. Today, like before, one
should be conscious of the responsibilities that we have when modifying the face or
body of human beings and should be reminded always of the old surgical saying,
Better prepare and prevent than repair and repent. This underlines how important is
visual teaching.
As written by the highly talented and respected Richard Aronsohn, Founder of the
American Board of Cosmetic Surgery, Psychiatry works from the inside out.
Cosmetic Surgery works from the outside in. Both help people to enhance their self-
esteem and to feel good about themselves. As a matter of fact, Cosmetic Surgeons are
Surgical Psychiatrists. A good result makes patient and Surgeon happy. A complica-
tion or a poor result makes patient and Surgeon unhappy.

vii
viii Foreword

It is not possible to comment about all that is offered in this book, but the publishers
should feel happy to have included all the procedures or trends presently offered or
requested by our patients of the present time. It summarizes for the Surgeon in a very
short time the necessary different steps of an operation.
This book is an indispensable up-to-date tool needed by Cosmetic Surgeons as it
visualizes the present advances in our specialty allowing us to maintain and/or
enhance Human Beauty or to fight against the Aging process.

Paris, France Pierre F. Fournier, M.D.

Preface

Cosmetic (or aesthetic) surgery is a specialty of medical practice that has attracted
physicians from most countries around the world interested in improving the beauty
of the patient. Patients are flocking to cosmetic surgeons to improve their appearance
to meet the expectations of their own body image. Although cosmetic surgery is an
elective procedure, the medical indication for these procedures is to improve the
patients psychological needs. Since health care has improved and life span has been
prolonged, individuals are trying to preserve or return to their youthful appearance.
Technology and techniques have improved to make cosmetic surgery safer for the
patient and less invasive in some aspects so that patients can return to their normal
activities sooner and with shorter periods of discomfort.
This book on Cosmetic Surgery contains step-by-step descriptions of the proce-
dures (old, new, and modifications) with illustrations and/or color photos. The con-
tents include a history of cosmetic surgery, anatomy, anesthesia, head and neck
surgery, breast surgery, abdominal and thoracic surgery, and extremities and buttocks
procedures. Also described are labioplasty, total body lift following massive weight
loss, and penile enhancement. Dermatologic procedures are described including laser
rejuvenation, radiofrequency rejuvenation, and chemical peeling.
The international contributors are experts in their fields and have published exten-
sively in the medical literature. Some contributors are professors and many lecture at
international meetings and workshops on a regular basis. This book is comprehensive
and is an attempt to expose the student training in cosmetic surgery, the physician
starting in cosmetic surgery, and the experienced practitioner in cosmetic surgery to
the many aspects of aesthetic procedures that may improve their results and improve
patient safety.
The editors, in this book, are interested in producing a means of exposing all
surgeons to procedures commonly used to improve a patients appearance and satis-
faction. The learning mechanism used is step-by-step descriptions with illustrations
and color photos of the procedures. We hope that cosmetic surgeons will thus be able
to better understand a variety of the techniques.

Tustin, CA, USA Melvin A. Shiffman, M.D., J.D., FCLM

ix
Contents

Part I History and Anatomy

1. History of Cosmetic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Melvin A. Shiffman
2. Anatomy of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Peter M. Prendergast
3. Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Peter M. Prendergast
4. Anatomy of the Anterior Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . 57
Peter M. Prendergast
5. Anatomy of the Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Oren G. Benyamini and Morris E. Hartstein

Part II Anesthesia

6. Regional Anesthesia for Cosmetic Surgery

of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Arnaud Deleuze, Marc Gentili, and Francis Bonnet
7. Liposuction with Local Tumescent Anesthesia
and Microcannula Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Bernard I. Raskin and Shilesh Iyer
8. Tumescent Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Melvin A. Shiffman
9. Anesthesia for Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Gary Dean Bennett

Part III Head and Neck

10. Facial Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Niti Khunger
11. Facial Resurfacing with the Ultrapulse Laser. . . . . . . . . . . . . . . . . . . . . 167
Bernard I. Raskin

xi
xii Contents

12. Capacitive Radiofrequency Skin Rejuvenation. . . . . . . . . . . . . . . . . . . . 195

Manoj T. Abraham and Joseph J. Rousso
13. Mesotherapy in Aesthetic Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Maya Vedamurthy
14. Upper Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Morris E. Hartstein
15. Lower Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Morris E. Hartstein
16. Blepharoptosis: The Check Ligament Technique . . . . . . . . . . . . . . . . . . 235
Antonio Stanizzi
17. Aesthetic Rhinoplasty Utilizing Various Techniques Depending
on the Abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Fernando D. Burstein
18. Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Cristina Isac, Aurelia Isac, Tiberiu I. Bratu, and Nicolae Antohi
19. Brow Lift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Shoib Allan Myint
20. Mid-Forehead Buttonhole Eyebrow Elevation . . . . . . . . . . . . . . . . . . . . 299
Harry Mittelman, Gregory J. Vipond, and Joshua D. Rosenberg
21. Facelift... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Phillip R. Langsdon and Courtney Shires
22. Short-Scar Purse-String Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Amir M. Karam, L. Mike Nayak, and Samuel M. Lam
23. Modified Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Phillip R. Langsdon and Courtney Shires
24. Subperiosteal Face-Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Lucas G. Patrocinio, Tomas G. Patrocinio, Jose A. Patrocinio,
and Marcell M. Naves
25. Suture Facelift Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Peter M. Prendergast
26. Facial Implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Bruce B. Chisholm
27. Fat Transfer to the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Melvin A. Shiffman
28. Facial Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Peter M. Prendergast
29. Ultrasound-Assisted Lipoplasty: Basic Physics,
Tissue Interactions, and Related Results/Complications . . . . . . . . . . . . 451
William W. Cimino
30. Facial Recontouring with Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Alberto Di Giuseppe and George Commons
Contents xiii

31. Chin, Cheek, and Neck Vaser Liposculpture. . . . . . . . . . . . . . . . . . . . . . 467

Alberto Di Giuseppe, George Commons, and Alessandro Scalise
32. An Integrated Technique for Facial Rejuvenation:
Adaptation to a Changing Clinical Environment . . . . . . . . . . . . . . . . . . 485
Moshe S. Fayman
33. Hair Restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Samuel M. Lam
34. Jowl and Neck Remodeling with Ultrasound-Assisted
Lipoplasty (VASER). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Alberto Di Giuseppe and George Commons

Part IV Breast

35. Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555

Lina Valero De Pedroza
36. The Inverted Dual Plane Mastoplasty Technique . . . . . . . . . . . . . . . . . . 571
Giovanni Di Benedetto, Luca Grassetti, Davide Talevi,
Daniele Bordoni, Manuela Bottoni, and Alessandro Scalise
37. Remodeling Breast and Torso with Combined Fat
Liposuction and Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Alfredo Hoyos
38. Breast Augmentation and Reconstruction with Fat Transfer . . . . . . . . 595
Todd K. Malan
39. The Staple-First Technique for Simultaneous Augmentation
Mastopexy for Moderately to Severely Ptotic Breasts . . . . . . . . . . . . . . 605
Ted S. Eisenberg
40. Circumareolar Nipple-Areola Complex Mastopexy
and Areolar Shifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Robert A. Shumway
41. Mastopexy/Breast Reduction with Short Inverted T Scar . . . . . . . . . . . 633
Toma T. Mugea
42. The Medial and Superior Pedicle Mastopexy
with Dual Plane Inverted-T Augmentation . . . . . . . . . . . . . . . . . . . . . . . 705
Tiberiu I. Bratu, Cristina Isac, Olariu Daniela, Grujic Daciana,
Dorina Mihaijlovic, and Nicolae Antohi
43. Breast Augmentation and Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
Toma T. Mugea
44. Periareolar Mammaplasty for the Treatment
of Massive Gynecomastia with Breast Ptosis. . . . . . . . . . . . . . . . . . . . . . 747
Marco Tlio Rodrigues da Cunha
45. Reduction Mammoplasty: The Piece of Art . . . . . . . . . . . . . . . . . . . . 755
Fahmy S. Fahmy and Mohamed Ahmed Amin Saleh
xiv Contents

46. The Moufarrege Total Posterior Pedicle Mammaplasty . . . . . . . . . . . . 775

Richard Moufarrege and Elia Botros
47. Mastopexy with Chest-Wall-Based Flap
and Pectoralis Muscle Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
Ruth Maria Graf, Andr Ricardo DallOglio Tolazzi,
and Maria Ceclia Closs Ono
48. Hypertrophic Tubular Breast Reduction:
Surgical Technique with New Inframammary Fold Level . . . . . . . . . . . 805
Toma T. Mugea
49. Breast Reduction with Vaser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 857
Alberto Di Giuseppe, Michael Nagy, Mario Scaglioni,
and Elisabetta Petrucci
50. Gynecomastia: Scarless Male Breast Reduction with Vaser . . . . . . . . . 871
Alberto Di Giuseppe, Antonella Belligolli, Marina Pierangeli,
Davide Talevi, and Luca Grassetti

Part V Abdomen

51. Abdominoplasty: Aesthetics of the Anterior

Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
Fahmy S. Fahmy and Mohamed Ahmed Amin Saleh
52. Circular Lipectomy with Lateral ThighButtock Lift . . . . . . . . . . . . . . 907
Hctor J. Morales Gracia
53. The Horseshoe Abdominoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
Richard Moufarrege and Elia Botros
54. Mini-Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Bruce A. Mast
55. Ultrasound-Assisted Abdominal Liposuction . . . . . . . . . . . . . . . . . . . . . 949
Peter M. Prendergast

Part VI Extremities and Buttocks

56. Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973

Sumeet N. Makhijani, Alain Polynice, Jerome D. Chao,
and James G. Hoehn
57. Circumferential Para-Axillary Superficial
Tumescent (CAST) Liposuction for Upper Arm Contouring . . . . . . . . 981
Andrew T. Lyos
58. Thigh Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
Sadri Ozan Sozer and Francisco J. Agullo
59. Buttock Lift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Sadri Ozan Sozer and Francisco J. Agullo
Contents xv

60. Liposuction of Lower Extremities and Buttocks. . . . . . . . . . . . . . . . . 1011

Alberto Di Giuseppe, Guido Zannetti, and Daniele Bordoni
61. Buttock and Hip Enhancement with Implants . . . . . . . . . . . . . . . . . . . 1043
Jesus Benito-Ruiz
62. Liposculpture and Buttock Augmentation with Fat Grafting . . . . . . . 1063
Arturo Grau
63. Large Volume Fat Transplant to Buttocks and Legs
for Enhancement and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Lina Valero De Pedroza
64. Treatment of Venous Insufficiency with Sclerotherapy . . . . . . . . . . . . 1093
Alessandro Frullini

Part VII Miscellaneous

65. Labioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101

Cristina Isac, Aurelia Isac, Nicolae Antohi, and Tiberiu I. Bratu
66. Total Body Lift After Extreme Weight Loss . . . . . . . . . . . . . . . . . . . . . 1111
Dennis J. Hurwitz
67. Penile Enhancement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1127
Hassan Abbas Khawaja and Melvin A. Shiffman
68. Complications of Cosmetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
Melvin A. Shiffman

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
 Part I
History and Anatomy
 History of Cosmetic Surgery
Melvin A. Shiffman
1.1 Introduction
In preparing a history of cosmetic surgery, it is, at times,
difficult to separate reconstructive procedures from
purely cosmetic procedures. Cosmetic (aesthetic) is
beautifying surgery compared to plastic that is repair
of a defect or deficit. Consider that reconstruction of
the face is to beautify a distorted, abnormal appear-
ing facial appearance. However, cosmetic (aesthetic)
surgery is considered to be only to beautify and not to
reconstruct to obtain beauty. Obviously, there is some
overlap between the two.
Sushruta lays down the basic principles of plastic
surgery by advocating proper physiotherapy before the
operation and describes various methods for different
types of defects, such as release of the skin for cover-
ing small defects [1], rotation of the flaps to make up
for the partial loss [2], and pedicle flaps for covering
complete loss of skin from an area [3]. He mentioned
various methods including sliding graft, rotation graft,
and pedicle graft. He also described labioplasty. All
the principles of surgery such as accuracy, precision,
economy, hemostasis, and perfection find an important
place in Sushrutas writings on this subject.
Tagliacozzi [4, 5] was considered by some to be the
Father of Plastic Surgery even though his 47 pages
of illustrations and guidelines to reconstructive surgery
were published in 1597, but when he died 2 years later,
his achievements died with him.
M.A. Shiffman
Chair, Section of Surgery, Newport Specialty Hospital,
Tustin, CA, USA
e-mail: shiffmanmdjd@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_1, Springer-Verlag Berlin Heidelberg 2013
1
In 1792, Chopart [6] performed an operative proce-
dure on a lip using a flap from the neck. The first
American plastic surgeon was Mettauer, who, in 1827
[6], performed the first cleft palate operation with
instruments that he designed himself. Joseph [7] per-
formed an otoplasty that resulted in his loss of his job
(that he had since 1892) in 1896 at the University
Polyclinic in Orthopedic Surgery headed by Professor
Julius Wolff.
In World War I, Gillies [8] developed many of the
techniques of modern surgery in caring for soldiers
suffering from disfiguring facial injuries. When the
United States entered World War I, Blair was chosen to
lead physicians in the treatment of craniofacial injuries
caused by trench warfare. As commander of the U.S.
Army Corps of head and neck surgeons, Blair worked
with assistant Ivy to set up teams of surgeons and den-
tists to treat complex jaw injuries using Blairs 1912
book as the standard operating manual [9]. After the
war, he formed one of the largest U.S. multidisciplinary
teams for the care of complex maxillofacial injuries at
Walter Reed Hospital. For these efforts, he was known
as a leader in posttraumatic reconstruction.
Blair contributed many outstanding clinical advances.
Although other surgeons had performed reconstructive
operations using the delay phenomenon, Blair first
defined the delay process in 1921 [10]. The follow-
ing year, Blair published a paper on Reconstructive
Surgery of the Face, based on his war experience and
set the standard for craniofacial reconstruction [11].
Blair reported on a variety of reconstructive procedures
such as rhinoplasty for saddle nose [12], nasal defor-
mities associated with congenital cleft of the lip [13],
cleft palate with orthodontic inclusion [14], correc-
tions of deformities of the external nose [15], primary
3
4 M.A. Shiffman
closure of harelip [16], and use of switched lower lip
flap for upper lip restoration [17]. In 1929, Blair and
Brown [18] reported the first cleft lip repair that could
be reproduced accurately. This article was the first to
provide accurate details on measurements needed to
perform cleft lip repairs.
Although plastic surgery was a specialty established
during the First World War, there were only three expe-
rienced plastic surgeons in Britain when the Second
World War broke out in 1939. One of them was
McIndoe [19]. He set up a specialist hospital in East
Grinstead to treat airmans burn, which was caused complex. The Schwarzmann [33] maneuver was devel-
when a planes fuel tanks exploded. The unprotected
hands and face of the pilot could be severely burned.
McIndoe treated several hundred airmen, skillfully
performing plastic surgery to give them new faces and
hands. Many of them went back to fly again.
1.2 Breast Reduction
Durston [20] gave a description of gigantomastia
occurring suddenly in a 23- or 24-year-old woman.
This woman developed ulcerations of the breasts that
were painful and became considerably larger [21].
In another publication the same year, Durston [22]
described that she died, and one breast weighed 64 lb
and the other about 40 lb. No cancer was found.
Dieffenbach [23] reported on aesthetic breast surgery
involving a small incision in the inframammary fold.
Pousson [24] reported removing a crescent-shaped
section from the upper anterior portion of the breasts in
order to treat bilateral mammary hypertrophy. The skin
and subcutaneous tissues were excised down to the
pectoralis fascia, and the breast was elevated and sus-
pended by suturing to the pectoralis fascia.
Guinard [25] reported on a patient with macromastia
using semicircular incisions in the submammary folds
to remove a large amount of skin and breast tissue.
Morestin and Guinard [26] reported their experi-
ence with discontinuous resections of up to 1400 g
performed through an inframammary incision. Thorek
[27] reported on breast amputation and free nipple
graft. Kraske [28] described reduction of large breast.
Aubert [29] performed resection and transposition of
the nipple. Hollander [30] described an inferolateral
excision of skin and breast tissue in order to eliminate
the inframammary scar of the inverted-T incision.
Biesenberger [31] noted the importance of leaving
subcutaneous tissue attached to the skin. He performed
extensive undermining and severing of the suspensory
ligaments (Coopers ligaments), and then wedge exci-
sions of breast tissue in an inverted S shape involved
the lateral aspect of the breast. This resulted in a high
risk of skin and breast loss, and the technique was
largely abandoned.
Schwarzmann [32] fashioned a periareolar cutis
bridge for maintenance of the blood supply to the
nipple. This allowed a superiorly based dermoglan-
dular pedicle to revascularize the nippleareolar
oped that involved cleavage between skin and gland,
preserving a periareolar zone stripped of skin. Maliniac
[34] used strips of dermis graft for stabilization of the
breast. Maliniac [35] presented a two-stage breast
reduction in order to preserve the blood supply. Bames
[36] preserved the lateral and medial breast segments
and resected the superior portion to preserve perforating
vessels. Aufricht [37] introduced an inferior pedicle
technique and showed a geometric method to plan the
reduction rather than using a free hand method and
preserving perforating vessels by preserving the lat-
eral and medial segments of breast and resecting the
superior portion.
Reports on free nipple transplantation for reduc-
tion mammaplasty included Conway [38], Conway
and Smith [39], Marino [40], and May [41]. Maliniac
[42] did total gland excision with nipple-areolar graft
and deepithelialized the inferior flap that was folded
superiorly under the superior flap. Wise [43] devised
a pattern to predetermine the shape of skin flaps
(Fig. 1.1) and a horizontal dermal parenchymal
bridge for the preservation of the arteriovenous and
cutaneous nervous system from above and below the
dermal pedicle. Arie [44] described a superior pedi-
cle technique, and Gillies and Marino [45] described
the periwinkle shell (spiral rotation) technique for
moderate ptosis.
Strombeck [46] modified a keyhole pattern. He
extended the concept of a dermal bridge technique,
described by Schwarzmann [33], to reintroduce the
dermal pedicle for nipple transposition. He used a
pattern similar to that described by Wise [43]. This
was a horizontal dermal pedicle that consisted of the
dermis of the two lateral pedicles to transpose the
nipple and create a fibrous balcony to prevent post-
operative ptosis. The skin and gland above the areola
were excised.
1 History of Cosmetic Surgery 5

a b

Fig. 1.1 (a) First prototype suction machine with a motor- inside. (d) When thumb is released, there is no aspiration
driven cannula. (b) Second prototype motor suction machine. (Photos courtesy of Giorgio Fischer)
(c) Motor-driven cannula with cutting and rotating cylinder
6 M.A. Shiffman
Pitanguy [47] performed a horizontal dermal bridge
and keel shaped resection of the gland from the
inferior and central portions of the breast. It had excel-
lent results when used for limited breast reductions
(<300 g) and breast ptosis.
Dufourmental and Mouly [48] introduced the lateral
wedge resection of skin, fat, and gland with a resultant
inferior oblique lateral scar. Preoperative markings
were made in the supine position. Strombeck [49]
reported the use of the horizontal bipedicle procedure
for reduction mammaplasty. Pitanguy [50, 51] described
the superior dermal pedicle technique. Wise et al. [52]
used a modification of the breast amputation and
nippleareola transfer. Skoog [53] described a superior
laterally based dermal flap separated from the gland at
the subcutaneous level. He transposed the nipple on a
unilateral skin flap disconnecting nipple from gland.
This was an intermediate procedure to free nipple trans-
plantation. Robertson [54] reported on the inferior flap
mammaplasty in conjunction with free nipple grafting.
Hoopes and Jabalay [55] described amputation with
nippleareola transplant, and prosthesis.
Hoopes [56] performed amputation and mamma-
plasty for gigantomastia using nippleareolar transplant
and prosthesis. Hinderer [57] described dermopexy
with reduction and reported attaching dermis strips to
help fixate the breast to the chest wall to support the
breast in 1972 [58]. McKissock [59] described the
bipedicle vertical pedicle for nipple transposition that
had simplicity of design and safety.
Lalardrie [60] reported a dermopexy with reduction
Dermal Vault technique.
Weiner et al. [61] described a modified superior
dermal pedicle technique for nipple transposition. This
technique cannot be used if the nipple site is to be more
than 7.5 cm above its original position. Pontes [62]
described removal of the lower half of the breast start-
ing 2 cm below the inferior edge of the areola after
deepithelialization of the periareolar area and supe-
rior pedicle. The nippleareolar complex is placed
into position after closure of the breast. Regnault [63]
reported on a reduction mammaplasty using the B
technique that resulted in a lateral oblique scar without
a medial extension. Lalarde 64] performed reduction
with transposition of the nipple. Gsell [65] described a
superior-based dermal flap similar to the McKissock
pedicle but transected at the inframammary end. This is
risky since much of the blood supply to the paren-
chyma is transected. Nippleareola necrosis may occur.
Aiache [66] fashioned a superior pedicle technique for
the ptotic and moderately enlarged breast. Ribeiro [67]
described an inferior pedicle technique. A vertical scar
was avoided by bringing the nippleareola complex
under and through the superior skin flap and into posi-
tion while tubing the inferior dermal pedicle. Orlando
and Guthrie [68] described a superior medial dermal
pedicle. de Castro [69] described a modified Pitanguy
technique using curved incisions to define the medial
and lateral breast flap borders and resection of the
breast tissue on a horizontal plane. He believed this
modification produced breasts that were less tense and
more desirable in shape.
Cramer and Chong [70] reported on a unipedicle
cutaneous flap with areolarnipple transposition or
an end-bearing, superiorly based flap. Weiner [71]
described the modified superior pedicle technique.
Wise [72] discussed nipple transposition versus nipple
transplantation. Courtiss and Goldwyn [73] described
an inferior dermal pedicle technique as an alternative
to free nippleareola grafting in severe macromastia or
ptosis. The inferior dermal pedicle extends transversely
across the full length of the inframammary fold inci-
sion. A keyhole pattern, described by McKissock, was
used. Robbins [74] described the technique of reduc-
tion mammaplasty with an inferior dermal pedicle.
Georgiade et al. [75] performed reduction mamma-
plasty utilizing an inferior pedicle nippleareola flap.
Marchac and de Olarte [76] tried to prevent ptosis
by fixation of the gland to the pectoral fascia. Ribeiro
[77] reported on the inferior dermal pedicle technique.
Meyer and Kesselring [78] described closure with an
L-shaped suture line. Galvao [79] described a method
of preserving the subdermal plexus of vessels with the
nippleareolar complex detached from the breast gland
leaving a completely free deepithelialized superior-
and inferior-based dermal pedicle with only the subcu-
taneous fat that is folded and the breast closed after
resection of the gland. The nippleareola complex is
brought out through the new position after complete
closure.
Cardoso [80] used three dermal pedicles for nipple
areolar complex movement in reduction of gigantomas-
tia. Hester et al. [81] performed breast reduction utilizing
the maximally vascularized central pedicle. Ren [82]
described the periareolar mastopexy. Teimourian et al.
[83] reported on reduction mammaplasty with liposuc-
tion. Marshak [84] described a short horizontal scar
mastopexy. Benelli [85] reported on the periareolar
1 History of Cosmetic Surgery
mastopexy described as the round block technique.
Lejour et al. [86] introduced the vertical mammaplasty
without an inframammary scar. Georgiade [87] reported
on the inferior pedicle technique.
Lejour and Abboud [88] described a vertical mas-
topexy without an inframammary scar combined with
liposuction for breast reduction. Sampaio-Goes [89]
described periareolar mammaplasty with the double
skin technique. Menesi [90] reported on a distally
based dermal flap for gland fixation. Ren [91] reported
on reduction mammaplasty with a circular folded pedi-
cle technique. Goes [92] performed the double skin
technique with application of polyglactin or mixed
mesh to fix the gland with allogenic mesh using a
circular flap of dermis with a central pedicle.
1.3 Mastopexy
Plastic surgery of the breast has been documented as
early as 1669 when descriptions of postmastectomy
reconstruction were reported. Some 200 years later,
Velpeau, in 1854 [93], published his analysis of
mastoptosis. Descriptions of the modern mastopexy
procedure were first seen as early as the nineteenth cen-
tury. Many of these early approaches offered a signifi-
cant basis for the techniques which are currently
utilized. Although the techniques mirrored those of the
reduction mammaplasty, the emphasis was placed on
correcting ptosis of the breast. Most of these proce-
dures involved elevation of the breast mound using
suspension techniques. Poussons technique [94] and
Vercheres mammaplasty [95] both relied on direct
excision of skin superior to the nippleareolar complex.
With closure, the nipple and breast gland were elevated,
providing a simple solution to breast ptosis. Dehner
utilized a semi-lunar resection of the superior breast
tissue and split the pectoralis muscle so the breast
tissue could be anchored to the periosteum of the ribs.
In 1882, the inframammary incision was first described
to facilitate tumor excision. It was implemented to
facilitate mastopexy and reduction mammaplasty and
eventually was utilized by Passot in 1925 [96].
Various pedicles to support the nippleareolar com-
plex were described by the 1930s. Further evolution in
the mastopexy resulted in refinement of technique and
analysis. One of the earliest techniques involved a two-
stage approach which Joseph described in 1925 [97].
The first stage transposed the nipples to their final
7
locations using broad and reliable pedicles. Shape and
symmetry were ignored until the second procedure
was performed several weeks subsequently. The sec-
ond procedure involved removing the excess lower
pole, shaping, and lifting the breast as well as maxi-
mizing symmetry between the two sides.
Kraske [98] described his innovative single-stage
technique in 1923. In retrospect, it offered many of the
principles of the modern mastopexy and reduction
operations. This technique removed the lower pole of
the breast tissue and avoided extensive undermining of
the skin from the breast tissue. The breast tissue and
overlying skin were then tightened with the excess tis-
sue laterally excised, leaving a traditional inverted-T
scar. Unfortunately, because the results were consid-
ered sub-optimal, it fell out favor. In contrast, despite
an extremely high rate of postoperative complications,
one of the most popular techniques in the first half of
the twentieth century was the Biesenberger procedure
[99]. This approach employed wide undermining of
the skin and excision of the lateral portion of the breast
with rotation of the medially based nipple pedicle to a
more superior position. The skin was then tightened
around the gland to provide shape.
1.3.1 Evolution of the Modern Approach
An anatomic-based approach was ultimately adopted,
and Strombeck described a bilateral horizontal pedicle
in 1960 [46]. Primarily implemented for reduction of
breast volume, a significant resection was performed
superiorly to the horizontal pedicle. The pedicle was
then imbricated along the vertical line from the nipple
areolar complex extending inferiorly. This glandular
tightening was in fact similar to the vertical type reduc-
tion utilized currently and in addition helped establish
the principle of maintaining the attachments of the
breast parenchyma and the skin. Skin resection and
closure were performed to remove excess skin rather
than to tighten or lift the breast, again a hallmark of
current mastopexy techniques.
The McKissock [59] vertical bipedicle technique
similarly offered a robust deepithelialized pedicle to
supple the nipple. Resection was performed medially
and laterally as well as beneath the thick vertical pedi-
cle. The pedicle was folded on itself to allow mobiliza-
tion of the nipple, and the thick dermalparenchymal
flaps were then closed. The vertical bipedicle technique
8 M.A. Shiffman
eventually evolved into the inferior pedicle technique
described by various authors [74, 100]. This approach
may currently be the most widely used technique,
particularly for reduction mammaplasty. It has been
applied to the mastopexy procedures; however, a
criticism of the approach is that pedicle tends to drop,
leading to recurrent ptosis and a boxy appearance of the
breast. Alternatively, the superior pedicle first described
by Weiner in 1973 [61] eliminated the inferior portion
of the vertical bipedicle reduction. The limitation of
this approach is the distance with which the nipple
can be safely transposed. As the long superior pedicle is
folded to elevate the nipple, the vascular supply is com-
pressed, and the risk of nipple slough is increased.
Just as the vertical bipedicle led to single pedicle
techniques, the Strombeck operation was the precursor
of the lateral and medial pedicle procedures. Originally
described by Skoog [53], the lateral required resection
from the medial and inferior quadrants of the breast.
The medial pedicle was also adapted from the hori-
zontal bipedicle technique. At the present, it is one of
the most popular techniques if not the most frequently
employed technique for reduction mammaplasty. It
also lends itself quite well for mastopexy procedures.
This approach can be combined with the vertical
mammaplasty.
While the importance of shaping the gland was rec-
ognized, significant emphasis was still placed on the
skin brassiere. These techniques utilized reshaping of
the skin envelope to tighten and lift the breast paren-
chyma [101, 102]. Unfortunately, these approaches did
not provide durable results. To avoid the dermal
stretching that can occur with dermal mastopexies,
both permanent and absorbable mesh have been des-
cribed to reshape the breast parenchyma with an inter-
nal brassiere [103, 104]. The Benelli round block or
periareolar purse string mammaplasty utilizes a per-
manent suture rather than mesh to tighten the breast
tissue [85]. In patients with limited breast ptosis, it
effectively limits scarring and provides tightening
[105]. Subsequent descriptions have demonstrated
reliable and safe results using mesh to reshape the
breast mound [106]. Most recently, the use of acellular
dermal matrix has been employed to avoid the use of
mesh material, providing a more natural texture of the
breast while achieving excellent early results. This
approach also provides an effective method to cover
prosthetic breast implants and has been used in
reconstructive efforts [107, 108].
1.3.2 Current Concepts
Autologous mastopexy procedures require rearrange-
ment of the breast tissue with minimal volume reduc-
tion. Some of the techniques for reduction mammaplasty
were more readily adaptable to this purpose than were
others. As indicated, the vertical mastopexy reliably
perfused the nipple with limited transposition of the
nippleareolar complex (NAC). Mobilization of the
remaining tissue can be suspended superiorly deep to
the superior pedicle. Additional procedures to recreate
breast fullness using autologous tissue have been
described using the dual-pedicle dermoparenchymal
mastopexy and the deepithelialized transverse rectus
abdominis muscle pedicle, using the Flip-Flap mas-
topexy [109, 110]. Lateral and inferior pedicles have
been used to auto-augment the breast. Placement of the
autologous tissue flap deep to a strip of pectoralis
muscle is reported to improve shape and maximize
longevity of the lift. The use of the vertical bipedicle
flap has also re-emerged, reported to minimize scar-
ring and preserve the blood supply to the nipple. Khan
[111] described a vertical scar bipedicle technique, a
combination for minimal scarring and robust blood
supply to the nippleareolar complex, as a further
option for mastopexies.
The vertical mastopexy eliminates the inframam-
mary scar and was introduced by Lassus [112] using
the superior pedicle. Subsequent modification by Lejour
[113] was to include the use of liposuction. The pur-
pose was to reduce the length of scar which extends
beyond the inframammary fold onto the chest wall.
The most recent modifications of the vertical mas-
topexy are based on the Hall-Findlay procedure [114].
Her proposal of a superior medial pedicle has led to
the growing popularity of the vertical mastopexy.
The superior medial pedicle can be combined with
auto-augmentation using either an inferior pedicle or
a lateral pedicle. This tissue normally discarded in
the reduction mammaplasty is suspended deep to the
nipple pedicle and securely suspended to avoid recur-
rent ptosis.
The vertical only incision has been advocated as
minimizing scars, but has also seen modifications to
address its shortcomings. The Y-scar vertical mamma-
plasty is an alternative to reduce further scar burden
[115]. Loustau et al. [116] used the owl technique
combined with the inferior pedicle in mastopexies.
More recently, the addition of a short inframammary
1 History of Cosmetic Surgery
scar has reduced the revision rate of the vertical mas-
topexy procedures. The inframammary resection is of
particular value in those patients who have significant
skin excess.
A variety of methods have been utilized to augment
the atrophic or hypoplastic breast tissue. These included
percutaneous injection of foreign material (such as
paraffin or silicone) and implantation of free dermal
fat grafts. The advent of breast prostheses allowed the
use of an implant to fill out the breast volume in com-
bination with tightening procedures [117]. Although
augmentation mammaplasty does not truly lift the
breast, mild cases of ptosis, particularly those with
involutional breast changes, can be corrected with
breast implant augmentation. Moderate ptosis can be
corrected using a circumareolar donut mastopexy
including the round bloc techniques with the use of an
implant [118]. The combination of volume increase
and limited tightening allows correction of more sig-
nificant ptosis than either approach alone. Improper
implementation of this approach can lead to undesir-
able results, including widened periareolar scars.
Moderate grade 2 ptosis can be addressed using the
vertical scar mastopexy procedures, including the
Regnault B technique and Lejour/Lassus techniques.
Severe grade 2 ptosis and grade 3 ptosis usually require
inverted-T incisions regardless of the pedicle used or
whether an implant is placed. Pseudoptosis can be
addressed with augmentation and/or skin excision at
the lower pole, but nipple transposition can often be
avoided.
1.4 Facelift
Hollander, in 1932 [119], claimed that he carried out
the first surgical facelift in 1901. Cantrell [120] wrote
the first published report of surgical procedures for
improving facial wrinkles. Lexer, in 1931 [121],
described skin excision and undermining and claimed
that he had performed a facelift surgery in 1906. Miller
[122] described a variety of surgical procedures for
improving facial wrinkles by subcutaneously section-
ing key muscles. In 1926, Nol [123], the first female
cosmetic surgeon, claimed that she performed facelifts
in 1912. She described cosmetic surgeries and contrib-
uted to the early acceptance of vanity procedures.
Joseph, in 1928 [124], claimed that he had performed
facelift surgery in 1912.
9
Bourget [125] described cases involving extensive
subcutaneous undermining and lipectomy. In 1927,
Bames [126] noted that undermining skin could fur-
ther improve results. Joseph, in 1928 [127], introduced
the post-tragal refinement.
Bettman [128] described the continuous temporal
periauricular incision. Burian [129] emphasized wide
undermining and proposed methods of preoperative
skin markings with methyl violet.
Passot [130] described a facelift with limited inci-
sion and dissection, that had already been described by
him in 1919 [131] and in his book, La Chirurgie
Esthetique des Rides du Visage, in 1917 [132].
Brown [133] emphasized using the ear to hide the
facelifting incisions. Mayer and Swanker [134] coined
the term rhytidoplasty. Hollander [135] stressed the
importance of a post-tragal incision, recommending
extending this under the earlobe and up into the hair-
line. In 1960, Aufricht [136] proposed improving lon-
gevity of the facelift procedure by suturing deep to fat.
Pangman and Wallace [137] were the first to describe
the superficial fascia, later known as the superficial
musculoaponeurotic system (SMAS). Pitanguy and
Ramos [138] emphasized the plication of the SMAS
and repositioning of the malar fat as well as preserva-
tion of the facial nerve. In 1968, Skoog developed a
flap to elevate the platysma muscle of the neck and
lower face without detaching the skin [139]. This was
reported in 1974 [140].
In 1976, Mitz and Peyronie [141] described the
superficial musculoaponeurotic system (SMAS). This
finding confirmed a fascial layer distinct from the
underlying parotidomasseteric fascia, which invests
the facial musculature. They found that the SMAS was
in a tissue plane continuous with the platysmal in the
neck and the temporoparietal fascia in the scalp.
Fibrous adhesions to the overlying subcutaneous tissue
and skin allowed for SMAS manipulations to effect
desired skin improvements.
The SMAS rhytidectomy combines a subcutaneous
dissection with separate SMAS elevation via plication
(pulling back, folding over, and suturing), as described
by Webster et al. in 1980 [142], or imbrication
(advancement, shortening, and suturing), as described
by Lemmon and Hamra [143].
In 1988, Faivre [144] performed the deep temporal
lift. The temporal soft tissues were elevated in the sub-
musculoaponeurotic plane and fixed to the temporalis
muscle. This produced correction of temporal, lateral
10
brow, and jugal ptosis. Psillakis et al. [145] reported a
subperiosteal approach to the midface. The ptotic
malar skin, fat, and muscle were mobilized and sus-
pended by anchoring the periosteum overlying the
lateral orbit, malar arch, and zygoma. Tessier [146]
performed subperiosteal facelifting.
The deep plane was pioneered by Hamra in 1990
[147], and composite rhytidectomy in 1992 [148]
followed. Versions of this technique then evolved, as
the bi- and tri-plane dissections by Baker [149] and
modifications by Kamer [150]. Ramirez [151] reported
a subperiosteal approach similar to Tessier. Kamer
and Frankel [152] reported substantial improvement
upon moving to the deep plane lift, with fewer touch-
ups required.
Chrisman [153] described the use of liposuction
with facelift. Ansari [154] introduced the S-lift, a
simplified facelift with smaller incision only anterior
to the ear. Hoefflin [155] reported on the extended
supraplatysmal plane facelift with dissection over
the platysma and SMAS. Freeman [156] described the
infra-orbital approach to the temporal lift as a viable
technique. Tonnard et al. [157] reported on a modified
S-lift concept termed the minimal access cranial
suspension lift (MACS-lift).
1.5 Liposuction
Dujarrier [158] reported a case of using a sharp uterine
curette through a small incision to remove fat of the
calves and knees of a ballerina that resulted in femoral
artery injury that necessitated amputation. Pangman
was reported to have performed curettement of the
submental fat using a small uterine curette in the 1940s
although there is no literature to support this contention
[159]. Pangman and Wallace [137] reported perform-
ing facelifts and removing excess fat from the neck
with a curette or scissors or both. They established the
use of the curette to remove fat.
There are reports that Schrudde [160] described
curettement of fat in 1964 [161, 162]; however, on
translation of the article (in German) by Giebler
(personal communication translation of the article
9/28/10), there is, in fact, no mention of curette, curet-
tage, or fat removal in the article. Schrudde, from
1972 to 1984 [163169], described the use of the
curette in removing fat deposits including the use of
suction to remove the fat. The technique was reported
M.A. Shiffman
as resulting in complications including bleeding and
seromas [162, 170, 171]. In 1982, Schrudde [172]
warned not to underestimate the possibility of
seroma, especially in the area of the thighs. This com-
plication occurred in more than 30% of cases. In
1984, Schrudde [173] reported performing suction
lipectomy (lipexheresis) with a cannula that has a
sharp leading edge with curettage performed using a
normal suction pump attached. The procedure was
used for removing fat in the subtrochanteric and knee
regions and secondarily on the lower thighs although
the procedure could be carried out on all parts of the
body. In 20 years, only 250 patients were treated using
strict criteria. He stated that if much fat is removed,
seroma cannot be avoided. Suction drainage and tight
compression bandages were used after surgery to pre-
vent seromas.
Vilain [174] described the use of a curette through a
small incision for fat removal of the knees and lower
leg for residual fat deposits following skin and fat
excisional surgery of the thigh. Only small amounts of
fat are removed.
Fischer [175] first reported his technique of small
incision removal of fat deposits with the cellusuc-
tiotome (Fig. 1.1). Fischer and Fischer [176] stated that
The region of the mass of cellulite is of no importance
because the operative technique remains the same for
every part of the body The region to be treated is
sterilized and then injected with 2% carbocaine with
epinefrineOn the region affected by cellulite 3 min
incisions measuring 5 mm each are performed at a
distance of one to the other of 10 cm. which creates an
imaginary circle or a Z The primary important
instrument is the first which has the task of melting the
fat lobules and the same time vacuums the fat. This
report established the techniques of:
1. All parts of the body with cellulite can be treated
with the same technique.
2. Use of local anesthesia (Carbocaine) with
epinephrine.
3. Small incisions (5 mm).
4. Multiple incisions apart from each other in a circle
or Z.
5. Vacuum removal of fat.
According to Fischer and Fischer [177], The patient
is examined in a standing position Photographs are
taken, in front, rear, and bi-lateral positionsGeneral
or local anesthesia is performed depending upon the
surgeons normal practice A 1 cm incision is made in
1 History of Cosmetic Surgery
Fig. 1.2 The planatome (Photo courtesy
of Giorgio Fischer)
Fig. 1.3 Swan-neck cannula and guided
cannula (first prototype) (Photo courtesy
of Giorgio Fischer)
the lowest point of the delimited area. Care should be
taken in placing the incision on the second leg in a posi-
tion asymmetrical to the incision on the first: this will
disguise the post-operative scar completelyThe
planatome (Fig. 1.2) is inserted through the inci-
sionThe thickness of the dissected zone varies from
case to case and depends upon the consistency of the fat
as well as the texture of the skinDissection is carried
out within the demarcation line in a clock-wise man-
nerThe tip of the Fischer handpiece is inserted into
the newly created pocket, taking care that the window
of the instrument faces downward, towards the mus-
cles. Drainage tubes were used on all patients. Of 245
cases treated with this method, 12 cases (4.89%) had
persistent formation of blood/serum, and 8 cases
(3.27%) had seroma after 1 month, with a total of
8.16%. This report established the techniques of:
1. Examination in a standing position.
2. Use of general or local anesthesia.
3. Small incision (1 cm) asymmetrically placed in the
extremities for riding breeches deformity.
11
4. The planatome is a dissector and used to dissect
the subcutaneous planes in order to facilitate aspira-
tion. It was used to isolate from the deep layer a fat
layer of 8 mm13 mm (Fischer G: personal com-
munication 9/5/10).
5. The opening of the cannula is directly downward
toward the muscles.
Fischer used the cellusuctiotome in 1977 (Fischer G:
personal communication 8/10/10; Fournier PF: personal
communication 8/10/10) when demonstrating the lipo-
suction procedure at Fourniers clinic (Fig. 1.3), La
Mouette, using fan-shaped tunnels and crossing tun-
nels as well as liposuctioning at various levels. He used
epinephrine in local anesthesia with sedation. The cel-
lusuctiotome device was a motor-driven cannula with a
rotating cylinder inside that was used to cut fat and was
connected to a suction machine. The cutting cylinder
inside the cannula could be used by pressing a lever.
In 1980, Fischer began massage of the tumescent
fluids in 1980 to distribute the fluid in the tissues
(Fischer G: personal communication 8/10/10). In 1982,
12
a guided cannula (Fig. 1.4) was produced with a sec-
ond overlying slide that moves over the surface of the
skin while the suction cannula works at a depth of
1.5 cm (personal communication September 13, 2008).
At the same time, the swan-neck cannula was devel-
oped to make it easier for the surgeon to maintain a con-
stant depth in the fatty layer (personal communication
September 13, 2008). In 1992, Fischer (personal com-
munication 8/10/10) [178] developed a table that could
bring a patient from a supine position to an upright posi-
tion. This allowed reversing the table to a supine posi-
tion if the patient became dizzy or faint. Liposuction
could be performed in the same position as the marking,
avoiding the distortion from reclining the patient.
Fig. 1.4 Fourniers Clinic where the liposuction operation was
demonstrated in 1977 (Photo courtesy of Giorgio Fischer)
Fig. 1.5 Metal suction curette of Kesselring
and Meyer [78]
M.A. Shiffman
Kesselring and Meyer [179] developed a metal
curette (Fig. 1.5) that was attached to a suction to
facilitate the task. The fat was curetted to detach the
unwanted portions of fat, which were then aspirated
from the wound by the suction. Teimourian and Fisher
[180] stated that Schrudde performs suction curettage
in two stages in the lower legs after experiencing three
instances of considerable skin necrosis. and claimed
to have significantly expanded the use of a lipectomy
procedure which heretofore had been restricted to the
removal of strictly localized excess fat deposits by
curettage through a small incision (23 cm). The authors
modified the fascia lata stripper and utilized it for
extensive body contouring; they were successful in
correcting relatively major fat deformities without caus-
ing any postoperative surgical deformities. Local use
included lipectomy of the ankles, calves, medial and
lateral thighs, flanks, and arms, and supplemental use
augmented standard operations for the lipectomy of the
thighs, buttocks, abdomen, upper and lateral chest-
axilla, and extremities. In 54 patients, there was dim-
pling in one patient, one hematoma, and seromas in
30%. Sensation usually returned within 36 months.
Illouz [181] favored a wet technique in which
hypotonic saline combined with hyaluronidase was
infiltrated into the adipose tissue and prior to suction
removal. He felt this would reduce trauma and decrease
bleeding. He mistakenly thought that the solution rup-
tured the fat cells. His techniques also included the use
of the Karman cannula and abortion suction machine.
In 1981, Illouz [182] stated that he started the technique
of lipolysisaspiration in 1977. He describes the use of
general anesthesia with hypotonic saline in the tissues
and used cannulas of different dimensions, from 5 mm
for the face to10 mm that he designed for the body. He
drained wounds for 48 h. Illouz [183] described lip-
odystrophies and the treatment with liposuction using a
10-mm cannula for the riding breeches, buttocks, and
hips; an 8-mm cannula for the ankles, arms, knees, and
abdomen; and a 5-mm cannula for the face.
1 History of Cosmetic Surgery
Fig. 1.6 Fischers technique
was exclusively for
trochanteric lipodystrophies,
and the technique formed
cavities (Fournier and Otteni)
[189]
Fournier and Otteni [184] concluded that the use of
a uterine curette employed to remove fat resulted in
irregularities, excess localized skin, and persistent
lymphorrhea. They also stated that Fischers technique
was exclusively for trochanteric lipodystrophies, and
the technique formed cavities (Fig. 1.6), prolonged
drainage, secondary cutaneous and fat ptosis, lymph-
orrhea, and irregularities. The authors described Illouzs
technique for liposuction.
Vogt and Dicksheet [185], commenting on the 1981
article by Temourian and Fisher, stated that the tech-
nique of Schrudde, Kesselring, and others greatly
fell into disrepute a long time agoKesselringhas
abandoned the technique except for use in trochanteric
lipodystrophy, because of the high rate of complica-
tions and unsatisfactory results. Pfulg [186] reported
a case of a patient who had suction curettage for fat
removal and developed hematomaseroma, skin necro-
sis, and anemia. He concluded that suction curet-
tage to remove excess fat for body contouring may not
be such a simple and always successful procedure.
Chajchir et al. [187] devised instruments named
suction curette cannula. The cannulas (1.5 cm) had
blunt ends with a 3-mm tube on the lateral side to allow
regulation of airflow. The suction apparatus was modi-
fied to produce 450500 mm vacuum to prevent venous
injury, cutaneous injuries, or depressions established
by the technique of low vacuum for liposuction.
Incisions were 1.53 cm. Suction drains were used on
all patients for 3040 days. Illouz [188] discussed the
use of numerous subcutaneous tunnels that would
result in homogeneous contraction of the skin.
Fournier and Otteni [189] reported the use of the
dry technique, as opposed to Illouzs wet tech-
nique for liposuction, feeling that using a hypo-
tonic solution was unnecessary since exactly the same
13
results were obtained without the solution. They stated
that the uterine curette was employed first by
Schruddebut it gavevariable results and compli-
cations such as localized skin excess, uneven contour,
and lymphorrheaLater Fischer and Fischer
(1977) described the suction curettage, which was
directed exclusively to trochanteric lipodystrophy
produced unsightly results with irregular bulg-
ings and depressions (with the planatome) and
persistent lymphorrhea in the cavity caused by the
cellusuctiotome, despite the use of drainage for a
long timeEpithelialization of the cavity occurred
with secondary sagging of the skin. The authors used
postoperative suction drains for 2448 h except for
small areas such as double chin, ankles, knees, and
small trochanteric lipodystrophies where there is min-
imal drainage. Although hematomas and lymphorrhea
are theoretically possible, the authors did not have
any. There was bruising, edema, and temporary skin
irregularities. Permanent depressions, bulging, and
asymmetry can usually be prevented and occur less
often the more experienced the surgeon with this tech-
nique. Skin excess or sagging may happen after treat-
ing trochanteric lipodystrophies in patients 35 years
of age or older, or in those having poor skin tone, or
when the trochanteric lipodystrophy is particularly
large.
Illouz [190] described the possibility of grafting fat
cells obtained during liposuction. He noted that with
the dry technique of liposuction, 90% of the cells will
be alive, and with the wet technique, 70% will be alive.
Teimourian and Kroll [191] were the first to report the
use of endoscopy to see what occurs to the tissues after
suction curettage. Both major and minor vessels and
nerves were noted to be intact while small vessels were
torn and bleeding. This kept the authors aware of
14
the possibility of hematoma and encouraged the
authors to use drains in all of the cases. sis, prevention, and treatment of pulmonary embolism;
Dolsky [192] used the dry technique since he felt
that large amounts of fluid obscured the field. In ten
patients, treated by the French technique with a
lipolytic solution of Illouz, there was one patient with
seroma (10%). In ten patients treated with the Teimou-
rian and Fisher technique, there were two patients with
seromas (20%) and one patient with hematoma (10%).
The dry technique with 125 patients had one patient
with seroma (0.8%). The authors opinion was that
the suction machine must draw as close to one
atmosphere of negative pressure as possible One
atmosphere of negative pressure is necessary for this
technique to be a suction extraction of the fatty tissues
rather than a curetting technique. The author states
that After approximately 15 strokes, blood will
become evident in the tubing. The instrument is
removed entirely to the level of the original incision
and inserted into the next tunnel. Suction drains
were used postoperatively for 4872 h after surgery. A
modified French cannula with blunt tip and dull-edged
aperture was used.
Morgan and Berkowitz [193] published a guide-
book to acquaint the reader about liposuction that was
essentially useful for potential patient considering lipo-
suction. Hetter [194] stated that low-dose epinephrine
can lessen the blood loss from blunt suction lipectomy.
The book on Franco-American Experience [195]
claimed that Illouz heard about the Fischer technique
in 1977 at the International Congress of Plastic
Surgeons, Mexico City, April 1977. The book stated
that Illouz felt that undermining the treated area and
leaving a cavity was wrong, and he postulated that
regular tunnels in the subcutaneous tissues would
contract in a regular and even manner. Irregular tunnel-
ing would produce an inconsistent pattern of scar in
the subcutaneous tissues and result in irregularities.
The book claimed that Illouzs first case was on a
lipoma of the back in June 1977. A 6-mm steel abor-
tion cannula and standard suction machine were used
for liposuction on several lipomas, and he felt that a
blunt cannula with blunt hole would prevent bleeding.
The technique of dissecting injection hydrotomy was
learned from Converse in 1962. The book stated that
Illouz created many tunnels at different levels and
suggested making larger tunnels in the deep plane and
smaller tunnels in the more superficial layers of fat.
The book discussed the fat embolus syndrome as a
M.A. Shiffman
theoretic potential complication; described the diagno-
and described combined procedures with liposuction.
The book claimed the use of liposuction for lipomas,
breast reduction, defatting of flaps, LaunoisBensaude
disease, Knickers Deformity, congenital and trau-
matic lymphedema, hematoma evacuation, dog ears,
and removal of silicone (face and breast).
Fournier (personal communication 8/10/10) started
syringe liposuction and cryoanesthesia in 1985. Isaacs
[196] introduced the hand-operated switch cannula,
eliminating the distraction of the foot pedal. Also, he
used a control to lower the vacuum that could then be
used as a backup suction. In 1987, Fournier [197]
advocated the use of the syringe for liposuction that he
stated simplified the equipment needed, improved the
quality of the results, and improved the reliability
of the procedure itself because the exact amount of
adipose tissue can be obtained, and symmetrical work
can be performed on the opposite of the body. Toledo
[198] lectured on the use of superficial liposuction to
smooth out excess fat and to improve skin retraction.
Illouz and de Villers [199] reported that Illouzs
refinements in lipolysis included the pinching test in
1980; suction-assisted abdominoplasty and treatment
of gynecomastia in 1981; cross-tunnel dissection, peri-
pheral mesh dissection, and trials in systemic lipoma-
tosis in 1982; and tapering technique, elimination of
drainage, and use in thinning of free flaps and in lym-
phedema in 1983. Illouz established the 10 command-
ments of adipoaspiration that included:
1. Create only tunnels.
2. Be as gentle as possible.
3. Respect the superficial layer of fat.
4. It is not so much what is removed that is impor-
tant, but what is left behind.
5. Use, anticipate, and estimate skin retraction
instead of fighting against it.
6. Do not undertake an important resection that is
locally and generally dangerous.
7. Indications should be restrictive.
8. All fat resection is final.
9. Results in the operating room approximate the
final results.
10. This technique demands blind surgery.
Prevention of problems was discussed, and it was
stated that the principal problems were:
1. Choosing the wrong indications
2. Choosing inappropriate instruments
1 History of Cosmetic Surgery
3. A poorly executed technique
4. Inattention to postoperative complications
Megaliposuction was started in 1990 by Fournier
(personal communication 8/10/10). Gasperoni [200]
reported subdermal liposuction for better skin retrac-
tion. Courtiss et al. [201] found that various concentra-
tions of epinephrine diluted in saline did not decrease
fluid/blood loss compared to saline injection or no
injection at all. Gross et al. [202] described the use of
low vacuum liposhaver cannula being adjustable for a
rotating or oscillating blade cutting the fat with suction
extraction of fat. This was very similar to Fischer and
Fischers cellusuctiotome. in 2045% blood loss [201, 215218]. Liposuction
Elam et al. [203] stated that by reducing the nega-
tive suction pressure to 20 in. (508 mm) of mercury
(negative pressure), there was clinical observation of a
significant improvement in liposuction results as well
as a decrease in the amount of bruising, pain, and
swelling in the postoperative period. Schaeffer [204]
described the use of a soft tissue shaver and endoscopy
for removal of fat in the neck over the platysma and on
the skin flap. Giese et al. [205] found that large-volume
liposuction decreased systolic blood pressure and
fasting insulin levels.
1.5.1 Assisted Liposuction
Ultrasonic liposuction was introduced by Zocchi [206].
The concept was that adipose cells could be treated
with ultrasound energy, presumably breaking up their
cell walls and facilitating fat aspiration. The American
Society of Plastic and Reconstructive Surgery quickly
adopted ultrasonic liposuction; however, over time,
problems were found with this technique. Internal
ultrasound (ultrasound tips contained within cannulas)
increased the risk of cutaneous burns and seroma
formation. Apfelberg [207] described laser-assisted
liposuction. Silberg [208, 209] introduced external
ultrasound-assisted liposuction. Fodor [210] reported
power- assisted liposuction in 1999 in order to facilitate
the fat removal and decrease the work of the surgeon.
Powered liposuction devices are largely electrically
operated, but some air- driven devices are also avail-
able [211]. There is an increase in the rate of fat har-
vesting and the ease of use. Powered liposuction is
particularly useful for difficult fibrofatty areas such as
male pseudogynecomastia or male love handles. Taufig
[212] reported hydro-jet liposuction in 2000; Jewel
15
[213], Vaser (vibration amplification of sound energy
at resonance) in 2002; and Mirrafati [214], external
percussion massage-assisted liposuction (vibrotumes-
cent liposuction).
1.5.2 Tumescent Technique
In the early days of liposuction, the dry technique
was used with either local anesthesia or general anes-
thesia. The technique used had no fluids, other than
local anesthesia, injected into the tissues and resulted
was limited to 20003000 mL because of the blood
loss, and patients were frequently given transfusions
[215].
The wet technique relies on infusions of 100300 mL
of normal saline into each site but has blood loss of
1530% [219223]. With epinephrine added to the
fluid, the blood loss is reduced to 2025%.
The tumescent technique has improved the problem
of blood loss reducing it to 17.8% [224, 225]. The
term superwet anesthesia has been used to describe
the same fluid injection as with the tumescent tech-
nique [226]. This technique consists of an infusion of
saline with epinephrine and an aspirate removal of
approximately 1:1. Local tumescent anesthesia usually
has a fluid infusion to aspirate of 2:1 or 3:1.
1.5.3 Local Tumescent Anesthesia
There appears to be much confusion in the medical
literature concerning Kleins solution. No one is certain
as to what so-called Kleins solution contains and what
a modification of Kleins solution is.
Klein first reported the use of local tumescent anes-
thesia in 1987 [227]. The report described solutions
used that consisted of:
1. For general anesthesia:
a. Normal saline 1,000 mL
b. Epinephrine 1 mg
2. For local tumescent anesthesia:
a. Normal saline 1000 mL
b. Epinephrine 1 mg
c. Lidocaine 1000 mg
The amount of tumescent solution compared to
removal of aspirate was 1:1. This is Kleins original
solution, and all the rest are modifications.
16
Klein, in 1990 [228], showed that 35 mg/kg was a
safe amount of lidocaine to use for local tumescent anes-
thesia. The solution utilized at that time consisted of:
1. Normal saline 1000 mL
2. Epinephrine 1 mg
3. Lidocaine 500 mg
4. Sodium bicarbonate 12.5 mEq
Klein, in 1993 [229], had changed the local tumes-
cent anesthesia solution to:
1. Normal saline 1000 mL
2. Epinephrine 0.50.75 mg
3. Lidocaine 5001000 mg
4. Sodium bicarbonate 10 mEq
5. Triamcinolone 10 mg (optional)
The mean tumescent solution compared to total
aspirate was 4609 mL:2657 mL or almost 2:1.
By 1995, Klein [230] had changed the tumescent
formula to:
1. Normal saline 1000 mL
2. Epinephrine 0.50.65 mg
3. Lidocaine 5001000 mg
4. Sodium bicarbonate 10 mEq
5. Triamcinolone 10 mg
In 2000, Klein [231] described a variation of drugs
in the local tumescent solution according to the area
being liposuctioned. The basic solution to be changed
after checking for anesthesia completeness was:
1. Normal saline 1000 mL
2. Lidocaine 500 mg
3. Epinephrine 0.5 mg
4. Sodium bicarbonate 19 mEq
If the anesthesia was not adequate, then a variety of
formulations were proposed for each area of the body
areas and ranged from lidocaine of 7501500 mg, epi-
nephrine from 0.5 to 1.5 mg, and sodium bicarbonate
of 10 mEq. Local tumescent anesthesia is used as the
anesthetic for performing liposuction, especially with
small cannulas (microcannulas). The same fluid can be
used with conscious sedation to provide the necessary
local anesthesia.
Ostad [232] proposed that the maximum safe
tumescent lidocaine dosage was 55 mg/kg.
1.5.4 Guidelines
Guidelines of care for liposuction were approved by
the American Academy of Dermatology in 1989 and
published in 1991 [233]. Additional guidelines of
M.A. Shiffman
care for liposuction were published by the American
Academy of Cosmetic Surgery, the American Society
for Dermatologic Surgery in 2000 [234], the American
Academy of Dermatology in 2001 [235], and the
Indian Academy of Dermatology, Venereology and
Leprology in 2008 [236].
1.6 Otoplasty
Sushruta, in Sushruta Samhita, described various
reconstructive methods or different types of defects
like release of the skin for covering small defects, rota-
tion of the flaps to make up for the partial loss and
pedicle flaps for covering complete loss of skin from
an area such as earlobe reconstruction [237]. In 30 AD,
Aulus Cornelius Celsus in De Medicina [238] referred
to repair of mutilated ears with advancement quadran-
gle flaps [239]. Gaspari Tagliacozzi, in his treatise De
Curtorium Chirurgia per Institionem, instructed sur-
geons on how to reconstruct ears [240].
The first correction of protruding (large) ears (mac-
rotia) was by means of triangular excisions taken from
the auricle described by de Martino in 1856 [241].
Dieffenbach [242] attempted to correct the protrud-
ing, or lop ear, deformity with postauricular skin
excision in the auriculocephalic sulcus with concho-
mastoidal fixation. In 1968, Rogers [243] claimed that
the origins of otoplasty for the prominent ear were by
Eli [244] who described prominent ear correction that
consisted of postauricular skin excision, concho-
mastoidal fixation, and conchal strip excision. Keen
[245] removed a narrow, V-shaped section of carti-
lage from the posterior surface of the auricle after a
large section of skin had been excised. Monks [246]
described removal of skin from the back of the ear
but if the cartilage was stiff, then excision of some
cartilage. Cocheril [247] modified the original tech-
niques by adding incision and excision of various
parts of the conchal cartilage to improve the results.
Haug [248] reported removal of triangular wedges of
cartilage along with excision of the skin on the pos-
terior surface of the auricle. In 1896, Joseph [249]
divided protruding ears into two types: the soft and
the hard cartilage types. For ears of the soft cartilage
type, he advised excision of skin at the auriculomas-
toid angle. For the hard cartilage type, he advised
resection of cartilage from the region along with
excision of skin.
1 History of Cosmetic Surgery
Gersuny [250] sutured the perichondrium to the
mastoid periosteum. Morestin [251] bent the cartilage
and held it in place with nonabsorbable sutures. He
believed that the incision through the cartilage must
extend well up to the upper and lower borders of the
cartilage. Payr [252] embedded a cartilage flap under
the periosteum. Miller [122] described his experience
in the correction of various facial deformities includ-
ing outstanding ears. Goldstein [253] described an
operation similar to Morestin, but he sutured the
cartilage to the mastoid periosteum.
Luckett [254] resorted to a cartilage-breaking tech-
nique consisting of crescent medial skin and cartilage
excision along the entire vertical length of the antiheli-
cal fold to restore the antihelical fold. However, this
produced a sharp outline to the antihelical fold in some
cases. Luckett attempted to alleviate this problem with
several horizontal mattress sutures, as adapted from
Lembert, that allowed the flat surfaces of the concha
and the antihelix to be apposed, not the edges of each,
as the sutures were tied tightly.
Modifications of Lucketts technique include: Barsky
[255] beveled the borders and kept an intact segment of
cartilage over the cartilage incisions by suturing the cut
edges under a bridge; Baxter [256] made parallel inci-
sions of the cartilage instead of a single one; Young
[257] prolonged the cartilage incision to break the
spring and avoid suturing; Farina [258] varied the skin
incision and cartilage resection; Vidaurre [259] added
an incision for the anterior crus; Hatch [260] modified
Lucketts procedure by removing three separate, though
continuous, crescent-shaped pieces of tissue, two of
which are cartilage and one of which is cartilage and
fat in the lobule. This repositioning allowed the ear to
open out in three separate and opposing directions
simultaneously to produce anatomic and aesthetic nor-
mality; Jones [261] excised a wider cartilage strip in
order to decrease the sharpness of the antihelical ridge;
Holmes [262] used a special gouge to make fish-like
scales up and down the proposed antihelix; Cloutier
[263] divided the cartilage from the top of the ear to
the lobule, and the skin overlying the anterior surface
of the cartilage dissected off the cartilage approxi-
mately 3/8 in. on each side. The upper and lower ends
of one edge of the cartilage are grasped with forceps
and turned back so that the anterior side of the carti-
lage faces the operator. The edge of the cartilage is
beveled with a razor blade. The edge of the cartilage
will curl, and the width of the curl will depend on the
17
width of the beveled edge. The proper width should
be made on the first attempt. A similar procedure is
carried out on the other edge of cartilage. The carti-
lage does not require suturing; McDowell [264] made
a precise placement of the main cartilage incision
from the posterior surface while continuously observ-
ing the marked line to follow on the anterior surface of
the ear. The knife point goes through the cartilage,
and its continuing path is easily seen under the ante-
rior skin. This method allows for a quicker and more
accurate incision than does the use of perforating
needles.
Ruttin [265] anchored the cartilage with fascia lata
strips. Kolle [266] corrected protruding (macrotia) ears
with excision of skin and an elongated ellipse of carti-
lage. Alexander [267] corrected ear prominence due to
a high concha by incising and overlapping the posterior
wall of the concha. Demel [268] advised the removal
of a large section of conchal cartilage to be turned on
itself and pedicled beneath a bridge of periosteum over
the mastoid region. Eltner [269] tried to eliminate the
wrinkling of skin on the anterior surface, that occurred
with the Joseph and Morestin techniques, by excising
two triangles of cartilage with a common base from the
region of the concha. The skin and perichondrium
were incised horizontally and then undermined before
excision of the cartilage. Davis and Kitlowski [270]
described the use of needles passed through and
through the auricle to mark the antihelix. They recom-
mended dipping the needles in a dye and then marked
the cartilage with a series of puncture points to assist in
the incision and remodeling of the auricular cartilage.
MacColumm [271] and Young [272] combined the
Luckett technique of antihelical correction with ear-
lier techniques of conchal reduction that now forms
the foundation for most of the modern otoplasty tech-
niques for correcting the prominent ear deformity.
New and Erich [273] described a technique of exter-
nal stay sutures that permitted and easy and flexible
method of modeling the antihelix fold and maintaining
the infolding of the cartilage in position during healing.
Fishman and Fishman [274] used a through and
through excision after premarking. The outer or lateral
portion followed the curve of the helix closely extend-
ing beyond the crura of the antihelix at the upper end
and into and through the length of the fossa of the
concha at the lower end. The medial incision was in
accordance with the amount of skin and cartilage
required to be excised. Subsequent modifications were
18
described by Pierce et al. [275], Dufourmental [276],
and Paletta et al. [277].
Borges [278] felt that Youngs technique had the
disadvantage of the middle ridge and the superior crus
being too sharp and does not conform to the normal
ear. He modified the technique by not excising the
elliptical strip of cartilage from the concha but just
incising and criss-crossing it while excising the infe-
rior and internal strip from the concha so that it may
give bulk and roundness to the superior crus and medial
part of the antihelix.
McEvitt [279] used multiple parallel antihelical inci-
sions to soften the hard-edge contours of the corrected
antihelical fold. He also divided protruded ears into
types.
Type 1: Ears of normal size with moderate protru-
sion caused by underdevelopment of the normal fold of
the antihelix. The concha and fossae are approximately
normal in size, and their ratio to one another is
correct. The antitragus is not overprominent.
Type 2: Large ears usually with marked protrusion,
underdevelopment of the fold of the antihelix,
overprominence of the antitragus, and wide scapha
(fossa of the helix).
Type 3: Long narrow ears with little or no evidence
of the antihelix. The structure seems curled forward.
The concha and fossae form a continuous hollow giv-
ing the ear almost the appearance of a shell. They tend
to be wide at the top and taper toward the lobule, being
roughly triangular.
Weaver [280] modified the technique of New and
Erich [273].
Becker [281] described a procedure with an incision
through the skin and perichondrium in the postauricu-
lar region of the margin between the scapha and the
concha, in the fossa antihelicis, and extended at the
superior portion to the junction of the ear and temporal
region, while at the inferior portion, it is extended
down to the base of the antitragus close to the mastoid
region. The skin and perichondrium are undermined
laterally almost to the mastoid angle and to the begin-
ning rim of the helix. The ear is folded back against the
head to show the new antihelix. Skin and cartilage are
pierced by a needle and the posterior surface of the
cartilage marked with methylene blue. The double row
of marks delineates the posterior and anterior borders
of the antihelix and superior crus. Two incisions are
made through the cartilage along the markings, and a
section of cartilage is removed from the antihelix. The
M.A. Shiffman
skin is undermined laterally for a few millimeters on
the anterior surface of the auricle. The sulcus antiheli-
cis transversus is incised completely through extend-
ing the incision into the previously incised cartilage of
the antihelix that breaks the spring of the inferior crus.
The cauda helicis is completely removed and the supe-
rior crus crosscut by incisions to weaken the spring of
the cartilage. A small transverse section of cartilage is
removed from the upper end of the superior crus to
completely break the spring of the antihelix and supe-
rior crus. Three or four surgical gut mattress sutures
are inserted in the perichondrium along the margins of
the original incisions in the cartilage and tied to form
the new antihelical fold. Excess skin is excised and the
skin sutured closed.
Jayes and Dale [282] modified the Luckett tech-
nique by also using antihelical incisions. Also, they
classified the prominent ear into types.
Type 1: The antihelix is formed but is not folded
back as sharply as in a normal ear, and the scapho-
conchal angle is widened. The ear is small, and it will
not be abnormally prominent, but if large it will defi-
nitely stick out.
Type 2: Superior crus of the antihelix is absent.
The upper part of the scapha looks abnormally
wide owing to the absence of the dividing ridge. The
whole upper part of the ear turns forward and tends to
droop as it lacks the stiffening support of the superior
crus.
Type 3: The whole of the antihelix is poorly formed,
and the scapho-conchal angle is widely obtuse. The
superior crus is absent. The inferior crus and the lower
part of the antihelix, though visible, are very much flat-
tened. The ear stands sharply out from the head at a
right angle.
Type 4: The antihelix is totally absent. The ear is of
the fetal type curving smoothly outward and forwards
from the head in the pane of the concha. This type of
deformity is sometimes associated with microtia or
relative shortness of the helix.
Sercer [283] resected the anterior spine of the
helix, thinned the back of the concha, and excised an
ellipse or myrtle-leaf piece of the retroauricular skin.
Kristensen [284] devised variations in skin resection
and cartilage incisions. Becker [285] described paral-
lel antihelical incisions held together by permanent
sutures to produce conical antihelical tubing in order
to soften the external contour of the corrected promi-
nent ear. This was refined by Converse et al. [286] and
1 History of Cosmetic Surgery
further elaborated by Converse and Wood-Smith [287]
and Wood-Smith and Converse [288].
Straith [289] corrected unpleasant effects of oto-
plasty by (1) running a cutaneous 0000 nylon suture
just back of the cut edges of the concha and helix and
(2) predetermining the correct height of concha and
antihelix by folding the ear back and placing needles,
after which the needles are removed and the ear folded
back to determine the amount of cartilage to be deter-
mined and excised accordingly. (3) The formation of a
normal curve of the antihelix can be predetermined by
folding the ear back and placing the needles along the
edges of the concha and triangular fossa. Usually a
strip no more than 2 mm wide is excised to give a
normal appearance.
Surgical abrasion of the antihelix was described by
Stark and Saunders [290]. Mustarde [291293] simpli-
fied these techniques by creating a conical antihelical
tubing with permanent conchoscaphal mattress sutures.
These sutures, placed full thickness through the carti-
lage of the concha and scapha in mattress fashion with-
out piercing the lateral skin, are particularly successful
to treat the pliable cartilage of children. All cartilage
tubing techniques depend on scarring to fill the tube
and lock the sculpted framework into position.
Tamerin and Mirehouse [294] noted the tendency of
the auricular cartilage in the region of the helix to
curl backward when it is incised near the free edge of
the ear and when it is separated from its anterior
lining perichondrium. Farrior [295] used the smallest
dermabrader to remove parallel concave troughs simi-
lar to the full-thickness wedges removed in the current
technique. The strips that remain between the troughs
give body and resilience to the ear. He used a method
of three incisions and an overriding cartilage strip in
the reconstruction of the antihelix proper. He did not
join the superior crus and conchal rim incisions but left
an isthmus of cartilage at the junction of the crura as in
Straiths [289] method.
Pitanguy and Rebello [296] used an island technique
to cover visible cartilage ridges. Gibson and Davis
[297], Chongchet [298], and Stenstrem [299] intro-
duced lateral cartilage weakening techniques to take
advantage of the unique ability of a sheet of cartilage
to warp away from the injured surface. In the Chongchet
technique, the lateral scaphal cartilage is scored with a
scalpel to form an antihelix. In the Stenstrem tech-
nique, postauricular incision is used so that a short-
tined rasp could be used to blindly scar the antihelix.
19
Morcellation of the antihelix through a direct lateral
incision was advocated by Ju et al. [300].
Crikelair and Cosman [301] described a new tech-
nique for the prominent ear with combined concha and
antihelix deformity. A postauricualr incision parallel
to the free border of the helix and 1 cm from the border
is extended from the cephaloauricular angle superiorly
to the fleshy lobule inferiorly. An ellipse of skin can be
excised using the incision line as the outer border.
Needles are passed posteriorly from the anterior sur-
face of the ear just beneath the helix overhang, tipped
with methylene blue and then withdrawn. The wound
edges are slightly undermined and the methylene blue
markings identified on the cartilage. The auricular car-
tilage is cut through along this line from superiorly at
the cephaloauricular angle inferiorly to where the tail
of the helix begins. This separates the rim of the ear
from the major ear cartilage. The auricular cartilage is
freed subchondrally on its anterior surface, and the
anterior dissection is carried forward in the upper part
of the ear until the inferior crus of the helix is exposed.
The middle and lower portion of the ear, the edge of
the cavum concha, is similarly exposed. The anterior
cartilage surface is lightly striated (not through the
full thickness of the cartilage) in at least three or four
directions. The cartilage will bend back on itself form-
ing the smooth roll of the antihelix. The acuteness
of the roll can be increased by increasing the number
and decreasing the spacing of the striations. The redun-
dant auricular cartilage can be trimmed. The amount to
be excised can be determined by replacing the helix
over the auricular cartilage and observing the excess
from behind. The width removed affects the width of
the new scaphoid fossa. The amount trimmed from the
superior pole affects the vertical length of the ear.
The edge of the cavum concha is trimmed, and the tail
of the helix is dissected free and excised. The anterior
skin flap is replaced on the cartilage and molded into
its new contours. The postauricular incision is closed.
In 1966, Barnes and Morris [302] reported use of
the Stenstrem technique by elevating the skin from
the postauricular skin excision site and freeing tail
of the helix from the conchal cartilage and the skin
anteriorly. Half of a Brown-Adson tissue forceps was
introduced into the subcutaneous tunnel to make mul-
tiple superficial scratches along the antihelix and its
crura. The ear can then be folded back quite easily and
held in its new position by simply closing the elliptical
skin defect. Kaye [303] developed a combination of
20
the Stenstrem technique of antihelical rasping and the
Mustarde concept of permanent mattress suture fixa-
tion to maintain the proper amount of antihelical roll
after a lateral rasp of the antihelix. Permanent sutures
are introduced through tiny lateral incisions along the
conchal crest, which are carried across the antihelical
fold and tied on the lateral side.
Further contributions of the Ely technique with
conchomastoidal sutures include Owens and Delgado
[304] and Furnas [305]. Spira et al. [306] combined
conchomastoidal suturing with conchoscaphal sutur-
ing with good results). Webster [307] stated that
regardless of the skill of the operator or the technique
of the operation, however, one falls short of the ideal
appearance in every case. Perfection is impossible to
attain. He used a combination of ideas of many authors
plus individual interpretation. The essential concept is
thinking of the concha as one entity and the rest of the
ear, including the helix and antihelix area, as another
unit. Wood-Smith [308] reported on correction of
prominent lobules when the lower third of the ear pro-
trudes with a modified fishtail excision.
Weerda [309], in cases of thick auricular cartilage
with low elasticity, used a diamond drill to weaken the
auricular cartilage immediately above and below the
intended new antihelical fold and the antihelical crus
through a retroauricular access. Full-thickness mattress
sutures of slowly absorbable suture material are placed
at the positions with the corresponding markings to fix
the helix in the intended position.
Wegener [310] stated that the procedure that
combined correction of protruding ears with reduc-
tion of hyperplastic auricles had been developed by
the author more than 30 years previously. During the
postauricular removal of the prominent cartilage in
a layer-by-layer fashion, the scalpel is used tangen-
tially following the outline of the individual crural
curvature to the antihelix margin and the auricle
base. Falciform excision of the cartilage of the supe-
rior helix is performed starting from the anterior fold
of the auricle peripherally toward the scapha. After an
anterior skin sickle excision, a new helix margin is
created by eversion of the still intact skin of the poste-
rior helix wall. The operation is finished by a wedge-
shaped skin-cartilage excision of the superior part of
the helix.
Horlock et al. [311] described a postauricular fas-
cial flap in otoplasty. Scuderi et al. [312] reported on a
posterior auricular muscle flap in otoplasty.
M.A. Shiffman
An excellent algorithm was developed by Stal and
Hatef [313] for the analysis and treatment of the
prominent ear.
1.6.1 Conclusions
Otoplasty history shows the development of the surgi-
cal treatment of the prominent ear with a multitudinous
variety of new and modified techniques. When per-
forming otoplasty, the surgeon should be thoroughly
informed of the variety of procedures available.
1.7 Rhinoplasty
The history of cosmetic rhinoplasty started with plastic
repair of the nose as early as the Edwin Smith Papyrus
that is thought to be at least 1700 years old. Although
replacement of portions of the nose from injuries or
disease was the main indication for rhinoplasty,
Dieffenbach, in 1845 [242], introduced the concept of
reoperation to improve the cosmetic appearance of the
reconstructed nose. Roe, in 1891, reduced the hump of
the nose. After that time, cosmetic rhinoplasty has
been improved and modified by many authors.
1.8 Early Rhinoplasty
The Edwin Smith Papyrus (purchased in Egypt by
Smith in 1862) is thought to be at least 1700 years old
and copied from treatises at least 1000 years older
[314]. Translated in 1930 by Breasted [315], the papy-
rus cited cases of a broken nose, a break in the nasal
bone, and a comminuted fracture in the side of the nose
that were treated with insertion of plugs of linen satu-
rated with grease into the nostrils.
The earliest recording of reconstruction of the nose
was Sushruta (Susruta) (approximately 600 BC) who
described in his Sushruta Samhita (Sushrutas Collec-
tion) an innovative method of rhinoplasty that was
reconstruction following amputation of the nose as a
punishment for crimes [316, 317]. This method is
mentioned as the Indian method of rhinoplasty in the
books of plastic surgery.
In 1816, Carpue [318] published the account of
the successful performance of operative procedures
on British military officers, one who had lost his nose
1 History of Cosmetic Surgery
to the toxic effects of mercury treatments while being
treated for liver infection, and the other lost the nose
from a saber cut. He used the Indian rhinoplastic
reconstruction with a flap of skin taken from the
forehead. In 1818, von Graefe [319] published his
major work entitled Rhinoplastik. He modified the
Italian method using a free skin graft from the arm
instead of the original delayed pedicle flap. von
Pfolspeundt, in Buch der Bundth-Ertznei [320],
described a process to make a new nose for one who
lacks it entirely, and the dogs have devoured it by
removing skin from the cheek or forehead and sutur-
ing it in place.
1.8.1 Cosmetic Rhinoplasty
In 1845, Dieffenbach [242] wrote a comprehensive
text on rhinoplasty, entitled Operative Chirurgie, and
introduced the concept of reoperation to improve
the cosmetic appearance of the reconstructed nose.
In 1891, Monks [321] described the successful use of
heterogeneous free bone grafting to reconstruct saddle
nose defects. In 1891, Roe [322] presented an example
of his work with a young woman on whom he reduced
a dorsal nasal hump for cosmetic indications. This was
one of the first procedures for purely cosmetic purposes.
In 1892, Weir [323] experimented unsuccessfully with
xenografts (duck sternum) in the reconstruction of
sunken noses. In 1896, Israel [324] described the use
of heterogenous free bone grafting to reconstruct
the saddle nose defect. The grafting of the cartilage of
the auricular concha in rhinoplasty was described by
Suslov in 1897, and modifications of the technique
were reported by Koltun in 1964 [325].
Joseph [326] published his first account of reduc-
tion rhinoplasty in 1898. The surgeries were performed
with external incisions that later were done through
incisions in the nose. In 1928, Joseph [327] published
his book Nasenplastik und Sonstige Gesichtsplastik
(Rhinoplasty and Facial Plastic Surgery). He popular-
ized the aesthetic rhinoplasty and described modern
techniques in 1932 [328].
Sheehan [329] advocated a columellar incision and
tunneling along the columella and tip of the nose to the
nasal bones. The costal cartilage graft was bent at a
right angle and placed at the tip of the nose to the nasal
bones and in the wound of the columella in order to lift
the tip. Rthi [330] described the transcolumellar skin
21
incision for rhinoplasty that is frequently referred to as
the Rthi incision or technique [331]. Roy [332]
described a technique of lifting the nasal tip through a
mucosal incision separating the tissues from the colu-
mella and from the tip of the nose to the nasal bones.
A costal cartilage graft was placed in the nasal vestibu-
lar wound in direct contact with the quadrangular car-
tilage taking its support from the superior maxilla,
pushing up the tip of the nose.
A number of different alloplastic materials were
reported being used in rhinoplasty. Holt and Lloyd
[333] used methyl methacrylate, Cottle et al. [334]
used hyaluronidase, Voloshin [335] used Plexiglass,
and Nolting [336] used a steel bridge.
Goodman [337] initiated the shift from the closed
technique of rhinoplasty to an open technique, and this
was refined and popularized by Anderson et al. [338].
Gunter and Rohrich [339] described the open rhino-
plasty technique for secondary rhinoplasty that resulted
in a shift in surgical approach to secondary rhinoplasty.
Sheen [340] described the use of a spreader graft to
reconstruct the roof of the middle nasal vault following
rhinoplasty.
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Plast Reconstr Surg 73(2):230239
 Anatomy of the Face and Neck
Peter M. Prendergast
2.1 Introduction
Safe and effective cosmetic surgical practice relies on a
clear knowledge and understanding of facial anatomy.
Techniques evolve and improve as the complex, lay-
ered architecture and soft tissue compartments of the
face are discovered and delineated through imaging,
staining techniques, and dissections both intraopera-
tively and in the research laboratory on cadavers [1]. To
create a more youthful, natural-looking form, the sur-
geon endeavors to reverse some of the changes that
occur due to aging. These include volumetric changes
in soft tissue compartments, gravitational changes, and
the attenuation of ligaments. Whether the plan of reju-
venation includes rhytidectomy, platysmaplasty, autol-
ogous fat transfer, implants, or endoscopic techniques,
a sound knowledge of facial and neck anatomy will
increase the likelihood of success and reduce the inci-
dence of undesirable results or complications.
This chapter describes the anatomy of the face in
layers or planes, with some important structures or
regions described separately, including the facial nerve,
sensory nerves, and facial arteries. The superficial
layers and topography of the neck are also described.
The facial skeleton forms the hard tissue of the face and
provides important structural support and projection
for the overlying soft tissues, as well as transmitting
nerves through foramina and providing attachments for
several mimetic muscles and muscles of mastication.
P.M. Prendergast
Venus Medical, Dublin, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_2, Springer-Verlag Berlin Heidelberg 2013
2
Following a description of the hard tissue foundation,
the soft tissues of the face will be described, from
superficial to deep, in the following order:
1. Superficial fat compartments
2. Superficial musculoaponeurotic system (SMAS)
3. Retaining ligaments
4. Mimetic muscles
5. Deep plane, including the deep fat compartments
2.2 Facial Skeleton
Facial appearance is to a large extent determined by
the convexities and concavities of the underlying facial
bones (Fig. 2.1). The high cheekbones and strong
chin associated with attractiveness are attributable to
the convexities and projection provided by the zygo-
matic bone and mental protuberance of the mandible,
respectively (Fig. 2.2). The facial skeleton consists of
the frontal bone superiorly, the bones of the midface,
and the mandible inferiorly. The midface is bounded
superiorly by the zygomaticofrontal suture lines, infe-
riorly by the maxillary teeth, and posteriorly by
the sphenoethmoid junction and the pterygoid plates.
The bones of the midface include the maxillae, the
zygomatic bones, palatine bones, nasal bones, zygo-
matic processes of the temporal bones, lacrimal bones,
ethmoid bones, and turbinates. The facial skeleton
contains four apertures: the two orbital apertures, the
nasal aperture, and the oral aperture. The supraorbital
foramen (or notch) and the frontal notch are found at
the superior border of each orbit and transmit the
supraorbital and supratrochlear nerves, respectively.
The maxillary bones contribute to the nasal aperture,
bridge of the nose, maxillary teeth, floor of the orbits,
29
30 P.M. Prendergast

Fig. 2.1 Frontal view of the facial skeleton

10 26
11
8

7
12 25 24
6
13 23

14

22 4
15 5
3
16
21

17

1
18

19 20

1 Angle of mandible 14 Zygomaticofacial foramen

2 Ramus of mandible 15 Infra-orbital foramen
3 Body of maxilla 16 Anterior nasal aperture
4 Zygomatic process of maxilla 17 Intermaxillary suture
5 Zygomatic bone 18 Mental foramen
6 Greater wing of sphenoid bone 19 Mental protruberance
7 Zygomaticofrontal suture 20 Body of mandible
8 Zygomatic process of frontal bone 21 Anterior nasal spine
9 Frontal bone 22 Nasal septum
10 Supra-orbital notch 23 Lacrimal bone
11 Frontal notch 24 Frontal process of maxilla
12 Superior orbital fissure 25 Nasal bone
13 Inferior orbital fissure 26 Glabella

and cheekbones. The infraorbital foramen lies in the
maxilla below the inferior orbital rim and transmits
the infraorbital nerve. The zygomaticofacial foramen
transmits the zygomaticofacial nerve inferolateral to
the junction of the inferior and lateral orbital rim.
The mandible forms the lower part of the face. In
the midline, the mental protuberance gives anterior
projection to the overlying soft tissues. Laterally, the
ramus of the mandible underlies the masseter muscle
and continues superiorly to articulate with the cranium
2 Anatomy of the Face and Neck
Fig. 2.2 Convexities of the facial skeleton
through the coronoid process and condylar process
of the mandible. The mental nerve emerges from
the mental foramen on the body of the mandible in
line vertically with the infraorbital and supraorbital
nerves.
As well as providing structural support, projection,
and protection of sensory organs such as the eyes,
the facial skeleton provides areas of attachment for
the muscles of facial expression and the muscles of
mastication (Fig. 2.3).
2.3 Supercial Fat Compartments
The pioneering work of Rohrich and Pessa [2], using
staining techniques and cadaver dissections, has
revealed a number of distinct superficial fat compart-
ments in the face. These compartments are separated
31
Temporal process of
zygomatic bone
Zygomatic bone
Zygomatic process
of maxilla
Mental protruberance of
mandible
from one another by delicate fascial tissue and septae
that converge where adjacent compartments meet
to form retaining ligaments. The superficial fat com-
partments of the face comprise the following: the naso-
labial fat compartment; the medial, middle, and lateral
temporal-cheek malar fat pads; the central, middle,
and lateral temporal-cheek pads in the forehead; and
the superior, inferior, and lateral orbital fat pads
(Fig. 2.4). Nasolabial fat lies medial to the cheek fat
pad compartments and contributes to the overhang of
the nasolabial fold. The orbicularis retaining ligament
below the inferior orbital rim represents the superior
border of the nasolabial fat compartment and the
medial cheek compartment (Fig. 2.5). The middle
cheek fat compartment lies between the medial and
lateral temporal-cheek fat compartments and is
bounded superiorly by a band of fascia termed the
superior cheek septum. The borders of the middle
32
Fig. 2.3 Areas of muscle
attachments to the facial
skeleton Corrugator
supercilii
Temporalis
Levator labii superioris
alaeque nasi
Levator labii superioris
Zygomaticus major
Zygomaticus minor
Levator anguli oris
Depressor septi
Buccinator
Platysma
Depressor anguli oris
Depressor labii inferioris
cheek compartment, the inferior, and the lateral orbital
fat pad compartments converge to form a tougher band
of tissue called the zygomatic ligament [3]. The con-
densation of connective tissue at the borders of the
medial and middle fat compartments correlates with
the masseteric ligaments in the same location [4]. The
lateral temporal-cheek fat pads span the entire face
from the forehead to the cervical area. Its anterior
boundary, the lateral cheek septum, is encountered
during facelift procedures with medial dissection from
the preauricular incision. In the forehead, its upper and
lower boundaries are identifiable as the superior and
inferior temporal septa. Medial to the lateral temporal-
cheek fat compartment in the forehead, the middle
temporal fat pad is bounded inferiorly by the orbicu-
laris retaining ligament and medially by the central
forehead fat compartment. Above and below the eyes,
the superior and inferior orbital fat compartments lie
within the perimeter of the orbicularis retaining liga-
ment. These periorbital fat pads are separated from
one another medially and laterally by the medial and
lateral canthi, respectively. The lateral orbital fat
compartment is the third orbital fat pad and is bounded
superiorly by the inferior temporal septum and inferi-
orly by the superior cheek septum. The zygomati-
cus major muscle attaches, through fibrous septae, to
overlying superficial fat compartments along its length.
In the lower third of the face, the jowl fat compartment
P.M. Prendergast
Procerus
Orbicularis oculi
Upper orbital part
Palpebral part
Lower orbital part
Masseter
Nasalis: transverse part
Nasalis: alar part
Temporalis
Masseter
Mentalis
adheres to the depressor anguli oris muscle and is
bounded medially by the depressor labii and inferiorly
by bands of the platysma muscle. Premental and pre-
platysmal fat abut the jowl fat compartment.
The compartmentalized anatomy of the superficial
subcutaneous fat of the face has implications in the
aging process. Volume loss appears to occur at
different rates in different compartments, leading to
irregularities in facial contour and loss of the seam-
less, smooth transitions between the convexities and
concavities of the face associated with youthfulness
and beauty.
2.4 Supercial Musculoaponeurotic
System
In 1976, Mitz and Peyronie [5] published their descrip-
tion of a fibrofatty superficial facial fascia they called
the superficial musculoaponeurotic system (SMAS).
This system or network of collagen fibers, elastic
fibers, and fat cells connects the mimetic muscles to
the overlying dermis and plays an important func-
tional role in facial expression. The SMAS is central to
most current facelift techniques where it is usually dis-
sected, mobilized, and redraped. In simple terms, the
SMAS can be considered as a sheet of tissue that
extends from the neck (platysma) into the face (SMAS
2 Anatomy of the Face and Neck
Fig. 2.4 The superficial fat Lateral Temporal-Cheek
compartments of the face
Lateral orbital
Medial
Middle
Lateral
temporal-cheek
Pre-platysma fat
proper), temporal area (superficial temporal fascia),
and medially beyond the temporal crest into the fore-
head (galea aponeurotica). However, the precise anat-
omy of the SMAS, regional variations, and even the
existence of the SMAS are debated [6]. Ghassemi et al.
[7] describe two variations of SMAS architecture.
Type I SMAS consists of a network of small fibrous
septae that traverse perpendicularly between fat lob-
ules to the dermis and deeply to the facial muscles or
periosteum. This variation exists in the forehead,
parotid, zygomatic, and infraorbital areas. Type II
SMAS consists of a dense mesh of collagen, elastic,
and muscle fibers and is found medial to the nasolabial
fold, in the upper and lower lips. Although extremely
thin, type II SMAS binds the facial muscles around the
33
Middle forehead
(forehead)
Central
Superior
orbital
Inferior
orbital
Nasolabial
Jowl
mouth to the overlying skin and has an important role
in transmitting complex movements during animation.
Over the parotid gland, the SMAS is relatively thick.
Further medially, it thins considerably making it diffi-
cult to dissect. In the lower face, the SMAS covers the
facial nerve branches as well as the sensory nerves.
Dissection superficial to the SMAS in this region pro-
tects facial nerve branches [8]. Above the zygomatic
arch, the SMAS exists as the superficial temporal fas-
cia, which splits to enclose the temporal branch of the
facial nerve and the intermediate temporal fat pad.
Dissection in this area should proceed deep to the
superficial temporal fascia, on the deep temporal fas-
cia, to avoid nerve injury. Although considered as one
system or plane, the surgeon should be mindful of
34
Fig. 2.5 Ligaments and septa Superior temporal septum
between fat compartments of
the face
Lateral canthus
Zygomatic
ligament
Lateral cheek
septum
Superior cheek septum
Platysma-auricular ligament
the regional differences in SMAS anatomy from supe-
rior to inferior and lateral to medial.
2.5 Retaining Ligaments
True retaining ligaments are easily identifiable struc-
tures that connect the dermis to the underlying perios-
teum. False retaining ligaments are more diffuse
condensations of fibrous tissue that connect superficial
and deep facial fasciae [9] (Fig. 2.6). The zygomatic
ligament (McGregors patch) is a true ligament that
connects the inferior border of the zygomatic arch to
the dermis and is found just posterior to the origin of
the zygomaticus minor muscle [3]. Other true liga-
ments include the lateral orbital thickening on the
superolateral orbital rim that arises as a thickening of
the orbicularis retaining ligament, and the mandibular
P.M. Prendergast
Interior temporal septum
Orbicularis retaining Ligament
Medial canthus
Masseteric
ligaments
Mandibular ligament
retaining ligament. The latter connects the periosteum
of the mandible just medial to the origin of depressor
anguli oris to the overlying dermis. This attachment
gives rise to the labiomandibular fold just anterior to
the jowl. The masseteric ligaments are false retaining
ligaments that arise from the anterior border of the
masseter and insert into the SMAS and overlying
dermis of the cheek. With aging, these ligaments atten-
uate, the SMAS over the masseter becomes ptotic,
and this leads to the formation of jowls [10]. Below
the lobule of the ear, the platysma-auricular ligament
represents a condensation of fibrous tissue where the
lateral temporal-cheek fat compartment meets the pos-
tauricular fat compartment. During facial rejuvenation
procedures, true and false retaining ligaments are
encountered and often released in order to mobilize
and redrape tissue planes. Extra care should be taken
when releasing ligaments as important facial nerve
2 Anatomy of the Face and Neck
Fig. 2.6 The retaining
ligaments of the face
Platysma-auricular
ligament
branches are intimately related to ligaments, such as
the zygomatic and mandibular retaining ligaments.
2.6 Mimetic Muscles
The muscles of facial expression are thin, flat muscles
that act either as sphincters of facial orifices, as dila-
tors, or as elevators and depressors of the eyebrows
and mouth. Frontalis, corrugator supercilii, depressor
supercilii, procerus, and orbicularis oculi represent
the periorbital facial muscles. The perioral muscles
include the levator muscles, zygomaticus major and
minor, risorius, orbicularis oris, depressor anguli oris,
depressor labii, and mentalis. The nasal group includes
compressor naris, dilator naris, and depressor septi. In
the neck, the platysma muscle lies superficially and
extends into the lower face (Fig. 2.7).
Frontalis represents the anterior belly of the occipito-
frontalis muscle and is the main elevator of the brows.
It arises from the epicranial aponeurosis and passes
forward over the forehead to insert into fibers of the
orbicularis oculi, corrugators, and dermis over the brows.
35
Orbicularis retaining ligament
Zygomatic ligament
(McGregors patch)
Masseteric ligament
Mandibular ligament
Contraction raises the eyebrows and causes horizontal
furrows over the forehead. Frontalis receives innervation
from the temporal branch of the facial nerve.
Orbicularis oculi acts as a sphincter around the eye.
It consists of three parts, the orbital, preseptal, and pre-
tarsal parts. The orbital part arises from the nasal part of
the frontal bone, the frontal process of the maxilla, and
the anterior part of the medial canthal tendon. Its fibers
pass in concentric loops around the orbit, well beyond
the confines of the orbital rim. Contraction causes the
eyes to squeeze closed forcefully. Superior fibers also
depress the brow. Preseptal orbicularis oculi arises from
the medial canthal tendon, passes over the fibrous
orbital septum of the orbital rim, and inserts into the
lateral palpebral raphe. The pretarsal portion, involved
in blinking, overlies the tarsal plate of the eyelid and
has similar origins and insertions to its preseptal coun-
terpart. These muscles receive innervation from the
temporal and zygomatic branches of the facial nerve.
Corrugator supercilii arises from the superomedial
aspect of the orbital rim and passes upward and out-
ward to insert into the dermis of the middle of the
brow. From its origin deep to frontalis, two slips of
36
Fig. 2.7 The mimetic facial
muscles Frontalis (medial)
Depressor supercilii
Levator labii superioris
alaeque nasi
Zygomatici
Orbicularis oris
Depressor anguli oris
Depressor labii
muscle, one vertical and one transverse, pass through
fibers of frontalis to reach the dermis. The superficial
and deep branches of the supraorbital nerve are inti-
mately related to corrugator supercilii at its origin and
are prone to injury during resection of this muscle.
Corrugator supercilii depresses the brow and pulls it
medially, as in frowning.
Depressor supercilii is a thin slip of muscle that is
difficult to distinguish from the superomedial fibers of
orbicularis oculi. It inserts into the medial brow and
acts as a depressor.
Procerus arises from the nasal bone, passes
superiorly, and inserts into the dermis of the glabella
between the brows. It depresses the lower forehead
skin in the midline to create a horizontal crease at the
bridge of the nose. Chemodenervation of procerus and
corrugator supercilii to alleviate frown lines is one of
the most common aesthetic indications for botulinum
toxins. Procerus is sometimes debulked during endo-
scopic brow lift procedures to reduce the horizontal
frown crease.
Zygomaticus major and minor are superficial mus-
cles that originate from the body of the zygoma and
pass downwards to insert into the corner of the mouth
P.M. Prendergast
Frontalis (lateral)
Procerus
Corrugator
Orbicularis oculi:
Pretarsal part
Preseptal part
Orbital part
Compressor naris
Dilator naris
Depressor septi
Mentalis
Platysma
and lateral aspect of the upper lip, respectively. They
receive their nerve supply on their deep surface from
the zygomatic and buccal branches of the facial nerve.
Zygomaticus major and minor lift the corners of the
mouth.
Levator labii lies deep to orbicularis oculi at its origin
from the maxilla just above the infraorbital foramen. It
passes downward to insert into the upper lip and orbicu-
laris oris. A smaller slip of muscle medial to this, levator
labii superioris alaeque nasi, originates from the frontal
process of the maxilla and inserts into the nasal cartilage
and upper lip. Both of these muscles are supplied from
branches of the zygomatic and buccal branches of the
facial nerve and elevate the upper lip.
Levator anguli oris arises deeply from the canine
fossa of the maxilla below the infraorbital foramen and
inserts into the upper lip. It is innervated on its superfi-
cial aspect by the zygomatic and buccal branches of
the facial nerve and elevates the corner of the mouth.
Risorius is often underdeveloped and arises from a
thickening of the platysma muscle over the lateral
cheek, the parotidomasseteric fascia, or both. It inserts
into the corner of the mouth and pulls the mouth
corners laterally.
2 Anatomy of the Face and Neck
Orbicularis oris acts as a sphincter around the mouth
and its fibers interlace with all of the other facial mus-
cles that act on the mouth. The buccal and marginal
mandibular branches of the facial nerve provide motor
supply to orbicularis oris, which has various actions,
including pursing, dilation, and closure of the lips.
Depressor anguli oris arises from the periosteum of
the mandible along the oblique line lateral to depressor
labii inferioris. Its fibers converge on the modiolus
with fibers of orbicularis oris, risorius, and sometimes
levator anguli oris. It is supplied by the marginal man-
dibular branch of the facial nerve and depresses the
mouth corners on contraction. Depressor labii inferio-
ris arises from the oblique line of the mandible in front
of the mental foramen, where fibers of depressor anguli
oris cover it. It passes upward and medially to insert
into the skin and mucosa of the lower lip and into fibers
of orbicularis oris.
Mentalis arises from the incisive fossa of the man-
dible and descends to insert into the dermis of the chin.
Contraction elevates and protrudes the lower lip and
creates the characteristic peach-pit dimpling of the
skin over the chin. Motor supply arises from the mar-
ginal mandibular nerve.
Nasalis consists of two parts, the transverse part
(compressor naris) and alar part (dilator naris).
Compressor naris arises from the maxilla over the
canine tooth and passes over the dorsum of the nose to
interlace with fibers from the contralateral side. It
compresses the nasal aperture. Dilator naris originates
from the maxilla just below and medial to compressor
naris and inserts into the alar cartilage of the nose. It
dilates the nostrils during respiration. Depressor septi
is a slip of muscle arising from the maxilla above the
central incisor, deep to the mucous membrane of the
upper lip. It inserts into the cartilaginous nasal septum
and pulls the nose tip inferiorly. Nasalis and depressor
septi receive innervation from the superior buccal
branches of the facial nerve.
2.7 Deep Plane Including the Deep
Fat Compartments
The superficial fat compartments described above lie
above the muscles of facial expression in the subcuta-
neous plane. In the midface, the suborbicularis oculi fat
and deep cheek fat represent deeper fat compartments
that provide volume and shape to the face and act as
gliding planes within which the muscles of facial
37
expression can move freely. Suborbicularis oculi fat
(SOOF) has two parts, medial and lateral [11]. The
medial component extends along the inferior orbital
rim from the medial limbus (sclerocorneal junction) to
the lateral canthus and the lateral component from the
lateral canthus to the temporal fat pad. Between the
SOOF and the periosteum of the zygomatic process of
maxilla, there is a gliding space, the prezygomatic
space [12]. This space is bounded superiorly by the
orbicularis retaining ligament and inferiorly by the
zygomatic retaining ligament (Fig. 2.8). The sublevator
fat pad lies medial to the medial SOOF compartment
and represents the most medial of the deep infraorbital
fat pads. This fat pad is an extension of the buccal fat
pad, behind levator labii superioris alaeque nasi and is
continuous below and laterally with the melolabial and
buccal extensions of the buccal fat pad [1]. The buccal
fat pad is an aesthetically important structure that sits
on the posterolateral part of the maxilla superficial
to the buccinator muscle and deep to the anterior part
of masseter. Functionally, it facilitates a free gliding
movement for the surrounding muscles of mastication
[13]. As well as the medial extensions described
above, it continues laterally as the pterygoid extension
(Fig. 2.9). Buccal branches of the facial nerve and the
parotid duct travel along its surface within the parotido-
masseteric fascia after leaving the parotid gland.
The galea fat pad lies deep to frontalis in the fore-
head and extends superiorly for about 3 cm [14]. It
envelops corrugator and procerus and aids gliding of
these muscles during animation. The retro-orbicularis
oculi fat (ROOF) is part of the galea fat pad over the
superolateral orbital rim from the middle of the rim to
beyond the lateral part. It lies deep to the superolateral
fibers of preseptal and orbital orbicularis oculi and
contributes to the fullness (in youth) and heaviness (in
senescence) of the lateral brow and lid.
With aging, the retaining ligaments under the eye
attenuate. This, together with volume loss in the super-
ficial and deep fat compartments, results in visible
folds and grooves in the cheeks and under the eyes
(Fig. 2.10).
The deep cervical fascia covering sternocleidomas-
toid in the neck continues upward to ensheathe the
parotid gland between the mandible and mastoid pro-
cess. The layer of fascia covering the parotid gland and
masseter, termed parotidomasseteric fascia, continues
superiorly to insert into the inferior border of the zygo-
matic arch. In the temporal area, the corresponding
fascia in the same plane is present as deep temporal
38 P.M. Prendergast

Fig. 2.8 The prezygomatic Sub-orbicularis oculi fat (SOOF)

space. This space extends
anteriorly to the infraorbital
area Orbicularis oculi

Prezygomatic space

Zygomatic retaining ligament

Fig. 2.9 The buccal fat pad

and its extensions

Sublevator extension
Buccal fat pad

Pterygoid extension

Parotid duct

Melolabial extension
Facial nerve
Buccal extension

fascia, which inserts into the superior border of the above the zygomatic arch and in the upper face, facial
zygomatic arch. In the lower face, branches of the nerve branches lie superficial to the deep fascia and are
facial nerve lie underneath the deep fascia, whereas susceptible to injury during superficial dissections.
2 Anatomy of the Face and Neck
Tear trough
Preperiosteal fat
Zygomatic retaining
ligament
Nasojugal groove
Nasolabial fold
Fig. 2.10 Frontal and lateral view of attenuated ligaments in the midface
2.8 Neck
Surgical rejuvenation of the neck is frequently
included in an overall plan of facial rejuvenation to
maintain harmony and enhance results. Cosmetic sur-
gical procedures in the neck typically address the
superficial structures: skin, subcutaneous fat, and plat-
ysma. Occasionally, subplatysmal fat and even the
digastric muscles are partially resected to improve
neck contour [15, 16]. The aim of surgery is to
improve or restore the definition of the topographical
landmarks of the neck. These include a sharp mento-
cervical angle, defined mandibular border, and promi-
nent anterior border of sternocleidomastoid.
The neck can be divided into anterior, posterior,
posterior cervical, and sternocleidomastoid regions
(Fig. 2.11). Most cosmetic surgical intervention takes
place in the anterior region or triangle. The contents of
each region are described in Table 2.1.
Just beneath the skin in the anterior cervical triangle
lies the platysma muscle. Platysma is a broad thin sheet
of muscle that arises from the fascia of the muscles of
the chest and shoulders and passes upward over the
clavicles and neck toward the lower face. Along its
39
Orbital septum
Orbicularis retaining ligment
Orbicularis oculi
Sub-orbicularis oculi
fat (SOOF)
Prezygomatic space
course, platysma covers the medial part of sterno-
cleidomastoid, transverse cervical and greater auricu-
lar nerves, cervical and mandibular branches of the
facial nerve, the facial vessels, the submandibular
gland, and inferior part of the parotid [17] (Fig. 2.12).
Fibers insert into the border of the mandible, perioral
muscles, modiolus, and dermis of the cheek. Although
variations exist [18], platysma usually decussates with
fibers from the other side 12 cm below the mandible.
As part of aging, its medial fibers attenuate or thicken
to create platysmal bands. Functionally, platysma
depresses the mandible during deep inspiration but is
probably more important as a mimetic muscle to
express horror or disgust. It is regarded as the inferior
most extension of the SMAS and is innervated by the
cervical branch of the facial nerve.
Between platysma and sternocleidomastoid, there
is a loose connective tissue layer termed the superficial
cervical fascia. This plane allows platysma to glide
easily over sternocleidomastoid and enables effective
minimally invasive suture lifting of platysma [19]. The
free edge of platysma is usually located about 3 cm
below the border of the mandible just anterior to the
anterior border of sternocleidomastoid.
40 P.M. Prendergast

Fig. 2.11 The triangles

of the neck

Submandibular Sternocleidomastoid

Submental
ANTERIOR
Carotid

Muscular
POSTERIOR

Table 2.1 Regions of the neck

Division Subdivision
Anterior triangle Submandibular triangle
Submental triangle
Muscular triangle
Carotid triangle
Sternocleidomastoid
Posterior triangle Supraclavicular triangle
Occipital triangle
Posterior cervical
Contents
Submandibular gland and nodes; facial and submental vessels;
hypoglossal, glossopharygeal, and mylohyoid nn.
Submental nodes and anterior jugular veins
Sternothyroid and sternohyoid muscles, thyroid and parathyroid
glands
Bifurcation of carotid, carotid body, hypoglossal, and vagus nn.
Sternocleidomastoid, carotid sheath with carotid a., internal jugular
v., vagus n., lymph nodes
Part of brachial plexus, subclavian a., superficial cervical and
suprascapular vessels, termination of external jugular v.
Accessory n., trunks of brachial plexus, occipital a., cutaneous
branches of cervical plexus
Vertebral a., cervical plexus, nuchal muscles

The anterior cervical triangle is bounded posteriorly
by the anterior border of sternocleidomastoid, anteriorly
by the median line of the neck, and superiorly by the
inferior border of the mandible. The triangle is further
divided into submandibular, submental, muscular, and
carotid triangles by digastric and omohyoid muscles
(Fig. 2.11). An intermediate tendon, attached to the
greater horn of the hyoid bone, divides the digastric into
posterior and anterior bellies. The posterior belly arises
from the mastoid notch behind the mastoid process of
the temporal bone. It passes anteriorly and inferiorly
below the mandible toward the hyoid bone where it
becomes the digastric tendon. The digastric tendon
passes through the intermediate tendon and arises ante-
riorly as the anterior belly of digastric. The anterior
belly inserts into the digastric fossa on the inferior bor-
der of the mandible near the midline. Digastric muscle
serves to depress and retract the mandible and support
the hyoid bone. It can be felt as a fleshy mass under the
chin when the tongue is retracted.
2 Anatomy of the Face and Neck
Fig. 2.12 Neck region
showing platysma and
underlying structures
Greater auricular n.
Transverse cervical n.
External jugular v.
2.9 Facial Nerve
The facial nerve (seventh cranial nerve) provides motor
innervation to the muscles of facial expression. It
begins in the face by emerging from the stylomastoid
foramen 68 mm medial to the tympanomastoid suture
of the skull. Before entering the substance of the
parotid gland, the posterior auricular nerve and nerves
to the posterior belly of digastric and stylohyoid branch
from the main trunk. Within the parotid gland, the
facial nerve divides into its main branches: temporal
branch, zygomatic branch, buccal branch, marginal
mandibular branch, and cervical branch (Fig. 2.13).
The temporal branch of the facial nerve leaves the
superior border of the parotid gland as three or four
rami. They cross the zygomatic arch between 0.8 and
3.5 cm anterior to the external acoustic meatus, and
usually about 2.5 cm anterior to it. At the level of the
zygomatic arch, the most anterior branch is always at
least 2 cm posterior to the lateral orbital rim. The tem-
poral branches pass in an envelope of superficial tem-
poral fascia with the intermediate fat pad, superficial to
the deep temporal fascia. The temporal branch enters
frontalis about 2 cm above the brow, just below the
anterior branch of the superficial temporal artery.
There are up to three zygomatic branches of the
facial nerve. The upper branch passes above the eye to
supply frontalis and orbicularis oculi. The lower branch
always passes under the origin of zygomaticus major
and supplies this muscle, other lip elevators, and the
41
Platysma
lower orbicularis oculi. Smaller branches continue
around the medial aspect of the eye to supply depres-
sor supercilii and the superomedial orbicularis oculi.
The buccal branch exits the parotid and is tightly
bound to the anterior surface of masseter within the
parotidomasseteric fascia. It continues anteriorly over
the buccal fat pad, below and parallel to the parotid
duct, to supply the buccinators and muscles of the
upper lip and nose. A second branch is occasionally
present, but this travels superior to the parotid duct in
its course anteriorly.
The marginal mandibular nerve exits the lower part
of the parotid gland as one to three major branches. It
usually runs above the inferior border of the mandible,
but may drop up to 4 cm below it. About 2 cm poste-
rior to the angle of the mouth, the nerve passes upward
and more superficially to innervate the lip depressors.
Although it remains deep to the platysma, it is vulner-
able to injury during surgical procedures in the lower
face at this location.
The cervical branch of the facial nerve passes into
the neck at the level of the hyoid bone to innervate the
platysma muscle.
2.10 Sensory Nerves
The sensory innervation of the face is via the three
divisions of the trigeminal nerve (fifth cranial nerve):
ophthalmic nerve, maxillary nerve, and mandibular
42
Fig. 2.13 Branches of the
facial nerve. Note: The greater
auricular, zygomaticotemporal,
infraorbital, and mental nerves
are sensory nerves
Posterior auricular
Greater auricular nv.
External jugularv.
nerve. The ophthalmic nerve supplies the forehead,
upper eyelid, and dorsum of the nose via the supraor-
bital, supratrochlear, infratrochlear, lacrimal, and
external nasal nerves. The maxillary nerve supplies
the lower eyelid, cheek, upper lip, ala of the nose, and
part of the temple through the infraorbital, zygomati-
cofacial, and zygomaticotemporal nerves. The maxil-
lary nerve also supplies the maxillary teeth and nasal
cavity via the alveolar nerves and pterygopalatine
nerves, respectively. The mandibular nerve has motor
and sensory fibers. Its branches include the inferior
alveolar nerve, lingual nerve, buccal nerve, and auric-
ulotemporal nerve. These supply the skin over the
mandible, lower cheek, part of the temple and ear, the
lower teeth, gingival mucosa, and the lower lip
(Fig. 2.14). The greater auricular nerve, derived from
the anterior primary rami of the second and third
cervical nerves, supplies the skin over the angle of the
mandible.
The supraorbital nerve emerges from the orbit at the
supraorbital notch (or foramen) 2.32.7 cm from the
midline in men and 2.22.5 cm from the midline in
women [20]. It has superficial and deep branches that
straddle the corrugator muscle. Sometimes, these
branches exit from separate foramina, the deep branch
arising lateral to the superficial one. The deep branch
usually runs superiorly between the galea and the
P.M. Prendergast
Zygomaticotemporal
Infraorbital
Temporal br.
Zygomatic br.
Buccal br.
Mental
Marginal mandibular br.
Cervical br.
periosteum of the forehead 0.51.5 cm medial to the
superior temporal crest line.
The supratrochlear nerve exits the orbit about 1 cm
media to the supraorbital nerve and runs close to the
periosteum under the corrugator and frontalis. Its sev-
eral branches supply the skin over the medial eyelid and
lower medial forehead. The infratrochlear nerve is a ter-
minal branch of the nasociliary nerve that supplies a
small area on the medial aspect of the upper eyelid and
bridge of the nose. The external nasal nerve supplies
the skin of the nose below the nasal bone, except for the
skin over the external nares. The lacrimal nerve supplies
the skin over the lateral part of the upper eyelid.
The infraorbital nerve is the largest cutaneous
branch of the maxillary nerve. It enters the face through
the infraorbital foramen 2.73 cm from the midline in
men and 2.42.7 cm from the midline in women, about
7 and 6 mm inferior to the inferior orbital rim in men
and women, respectively. The nerve appears from
the foramen just below the origin of levator labii supe-
rioris. It supplies the lower eyelid, ala of the nose,
and upper lip. The zygomaticofacial nerve arises from
the zygomaticofacial foramen below and lateral to the
orbital rim and supplies skin of the malar eminence. The
zygomaticotemporal nerve emerges from its foramen
on the deep surface of the zygomatic bone and supplies
the anterior temple.
2 Anatomy of the Face and Neck 43

Fig. 2.14 Sensory innervation of the face

SO
SI
GO

LO

L
ZT
CZ IT

AT
EN
ZF IO

GA B

C2/C3 M

Green = ophthalmic nerve (V1) Red and Blue = Cervical nerves (C2/C3)
Supraorbital nerve (SO) Greater occipital nerve (GO)
Supratrochlear nerve (ST) Lesser occipital nerve (LO)
Infratrochlear nerve (IT) Greater auricular nerve (GA)
External nasal nerve (EN)
Latrimal nerve (L)
Oronge = Maxillary nerve (V2)
Zygomaticotemporal nerve (ZT)
Zygomaticofacial nerve (ZF)
Infraorbital nerve (IO)
Purple = Mandibular nerve (V3)
Auriculotemporal nerve (AT)
Buccal nerve (B)
Mental Nerve (M)

The mental nerve is a branch of the inferior alveolar
nerve that exits the mental foramen in line vertically with
the infraorbital foramen, between the apices of the pre-
molar teeth. It is often visible and easily palpable through
stretched oral mucosa. It supplies the skin over the lower
lip and mandible. The buccal branch of the mandibular
nerve supplies the buccal mucosa and skin of the cheek,
and the lingual nerve provides sensory innervation to the
anterior two-thirds of the tongue and the floor of the
mouth. The auriculotemporal nerve emerges from behind
the temporomandibular joint to supply the skin of the
upper one-third of the ear, the external acoustic meatus,
tympanic membrane, as well as the skin over the tempo-
ral region. Secretomotor fibers also pass via the auricu-
lotemporal nerve to the parotid gland.
2.11 Arteries of the Face
The skin and soft tissue of the face receive their arterial
supply from branches of the facial, maxillary, and
superficial temporal arteries all branches of the
44
Fig. 2.15 Arterial supply
to the face
Middle temporal
Superficial
temporal
Transverse facial
Intemal maxillary
External carotid
external carotid artery. The exception is a mask-like
area, including the central forehead, eyelids, and upper
part of the nose, which are supplied through the internal
carotid system by the ophthalmic arteries (Fig. 2.15).
The facial artery arises from the external carotid
and loops around the inferior and anterior borders of
the mandible, just anterior to the masseter. It pierces
the masseteric fascia and ascends upward and medially
toward the eye. It lies deep to the zygomaticus and
risorius muscles but superficial to buccinator and leva-
tor anguli oris [21]. At the level of the mouth, the facial
artery sends two labial arteries, inferior and superior,
into the lips where they pass below orbicularis oris.
The continuation of the facial artery near the medial
canthus beside the nose is the angular artery.
The maxillary artery is a terminal branch of the
external carotid with three main branches, mental, buc-
cal, and infraorbital arteries. The mental artery is the
terminal branch of the inferior alveolar artery that
passes through the mental foramen to supply the chin
and lower lip. The buccal artery crosses the buccina-
tors to supply the cheek tissue. The infraorbital artery
reaches the face through the infraorbital foramen and
supplies the lower eyelid, cheek, and lateral nose. It
anastomoses with branches of the transverse facial,
ophthalmic, buccal, and facial arteries.
The superficial temporal artery is the terminal
branch of the external carotid artery. In the substance
P.M. Prendergast
Internal carolid
Ophthalmic
Lacrimal
Supraorbital
Supratrochlear
Infratrochlear
Infraorbital
Angular
Superior labial
Inferior labial
Facial
of the parotid, just before reaching the zygomatic arch,
it gives off the transverse facial artery which runs
inferior and parallel to the arch and supplies the parotid,
parotid duct, masseter, and skin of the lateral canthus.
The superficial temporal artery crosses the zygomatic
arch superficially within the superficial temporal fas-
cia. Above the arch, it gives off a middle temporal
artery that pierces the deep temporal fascia and sup-
plies the temporalis muscle. Thereafter, about 2 cm
above the zygomatic arch, the superficial temporal
artery divides into anterior and posterior branches. The
anterior branch supplies the forehead and forms anas-
tomoses with the supraorbital and supratrochlear ves-
sels. The posterior part supplies the parietal scalp and
periosteum.
The ophthalmic artery is a branch of the inter-
nal carotid system (Fig. 2.15). Its branches include
the lacrimal, supraorbital, supratrochlear, infratro-
chlear, and external nasal arteries. There is significant
communication between the external and internal
carotid artery systems around the eye through several
anastomoses. Inadvertent intra-arterial injection of
fillers for soft tissue augmentation around the eye
can lead to occlusion of the central retinal vessels
and potentially blindness [2224]. To avoid this com-
plication, fillers should be injected in small volumes
using blunt cannulas and a careful retrograde injection
technique [25].
2 Anatomy of the Face and Neck 45

References 13. Larrabee WF, Makielski KH, Henderson JL (2004) Cheeks

and neck. In: Larrabee WF, Makielski KH, Henderson JL
(eds) Surgical anatomy of the face. Lippincott Williams &
1. Gassner HG, Rafii A, Young A, Murakami C, Moe K,
Wilkins, Philadelphia, p 178
Larrabee WF (2008) Surgical anatomy of the face.
14. Zide BM (2006) ROOF and beyond (superolateral zone).
Implications for modern face-lift techniques. Arch Facial
In: Zide BM, Jelks GW (eds) Surgical anatomy around the
Plast Surg 10(1):919
orbit. The system of zones. Lippincott Williams & Wilkins,
2. Rohrich RJ, Pessa JE (2007) The fat compartments of the
Philadelphia, p 57
face: anatomy and clinical implications for cosmetic sur-
15. Rohrich RJ, Pessa JE (2010) The subplatysmal supramy-
gery. Plast Reconstr Surg 119(7):22192227
lohyoid fat. Plast Reconstr Surg 126(2):589595
3. Furnas DW (1989) The retaining ligaments of the cheek.
16. Connell BF, Shamoun JM (1997) The significance of digas-
Plast Reconstr Surg 83(1):1116
tric muscle contouring for rejuvenation of the submental
4. Stuzin JM, Baker TJ, Gordon HL (1992) The relationship of
area of the face. Plast Reconstr Surg 99(6):15861590
the superficial and deep facial fascias: relevance to rhytidec-
17. De Castro CC (2000) The changing role of platysma in face
tomy and aging. Plast Reconstr Surg 89(3):441449
lifting. Plast Reconstr Surg 105(2):764775
5. Mitz V, Peyronie M (1976) The superficial musculo-aponeurotic
18. De Castro CC (1980) The anatomy of the platysma muscle.
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Plast Reconstr Surg 66(5):680683
58(1):8088
19. Labbe D, Franco RG, Nicolas J (2006) Platysma suspen-
6. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza-Katzer H,
sion and platysmaplasty during neck lift. Anatomical study
Fritsch H (2003) Does a superficial musculoaponeurotic
and analysis of 30 cases. Plast Reconstr Surg 117(6):
system exist in the face and neck? An anatomical study by
20012007
the tissue plastination technique. Plast Reconstr Surg
20. Zide BM (2006) Supraorbital nerve. Nuances/dissections
111(2):664672
from above. In: Zide BM, Jelks GW (eds) Surgical anatomy
7. Ghassemi A, Prescher A, Riediger D, Axer H (2003)
around the orbit. The system of zones. Lippincott Williams
Anatomy of the SMAS revisited. Aesthetic Plast Surg
& Wilkins, Philadelphia, p 77
27(4):258264
21. Berkovitz BKB, Moxham BJ (2002). Head and neck anat-
8. Wobig JL, Dailey RA (2004) Facial anatomy. In: Wobig JL,
omy. a clinical reference, Martin Dunitz, London, p 118
Dailey RA (eds) Oculofacial plastic surgery. Thieme, New
22. Silva MT, Curi AL (2004) Blindness and total ophthal-
York, p 5
moplegia after aesthetic polymethylmethacrylate injection:
9. Jones BM, Grover R (2008) Anatomical considerations. In:
case report. Arg Neuropsiquiatr 62(3B):873874
Jones BM, Grover R (eds) Facial rejuvenation surgery.
23. McCleve D, Goldstein JC (1995) Blindness secondary to
Mosby Press, London, pp 1822
injections in the nose, mouth, and face: cause and preven-
10. Mendelson BC, Freeman ME, Wu W, Huggins RJ (2008)
tion. Ear Nose Throat J 74:182188
Surgical anatomy of the lower face: the premasseter space,
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the jowl, and the labiomandibular fold. Aesthetic Plast Surg
after autologous fat injection into the glabellar area. Am J
32(2):185195
Ophthalmol 107:8587
11. Rohrich R, Arbique GM, Wong C, Brown S, Pessa JE (2009)
25. Coleman SR (2002) Avoidance of arterial occlusion
The anatomy of suborbicularis fat: implications for perior-
from injection of soft tissue fillers. Aesthet Surg J 22(6):
bital rejuvenation. Plast Reconstr Surg 124(3):946951
555557
12. Mendelson BC, Muzaffar AR, Adams WP (2002) Surgical
anatomy of the midcheek and malar mounds. Plast Reconstr
Surg 110(3):885896
 Anatomy of the Breast
Peter M. Prendergast
3.1 Introduction
The adult female breast represents a modified sudo-
riferous milk-producing gland of varying size and
shape. In addition to its role in lactation, the breast is
an important feature of the development of secondary
sexual characteristics and is frequently modified sur-
gically in order to enhance volume, shape, and posi-
tion. It consists of skin and subcutaneous fat overlying
superficial fascia that splits to envelop deeper adipose
tissue, glandular tissue, and stroma. The breast is sus-
pended and supported by fibrous tissue bands and
ligaments that determine the position and shape on
the chest wall. It has a rich sensory innervation and
vascular supply and an extensive network of lymphat-
ics that drain into several well-defined nodal groups
medially and laterally. In cosmetic surgery, various
incisions and approaches to the breast are made to
manipulate the breast tissue or its supporting fascial
systems, insert prostheses, resect tissue, or fashion
more aesthetic positions and volumes. Injudicious
incisions or dissections in and around the breast
can result in poor aesthetic outcomes or, worse, com-
plications such as sensory loss or hematoma. By
studying and respecting the anatomy of the breast,
P.M. Prendergast
Venus Medical, Dublin, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_3, Springer-Verlag Berlin Heidelberg 2013
3
the incidence of such undesirable outcomes can be
reduced or eliminated.
3.2 Surface Anatomy
The breast occupies the anterior chest from the second
or third rib superiorly to the sixth rib inferiorly and
from the sternal edge medially to the midaxillary line
laterally (Fig. 3.1). The breast varies in shape and size
depending on age, parity, body mass index, genetics,
and race. They can be hemispherical, conical, teardrop-
shaped, pendulous, or flattened. On profile, the aes-
thetically ideal breast appears as a teardrop-shaped
protuberance projecting at variable angles from the
chest wall. Its ventral surface forms a line that is almost
straight from the second rib to the nipple, while the
lower part from the nipple to the inframammary crease
is rounded (Fig. 3.2). In the non-pendulous breast, the
nipple is located over the fourth intercostal space.
Around the base of the nipple lies the areola, a circular
area or skin containing numerous sebaceous glands
and accessory glands that appear externally as small
bumps or whitish nodules. There are numerous mel-
anocytes in the epidermis of the nipple and areola,
which appear pink or brown, depending on skin type.
The inframammary crease represents the inferior
border of the base of the breast and is an important
aesthetic landmark. The crease usually lies over the
fifth rib medially with its lowest point at the sixth inter-
costal space [1]. The distance from the inferior margin
of the areola to the inframammary crease ranges from
5 to 9 cm.
47
48 P.M. Prendergast

Deep pectoral fascia

Breast glandular tissue

Breast adipose tissue

Pectoralis major
Breast

Nipple

Areola

Fig. 3.1 Overview of breast anatomy

3.3 Fasciae and Ligaments

of the Breast

The superficial fascia divides to form an envelope for

the breast. Between the two layers of superficial fascia,
there are fine cords of connective tissue, termed as
Coopers ligaments. These pass through the paren-
chyma of the breast and provide architectural support,
preventing ptosis and laxity in the young adult breast.
Coopers ligaments stretch or attenuate during preg-
nancy, lactation, or in senescence, causing the breasts
to eventually droop and flatten.
The breast lies on the deep pectoral fascia. This is a
tough layer that is attached superiorly to the clavicle
and sternum and is continuous inferiorly with the
fascia covering the serratus anterior, rectus abdominis,
and external oblique muscles. Deep to pectoralis major
lies pectoralis minor, enveloped in a clavipectoral fas-
cia that extends laterally to fuse with the axillary fascia
Fig. 3.2 Breast contours on side profile
and superiorly to attach to subclavius and the clavicle.
3 Anatomy of the Breast
Fig. 3.3 Breast anatomy
showing transverse horizontal
septum
Between the deep layer of superficial fascia and the
deep pectoral fascia is a potential space, the retromam-
mary space, over which the mammary gland glides.
Wringer [2] describes a ligamentous structure that
suspends the breast and transmits vessels and nerves to
the nipple. This transverse horizontal septum originates
at the inferior border of the deep pectoral fascia at the
level of the fifth rib and travels through the breast tissue
to the skin and nipple (Fig. 3.3). Medially and laterally
it continues along the border of pectoralis major as the
49
Skin
Subcutaneous fat
Superficial pectoral fascia envelope
Breast tissue
Retromammary space
Deep pectoral fascia
Pectoralis major
Intercostal arteries
Transverse horizontal septum
Inframammary crease ligament
Inframammary crease
deep medial and lateral ligaments respectively.
The medial ligament attaches to the sternum, while the
lateral ligament attaches to the axillary fascia at the
midaxillary line (Fig. 3.4). From the origin of the trans-
verse septum at the pectoral fascia, another fascial
thickening passes to the dermis at the inferior border of
the breast. The tethering effect on the dermis of this
ligament along its length forms the inframammary
crease. The anatomy and even the existence of this so-
called inframammary ligament here are debated [3, 4].
50
Fig. 3.4 Supporting
ligaments of the breast
Deep cranial ligament
Deep lateral ligament
3.4 Breast Tissue
Within the envelope of the superficial fascia lie
epithelial parenchymal tissue, stroma, and adipose
tissue. The epithelial parenchymal component com-
prises about 1015% of the breast tissue, and the
remainder is stromal tissue and fat [5]. Variations in
breast size are due predominantly to a difference in
the amount of adipose rather than glandular tissue.
The glandular architecture of the breast consists of
1520 lobes arranged radially deep to the nipple
within the supporting stroma and fat. Each lobe con-
sists of several smaller lobules that drain into a single
lactiferous duct. The lobules contain several blind-
ending alveoli or acini that are potentially milk-
secreting. The lactiferous ducts, one per lobe, open
onto the nipple and function as a conduit for milk
during lactation (Fig. 3.5).
The stroma of the breast consists of loose connec-
tive tissue that surrounds and supports the ducts and
lobules. Within the stroma and between the lobes, a
varying amount of adipose tissue contributes to the
volume of the breasts. Although the breast is fairly
well-circumscribed, a distinct slip of glandular tissue
projects from the upper outer quadrant toward the
axilla deep to the pectoral fascia as the tail of Spence.
Occasionally, normal glandular tissue can be found
P.M. Prendergast
Deep medial ligament
Horizontal fibrous
septum
piercing the pectoral fascia or in the fascia of the infra-
mammary ligament and crease.
3.5 Blood Supply
The breast receives its blood supply from branches
of the axillary, internal thoracic arteries, and inter-
costal arteries (Fig. 3.6). The superior thoracic and
pectoral branches of the thoracoacromial artery arise
from the first and second part of the axillary artery
respectively and pass medially between the pectora-
lis muscles to supply them and the breast. They
anastomose with the internal thoracic and upper
intercostal arteries. The lateral thoracic artery arises
from the axillary artery and gives lateral mammary
branches that course around the lateral border of
pectoralis major to supply the breast. Branches from
the subscapular artery, the largest branch of the axil-
lary artery, pass to the thoracic wall and breast and
anastomose with the lateral thoracic and intercostal
arteries. Perforating branches of the internal tho-
racic artery provide the majority of blood to the
breast. They traverse the first five or six intercostal
spaces, enter pectoralis major, and course laterally
to supply the breasts and skin. The first and second
branches are usually the largest vessels supplying
3 Anatomy of the Breast
Lobes
Fig. 3.5 Architecture of breast glandular tissue
the breasts. The anterior intercostal arteries arise
from the internal thoracic artery in the upper six
intercostal spaces and pass laterally, first between
the pleura and internal intercostals, then between
the intercostales intimi and internal intercostals [6].
Perforating branches from the second, third, and
fourth intercostal arteries pass through the pectoral
muscles to supply the breast and skin.
Variations in blood supply to the breasts exist.
In 18% of individuals, arterial supply is from all three
of the above sources. In 30%, the axillary artery supplies
little or no blood to the breast, and in 50%, there is little
or no contribution from the intercostal arteries [7].
Venous drainage of the breast corresponds to the
arteries, with most drainage to the axillary, internal
51
Lobules
Lactiferous duct
Lactiferous
Acini sinus
thoracic, and second to fourth intercostal veins. The
medial breast drains into the internal thoracic vein, lat-
eral breast to tributaries of the axillary vein and to the
intercostal veins. The intercostals in turn drain into the
vertebral veins, azygous, and hemiazygous systems.
3.6 Innervation
The breast is innervated by sensory and sympathetic
efferent fibers from the anterior and lateral cutaneous
branches of the second to sixth intercostal nerves
(Fig. 3.7). The anterior and lateral branches contribute
equally to the innervation of the breast. The fourth
intercostal nerve supplies the nipple and areola with
52 P.M. Prendergast

Subclavian a.
Axillary a. Thoracoacromial a.
Superior thoracic a.
Lateral thoracic a.
Internal thoracica.

Perforating branches
Lateral mammary
branches of
posterior intercostal a.
Pectoral branches of
thoracoacromial a.

Lateral mammary branches

Medial mammary branches

Fig. 3.6 Arterial supply of the breast

Supraclavicular nn.

Anterior cutaneous branches of

intercostal nn.

Lateral cutaneous branches

of intercostal nn.

Fig. 3.7 Sensory innervation of the breast

3 Anatomy of the Breast
Fig. 3.8 Muscles and nerves
around the breast
Thoracoacromial a.
Median n.
Axillarya a.
Medial brachial
cutaneous n
Intercostobrachial n.
Long thoracic n.
Thoracodorsal n.
additional cutaneous branches from the third to fifth
nerves [8]. Skin incisions or traction on these sensory
nerves during surgery may lead to transient dysaesthe-
sias or sensory loss [9].
Beneath the breast, pectoralis major is supplied on
its deep surface by the lateral pectoral nerve. This
nerve is derived from the ventral rami of the fifth to
seventh cervical nerves. It sends a ramus to the medial
pectoral nerve in front of the axillary artery, to supply
fibers of pectoralis minor, before piercing the clavipec-
toral fascia to arrive at pectoralis major. The medial
pectoral nerve is derived from the eighth cervical and
first thoracic nerves. It creates a loop with the lateral
pectoral nerve and sends branches to the pectoralis
minor and major (Fig. 3.8).
Around the breast, the thoracodorsal nerve passes
inferomedially from the posterior cord of the brachial
plexus on the ventral surface of the subscapularis mus-
cle to innervate the latissimus dorsi muscle. The long
thoracic nerve arises from the fifth to seventh cervical
nerves and innervates the serratus anterior. It is found
posterior to the axillary vein at the level of the second
rib. The intercostobrachial nerve represents a lateral
cutaneous branch of the second or third intercostal
nerves and supplies skin of the inner upper arm.
3.7 Lymphatic Drainage
The lymphatic drainage of the breast has important
implications in breast cancer and its spread. The
axilla and the internal mammary nodes are the two
53
Pectoralis major
Pectoralis minor
Lateral pectoral n.
Medial pectoral n.
main sites for lymphatic drainage of the breast; at
least three quarters of drainage is to the axillary
nodes (Fig. 3.9). A plexus of lymphatic channels
below the nipple, the subareolar plexus of Sappey,
drains to nodes in the axilla, internal mammary
nodes, and to the contralateral breast. Lymphatics
from the medial breast follow the perforating vessels
toward the sternal edge. They pass through pectora-
lis major and the intercostal muscles to the internal
mammary nodes. Most of the internal mammary
nodes are found in the first three intercostal spaces
[10]. Skin from the anterior abdominal wall drains to
lymphatics along the superior epigastric vessels that
empty into the internal mammary nodes. From the
internal mammary nodes, drainage is to mediastinal
nodes, paraaortic nodes, bronchomediastinal trunks,
and the right thoracic duct. The axillary nodes, which
drain most of the breast, have been identified, named,
and classified as level I, level II, and level III nodes,
depending on their relationship to pectoralis minor
as follows (Fig. 3.10).
Level I nodes are those found below pectoralis
minor. These include external mammary nodes, the
large axillary group of nodes, and scapular nodes that
lie on the subscapular vessels. Level II nodes lie behind
pectoralis minor and include central nodes and some
subclavian nodes. The central nodes are found in the
fatty tissue of the axilla and are easily palpable when
enlarged. Level III nodes lie between the upper border
of pectoralis minor and lower border of the clavicle.
They comprise the subclavicular nodes on the axillary
vein and medial to the axillary vein nodes. One or two
54 P.M. Prendergast

Right subclavian lymphatic trunk Right lymphatic duct

Subclavicular nodes Right bronchomediastinal

lymphatic trunk
Apical nodes
Right brachiocephalic
vein
Central nodes

Humeral nodes
Interpectoral (Rotters) nodes

Parasternal nodes

Pectoral nodes

Subscapular nodes

Subareolar lymphatic plexus

Fig. 3.9 Lymphatic drainage of the breast

Level III
Level II

Level I

Parasternal
nodes

Fig. 3.10 Classification of

axillary nodes draining the
breast
3 Anatomy of the Breast
additional nodes (Rotters nodes) can be found between
pectoralis major and minor.
References
1. Bayati S, Seckel BR (1995) Inframammary crease ligament.
Plast Reconstr Surg 95(3):501508
2. Wringer E, Mader N, Posch E, Holle J (1998) Nerve and
vessel supplying ligamentous suspension of the mammary
gland. Plast Reconstr Surg 101(6):14861493
3. Nava M, Quattrone P, Riggio E (1998) Focus on the breast
fascial system: a new approach for the inframammary fold
reconstruction. Plast Reconstr Surg 102(4):10344105
4. Garnier D, Angonin R, Foulon R, Chavoin JP, Ricbourg B,
Costagliola M (1991) Le sillon sous-mammaire: mythe ou
realite? Ann Chir Plast Esthet 36(4):31319
55
5. Morrow M, Khan S (2005) Breast disease. In: Mulholland
MW, Lillemore KD, Doherty GM, Maier RV, Upchurch GR
(eds) Greenfields Surgery: scientific principles and practice,
4th edn. Lippincott Williams & Wilkins, Philadelphia, p 1251
6. Williams PL (1995) Grays Anatomy: the anatomical basis
of medicine and surgery, 38th edn. Edinburgh, Churchill
Livingstone, p 1534
7. Skandalakis JE (2009) Embryology and anatomy of the
breast. In: Shiffman MA (ed) Breast augmentation: principles
and practice. Springer, Berlin, p 12
8. Jaspars JJ, Posma AN, Van Immerseel AA, Gittenberger-de
Groot AC (1997) The cutaneous innervation of the female
breast and nipple-areola complex: implications for surgery.
Br J Plast Surg 50(4):24959
9. Bengston BP (2009) Sensory nerves in the lower pole of the
breast encountered in breast (augmentation) surgery. Plast
Reconstr Surg 123(1):32e33e
10. Sacre R (1989) Modern thoughts on lymph nodes in breast
cancer. Semin Surg Oncol 5(2):11825
 Anatomy of the Anterior
Abdominal Wall
Peter M. Prendergast
4.1 Introduction
Surgical procedures aimed at improving the appearance
of the abdomen typically remove fat through suction,
resect skin and soft tissue, plicate the myofascial
abdominal wall, or combine these procedures [1].
A sound knowledge of the layered anatomy and neuro-
vascular structures of the anterolateral abdominal wall
is a prerequisite for successful body contouring in this
region, and it helps reduce complications through judi-
cious placement of incisions and appropriate dissection
and undermining without compromising the vascular
supply. The bony and soft tissue landmarks of the
abdominal wall should be identified and marked prior
to liposculpture or abdominoplasty to visualize ideal
aesthetic contours and optimize placement and symme-
try of incisions. This chapter describes the surface anat-
omy, myofascial layers, important vessels, nerves, and
lymphatics of the anterolateral abdominal wall.
4.2 Surface Anatomy
For descriptive purposes, two vertical and two hori-
zontal imaginary lines divide the anterior abdominal
wall into nine segments (Fig. 4.1). The subcostal line
and interspinous line pass horizontally between the
costal margins and anterior superior iliac spines,
respectively. Vertically, a left and right midclavicular
line form the nine segments with the horizontal planes
P.M. Prendergast
Venus Medical, Dublin, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_4, Springer-Verlag Berlin Heidelberg 2013
4
as follows: epigastrium, left and right hypochondrium,
umbilical, left and right lumbar, hypogastrium, and left
and right iliac. Although they are commonly used to
describe clinical scenario, referred pain, and patho-
logical processes in the intra-abdominal cavity, these
anatomical zones are also useful in cosmetic surgery
when describing body contour, scars and incisions,
extent of dissection or lipoplasty, hernias, and compli-
cations such as skin necrosis and postlipoplasty con-
tour irregularities.
In slim, athletic individuals, surface markings on
the anterolateral abdominal wall are easily identifiable
(Fig. 4.2). The abdominal wall is bounded superiorly
by the xyphoid process and costal margins and inferi-
orly by the pubic crest, inguinal ligaments, and iliac
crest. In the left and right hypochondria, fibers of ser-
ratus anterior interdigitate with the external oblique
muscles. The lateral borders of rectus abdominis are
visible as the linea semilunaris, a curved depression
running vertically from the costal margin near the ninth
costal cartilage to the pubic tubercle on either side. In
the midline, a narrow vertical skin groove from the
xyphoid process to the umbilicus represents the fibrous
linea alba that runs the full length of the abdominal
wall from the xyphoid process to the pubic symphysis
[2]. Further horizontal tendinous intersections in the
rectus abdominis create the appearance of protrusions
or bulges when the muscle is well developed and over-
lying subcutaneous fat is minimal. The umbilicus is an
aesthetically important landmark that represents the
scar following ligation of the umbilical cord where it
entered the fetus. Normally, it lies near the midline on
the anterior abdominal wall at the level of the fourth
intervertebral disc [3]. In cosmetic surgery, it presents
a novel approach site for body contouring or skin
57
58 P.M. Prendergast

Fig. 4.1 Divisions of the

anterior abdomen. MC
midclavicular, SC subcostal,
IS interspinous

xiphoid

serratus anterior
linea alba

linea semilunaris umbilicus

tendinous anterior superior

intersection iliac spine

external oblique
inguinal crease

Fig. 4.2 Surface markings of the abdominal wall

4 Anatomy of the Anterior Abdominal Wall
excision and itself is frequently reconstructed to
improve the appearance of the abdomen, particularly
following abdominoplasty where scarring may result
in contracture or stenosis [4]. The inferior extent of the
anterolateral abdominal wall is visible as the inguinal
groove, a depression below and parallel to the inguinal
ligament that runs from the anterior superior iliac spine
to the pubic tubercle. Below this is the upper limit of
the anterior thigh.
4.3 Skin
The skin of the anterolateral abdominal wall is loosely
attached to the underlying superficial fascia and fat. In
nulliparous individuals with normal body mass indices,
collagen and elastin fibers in the dermis allow smooth
and even draping of the skin over the contours of the
abdomen. Langers lines are present as visible cleavage
lines that run parallel to the horizontally and anteroin-
feriorly arranged collagen fibers in the skin. Incisions
in the anterolateral abdominal wall should be made par-
allel to these lines to ensure optimum apposition of
wound edges and avoid retraction and gaping of the
incision. Transverse or anteroinferior incisions also
respect the course of the nerves and vessels of the
abdominal wall, which run parallel to the cleavage
lines. Extensive stretching of abdominal skin following
pregnancy or in obese individuals disrupts dermal con-
nective tissue fibers, leading to stretch marks or striae
perpendicular to Langers lines. Immature striae appear
as prominent red or purplish lines, usually running ver-
tically in the lower abdominal skin, whereas mature
striae are less vascular and appear silvery or white.
Although difficult to treat, nonsurgical modalities such
as intense pulsed light, vascular lasers, skin resurfac-
ing, and collagen stimulation procedures may improve
the appearance of immature and mature striae. Skin
excision during abdominoplasty is more definitive.
4.4 Fascia
4.4.1 Supercial Fascia
The subcutaneous tissue of the upper and lower
abdominal wall is occupied by a fatty layer of superfi-
cial fascia known as Campers fascia (Fig. 4.3). This
59
layer varies in thickness depending on body habitus
and is amenable to reduction or partial excision during
lipoplasty and abdominoplasty, respectively. In the
upper abdomen, Campers fascia tends to be more
fibrous compared to the lower, softer fat of the lower
abdomen. This can easily be felt during suction or
ultrasound-assisted lipoplasty. A second, deeper layer
of superficial fascia exists in the lower abdominal wall
as Scarpas fascia. This layer is thin and membranous
and is loosely adherent to the underlying deep fascia
above the muscles, except in the midline where it
firmly attaches to the linea alba. Superiorly and later-
ally, it becomes thinner and is continuous with the
superficial fascia of the thorax and back. Inferiorly,
Scarpas fascia forms a sheath for the penis or clitoris
that is continuous with the deep fascia of the genitalia.
Campers fascia continues toward the scrotum in males
to become the dartos muscle, containing smooth mus-
cle fibers. In the perineum, Scarpas fascia is a tough
fibrous layer that inserts into the pubic arch as Colles
fascia [5]. Below the inguinal ligament, it is continu-
ous with the fascia lata of the upper and lateral thigh.
4.4.2 Deep Fascia
Deep to Scarpas fascia, a thin layer of deep fascia lies
closely adherent to the flat muscles of the abdominal
wall and their aponeuroses. This layer is continuous
inferiorly with the suspensory ligament of the penis
and the deep fascia of the genitalia.
4.4.3 Transversalis Fascia
This thin connective tissue layer lies between the inner-
most muscle of the abdominal wall and the extraperito-
neal fatty layer. It is continuous superiorly with the
connective tissue lining of the diaphragm and inferiorly
with the iliac and pelvic fascia. The spermatic cord (or
round ligament of the uterus) passes through the trans-
versalis fascia at the deep inguinal ring. The deep ring
is located at the midpoint between the anterior superior
iliac spine and the pubic symphysis about 1.25 cm
above the inguinal ligament (Fig. 4.4). The ring is
bordered superiorly by arching fibers of transversus
abdominis, medially by the inferior epigastric vessels,
and laterally by fibers of internal oblique.
60 P.M. Prendergast

skin

Campers fascia

external oblique

Internal oblique

transversus abdominis

transversalis fascia

extraperitoneal fat

peritoneum

Fig. 4.3 Layers of the anterolateral abdominal wall. Campers fascia lies superficially and contains variable amounts of subcutaneous
fat. In the lower abdomen, Scarpass fascia exists as a second deeper layer that is adherent to the fascia overlying the muscle

rectus abdominis

transversus abdominis

internal oblique

external oblique

arcuate line

anterior superior iliac spine

inguinal ligament

aponeurosis of external oblique

femoral nerve

deep inguinal ring

Fig. 4.4 Inguinal region and

muscles of the lower intercrural fibers
abdominal wall. The arcuate
line is seen below the level of
femoral a & v
the umbilicus where the
aponeuroses of the flat
muscles pass anterior to superficial inguinal ring
rectus abdominis spermatic cord
4 Anatomy of the Anterior Abdominal Wall
Fig. 4.5 Muscles of the
anterolateral abdominal wall
external
oblique m.
internal
oblique m.
4.5 Muscles
The muscles and aponeuroses of the anterolateral
abdominal wall form a strong, flexible structure that pro-
tect the abdominal viscera, facilitate movement of the
trunk, and work synergistically with the diaphragm dur-
ing respiration, micturition, and defecation (Fig. 4.5).
When the fatty superficial fascial layer above the mus-
cles is thin and the muscles are toned, they also play an
important role in the aesthetics of the abdomen, as their
borders and prominences are visible. Attenuation and
laxity in the abdominal wall muscles lead to protrusion
of the abdomen [6]. For the most part, the three flat
abdominal muscles that occupy the lateral abdominal
wall become aponeurotic anteriorly at the midclavicular
line. Between the midclavicular line and the midline,
the aponeuroses of the three flat muscles form the rectus
sheath, a tough fibrous envelope that encloses the verti-
cal rectus abdominis muscles. Above the umbilicus, and
to a point just below it, the anterior wall of the rectus
sheath is formed by the aponeurosis of external oblique
and the anterior lamina of the internal oblique aponeu-
rosis. The posterior wall of the rectus sheath (deep to
rectus abdominis) comprises the posterior lamina of
internal oblique aponeurosis and the aponeurosis of
transversus abdominis. The exception is over the costal
61
5th 7th
costal cartilages
rectus
abdominis m.
tendinous
intersection
transversus
abdominis m.
cartilages where rectus abdominis lies directly on the
chest wall and the transversus abdominis is continuous
with the thoracic muscles under the ribs. At the arcuate
line of Douglas below the level of the umbilicus, the
posterior wall of the rectus sheath becomes deficient
where the aponeuroses of the flat muscles comprising it
course anteriorly to cover the anterior surface of rectus
abdominis (Fig. 4.6). The arcuate line lies in the upper
half of a line from the pubic symphysis to the umbilicus
and is consistently found to be at the level of the most
distal horizontal tendinous intersection or rectus abdo-
minis [7]. Fibers from the flat muscles from each side
decussate in the midline to form the linea alba with
additional interweaving of superficial and deep fibers
[8]. The rectus sheath is occupied primarily by the large
vertical paired rectus abdominis and also by the smaller
pyramidalis muscle in the lower abdomen.
4.5.1 External Oblique
This muscle forms the fleshy part of the lateral abdomi-
nal wall as its fibers pass inferiorly and inferomedially
superficial to the other flat muscles (Fig. 4.5). It origi-
nates from the external surfaces of the inferior 78 ribs.
The most posterior fibers pass vertically from the lower
62
Fig. 4.6 Anatomy of the aponeurosis of
rectus sheath above and transversus abdominis
below the arcuate line
aponeurosis of
aponeurosis of
internal oblique
external oblique
two ribs to insert into the iliac crest, creating a posterior
free border. These fibers do not insert into the thora-
columbar fascia and constitute the anterior border of
the inferior lumbar triangle of Petit, with posterior and
inferior borders are formed by the latissimus dorsi and
iliac crest, respectively [9]. Unusual cases of herniation
through Petits triangle have been reported [10].
External oblique becomes aponeurotic medially at the
midclavicular line and inferiorly at the spinoumbilical
line (between anterior superior iliac spine and umbili-
cus). The aponeurosis passes anterior to rectus abdomi-
nis as part of the rectus sheath and decussates with
aponeurotic fibers of the contralateral external oblique,
internal oblique, and transversus abdominis at the mid-
line. The external oblique aponeurosis passes the mid-
line to be continuous with the aponeurosis of the
contralateral internal oblique. Functionally, external
oblique and the contralateral internal oblique can be
considered as a digastric muscle since their simultane-
ous action flexes and rotates the abdomen, as occurs
when the shoulder is turned toward the contralateral
hip. The inferolateral fibers of external oblique, below
the spinoumbilical line, turn backwards and upwards
between the anterior superior iliac spine and the pubic
tubercle to form the inguinal ligament. Superior and
medial to the pubic tubercle, the superficial inguinal
ring is a triangular-shaped defect in the external oblique
aponeurosis that transmits the spermatic cord (or round
ligament of the uterus) (Fig. 4.4). Medial and lateral
crura with fibers connecting them surround this ring.
Fibers from the medial end of the inguinal ligament
turn posteriorly and then upwards along the pectineal
line of the pubic crest, first, as the lacunar ligament and
P.M. Prendergast
posterior lamina
of internal
oblique
anterior lamina
linea alba
rectus
abdominis
above the arcuate line
below the arcuate line aponeuroses from all three
muscles pass anterior to
rectus abdominis
then, as the pectineal ligament where it merges with the
periosteum.
The blood supply to external oblique is from inter-
costal arteries superiorly and branches of the deep
circumflex artery inferiorly with the iliolumbar artery
supplying the inferior part of the muscle in a small
percentage of the population [11]. External oblique is
innervated from the anterior primary rami of the
seventh to twelfth intercostal nerves.
4.5.2 Internal Oblique
The internal oblique is a broad thin flat muscle that runs
deep to the overlying external oblique (Fig. 4.5). Fibers
of internal oblique originate from the thoracolumbar
fascia, the anterior two-thirds of the iliac crest and
lateral half of the inguinal ligament, run forwards and
upwards mostly perpendicular to fibers of external
oblique, to insert into the inferior borders and costal
cartilages of the lower three ribs, xyphoid process,
linea alba, and pubic symphysis. At the midclavicular
line, internal oblique becomes aponeurotic. Above the
arcuate line, this aponeurosis splits at the lateral border
of rectus abdominis to contribute to both anterior and
posterior parts of the rectus sheath. Below the arcuate
line, the internal oblique aponeurosis passes as a single
sheet anterior to rectus abdominis. Lower medial fibers
of the internal oblique arch over the spermatic cord in
males and round ligament of the uterus in females to
insert into the pubic crest and pectineal line. Fibers of
underlying transversus abdominis join some of these
fibers to insert into the linea alba as the conjoint tendon.
4 Anatomy of the Anterior Abdominal Wall
Internal oblique contributes to flexion, lateral flexion,
and rotation of the lumbar vertebrae with the other main
muscles of the anterior abdominal wall, as well as rais-
ing intra-abdominal pressure during forced expiration.
The internal oblique is innervated by the ventral
rami of the lower six thoracic spinal nerves and the
iliohypogastric and ilioinguinal nerves (L1, L2).
4.5.3 Transversus Abdominis
Transversus abdominis lies deep to internal oblique
and represents the innermost of the three flat muscles
of the anterolateral abdominal wall. Its fibers run
transversely, except at its inferior part where fibers run
inferomedially parallel to fibers of internal oblique.
Transversus abdominis originates from the thora-
columbar fascia, the inner parts of the lower six costal
cartilages, the lateral two-thirds of the iliac crest and
the lateral third of the inguinal ligament. It passes
medially to insert in the xyphoid process and linea alba
with lower fibers forming the conjoint tendon with
fibers of internal oblique and inserting into the pecten
and crest of the pubis. Near the midline, transversus
abdominis becomes aponeurotic and contributes to the
posterior part of the rectus sheath, except below the
arcuate line where its aponeurosis passes anterior to
rectus abdominis. Unlike the two overlying flat muscles
that become aponeurotic at the midclavicular line,
transversus abdominis continues as a muscle for vari-
able distances toward the midline [12]. At the level of
the xyphoid process, muscle fibers pass behind rectus
abdominis and only become aponeurotic 23 cm from
the linea alba. The aponeurosis broadens inferiorly
and is widest at the level of the umbilicus where it
starts about 56 cm from the lateral border of rectus
abdominis. Further down, the width of the transversus
abdominis aponeurosis again narrows.
Transversus abdominis is innervated by the ventral
rami of the inferior six thoracic spinal nerves and first
two lumbar nerves. It acts to compress and protect the
abdominal contents.
4.5.4 Rectus Abdominis
This vertically oriented paired strap muscle occupies
most of the central part of the anterior abdominal wall.
It is narrow and thick inferiorly and broader and flatter
63
in the upper abdomen. Rectus abdominis arises from
the symphysis, crest, and pecten of the pubis and runs
upwards to insert into the xyphoid process and costal
cartilages of the fifth to seventh ribs. For most of its
course, it runs in the tendinous rectus sheath formed by
the aponeuroses of the three flat muscles described
above. The inferior part of rectus abdominis is covered
only on its anterior surface by the rectus sheath, and
above the costal margin, the muscle lies directly on the
costal cartilages. The paired rectus abdominis is sepa-
rated in the midline by the linea alba and by three to
four horizontal tendinous intersections; fibrous bands
that are usually located at the level of the xyphoid pro-
cess, at the umbilicus, and halfway between these two.
A fourth tendinous intersection may be visible below
the umbilicus and marks the location of the arcuate
line. These tendinous bands are intimately related to
the anterior wall of the rectus sheath. The lateral bor-
der of rectus abdominis is often visible as a groove in
the anterior abdominal wall between the ninth costal
cartilage and the pubic tubercle. Diastasis or separa-
tion of the recti muscles at the midline with widening
of the linea alba occurs following pregnancy or as a
congenital deformity and may result in an abnormally
convex abdominal contour. Plication of the anterior or
posterior rectus sheath, sometimes combined with pli-
cation of the external oblique aponeurosis, improves
this myoaponeurotic deformity [13].
Rectus abdominis is innervated by the ventral rami
of the inferior six or seven thoracic spinal nerves. Its
main action is to flex the trunk. Unlike the flat muscles,
rectus abdominis contributes minimally to raising
intra-abdominal pressure.
4.5.5 Pyramidalis
This small triangular muscle lies in the rectus sheath
anterior to inferior part of rectus abdominis and is
absent in 20% of subjects. It arises from the pubic
symphysis and inserts into the linea alba.
4.6 Arterial Supply
The anterolateral abdominal wall receives its blood
supply from branches of the subclavian, external iliac,
and femoral arteries as well as intercostal and lumbar
arteries directly from the descending aorta (Fig. 4.7).
64
Fig. 4.7 Arterial supply and
innervation of the anterior
abdominal wall
thoracoabdominal
nn.
lateral cutaneous
branches
T4
anterior cutaneous
branches
L1
iliohypogastric n.
ilioinguinal n.
4.6.1 Musculophrenic Artery
The musculophrenic artery is one of the terminal
branches of the internal thoracic artery. It runs behind
the fifth to ninth costal cartilages and supplies the mus-
cles of the anterolateral abdominal wall via direct
branches and anastomoses with the posterior intercos-
tal and deep circumflex iliac arteries. The musculo-
phrenic artery also gives off the fifth to ninth anterior
intercostal arteries.
4.6.2 Superior Epigastric Artery
The other terminal branch of the internal thoracic
artery, the superior epigastric artery, travels inferiorly
between the costal and xyphoid attachments of the dia-
phragm to enter the abdominal wall anterior to trans-
versus abdominis. It passes inferiorly in the rectus
sheath under rectus abdominis and supplies this mus-
cle as well as the overlying central abdominal skin
through perforating branches that pierce the muscle. In
contrast to the heterogenously arranged perforating
branches from the inferior epigastric artery, the anat-
omy of superior epigastric artery perforators tends to
be more predictable [14]. The superior epigastric artery
has lateral and medial branches and anastomoses with
branches of the inferior epigastric artery about 4 cm
superior to the umbilicus (Fig. 4.8).
P.M. Prendergast
internal
thoracic a.
musculophrenic a.
superior
epigastric a.
posterior intercostal aa.
subcostal a.
lumbar a.
inferior epigastric a
superficial
egigastric a.
deep
circumflexiliac a.
superficial
circumflexiliac a.
4.6.3 Inferior Epigastric Artery
The inferior epigastric artery arises from the external
iliac artery just proximal to the inguinal ligament. It
courses superiomedially deep to the transversalis fas-
cia medial to the deep inguinal ring and then pierces
the fascia to lie deep to rectus abdominis below the
arcuate line. Above the arcuate line, it lies between
rectus abdominis and the aponeuroses of the posterior
rectus sheath. The inferior epigastric artery divides
into lateral and medial branches below the umbilicus,
with the lateral one usually being more prominent [15].
It supplies the rectus abdominis and anastomoses with
the superior epigastric and posterior intercostal arter-
ies. Smaller branches perforate rectus abdominis to
supply the skin over the lower abdominal wall and
around the umbilicus. Traction or torsional forces on
these pedicle vessels may compromise perfusion of the
transposed umbilicus following abdominoplasty. A
broad subcutaneous base and a diameter of at least
2.5 cm around the umbilicus will improve perfusion by
sparing more of the diverging perforating vessels to
the umbilicus [15]. Anastomoses across the midline
occur between medial and lateral deep inferior epigas-
tric row perforators through the subdermal plexus [16].
Flap techniques for autologous breast reconstruction
require that these perforating arteries are preserved.
Preserving posterior intercostal perforating arteries
during lipoabdominoplasty may also reduce ischemic
4 Anatomy of the Anterior Abdominal Wall 65

Fig. 4.8 Sagittal section

through the abdominal wall
showing the level of the
arcuate line and the
skin
anastomosis of superior and
inferior epigastric arteries
above the umbilicus
subcutaneous fat

external oblique
superior and inferior epigastric
aponeurosis
arteries

ant. layer on internal

oblique aponeurosis post layer of internal oblique
aponeurosis

rectus abdominis transversus abdominis

aponeurosis

transversalis fascia

extraperitoneal fat

peritoneum

complications without compromising the aesthetic
result [17].
4.6.4 Deep Circumex Iliac Artery
The deep circumflex iliac artery arises from the external
iliac opposite the origin of the inferior epigastric and
runs parallel to the inguinal ligament before entering
the vascular plane between transversus abdominis and
internal oblique. It supplies the inferolateral abdominal
wall and has multiple anastomoses in this area.
4.6.5 Supercial Circumex Iliac Artery
This small branch of the femoral artery passes below
and parallel to the inguinal ligament and supplies the
superficial fascia and skin of the inferolateral abdomi-
nal wall and the upper outer thigh.
4.6.6 Supercial Epigastric Artery
The superficial epigastric artery arises from the femoral
artery near the origin of the superficial circumflex iliac
66
Fig. 4.9 Veins and
lymphatics of the anterior
abdominal wall
axillary
lymph nodes
superficial lymphatic
vessels of the
abdominal wall
superficial inguinal
lymph nodes
artery and courses over the inguinal ligament toward
the umbilicus in the subcutaneous tissues before anas-
tomosing with the inferior epigastric artery. It supplies
the superficial tissues over the lower abdominal wall.
4.6.7 Posterior Intercostal Arteries
The inferior two posterior intercostal arteries and sub-
costal artery have a circumferential course around the
abdominal wall before entering the rectus sheath at the
lateral border of rectus abdominis to anastomose with
the superior and inferior epigastric vessels.
4.6.8 Lumbar Arteries
The lumbar arteries arise directly from the descending
aorta and travel around the anterolateral abdominal
wall toward the lower abdomen. Cutaneous branches
arise from the main vessels in the vascular plane
between internal oblique and transversus abdominis
P.M. Prendergast
parasternal
lymph nodes
thoracoepigastric v.
sup. epigastric
c. (deep)
inf. epigastric
c. (deep)
superficial
epigastric vein
to supply the skin and soft tissues of the lower anterior
abdominal wall. The transverse course of the lumbar
vessels renders them less susceptible to injury during
abdominoplasty. As such, they play an important role
in preserving vascular supply to the flap, particularly
when vertically oriented vessels have been ligated.
4.7 Venous Drainage
Venous drainage of the abdominal wall is through
superficial and deep networks. A delicate subcutane-
ous venous plexus drains superficial tissues above the
umbilicus to the lateral thoracic vein via the thora-
coepigastric vein (Fig. 4.9). Superficial veins below
the umbilicus drain into the superficial epigastic and
superficial circumflex iliac veins, and from these, into
the great saphenous vein, femoral vein, iliac veins, and
inferior vena cava. Drainage of the lower abdominal
tissues into the superior vena cava also occurs via
the thoracoepigastric vein, a tributary of the axillary
vein. A portal-systemic anastomosis exists around the
4 Anatomy of the Anterior Abdominal Wall
umbilicus where paraumbilical veins that drain into
the hepatic portal vein communicate with superficial
epigastric veins. The deep veins of the anterolateral
abdominal wall generally follow the arteries of the
same name: superior epigastric veins drain into the
internal thoracic vein, inferior epigastric veins into
the external iliac veins, and posterior intercostal veins
receive drainage from the lateral abdominal wall.
4.8 Lymphatics
The lymphatic channels draining the abdominal wall
follow the veins. Above the umbilicus, superficial
drainage is mostly to the axillary nodes, with some
drainage to the parasternal nodes. Below the umbilicus,
the superficial tissues drain into the superficial inguinal
lymph node chain along the inguinal ligament (Fig. 4.9).
Lymphatic drainage of the deeper tissues of the abdom-
inal wall is through channels that accompany the deeper
named veins and includes external iliac, common iliac,
caval, and aortic lymph node groups.
4.9 Innervation
The skin, superficial fascia, and muscles of the antero-
lateral abdominal wall are innervated by the anterior
primary rami of the lower six thoracic (T7T12) and
first lumbar (L1) spinal nerves (Fig. 4.7). These nerves
leave their respective intervertebral foramina and course
around the thoracic and abdominal wall staying within
the confines of the dermatome they supply. Apart from
the first lumbar spinal nerve, which bifurcates, they do
not form neural plexuses. In the chest, the thoracoab-
dominal nerves lie in the neurovascular plane between
the internal intercostal and innermost intercostal mus-
cles. When these nerves leave the confines of the thorax
to enter the anterolateral abdomen, they lie between the
internal oblique and transversus abdominis muscle
layers. At the level of the anterior axillary line, the tho-
racoabdominal nerves send lateral cutaneous branches
that pierce the overlying muscles to innervate the skin
of the hypochondriac and lumbar areas. Near the mid-
line, anterior cutaneous branches pierce the rectus
sheath and supply rectus abdominis as well as the skin
in the midline and central part of the abdomen. Anterior
cutaneous branches of the tenth spinal nerve con-
sistently supply the umbilicus. Below the umbilicus,
67
the skin is supplied by the subcostal nerve (T12). The
subcostal nerve also innervates pyramidalis, when pres-
ent. The iliohypogastric nerve is the superior terminal
branch of the anterior ramus of L1. Its cutaneous
branches pierce the external oblique aponeurosis 2.5 cm
medial and 2.0 cm inferior to the anterior superior iliac
spine to supply the skin over the iliac crest, above the
inguinal crease, and hypogastric areas [18]. The second
terminal branch of L1, the ilioinguinal nerve, emerges
about 0.5 cm below the iliohypogastric nerve and sup-
plies the inner two flat muscles before traversing the
inguinal canal. Cutaneous branches innervate the mons
pubis, scrotum, labium majus, and inner thigh. Incisions
in the anterior or anterolateral abdominal wall should
respect the orientation of the nerves within the der-
matomes to minimize postoperative dysesthesias and
muscular denervation.
References
1. Hunstad JP, Repta R (2009) Anatomical considerations in
abdominal contouring. In: Hunstad JP, Repta R (eds) Atlas
of abdominoplasty. Saunders Elsevier, Philadelphia, p 7
2. Lumley JSP (2008) Surface anatomy: the anatomical basis
of clinical examination, 4th edn. Churchill Livingstone,
Edinburgh, p 98
3. Rohrich RJ, Sorokin ES, Brown SA, Gibby DL (2003) Is the
umbilicus truly midline? Clinical and medicolegal implica-
tions. Plast Reconstr Surg 112(1):259263
4. Shiffman MA (2005) Umbilical reconstruction in abdomi-
noplasty. In: Shiffman MA, Mirrafati S (eds) Aesthetic
surgery of the abdominal wall. Springer, Berlin, p 147
5. Snell RS (2008) Clinical anatomy by regions, 8th edn.
Lippincott Williams & Wilkins, Baltimore, p 148
6. Brauman D (2008) Diastasis recti: clinical anatomy. Plast
Reconstr Surg 122(5):15641569
7. Mwachaka PM, Saidi HS, Odula PO, Awori KO, Kaisha WO
(2010) Locating the arcuate line of Douglas: Is it of surgical
relevance? Clin Anat 23(1):8486
8. Moore KL, Dalley AF, Agur AMR (2010) Clinically oriented
anatomy, 6th edn. Lippincott Williams & Wilkins, Baltimore,
p 188
9. Arslan OE (2005) Anatomy of the abdominal wall.
In: Shiffman MA, Mirrafati S (eds) Aesthetic surgery of the
abdominal wall. Springer, Berlin, p 10
10. Florer RE, Kiriluk L (1971) Petits triangle hernia: incarcer-
ated: two case reports. Am Surg 37(8):527530
11. Schlenz I, Burggasser G, Kuzbari R, Eichberger H, Gruber
H, Holle J (1999) External oblique abdominal muscle: a new
look on its blood supply and innervation. Anat Rec 255(4):
388395
12. Williams PL (1995) Grays anatomy: the anatomical basis of
medicine and surgery, 38th edn. Churchill Livingstone,
Edinburgh, p 825
68
13. Nahas FX (2001) An aesthetic classification of the abdomen
based on the myoaponeurotic layer. Plast Reconstr Surg
108(6):17871795
14. Tregakiss AP, Goodwin AN, Acland RD (2007) The
cutaneous arteries of the anterior abdominal wall: a three-
dimensional study. Plast Reconstr Surg 120(2):442450
15. ODey DM, Heimburg DV, Prescher A, Pallua N (2004) The
arterial vascularisation of the abdominal wall with special
regard to the umbilicus. Br J Plast Surg 57(5):392397
16. Schaverien M, Saint-Cyr M, Arbique G, Brown SA (2008)
Arterial and venous anatomies of the deep inferior epigastric
P.M. Prendergast
perforator and superficial inferior epigastric artery flaps.
Plast Reconstr Surg 121(6):19091919
17. Kolker AR (2008) Improving esthetics and safety in
abdominoplasty with broad lateral subcostal perforator pres-
ervation and contouring with liposuction. Ann Plast Surg
60(5):491497
18. Rahn DD, Phelan JN, Roshanravan SM, White AB,
Corton MM (2010) Anterior abdominal wall nerve and
vessel anatomy: clinical implications for gynecologic sur-
gery. Am J Obstet Gynecol 202(3):234.e1e5
 Anatomy of the Eyelid
Oren G. Benyamini and Morris E. Hartstein
5.1 Introduction
The eyelid is a three-dimensional, multilayered, and
dynamic organ that has crucial functional role in
protecting and lubricating the eyes as well as being a
key feature in facial aesthetics. Understanding the
anatomy is critical for the surgeon to ensure that the
eyelid continues in its functional capacity as well as
undergo rejuvenation.
5.2 Anatomy
Beginning superiorly, external examination of the eye-
lids reveals some key landmarks. The eyebrows reside
just above the superior orbital rim in women and on the
orbital rim in men. Below the superior orbital rim is
the sulcus which lies between the brow and the lid.
The sulcus can be deeper and more prominent with
atrophy of orbital fat, a larger and deeper orbit, or after
overzealous fat removal during upper lid blepharo-
plasty. Alternatively, the superior sulcus may be fuller
O.G. Benyamini
Department of Ophthalmology, Assaf Harofeh Medical Center,
Zerifin, Israel
M.E. Hartstein (*)
Department of Ophthalmology, Assaf Harofeh Medical Center,
Zerifin, Israel
Clinical Associate Professor of Ophthalmology and
Plastic Surgery, Saint Louis University School of Medicine,
St. Louis, MO 63104, USA
e-mail: mhartstein@earthlink.net
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_5, Springer-Verlag Berlin Heidelberg 2013
5
in a shallower orbit or from bulging of orbital fat
behind the septum (Fig. 5.1) [13, 7].
Inferior to the sulcus is a fine horizontal skin line
that is the upper eyelid crease. The crease corresponds
to an area at or above the superior tarsal border and is
created by the insertion of fibers from the levator
palpebrae aponeurosis to the skin where it fuses with
the orbital septum. The lid crease also marks the tran-
sition between the looser preseptal skin and the tighter,
more adherent pretarsal skin. In Caucasian women, the
lid crease usually resides 10 mm above the lid margin,
whereas in men, it is usually a little lower at 78 mm
above the lid margin. In Asians, the fusion of levator to
septum occurs at or below the superior tarsal border,
resulting in a lower or even absent crease [1, 3, 4, 7].
The periorbital region and eyelids are covered by
very thin skin. The transition between the thicker
eyebrow skin upper lid skin and the thicker malar skin
to the lower lid skin should be taken into account.
For example, the upper border of the upper blepharo-
plasty incision should not incorporate the thicker brow
skin. The preorbital and preseptal skin has a very thin
subcutaneous layer with very little fat; whereas the
pretarsal skin lacks any fat at all (Fig. 5.2) [1, 3, 4].
The palpebral fissure, the opening between the
upper and lower lids, measures approximately 30 mm
horizontally. In the primary position, the upper eyelid
rests 12 mm below the upper limbus, and the lower
lid rests on the lower limbus, creating a vertical palpe-
bral fissure measurement of 1012 mm. It terminates
at the fusion of the upper and lower lids laterally. The
angle formed by this union is the lateral canthus, while
the point of fusion is termed the lateral commissure.
The lateral canthus maintains its position and stability
69
70 O.G. Benyamini and M.E. Hartstein

a b

Levator palpebrae
superioris muscle

ROOF
Superior tarsal
muscle (smooth)

Tarsal
(Meibomian glands)
Superior tarsus
Sebaceous glands
Cilia (lashes)

Openings of tarsal glands

Inferior tarsus
Orbicularis oculi
muscle (palpebral part)
Orbital septum

Orbitomalar ligament

SOOF

Fig. 5.1 Surface anatomy demonstrating differences full and more hollow superior sulcus and lateral canthal position
5 Anatomy of the Eyelid
Fig. 5.2 Skin marking for upper blepharoplasty. Upper limit
of incision should not incorporate thicker brow skin
Fig. 5.3 Cadaver dissection demonstrating lateral canthal
tendon with its insertion to lateral orbital rim
by a deeper (subcutaneous) connection to bone the
lateral canthal tendon (LCT). The LCT is a fibrous
structure that integrates dense connective tissue (the
tarsus) to the bone (Fig. 5.3) [5, 6].
Both anterior and posterior lamella of the eyelids
contribute to the formation and integrity of the LCT.
The orbicularis oculi muscle, the protractor of the
eyelids, comprises part of the anterior lamella and is
divided into an orbital and palpebral portion. The
palpebral portion of the orbicularis muscle is further
divided into a preseptal and pretarsal segment. The
pretarsal portion is anterior to the tarsus. At the termi-
nation of the tarsus, the orbicularis continues as a
71
superficial and deep connective tissue band to form the
LCT. The deep head attaches to the lateral orbital
tubercle (Whitnalls tubercle), a bony prominence
4 mm posterior to the lateral orbital rim. This is a
critical attachment point of the LCT as it maintains the
lid apposition to the globe. Also, the attachments of
the LCT are 3 mm higher at the lateral canthus than
the medial canthus [5, 6].
The malar crease arises from the lateral canthus and
descends in a 45 angle inferiorly and medially, where
it joins the nasojugular crease (tear trough) that arises
from the medial canthus and descends inferiorly and
medially in a similar angle. These lines meet 15 mm
below the center of the lower eyelid margin.
5.3 Orbicularis Oculi Muscle
The orbicularis oculi muscle, the main eyelid protractor
muscle, is responsible for eyelid closure. The concen-
trically arranged fibers are firmly attached to the under-
lying bony structures, as well as to the medial and
lateral canthi and upper and lower tarsi. The muscle
consists of three anatomical regions: orbital, preseptal,
and pretarsal. The orbital part of the muscle, which adheres
directly to the bony structures of the orbital rim, is
responsible for voluntary or forced eyelid closure.
The preseptal portion of the muscle overlies the orbital
septum, although a loose sheath of fibroadipose layer
may be found between the two. It is important to dis-
tinguish between this fat layer and the preaponeuorotic
fat pads that lie deep to the orbital septum. Laterally,
the preseptal orbicularis inserts 34 mm behind the lat-
eral commissure, deep to the orbital rim onto Whitnalls
tubercle to form the lateral canthal ligament [3].
Medially, the muscle divides to an anterior or
superficial head, which inserts to the anterior head of
the medial canthus, and a posterior, deep head, which
invests the lacrimal sac and lacrimal fascia. This part
of the muscle supports both voluntary and involuntary
lid closure. The pretarsal portion of the orbicularis is
firmly adherent to the anterior face of the tarsal plate.
At the superior tarsal border, the muscle is joined by
superficial fibers from the levator palpebrae aponeuro-
sis to form the lid crease. Laterally, the muscle has
insertions to the lateral canthal ligament. Medially, as
with the preseptal portion, the muscle also divides into
an anterior and posterior heads. The posterior head
inserts 4 mm deep to the posterior lacrimal crest.
72
Fig. 5.4 Dissection through
the orbicularis, and then the
orbital septum reveals the
medial fat pad of the upper lid
Suborbicularis
oculifat
Orbitomalar ligament
Zygomaticus minor
Contraction of this portion of the muscle pulls the
eyelids together, medially and posteriorly following
the convexity of the globe. The anterior head inserts
into the anterior lacrimal crest and contributes to
involuntary blinking, the main function of the pretarsal
orbicularis. The anterior and posterior portion of the
muscle engulf the lacrimal sac and compress it during
blinking. This creates negative pressure in the sac
which facilitates tear drainage [3].
The orbicularis muscle in the lower lid attaches
directly to the orbital rim medially, contributing to the
nasojugal groove. Laterally, the orbicularis attaches
via the orbitomalar ligament that arises from the
periosteum outside the orbital rim to the fascia on the
underside of the orbicularis (Fig. 5.4) [6].
5.4 The Orbital Septum
The orbital septum is a multilayered condensed
fibro-connective tissue. It originates from the orbital rim
at the arcus marginalis, where the periorbital fuses with
the periosteum of the anterior surface of the bones sur-
rounding the orbital cavity. Several millimeters above
the superior tarsal border, the septum fuses with the
levator aponeurosis. Together they insert into the ante-
rior surface of the superior tarsal plate. In the lower
eyelid, the orbital septum inserts directly into the infe-
rior tarsal plate in a similar fashion. Approximately
45 mm below the inferior tarsal border, the septum
fuses with the lower lid retractors to form a single unit
that inserts to the lower border of the inferior tarsus. The
O.G. Benyamini and M.E. Hartstein
Orbicularis oculi
Inferior orbital rim
Malar fat pad
orbital septum provides a barrier between the orbit and
its contents and the more superficial preseptal tissues.
5.5 Fat Pads
Immediately posterior to the orbital septum are the
fat pads that serve to cushion and protect the globe
(Fig. 5.5). The upper lid has two main fat pads.
The central fat pad or the preaponeuorotic fat pad is
usually larger, with more connective tissue and a
more yellow appearance. It is a useful landmark as it
lies just anterior to the levator palpebrae muscle. The
trochlea, or the superior oblique muscle pulley,
together with other looser connective tissue septa,
separates this pad from the medial fat pad which is
smaller, has less connective tissue, and is whiter in
appearance. Lateral to the central preaponeurotic fad
pad is the lacrimal gland. This structure that is whiter
and more globular in appearance than the fat pads
should never be resected, although sometimes it may
need to be repositioned more superiorly. The lower
eyelid harbors three distinct fat pads. The inferior
oblique always lies between the central and nasal
fat pad and should be identified prior to resecting
or sculpting any of the fat pads (Fig. 5.6). Anterior
to the muscle, the central and nasal pads need to be
separated in order to locate the muscle posteriorly.
The temporal fat pad is divided from the central pad
by the arcuate expanse of the inferior oblique
(Fig. 5.7). Sometimes, there is even a fourth fat pad
which lies temporally, more anteriorly on the lower
5 Anatomy of the Eyelid 73

Fig. 5.5 (a) Dissection a

through the orbicularis, and
then the orbital septum
reveals the medial fat pad of
the upper lid. (b) The fat
pads of the upper and lower
lids with septum removed

b Preaponeurotic fat Trochlea

Lacrimal gland

Nasal fat pad

Medial fat pad

Laveral fat pad
Inferior oblique
muscle

Arcuate expansion of Middle fat pad

inferior oblique muscle

lid retractors. This fat pad may be missed during
blepharoplasty, resulting in a temporal bulge [1].
5.6 Eyelid Retractors
Counteracting the orbicularis oculi in each eyelid are
two separate eyelid retractor muscles responsible for
opening the eye. The upper eyelid has one major
striated voluntary muscle called the levator palpebrae
and the sympathetically innervated smooth muscle
called Mullers. In the lower lid, the retractors are the
capsulopalpebral fascia and the sympathetically inner-
vated inferior tarsal muscle [3].
The levator consists of two portions. The first por-
tion is made of striated muscle, originates from the
orbital apex, and courses anteriorly for about 36 mm.
At the level of the globe, the levator fans medially
and laterally, creating Whitnalls suspensory ligament.
Whitnalls ligament is attached to the periorbital on both
sides. Medially, Whitnalls ligament is attached to the
trochlea and laterally to the fronto-zygomatic suture.
74 O.G. Benyamini and M.E. Hartstein

Fig. 5.6 Transconjunctival lower blepharoplasty. A cotton-

tipped applicator demonstrates the inferior oblique muscle
which is always located between the nasal and central fat pad

Fig. 5.8 Levator/Mullers recession demonstrating the upper

lid retractors

Fig. 5.7 Transconjunctival lower blepharoplasty. Temporal fat

pad separated by the arcuate expanse of the inferior oblique

As the muscle passes the level of Whitnalls it loses its

muscular nature and becomes the levator aponeurosis.
Medially, the aponeurosis attaches to the medial can-
thus. Laterally, it splits the lacrimal gland to its palpe-
bral and orbital lobules before it inserts into the medial Fig. 5.9 Transconjunctival approach demonstrating lower lid
canthal tendon. Centrally, the aponeurosis descends to retractors immediately posterior to the conjunctiva
approximately 25 mm superior to the upper border of
the superior tarsus where it fuses with the orbital septum
to insert into the anterior surface of the tarsal plate [3]. conjunctiva in its superior aspect. However, close to its
The second upper lid retractor, Mullers muscle, insertion into the superior tarsus, the muscle is more
originates from the underside of the levator muscle adherent to the conjunctiva (Fig. 5.8).
about 22 mm above the tarsus. This sympathetically The lower eyelid retractors are less defined than in
innervated smooth muscle is loosely attached to the the upper lid, and their action is less prominent. The
5 Anatomy of the Eyelid 75

capsulopalpebral fascia and the inferior tarsal muscle
both originate as fibrous extensions of the inferior rectus
muscle. They encircle the inferior oblique muscle, before
the capsulopalpebral fascia inserting, together with the
orbital septum onto the inferior tarsal border (Fig. 5.9).
5.7 Tarsus
oriented meibomian glands, which open into the lid
margin. Posteriorly, the tarsus is lined with the palpe-
bral conjunctiva and together these comprise the poste-
rior lamella of the eyelid (Fig. 5.10). The anterior
lamella consists of the orbicularis muscle and the skin.
The orbital septum can be thought of as the middle
lamella [3, 7].

The upper and lower tarsus are made of dense fibro-
connective tissue to provide the eyelids their structural
support. The upper tarsus is 10 mm in vertical height,
while the lower tarsus is about 35 mm in its vertical
dimension. Each tarsal plate contains the vertically
Fig. 5.10 Tarsal plate, which is about 100 mm in height in the
upper lid, demonstrating the vertically oriented meibomian
glands
5.8 Arterial Blood Supply
The eyelids receive a very rich blood supply. Terminal
branches of the internal carotid artery anastomose with
branches of the external carotid artery in the perior-
bital region via the lacrimal, supraorbital, supratro-
chlear, and dorsal nasal artery (Fig. 5.11) [3, 8].
The medial palpebral artery anastomoses with a ter-
minal branch of the external carotid artery the lateral
palpebral artery. In the upper lid, this anastomosis has
two well-defined vascular arcades. The superior mar-
ginal palpebral arcade lies on the anterior tarsal sur-
face 23 mm above the lid margin, and the peripheral
palpebral arcade lies above the superior tarsal border
between the levator aponeurosis and Mullers muscle.
In the lower lid, theres only one well-defined vascular
arcade, the inferior marginal arcade, which can be
found 23 mm below the lower lid margin on the ante-
rior surface of the tarsus. Other branches of the exter-
nal carotid include the superficial temporal artery,
facial artery, and infraorbital artery [3, 8].

Superior marginal arcade

Supraorbital artery
Superficial temporal
artery, frontal branch Supratrochlear artery
Superior medial
palpebral artery
Dorsal nasal artory
Lacrimal artery
Superior and
Nasal branch
inferior lateral
palpebeal arteries
Zygomafoofacial
artery
Angular artery

Transverse
facial artery
Infraorbital artery

Fig. 5.11 Arterial supply of

the eyelids Inferior marginal arcade
76
5.9 Venous Drainage of the Eyelids
The venous drainage of the periorbital region follows a
parallel path to the arterial supply, dividing into a deep
system that drains to the orbital venous system and
a superficial system that eventually drains into the
external jugular vein [3].
5.10 Nerve Supply
The orbicularis receives its motor innervations from a
branch of the facial nerve via the zygomatic division.
Some debate remains regarding the precise anatomy
of this nerve; however, it appears that the nerve
fibers travel in a radial direction as they approach the
lid margin. The levator muscle receives innervations
from the oculomotor nerve, while Mullers is sympa-
thetically innervated. Sensory innervations of the
upper lid comes from trigeminal nerve via the lacri-
mal, supraorbital, supratrochlear, and infratrochlear
nerves. The lower lid receives sensory innervation via
the zygomaticofacial and infraorbital nerves [3].
O.G. Benyamini and M.E. Hartstein
References
1. Bedrossian EH Jr (2002) Surgical anatomy of the eyelids.
In: Della Rocca RC, Bedrossian EH Jr, Arthus BP (eds)
Ophthalmic plastic surgery. Decision making and tech-
niques. McGraw-Hill, New York, pp 2541
2. Jordan D, Anderson R (1996) Surgical anatomy of the ocular
adnexa-a clinical approach. Ophthalmology monograph
9. American Academy of Ophthalmology, San Francisco
3. Anatomy (20102011) In Basic and Clinical Science Course
Sec 7: Orbit, Eyelids, and Lacrimal System. American
Academy of Ophthalmology, San Francisco, part II chap
9:137149
4. Kakizaki H, Malhotra R, Selva D (2009) Upper eyelid
anatomy: an update. Ann Plast Surg 63(3):336343
5. Kakizaki H, Malhotra R, Madge SN, Selva D (2009) Lower
eyelid anatomy: an update. Ann Plast Surg 63(3):344351
6. Harris PA, Mendelson BC (2008) Eyelid and midcheek
anatomy. In: Fagien S (ed) Puttermans cosmetic oculoplastic
surgery, 4th edn. Elsevier, Philadelphia, pp 4562
7. Gausas RE (2004) Advances in applied anatomy of the
eyelid and orbit. Curr Opin Ophthalmol 15(5):422425
8. Tucker SM, Linberg JV (1994) Vascular anatomy of the
eyelids. Ophthalmology 101(6):11181121
 Part II
Anesthesia
 Regional Anesthesia for Cosmetic
Surgery of the Face and Neck
Arnaud Deleuze, Marc Gentili, and Francis Bonnet
6.1 Introduction
Plastic surgery has increased significantly because of
the representation of ones personal image in the mod-
ern world. Moreover, a prolonged lifespan and extended
sun exposure cause an increase in the incidence of skin
tumors. In the U.S. the American Society for Aesthetic
Plastic Surgery recorded 11.7 million cosmetic proce-
dures in 2007: eyelid surgery was one of five most fre-
quent operations [1]. The possibilities for cosmetic
surgery and face reconstruction are multiple, and a
large number can be performed on an outpatient basis:
this is choice ground for face blocks.
The effectiveness of cephalic blocks is based on a
sound knowledge of nerve territories and their bound-
aries. After some anatomical reminders, different tech-
niques of anesthesia applied to each type of surgery
will be described. The realization of these blocks
follows the general rules of any anesthesia especially
with regards to clinical supervision and asepsis. These
are techniques that fall within the framework of an
alternative to conventional general anesthesia and that
can be combined with sedation.
A. Deleuze, MD (*)
Department of Anaesthetics and Intensive Care, lEsprance
Private Hospital, Mougins, France
e-mail: arnaud.deleuze@free.fr
M. Gentili, MD
Department of Anaesthetics and Intensive Care,
Saint Grgoire Private Hospital, Rennes, France
F. Bonnet, MD
Department of Anaesthetics and Intensive Care, Tenon
Hospital, Assistance Publique hpitaux de Paris,
University Pierre & Marie Curie, Paris, France
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_6, Springer-Verlag Berlin Heidelberg 2013
6
6.2 Anatomical Data
6.2.1 Innervation of the Face
The sensory innervation of the face depends mainly on
the trigeminal nerve which is derived from two roots,
one sensory and one motor (Fig. 6.1). The cell bodies
of the sensory root are grouped in the trigeminal gan-
glion located in the cervical cord, which presents a
corporeal organization corresponding to the three parts
relating to:
1. The ophthalmic nerve or V1
2. The maxillary nerve or V2
3. The lower jaw or mandibular nerve or V3
The V3 nerve also contains motor fibers for masti-
cation muscles: the temporalis muscle and the masseter
muscle [2].
6.2.2 The Ophthalmic Nerve (V1)
1. The ophthalmic nerve leaves the skull through the
superior orbital fissure and has branches: the lacri-
mal nerve which innervates the conjunctiva, the
skin of the outer part of the eye, and the lacrimal
gland.
2. The frontal nerve, which has a supraorbital and
a supratrochlear branch innervating the upper eye-
lid and the hemifront to the coronal suture,
respectively.
3. The nasociliary nerve which divides into several
branches.
4. The long ciliary nerves innervating the eye.
5. The infratrochlear nerve innervating the skin of the
dorsum of the nose and the commissure of the eye.
79
80
Fig. 6.1 According to the
Guide to Regional anesthesia
AstraZeneca 2001
nerf ophtalmique (V1)
nerf maxillaire (V2)
nerf mandibulaire (V3)
6. The anterior ethmoid which provides nerve nets for
the anterior ethmoid, nasal branches for the internal
septum, and lateral wall of the nasal cavity, and
ends in external nasal branch for the nasal bone, the
tip of nose, and wing area.
6.2.3 The Maxillary Nerve (V2)
1. The maxillary nerve exits the skull through the
foramen large circle and enters the rear end of
the pterygopalatine fossa maxillary. It then divides
into several branches:
a. A meningeal and orbital branch for the ethmoi-
dal and sphenoidal sinuses
b. A zygomatic branch to the skin of the temporal
region and the zygomatic bone
c. Dental upper branches, innervating the posterior,
middle, and upper molar teeth prior to the inci-
sor-canine mass
2. Pterygopalatine roots forming, with the sympathetic
and parasympathetic pterygopalatine ganglion, a
complex with nasal branches to the sides of the
nose; nasopalatine for the posterior part of the
septum and the anterior part of the palate.
A. Deleuze et al.
3. Palatine nerves innervate the posterior part of the
palate with a few branches for the veil and the
tonsils.
4. The terminal branch or infraorbital nerve exiting
through the infraorbital foramen, innervating the
skin of the lower eyelid, cheek, nostril, and upper
lip.
Overall, the deep branches carry the sensitivity of
the mucosa (maxillary sinus, nasal cavity, gums, higher
palatal vaults, and velum). The branches innervate the
intracranial temporal and parietal dura mater, and the
middle meningeal artery.
6.2.4 The Mandibular Nerve
or Mandibular (V3)
The mandibular nerve is a mixed nerve exiting the
skull through the foramen ovale and divided into two
branches, the anterior and posterior sensory motor.
The sensation contingent is divided into:
1. The buccal branch which innervates the skin and
the lining of the cheek.
2. The auriculotemporal nerve innervating the anterior
part of the pinna, the ear, and temporal region.
6 Regional Anesthesia for Cosmetic Surgery of the Face and Neck
3. The inferior alveolar nerve divides into two termi-
nal branches at the chin foramen: the incisive and
chin nerve innervating the entire lower jaw (bone,
teeth, gums).
4. The lingual nerve innervating the anterior two thirds
of the tongue and floor of the mouth.
The motor contingent provides innervation of
mastication muscles and palati hammer muscles. The
mandibular nerve carries VIIa fibers providing taste
sensitivity at the tip of the tongue and the propriocep-
tion of facial expression muscles.
6.3 Special Case of the Innervation
of the Ear
The auriculotemporal nerve innervates only a portion
of the ear; the rest is provided by several other contin-
gent nerves. The posterior inferior part of the flag, the
external auditory canal, and the lobe are innervated by
the auricular branches of the cervical plexus surface.
The shell and the outer ear canal (Ramsay Hunt area)
are innervated through the Wrisberg (VIIa). The auric-
ular branch of the vagus (X) provides sensory innerva-
tion to the deep ear canal and the lower portion of the
eardrum. The eardrum, in turn, is innervated by
Jacobsons nerve or the tympanic nerve which is a
branch of the glossopharyngeal nerve.
6.4 Innervation of the Cervical Region
The sensory innervation of the cervical region and the
occipital region is provided by the anterior branches
of the superficial cervical plexus, constituted by the
first four cervical roots. The emergence of mastoid,
transverse, and clavicular branches from cervical
plexus is at the posterior part of the sternocleidomas-
toid muscle.
6.5 Anesthetic Techniques
6.5.1 Block Branches of the Ophthalmic
Nerve (V1)
6.5.1.1 The Frontal Nerve
After its emergence from the supraorbital foramen, the
frontal nerve divides into two branches: the supraor-
bital and supratrochlear rami.
81
Infiltration of the supraorbital branch of the frontal
nerve is performed at the supraorbital foramen located
on the orbital rim, on the eyebrow, directly above the
centered pupil. The tip of the needle should point up
and out and will come into contact with the hole with-
out penetrating it. For infiltration of the supratrochlear
branch, the needle is directed into the angle formed by
the upper edge of the orbit and nasal stops. The total
volume of local anesthetic is 46 mL. The injection is
performed outside the bony canal to prevent neuronal
damage due to high pressure [3, 4]. The infiltration of
the nerve will allow surgery on the outer portion of the
forehead and upper eyelid (Fig. 6.2).
If the infiltration is carried out bilaterally, surgery
from the forehead to the coronal suture and the upper
eyelids is possible [5].
6.5.1.2 The Internal Nasal Nerve
or Anterior Ethmoidal
This nerve, after its exit from the supraorbital foramen,
provides sensory innervation to the root and the ala.
It divides into two branches: the internal nasal branch
and the nasolabial branch. The infiltration of the nerve
is performed bilaterally. The internal nasal branch is
infiltrated by a subcutaneous injection at the root of the
nose, and the nasolabial branch is infiltrated by a sub-
cutaneous injection into the nostril. These injections
are performed using a dermatological needle. A small
volume of local anesthetic is needed (about 46 mL).
Any extra-bone surgery of the nose can be performed
as well (Fig. 6.2). The supraorbital nerve block does
not interfere with the ability to open the eyelid [6].
6.5.2 Nerve Block of the Infraorbital
Branch of the Maxillary Nerve (V2)
This nerve leaves the skull through the infraorbital
foramen, which lies directly below the center of the
pupil, 2 cm from the ala and 1 cm below the inferior
orbital rim. Once the foramen is located, the skin is
punctured and the needle is directed upward and out-
ward. The injection is performed outside the bony
canal to avoid neural damage due to excess pressure.
A volume of 34 mL of local anesthetic is sufficient.
This block anesthetizes the suborbital area, the upper
lip, and the ala [7] (Fig. 6.2). The authors used a stimu-
lator to locate the emergence of the nerve: when the
needle approaches the nerve in the infraorbital hole,
there is bilateral eye blinking. Once the motor response
82
Fig. 6.2 Based on the Guide
to Regional anesthesia
AstraZeneca 2001
C2
C3
C4
is obtained, the current is progressively lowered from
0.6 to 0.8 mA and the injection of 37 mL of the solu-
tion provides an effective block [8]. A case of transient
diplopia has been reported [7].
6.5.3 Block of the Mandibular Nerve (V3)
and Its Branches
6.5.3.1 Mandibular Nerve Block
This is the only sensory-motor nerve of the face, and
thus using a nerve stimulator to locate the nerve is of
interest. Indeed, it provides sensory innervation to the
cheek, ear, lower lip, and the temple and has motor
branches to the masseter and temporal muscles. The
puncture site is located at the sigmoid fossa opposite
the tragus between the coronoid process and the
condyle. The puncture was performed using a 50-mm
needle. The puncture axis is perpendicular to the plane
of the face at first, and then the needle takes a cranial
direction. The motor response being sought is the
closing of the lower jaw. Once the motor response has
been obtained, the current is reduced gradually from
0.6 to 0.8 mA. Four to six milliliters of anesthetic solu-
tion is then injected into the nerve.
This nerve can also be infiltrated by an injection per-
formed between the coronoid and condylar processes.
However, this technique has a high failure rate, and there
is a significant risk of puncturing the maxillary artery
[9] or penetrating the orbit or skull [5]. It is therefore
recommended not to practice this technique without
the aid of a neurostimulator. It is also possible to leave
a catheter in place near the mandibular nerve to have a
A. Deleuze et al.
nerf ophtalmique (V1)
nerf maxillaire
(V2)
C2
nerf mandibulaire
(V3)
C3
C4
continuous perfusion of local anesthetic which ensures
quality analgesia during surgery following particularly
painful procedures such as cancer surgery [10].
6.5.3.2 Chin Nerve Block
The branch of inferior alveolar nerve leaves the anterior
surface of the mandible through the mental foramen of
the chin. This hole is located directly above the lower
premolar and is easily identifiable using ones finger.
The puncture site is 1 cm lateral to the foramen.
Once the needle goes through the skin, it is directed
downwards and inwards, while being careful not to
inject into the canal. Two mL of anesthetic solution is
injected. This simple infiltration enables surgery on
the lower lip and chin (Fig. 6.2).
6.5.3.3 The Auriculotemporal Nerve
This part of the contingent sensory nerve V3 has
subcutaneous branches which are opposite the tragus.
It supplies the superficial temporal and auricular area.
The infiltration is performed simply by dermal infiltra-
tion using 23 mL of local anesthetic, opposite the
tragus. Surgery of the anterior part of the pinna, the ear
canal, and the superficial temporal region can thus be
performed.
6.6 The Special Case of External
Ear Surgery
The sensory innervation of the ear is dependent on
several nerve branches. The auriculotemporal nerve is
infiltrated. In addition, a subcutaneous infiltration into
6 Regional Anesthesia for Cosmetic Surgery of the Face and Neck
34 points in the area above and behind the atrial
auricular nerve block the auricular branches of the
superficial cervical plexus, which provide sensory
innervation to the lower posterior auricle, the external
ear canal, and the lobule. Surgery of all the external ear
is thus possible [11].
6.7 Special Case of External
Auditory Canal
An injection at the junction of the pilosebaceous area
is performed to anesthetize the posterior external audi-
tory canal. The needle is directed into the major axis of
the ear canal, and 23 mL of local anesthetic is infil-
trated in a superficial manner. Regarding the anterior
part of the conduit, 12 mL of local anesthetic is
injected at the cartilage-bone junction. A spray of local
anesthetic may also be used on the eardrum if paracen-
tesis-type surgery is contemplated [11].
6.8 Inltration of the Supercial
Cervical Plexus
The superficial cervical plexus is formed by the ante-
rior branches of the first four cervical roots. These
emerge along the posterior border of the sternocleido-
mastoid. They provide sensory innervation to the
neck, shoulders, and the back of the scalp like a cape.
The superficial cervical plexus block requires a set of
subcutaneous injections in a star shape along the pos-
terior border of sternocleidomastoid which involves
the mastoid and ear branches of this plexus [12]. This
simple infiltration is useful to know about when the
surgery concerns an area on the edge of the face and
neck region (Fig. 6.2).
6.9 Regional Blocks in Relation
to Inltration Techniques
Face surgery, like many superficial operations, can be
achieved by simple infiltration techniques [13, 14].
The interest of using a block rather than a simple
infiltration is that this limits the quantity of product
injected. This latter is often underestimated, and there-
fore integument swelling can be avoided by using less
anesthetic [14]. The infiltration may also be comple-
mentary to an inadequate regional block.
83
6.10 Indications for Using a Face Block
with Respect to the Operation
Itself and the Terrain
The choices of technique with regional blocks, which
are often bilateral, depend on the indications for
surgery: this may include nasal surgery [5, 7], lifting
[15], lip surgery [16], or eyelid and lacrimal surgery
[17], or finally hair implants [18]. Face blocks are of
particular interest in elderly patients or with fragile
patients, especially for skin tumors [19].
6.11 Local Anesthetics and Adjuvants
The injection of local anesthetics into the face requires
some specific knowledge which may affect their phar-
macokinetics, of which intravascular resorption is one
possibility. Indeed there is a large amount of capillary
absorption, and the immediate and massive absorption
of local anesthetic by the mucosa can generate plasma
levels comparable to those produced after an intrave-
nous injection [10]. The injection is, thus, performed
slowly, in small doses, after successive tests of aspira-
tion, while being aware of and respecting the maxi-
mum doses. A peripheral vein, minimal supervision
including an electrocardiogram, blood pressure, and
oxygen saturation are needed together with an oxygen
supply in case of sedation in elderly patients whose
general condition is impaired: repeated verbal contact
is a good way of monitoring the patient, and it also
helps to reassure them.
Adrenaline solutions are widely used because they
reduce perioperative bleeding and prolong the anesthetic
block, but epinephrine solutions should be used with
care near terminal arteries (tip of nose, earlobe) or the
orbit due to the risk of spasm of the central retinal artery
and ischemia. The benefit of adding adrenaline to reduce
the risk of secondary hematoma needs further verifica-
tion: in a study combining non-randomized retrospec-
tive and prospective data, Jones et al. [20] did not find
any significant impact on the occurrence of secondary
hematoma whether the solution was adrenaline or not.
The recommended concentration is 1/200,000. The
most commonly used local anesthetics are 1% lidocaine,
bupivacaine 0.25%, and 2% or 7.5% ropivacaine. For
short and painless surgery, lidocaine or mepivacaine
are used. The maximum recommended dose for adults
is 7 mg/kg with a maximum dose of 500 mg [1].
For long and painful surgery that requires postoperative
84
analgesia, it seems preferable to use ropivacaine.
Ropivacaine has interesting intrinsic properties in this
indication. In a study on frogs, Ackerman et al. showed
that the duration of the analgesic effect of ropivacaine
infiltration was greater than that obtained with bupiva-
caine [21]. These results were confirmed with healthy
volunteers, but this advantage disappears with the use
of adrenaline solutions [22]. The same team had pre-
viously shown that ropivacaine has, if not vasocon-
strictive properties, then at least not vasodilator ones,
compared to other local anesthetics, which could
explain this effect [23, 24]. In all cases the plasma con-
centrations, regardless of the local anesthetic used, are
below critical levels but remain high for at least 2 h
[24]. The addition of sodium bicarbonate (1 mL at
84/1000 for 10 mL) neutralizes the acidity of the local
anesthetic solution and reduces the burning sensation
at the point of injection [25].
The injection of local anesthetic using a syringe and
needle is the usual technique to achieve local anesthe-
sia by infiltration. Due to the limited doses of local
anesthetic that can be injected into a patient in this
way, this technique is inadequate when local anesthe-
sia is required for large areas. Moreover, the injection
of large volumes may be responsible for pain related to
rapidly distended tissue.
Tumescent local anesthesia was initially discov-
ered in 1892 [26], but it would take until 1990 to see
it appear in the context of liposuction without seda-
tion or anesthesia: the subcutaneous fat is injected
with large volumes of diluted lidocaine with epi-
nephrine [27]. This technique reduces bleeding, faci-
litates dissection and reduces the occurrence of
swelling and bruising, and allows prolonged analge-
sia. Ramon et al. [1] conducted a prospective study
of surgical facial lifting with a solution of lidocaine
diluted by three with epinephrine 1:600,000. The
total dose of lidocaine was 21 mg/kg injected over
20 min in the subcutaneous tissue of the face and
neck. The dosages of lidocaine showed between 2
and 12 h after injection, and plasma levels reached a
plateau at 1.2 mg/mL and a maximum plasma con-
centration of 2.25 mg/mL. This study strongly sug-
gests that the high dilution of local anesthetic
combined with epinephrine limits the peak plasma
concentration to well below what is considered toxic,
despite a total dose which was well above the usually
recommended doses.
More recently, ropivacaine has found a place in
local tumescent anesthesia [28] and has the advantage
A. Deleuze et al.
of having an average duration of analgesia of 15 h,
which is three times longer than that observed with
0.1% lidocaine.
It is possible to achieve a continuous infiltration of
local anesthetic which is smooth and progressive
using a volumetric infusion pump and a 3022 gauge
needle. The infiltration rate will vary depending on
the diameter of the needle and the anatomical site of
injection.
Injection volumes ranged from 10 to 1500 mL,
depending on the surgical site and the patients weight
according to the currently recommended maximum
doses. Monitoring pre-, peri-, and postoperatively are
required as for any type of anesthesia. The contraindi-
cations are the same as for the use of local anesthetic.
Solutions of local anesthetics containing adrenaline
are a contraindication for finger and penis surgery.
Apart from classic liposuction, there are many
indications [29]:
Dermatologic surgery in adults or in children
Removal of lipomas
Surgery for varicose veins and leg ulcers
Breast surgery (implants, gynecomastia)
Pilonidal cyst
Lymph node surgery
Plastic surgery (hair transplant, facelift, dermabrasion)
6.12 Conclusions
Regional anesthesia techniques in head and neck
surgery represent a set of different techniques which
are reliable and reproducible. These techniques may
well be an alternative to general anesthesia in surgery
of the face or neck, particularly when the patient
requests them. Their simplicity should make their use
more frequent.
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26. Scheich C (1892) Die infiltrationsansthsie (lokale ansth-
esie) und ihr verhltnis zur allgemeinen narkose (inhalation-
sansthesie). Vehrdtsch Ges Chir 1:121
27. Kucera IJ, Lambert TJ, Klein JA, Watkins R, Hoover JM,
Kaye AD (2006) Liposuction: issues for the cotemporary
anaesthesiologists. J Clin Anesth 18(5):379387
28. Breuninger H, Hobbach PS, Schimek F (1999) Ropivacaine:
an important anesthetic agent for slow infusion and other
forms of tumescent anesthesia. Dermatol Surg 25(10):
799802
29. Hanke CW, Sommer B, Sattler G (eds) (2001) Tumescent
local anesthesia. Springer-Verlag, Berlin
 Liposuction with Local Tumescent
Anesthesia and Microcannula
Technique
Bernard I. Raskin and Shilesh Iyer
7.1 Background and History
Tumescent liposuction is the process of suction-
assisted aspiration of subcutaneous fat after infiltration
with a dilute crystalloid solution containing lidocaine,
bicarbonate, and epinephrine. By definition, pure
tumescent liposuction is performed entirely under
local anesthesia and excludes the use of general anes-
thesia or intravenous sedation [1]. However, while
many surgeons adhere strictly to tumescent anesthesia
for all pain relief, other surgeons commonly utilize
supplemental oral or injected agents as anxiolytics or
for enhanced sedation and/or pain management.
The concept of liposuction utilizing local tumes-
cent anesthesia and microcannulas was reported by
Klein [2] in 1987. Prior to this innovation, liposuc-
tion techniques employed larger-diameter cannulas
under general anesthesia. The field of modern lipo-
suction was first described by Fischer [3] in 1976
and further expanded by liposuction pioneers Pierre
Fournier and Yves-Gerard Ilouz. Initially, the proce-
dure was performed with larger-diameter cannulas
under a dry technique until Ilouz of France introduced
B.I. Raskin (*)
Division of Dermatology, Department of Medicine,
Geffen School of Medicine UCLA, Los Angeles, CA, USA
Advanced Dermatology & Cosmetic Care, Inc.,
28212 Kelly Johnson Parkway, Suite 245, Valencia, CA, USA
e-mail: braskin@creatingbeauty.com
S. Iyer
Instructor in Clinical Dermatology, Department of Dermatology,
Columbia University Medical Center, Los Angeles, CA, USA
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_7, Springer-Verlag Berlin Heidelberg 2013
7
the wet technique utilizing an infiltrated hypotonic
saline and hyaluronidase solution to facilitate the fat
removal. While these early techniques were effective,
they were associated with more trauma and potential
complications including hemorrhage, fluid loss, and
pain [46].
Kleins invention of tumescent anesthesia revolu-
tionized the field of liposuction. Klein described a
technique for aspirating adipose tissue entirely under
local anesthesia with a dilute solution of lidocaine and
epinephrine. The technique provided excellent hemo-
stasis, maintained fluid balance, and eliminated the
need for general anesthesia and associated complica-
tions. In conjunction with the innovation of tumescent
anesthesia, small microcannulas were developed to
more gently and precisely remove layers of adipose
tissue to achieve a sculpting effect. These cannulas
have a diameter of 10 to 20 gauge (0.582.7-mm inner
diameter) compared with the larger cannulas having a
diameter from 3 to 6 mm or greater. With the proper
technique, liposuction utilizing microcannulas under
local tumescent anesthesia is an exceedingly safe and
effective procedure with a relatively comfortable post-
operative recovery period for the patient [7].
7.2 Tumescent Anesthesia
7.2.1 Advantages of Tumescent
Anesthesia
The concept of tumescent anesthesia relies on infiltrat-
ing a dilute solution of normal saline with lidocaine,
bicarbonate, and epinephrine that is partially removed
87
88
in the lipoaspirate (1030%), but largely dissipates
naturally from the subcutaneous tissue over several
hours after the procedure has been completed. This
slow absorption allows for gradual intravascular
volume replacement and elimination of the lidocaine
over several hours without achieving toxic plasma
lidocaine levels (over 5 mg/mL) [8]. This technique
provides excellent anesthesia obviating the need for
general anesthesia and the associated complications,
and provides excellent hemostasis provided by the
vasoconstrictive effects of the epinephrine. Further-
more, owing to delayed lidocaine absorption, pro-
longed anesthesia can last up to 18 hours, mitigating
the need for postoperative analgesic medications [7].
Even with large area-aggressive liposuctions in the
authors experience, postoperative analgesia is rarely
needed. The typical patient reports taking a mild nar-
cotic postoperatively prior to bedtime only because
they worry about waking up with discomfort although
all usually report no significant problems through the
first night. The most common pain complaint on sub-
sequent days is mild soreness aggravated by movement
and it is the exceptional patient that requires anything
beyond acetaminophen or ibuprofen over the next sev-
eral days.
In addition to its local anesthetic effects, an added
benefit of tumescent solution with lidocaine appears to
be an antibacterial effect. The antibacterial properties
of lidocaine are known and have previously been
reported [9, 10]. Contradictory studies, however, have
questioned the antibacterial properties of lidocaine
when very low concentrations are used as in tumescent
fluid [11]. Nevertheless, although studies on this issue
are not definitive, physicians experienced in the tumes-
cent technique have noted a low rate of significant
clinical infections which may be attributed in part to
the antibacterial properties of lidocaine [5, 12, 13].
Addition of bicarbonate to lidocaine appears to enhance
the in vitro antibacterial effect [14].
The tumescent liposuction procedure can be done
safely on an outpatient basis with rapid postoperative
healing. Many physicians, particularly dermatologists,
perform this procedure without additional intravenous
sedation entirely in an office or minor procedure room
setting rather than a surgery center. More significant
risks with liposuction occur with larger volume aspi-
rants in a situation associated with general or deep-
sedation anesthesia in contrast to standard tumescent
anesthesia liposuction.
B.I. Raskin and S. Iyer
7.2.2 Pharmacology of Tumescent
Anesthesia
Tumescent anesthesia relies on the effects of lidocaine,
which acts by blocking the sodium ion flux across
nerve membranes and slowing the rate of depolariza-
tion such that threshold potentials are not reached and
impulses are not propagated [15]. The tumescent
concept works because lidocaines aromatic structure
is lipophilic in nature. Lidocaine is therefore highly
soluble in fat and has a high affinity for the subcutane-
ous compartment. When skin is excised after infiltrat-
ing tumescent anesthesia, there is a marbled appearance
and puddles of anesthetic solution are loculated within
and between connective tissue septa. These lakes act as
physical reservoirs of lidocaine. The lipophilic prop-
erty of lidocaine in the tumescent technique delays the
absorption of lidocaine into the systemic circulation.
The lidocaine is slowly absorbed from the subcutane-
ous compartment over several hours owing to its
affinity for the subcutaneous tissues, the relative hypo-
vascular nature of the subcutaneous tissues, and the
vasoconstrictive effects of epinephrine, all of which
minimize intravascular absorption of the lidocaine
[15]. Compression of the vasculature by the infused
fluid may also contribute to the slow absorption [8].
After infiltration, clinical observation has determined
that optimal anesthesia and hemostasis occur after
1530 minutes. Greater duration of time may allow
additional anesthetic effect. Elimination of the lidocaine
from the fat occurs over 48 hours, with peak plasma
concentrations occurring around 12 hours. When utiliz-
ing a maximum dose of 35 mg/kg, lidocaine concen-
trations have been shown to peak 1214 hours after
infiltration and were in the range 0.82.7 mg/mL [7].
With the tumescent anesthesia formulation, sig-
nificantly higher doses of lidocaine can be used com-
pared with the traditional upper limit of 7 mg/kg
lidocaine with epinephrine. Early work by Klein and
Lillis [16] dramatically altered the manner in which
local anesthesia metabolism and safe dose determina-
tions were viewed. Now it is firmly established that
35 mg/kg lidocaine as performed in liposuction is a
safe level and studies indicate that levels up to 55 mg/
kg may be tolerated safely, presuming there are no
contraindications such as potential drug interactions
or underlying hepatic insufficiency [7, 8]. Caution
must be exercised when using higher doses of lido-
caine in the range 5055 mg/kg as cases of mild
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique
nausea and vomiting have been reported, although
the plasma lidocaine levels were below 3.5 mg/mL
[17]. Doses exceeding 55 mg/kg are associated with
a 2% incidence of mild toxicity of nausea and vomit-
ing and the incidence is 10% or greater if dosages
above 60 mg/ml are used. The cited threshold for
lidocaine toxicity is 5 mg/mL, although deaths have
been reported in the literature at lower levels. Those
patients, however, did not solely have tumescent lipo-
suction under local anesthesia [15].
Tumescent anesthesia is highly effective and has
an extraordinary safety profile when appropriate dos-
ing is used and strict guidelines are maintained.
According to the textbook Tumescent Technique by
Klein [15], tens of thousands of tumescent liposuc-
tion patients have received 3550 mg/kg of lidocaine
with no known reports of deleterious effect, which
has proved the safety of tumescent local anesthesia
for liposuction.
7.2.3 Tumescent Anesthesia Formulation
The tumescent fluid formulated for microcannula
liposuction most often consists of a concentration of
0.050.1% lidocaine. A typical standard 0.1% solution
contains a total of 1,000 mg lidocaine, 10 mEq sodium
bicarbonate, and a concentration of 1:1,000,000
1:2,000,000 epinephrine in 1 liter of normal saline
solution [15]. The full-strength 0.1% solution is useful
when treating smaller areas (neck, jowls) or when
treating those areas which tend to be more fibrous and
tender (periumbilical abdomen, back, breasts, and
female or male flanks). However, tumescent formula-
tions vary depending on the clinical circumstance.
Different concentrations of lidocaine are chosen
depending on the area and volume required. For
instance, a 0.05% lidocaine formulation may be used
when treating more extensive areas where larger
amounts of fluid are required but the maximum safe
dosing is to be maintained. Alternatively, extremely
sensitive areas such as the periumbilical region are
often resistant to 0.05 and 0.1% solutions and a 0.15%
mixture may be required. When infusing just a neck,
higher lidocaine concentrations can be used since only
smaller volumes of total fluid are required. This con-
trasts with the abdomen and flanks, where significantly
larger volumes are required, making use of higher
concentrations potentially problematic. Keeping in
89
mind the 3555-mg/kg upper limit and the volumes of
infiltration needed, varying concentration levels can be
utilized.
Determining which the concentration of anesthetic
fluid to infuse has been empirically determined.
Recently, in a study of 3,430 patients where the only
anesthesia was the tumescent lidocaine infiltration, it
was determined that 500 mg/L (0.05%) was effective
for all areas treated and 400 mg/L (0.04%) was effec-
tive for most areas treated. However, in this report, oral
sedation was occasionally given. After infiltration, 30
to 60 minutes was allowed before lipoaspiration was
begun. If pain occurred during aspiration, the areas
were reinfiltrated with tumescent anesthesia [18].
Epinephrine is a potent adrenergic agent that
acts as a vasoconstrictor that enhances hemostasis
and prevents rapid systemic absorption of lidocaine
from the subcutaneous tissues. Epinephrine dosing
was empirically derived, with experience showing
that doses of 0.51 mg/L (which yields a final epi-
nephrine concentration of 1:1,000,0001:2,000,000)
provided consistent vasoconstriction with a low inci-
dence of tachycardia. The addition of epinephrine to
the mixture results in prolonged local anesthetic
effect and permits higher lidocaine doses by slow-
ing its absorption. Furthermore, the epinephrine pro-
vides a dramatic hemostasis that substantially reduces
blood loss. Although higher concentrations of epi-
nephrine provide more effective hemostasis, patients
should be monitored for tachycardia and hyperten-
sion. Thorough preoperative evaluations should be
performed and lower concentrations of epinephrine
considered in patients with underlying medical con-
ditions such as thyroid or cardiovascular disease.
Smaller areas over multiple sessions can be per-
formed if required. Premedication with clonidine
may also be helpful (described in additional detail
below) in patients who may be sensitive to epineph-
rine effects [15].
The solubility of lidocaine is enhanced in acidic
solutions but these are often more painful to inject.
Buffering of lidocaine solution with sodium bicarbon-
ate has been shown to decrease pain [19]. Because
non-acidic solutions cause the spontaneous degrada-
tion of epinephrine, it is recommended that anesthetic
solutions be freshly mixed on the day of surgery
(Table 7.1) [15]. In the authors personal experience,
hemostasis is more problematic with tumescent mix-
tures prepared the night before surgery.
90
Table 7.1 Standard
tumescent anesthesia Lidocaine (mg)
formulation
0.15% lidocaine 1500
0.1% lidocaine 1000
0.075% lidocaine 750
0.05% lidocaine 500
7.3 Calculating the Maximum
Lidocaine Dose
The maximum lidocaine dose must be calculated for
each patient individually on the basis of the patients
weight, which should be obtained on the day of surgery.
Because of the clinical importance, the author strongly
recommends that a patient is weighed rather than
depending on a stated value. As an aside, the patient
who returns months later complaining about results has
often gained weight and the value documented in the
chart can save the surgeon considerable time with such
a patient. A dose of 3555 mg/kg should not be
exceeded. For a 160-lb man, the maximum lidocaine
dose is calculated as follows: 160 lb/2.2 = 72.3 kg (stan-
dard formula 2.2 lb per kilogram). The total dose range
is from (35 72.3) to (55 72.3), i.e. from 2530.5 to
3976.5 mg of lidocaine.
The absolute upper limit of lidocaine is 3976.5 mg
in this example. Various concentrations and volumes
of tumescent fluid can be used depending on the areas
being treated but the total dose of lidocaine should
not exceed 3976.5 mg. Thus, with a 0.1% lidocaine
solution, the total volume of fluid used should be less
than 4 Liters.
The question arises as to which patients can tolerate
more than the absolute safe limit of 35 mg/kg of
lidocaine. Since lidocaine is lipophilic, then it stands to
reason that thin individuals with reduced body fat
would be at increased risk with higher doses. Similarly,
muscular men with minimal body fat could also be at
increased risk. In contrast, patients with higher overall
body fat content could reasonably be expected to toler-
ate the 55 mg/kg dosing. The surgeon must also con-
sider the impact of any other medications given,
especially intravenous agents that might conflict with
the same metabolic pathways. Consideration must also
be given to the patients overall health status such as
those with impaired hepatic function in deciding the
appropriate maximum dose.
B.I. Raskin and S. Iyer
Sodium Normal
Epinephrine (mg) bicarbonate (mEq) saline (L)
0.51 10 1
0.51 10 1
0.51 10 1
0.51 10 1
7.4 Lidocaine Metabolism
and Toxicity
Metabolism of lidocaine occurs through the hepatic
cytochrome enzymes which convert the lipophilic lido-
caine to a hydrophilic molecule that can be more read-
ily eliminated. Lidocaine is metabolized rapidly with
70% elimination with first pass through the liver where
the molecule undergoes oxidative N-dealkylation.
Lidocaine is largely metabolized by the cytochrome
P450 3A4 (CYP3A4) enzyme. Reduction in the cyto-
chrome enzymes, either through downregulation or
competitive inhibition by other medications, can reduce
the clearance of lidocaine and augment the potential for
lidocaine toxicity. Alternatively, parenchymal liver dis-
ease or decreased hepatic blood flow can also reduce
the rate of lidocaine clearance [7, 20, 21].
Medications such as ketoconazole and erythromycin
can impair lidocaine metabolism by inhibiting its cyto-
chrome P450-mediated metabolism. A thorough under-
standing of lidocaine metabolism and drug interactions
is essential prior to performing tumescent liposuction
to avoid possible lidocaine toxicity. A report of medica-
tion-related lidocaine toxicity after tumescent liposuc-
tion was attributed to concomitant use of sertraline or
flurazepam via their inhibitory effects on the cyto-
chrome P450 enzymes [21]. Table 7.2 includes a list of
some CYP3A4 inhibitors that are clinically relevant
when evaluating a patient preoperatively for liposuc-
tion. It should be emphasized that many medications
are metabolized by the CYP3A4 enzyme system and
the table shown is only a partial list. Furthermore, some
food ingredients such as naringenin and quercetin in
grapefruit juice can also have inhibitory effects on the
cytochrome system [20]; therefore, careful preopera-
tive evaluation for all possible CYP3A4 interactions
must be diligently performed. Each and every medica-
tion that the patient is taking along with their dietary
and health habits should be closely reviewed for possi-
ble cytochrome P450 interactions.
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique 91

Table 7.2 Drugs with potential cytochrome P450 interactions Table 7.3 Signs of lidocaine toxicity
Acebutelol Midazolam (Versed) Lidocaine
Acetazolamide Nadolol level (mg/mL) Signs of toxicity
Alprazolam (Xanax) Naringenin (grapefruit juice) 35 Nausea, vomiting, drowsiness,
Amiodarone (Cordarone) Nefazodone (Serzone) lightheadedness
Anastrozole (Arimidex) Nelfinavir (Viracept) 58 Tinnitus, paresthesias, CNS changes,
cardiovascular toxicity
Atenolol Nevirapine (Viramune)
>8 Coma, seizures, and severe cardiac
Cannabinoids Nicardipine (Cardene)
and respiratory depression
Carbamazepine (Tegretol) Nifedipine (Procardia)
Cimetidine (Tagamet) Norfloxacin(Noroxin)
Chloramphenicol Norfluoxetine
of lidocaine should be kept at or below 35 mg/kg.
Clarithromycin (Biaxin) Omeprazole (prilosec)
The same is true for those patients with decreased
Cyclosporine (Neoral) Paroxetine (Paxil)
Danazol (Danocrine) Pentoxyfylline
hepatic perfusion due to medications or cardiovascular
Dexamethasone Pindolol disease due to possible impaired lidocaine metabolism
Diazepam (Valium) Propranalol and toxicity [7, 15].
Diltiazem (Cardizem) Propofol The issue of medication interactions is especially
Erythromycin Quinidine (Quinaglute) important when considering the choice of ancillary
Esmobolol Remacemide medications. Careful attention must be paid to possible
Felodipine (Plendil) Ritanavir (Norvir) cytochrome P450 interactions when choosing prophy-
Fluconazole (Diflucan) Saquinavir (Invirase) lactic antibiotics, analgesics, and anxiolytics. For exam-
Flurazepam (Dalmane) Sertinadole ple, benzodiazepams are frequently administered orally
Flouxetine (Prozac) Sertraline (Zoloft) prior to tumescent liposuction. While most benzodiaza-
Fluvoxamine (Luvox) Stiripentol pams are metabolized by CYP3A4, lorazepam is not
Indinavir (Crixivan) Terfenadine (Seldane) and can be safely used without altering lidocaine
Isoniazid Thyroxine metabolism [15]. Thus, many liposuction surgeons favor
Itraconazole (Sporanox) Timolol
lorazapam as an anxiolytic. Usual dosing is 0.51.0 mg
Ketoconazole (Nizoral) Triazolam (Halcion)
although dosing to 2 mg may be utilized. The only
Labetalol Troglitazone (Rezulin)
disadvantage is a relatively slower onset compared to
Methadone Troleandomycin (TAO)
diazepam. Lorazapam has the benefit of a prolonged
Metoprolol Valprolic acid
Metronidazole (Flagyl) Verapamil (Calan)
half-life and thus can be given the night before for those
Mibefradil (Posicor) Zafirlukast (Accolate) patients with prohibitive anxiety and additional dosing
Miconazole (Monistat) Zileuton (Zyflo) may not be necessary before surgery.
In addition to concomitant medication use and
underlying medical disease, there are several factors
In patients on medications that affect the cyto- that should be considered in determining the maximum
chrome enzyme system, the dose of lidocaine used safe dose of lidocaine. Both male patients and thinner
during tumescent liposuction should be maintained at patients tend to have a lower volume of distribution for
or below 35 mg/kg in the authors opinion. If possible, lidocaine in the subcutaneous compartment and may
medications with cytochrome P450 interactions should not tolerate higher doses of lidocaine. Elderly patients
be discontinued prior to surgery. Because some medi- as well may not tolerate higher doses owing to dimin-
cations which are cytochrome inhibitors have a ished liver perfusion that occurs with age [21].
prolonged half-life and are tightly bound to plasma When lidocaine is employed properly, the risk of
proteins, at least 7 days should elapse between the time lidocaine toxicity is very low with the pure tumescent
that the medication is discontinued and the surgery liposuction technique. However, all surgeons practicing
date. As previously noted, patients with a history of tumescent liposuction should be familiar with the signs
liver disease or hepatic insufficiency should also be of lidocaine toxicity that occur when serum levels
treated conservatively. Generally, these patients should exceed 5 mg/mL (Table 7.3). Treatment of lidocaine
be treated only if hepatic transaminases and liver toxicity, which is beyond the purview of this text,
enzymes are in the normal range and the total dose includes supportive measures and seizure treatment.
92
The author advises that all liposuction surgeons be
certified in advanced cardiac life support.
7.5 Alternative Anesthetic Agents
Various alternative tumescent formulations have been
utilized, including infusion of dilute epinephrine with-
out local anesthesia with supplemental bupivacaine
after surgery [22]. However, owing to bupivacaines
effect on the myocardium, the potential for cardiotox-
icity is greater and its use is not advocated [23]. Use of
prilocaine 35 mg/kg was reported in the European lit-
erature at and it was found to be safe. Methemo-
globinemia is a potential side effect of prilocaine,
however, and there is a paucity of data in the literature
to date on this anesthetic agents use in liposuction
[24]. At this time, the use of alternative anesthetic
agents is not well studied and their safety profiles
remain unclear. Lidocaine is well documented to be
safe and effective in tumescent liposuction and remains
the standard in the USA.
7.6 Ancillary Pharmacology
The material in this section is presented only as a gen-
eral discussion on alternative and additional drugs.
The reader should be conversant with the medications
before prescribing.
The decision for prophylactic and perioperative
antibiotics has no current standard. As discussed ear-
lier, infection rates are extremely low with the tumes-
cent technique. This may be related to lidocaine acting
as discussed earlier a few lines above [5, 9, 10].
Clinically, the decision for antibiotics at this time is
determined by the surgeon. The authors routinely pre-
scribe prophylactic broad-spectrum antibiotics initi-
ated orally the day prior to surgery and repeated the
morning of surgery. It is essential that the antibiotic of
choice is not metabolized by the CYP3A4 system so as
to avoid interaction with lidocaine metabolism.
Lorazepam by mouth (as low as 0.5 mg but usually
12 mg) should be considered as the recommended
sedative preoperatively because it is not metabolized
by the cytochrome P450 system. Other benzodiaze-
pams, including diazepam, may have interactions
with lidocaine through the CYP3A4 system and are
generally avoided. Orally administered lorazepam can
B.I. Raskin and S. Iyer
be used to produce the same sedative, anxiolytic, and
anterograde amnestic effects as 1020 mg diazepam.
Nausea may occur with 2 mg and often only 1 mg is
needed. The drug has a half-life of 10 h or longer and
frequently a dose taken the night before might be all
that is needed. Alternatively, a dose of 1 mg lorazepam
may be administered 1 hour prior to surgery [1].
Clonidine has been popularized as an effective anal-
gesic with mild sedative and antianxiolytic properties
at a single dose of 0.1 mg orally and can be safely used
unless patients have low blood pressure or slow pulse.
It is also especially useful in patients who may be bor-
derline with regard to tachycardia and hypertension to
maintain a lower heart rate and blood pressure during
surgery. Clinical effects begin 2040 minutes after
ingestion. Repeated doses should not be given.
Clonididine is a drug underappreciated by liposuction
surgeons and should be recognized as an effective sup-
plement for analgesia, which can help minimize the
need for narcotics. Furthermore, clonidine may poten-
tiate the anesthetic effects of lidocaine and enhance the
effects of opiates [15]. The authors frequently utilize
clonidine in various office surgeries such as fraction-
ated CO2 lasers, with tissue tightening technologies,
or when blepharoplasty is performed under local
anesthesia.
Klein also advocates the use of 0.30.4 mg of intra-
venous atropine given in a dilute mixture after intrave-
nous access has been established to prevent vasovagal
events when clinically needed [15]. The authors have
never determined atropine to be necessary.
Midazolam is widely used by surgeons and anes-
thesiologists in cosmetic surgery both before surgery
and as part of intravenous sedation. According to
Klein, 3% of patients require intravenous midazolam
at a dose of 1 mg during infiltration to supplement oral
clonidine and lorazapam. Midazolam has a short dura-
tion of effect after a single dose. Problems with disin-
hibition may occur with this drug but the amnestic
effect is significant and often beneficial during the
infiltration phase where discomfort may be present in
select patients [15]. While respiratory depression is
possible, the drug may be immediately reversed with
intravenous Flumazacon [25].
There is a theoretical problem with concomitant use
of beta-blockers in conjunction with epinephrine as
unopposed alpha stimulation could result. However, this
appears to be primarily a theoretical issue. In clinical
practice, it appears that the absorption of epinephrine
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique
from the tissue is too slow to result in a significant prob-
lem. This problem has not surfaced in any of the major
studies on morbidity and mortality (see subsequent por-
tion of this chapter). As a result, patients on beta-block-
ers generally continue their usual doses [17]. However,
if a modified tumescent technique is used and general
anesthesia is employed, the anesthesiologist should be
advised to avoid the use of propranalol, owing to the
potential for unopposed adrenergic stimulation [26].
Narcotics are utilized by many liposuction surgeons
[27]. They may be provided as part of intravenous
sedation and anesthesia or as supplemental analgesia
for surgeons utilizing the local anesthetic liposuction
approach. The combination of meperidine and antihis-
tamine has a long and established usage for all types of
pain management in various outpatient clinical circum-
stances and may be provided by intravenous or intra-
muscular routes. Sometimes doses as low as 10 mg can
be effective in the authors experience, although dosing
of 50 mg may be necessary. Naloxone should always be
available when administering narcotics. Butarphanol in
low doses is a safe alternative [28]. Butarphanol has
minimal respiratory depression and has the advantage
of not requiring special narcotic storage or ordering
because of its low potential for abuse. This drug is
given in 1 mg increments and the authors favor IM
injection. Onset takes about 5 minutes with peak effects
occurring over the next 15 minutes in the authors expe-
rience. The author usually uses a single 1 mg dose and
follows up with another 1 mg in about 15 min if neces-
sary. Few, if any, patients experience nausea, making
this another easy-to-use medication especially when
combined with 2550 mg of hydroxyzine. Butorphenol
lasts about 1 hour and interestingly appears to wear off
quite abruptly with the patient transitioning from quiet
comfort to pain complaints. Fentanyl in a 2550-mg
dose may be substituted for meperidine, although cau-
tion must be exercised as it is metabolized by the cyto-
chrome 3A4. In general, with intravenous dosing,
fentanyl has a relatively short duration of action and
causes less nausea and orthostatic hypotension [15].
7.7 Tumescent Liposuction Technique
7.7.1 Tumescent Fluid Inltration
Various techniques for fluid infiltration have been
described and individual variations among surgeons
93
are extremely common. Routinely, a warmed solution
of the tumescent formula is prepared. Warm and neutral
tumescent anesthetic solutions are beneficial for reduc-
ing painful injections [29]. A temperature of 3740C
has been reported to be ideal to maximize patient com-
fort upon infiltration [30]. The use of a bicarbonate
buffer also helps to minimize discomfort. Water baths
are the most accurate way of achieving consistent tem-
peratures. If a microwave is utilized to heat the solution,
make sure and allow the bag to stand for several min-
utes so that the heat will equalize since some regions
can be excessively hot due to uneven heating.
The tumescent fluid is infiltrated first using a
25-gauge spinal needle to sprinkle the fluid diffusely.
Once a small amount of fluid has been distributed over
the area to be treated, a 20-gauge spinal needle is
subsequently used to infiltrate more fluid. Finally,
small incisions with a no. 11? blade or a 2-mm punch
are made in the skin and a 14-gauge multihole infiltra-
tion cannula is inserted into the subcutaneous plane to
achieve complete tumescence. Most surgeons utilize
the same incision ports for infiltration that are used for
fat aspiration. When performed in this stepwise fash-
ion, patient comfort is maximized. Although spinal
needles may help with patient comfort, some surgeons
opt to avoid these needles and use only the blunt infil-
tration cannulas as they are potentially less traumatic.
During the infiltration process, attention must be
paid to maintaining the needle at approximately a
3045 angle with respect to the horizontal plane.
A fanlike pattern is utilized to ensure wide distribution
of the fluid (Fig. 7.1). The surgeon at all times should
be aware of where the end of the needle resides to
avoid injury to thoracic and intra-abdominal structures.
Pinching the skin while infiltrating creates a tunnel for
the cannula resulting in more control of the cannula
tip. When the infiltration cannula is used in the final
stages, it is passed in a plane that is parallel to the hori-
zontal plane. Fluid must be delivered to all levels of
fat. Infiltrating only the more superficial fat may clini-
cally give a tumesced feel to the skin, but the deeper fat
has not been anesthetized; therefore, it is recommended
that the deeper fat be infiltrated first. The subcutaneous
tissue can be gently grasped and lifted during the
infiltration process to ensure that the deeper fat is anes-
thetized and to prevent inadvertent injury to deeper
structures (Fig. 7.2).
The tumescent fluid is infiltrated under pressure.
Most physicians utilize pumps where the rate can
94 B.I. Raskin and S. Iyer

Fig. 7.1 Fanlike pattern from multiple sites for infiltration and Fig. 7.2 Fat being grasped and lifted to infiltrate deep layers
liposuction without injuring deeper structures

be preset and a foot pedal allows on/off control.

The amount of time required for infiltration can be
reduced by increasing the rate of lidocaine infusion but
this is often accompanied by increased patient discom-
fort and may require more premedication depending
on patient tolerance [31]. Additionally, rapid infusion
may result in patchy or uneven distribution and incom-
plete anesthesia and hemostasis. Meticulous infiltra-
tion with tumescence throughout the fat results in less
than 1% blood loss per liter of aspirate, whereas rapid
infiltration results in 7% blood loss per liter aspirated
(Fig. 7.3) [15]. It has been shown that serum levels of
lidocaine are not affected by the pressure or the rate of
Fig. 7.3 Fat aspiration in multiple planes with a fanlike pattern
infusion [32, 33]. Alternative methods include hanging
an intravenous bag with a pressure cuff. The surgeon
must monitor both the total volume infiltrated and the Hydrodissection with to tumescent fluid helps main-
total lidocaine dose carefully during the infiltration tain patient comfort in that the infiltration cannula is
process. To avoid errors, the authors label each IV bag not pushed through the tissue so much as the fluid is
and do not discard them until the case is completed. utilized to open the tissue beyond the cannula tip.
Infiltration is continued until the tissue has become Properly performed infiltration is slow and steady,
fully tumesced. The infiltrated areas have a firm, edem- allowing the cannula to slip between fibrous septa
atous quality to palpation. The skin is characterized by smoothly rather than imposing excessive traction as it
pallor and is slightly cool owing to the vasoconstrictive is pushed through resistant tissue.
effects of the tumescence. A peau dorange appearance The volume infiltrated is the minimal amount to
is undesirable and should be avoided. achieve complete local anesthesia. Empirically it is
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique
usually on the order of 2:1 or 3:1 (fluid infiltrated to
expected volume of aspirated fat) [15]. Maximum
tumescence is not required for complete anesthesia or
vascular stabilization, and excess volumes should be
avoided as it results in a more difficult liposuction.
Certain areas are typically more uncomfortable to
infiltrate. Generally, these are the more fibrous loca-
tions such as the periumbilical region. Aspirating near
scars such as abdominal scars can also be uncomfort-
able, such as abdominal surgical scars. The authors
recommend infiltrating parallel to the scar on both
sides and underneath before trying to dissect the fibrous
underlying tissue. In the authors experience, the act of
infiltrating the tissue informs the surgeon of the rela-
tive difficulty of the liposuction and also increases
awareness of borderline areas of the field such as under
the ribs. The surgeon can spend extra time infiltrating
difficult areas to reduce any problems during the
remainder of the procedure.
7.8 Microcannulas and Lipoaspiration
The tumescent liposuction technique is nicely comple-
mented by the use of microcannulas. These cannulas
are designed to have a narrow diameter and may have
multiple apertures or only one or two holes. They vary
in length, so both large and small areas can be effec-
tively treated and proximal and distal areas can be
reached from a single incision site. Microcannulas offer
a number of advantages. First, owing to the small diam-
eter, they are generally less painful as they penetrate
through the subcutaneous tissue. Additionally, the
smaller-diameter cannulas often pass more easily
through fibrous tissue, which is especially advanta-
geous in specific areas such as the upper abdomen,
back, and breasts. Generally, the microcannulas remove
small amounts of fat with each stroke. This allows for
gradual and precise removal of fat to prevent textural
irregularities and depressions and facilitates the art of
sculpting. Although slower than larger cannulas, micro-
cannulas can ultimately be just as aggressive in remov-
ing large volumes of adipose tissue. Cannula size and
type is a matter of each surgeons individual preference
and a variety of cannulas can be used effectively
depending on the surgeons experience and skill.
Before beginning infiltration, the areas to be treated
should be marked in a topographical fashion while the
patient is standing. These markings should indicate
95
those areas of denser fat accumulations where more fat
is to be removed as well as those areas where less fat is
present. The markings should also designate the edges
of the region being treated where feathering will occur
for optimal blending and cosmetic outcome [15].
After infiltration of the tumescent fluid, the surgeon
should wait approximately 1530 minutes to allow the
tumescent fluid to reach maximum effect. As patients
generally are awake during the tumescent liposuction
procedure, they can be positioned precisely to allow
for optimal liposuction.
Initially, smaller-diameter cannulas can be used to
penetrate the subcutaneous tissue and create tunnels
through which larger cannulas can be passed. Through
this method, intraoperative comfort will be maximized
[27]. The cannula is generally passed through the same
incisions used for infiltration of the tumescent fluid.
These entry points are strategically placed to be mini-
mally visible after the patient has fully recovered.
Multiple entry points may be required to access the
entire area to be treated. Entry sites should be ran-
domly placed without symmetry within any given area
that is being treated. This will ultimately produce the
most inconspicuous results.
The fat is removed in layers, starting first with the
deepest layers. The skin is lifted with the non-dominant
hand to create a tunnel of tissue through which the can-
nula is passed. A fanning pattern is used to remove an
entire plane of fat. This fanning pattern can be repeated
in different planes, starting in the deep subcutaneous fat
and moving more superficially (Fig. 7.3) [15]. The end
point with tumescent liposuction is somewhat different
from that of non-tumescent techniques in that there is
still fluid in the tissue after the appropriate amount of
fat has been aspirated. Determining the end point is a
matter of surgical experience and depends on tissue
palpation and visual configuration.
7.9 Postoperative Care: Open Drainage
and Compression
The postoperative course following tumescent liposuc-
tion is generally rapid and comfortable. However,
patients must be well informed as significant edema,
purpura, and fluid drainage can occur. Furthermore,
the drainage may be blood tinged and alarming to the
unprepared patient. The entry sites through which the
liposuction is performed are not closed. Rather, they
96
remain open and serve as drainage points through
which the tumescent fluid can flow resulting from a
combination of compression and gravitational forces.
Open drainage can continue for up to 34 days and
appropriate absorbent dressings are required [15].
Immediately after the procedure is completed,
highly absorbent pads are applied. The pads are applied
under compressive elastic garments and left in place
for 24 hours. They should be replaced as needed if they
become soaked and should be utilized until drainage
ceases. After the drainage has discontinued, the dress-
ing should be changed to a mildly compressive support
garment. This dressing provides support and can help
to contour the skin as it retracts during the weeks fol-
lowing liposuction. Heavy compression during this
period is unnecessary and may be counterproductive
by impeding lymphatic drainage. Klein [34] has
described this two-phased postoperative compression
system as bimodal compression.
Rapid return to normal function with tumescent
liposuction can be dramatic. In general, for abdomen
and flanks, most patients prefer a few days of rest and
typically return to work 4 or 5 days after surgery.
However, with tumescent liposuction many patients
rebound quickly and we have had patients leave on
vacation the next day or return to work within a day or
two. This is because of the less traumatic nature of
tumescent liposuction under local anesthesia owing to
techniques of infiltration and use of microcannulas.
Skin retraction during the postoperative period occurs
over several weeks (Fig. 7.4). Some postoperative edema
in the treated fields may persist for a few weeks. Patients
need to be reassured that the final cosmetic outcome
will not be apparent for at least 2 months after the pro-
cedure. Occasionally, touch-up procedures can be per-
formed if needed but waiting at least 23 months or
longer after the initial procedure is prudent.
7.10 Complications
As with any surgical procedure, inherent risks and
potential complications exist with tumescent liposuc-
tion. The advantage of the tumescent microcannula
liposuction technique is that the potential risks of
liposuction are minimized. Given the excellent hemo-
stasis provided by the epinephrine in the tumescent
fluid, the risk of postoperative bleeding is very low.
Thorough knowledge of the underlying anatomy is
B.I. Raskin and S. Iyer
essential, however, to make sure that larger vessels
are not transected by the smaller-diameter cannulas
which are potentially more traumatic than larger-
diameter cannulas [15]. As discussed earlier, there is a
low rate of postoperative infection possibly owing to
antibacterial properties of lidocaine [9, 10]. Periopera-
tive prophylactic antibiotic use may also help to mini-
mize infection rates. Scarring is generally minimal
if microcannulas and small entry points are used.
Reduced scarring is a major advantage of the micro-
cannula technique, but patients must still be warned of
possible pigmentary alteration and even hypertrophic
scarring in prone individuals. Patients should also be
advised that persistent numbness or dysesthesia may
occur in treated areas, although this is usually not
permanent [15, 35].
Textural irregularities, rippling, and dimpling are
complications associated with liposuction that are
greatly minimized with the tumescent microcannula
technique. Because small volumes of fat are removed
with each stroke, the fat can be removed in thin layers
to achieve a gradual and uniform reduction in the sub-
cutaneous layer. This allows for sculpting the tissue
with uniformity giving a smooth, even result.
Some complications unique to or more pronounced
with the tumescent technique relate to the large vol-
umes of lidocaine-containing fluid that are infiltrated.
Significant ecchymoses and edema can occur espe-
cially in the scrotal/labial areas or the distal upper and
lower extremities. When performing liposuction of the
abdomen, thighs, arms, or distal lower extremities,
patients should be forewarned that this is normal for
the postoperative course. Gradual resolution of the
purpura and edema occurs over several days following
the procedure [15, 3436].
In some patients, seromas may form and larger
patients with a pannus where fluid can collect are at an
increased risk for this complication. Small seromas
generally spontaneously resolve but larger seromas
may require aspiration of the fluid with a 20-gauge
needle [15, 36].
Skin ulceration secondary to necrosis is a rare com-
plication and can occur from excessive injury to the der-
mis. Care must be taken to avoid superficial liposuction
in the dermis which can compromise the dermal and
epidermal vascular supply. With the proper liposuction
technique, a superficial layer of fat should be left intact
and the dermis should be free from injury, thereby avoid-
ing the risk of skin ulceration and necrosis [15].
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique 97

Fig. 7.4 Liposuction of lateral thighs and hips: (a) Preoperative; (b) postoperative
98
7.11 Safety of Tumescent Liposuction
A 1999 article detailing five deaths involved patients
with systemic anesthesia, either intravenous sedation
or general anesthesia [37]. None of the patients had
evidence of lidocaine toxicity. One developed abrupt
EKG and physiologic changes within 30 seconds of
being rotated from the prone to the supine position,
which may have been related to severe hypotension
that can develop with combinations of droperidol and
fentanyl [38]. None of these patients had true tumes-
cent liposuction in that the tumescent fluid was not
used as the main source of pain control. Three patients
succumbed to intraoperative hypotension of unknown
cause; one from pulmonary thromboembolism and one
from fluid overload. Only one patient had an elevated
lidocaine level of 5.2 but this was after resuscitative
efforts. The author concluded that two of the cases
may have been caused by lidocaine toxicity, but this
does not appear to be supported by the data [13].
In 2000, Coldiron [39, 40] reviewed reports of deaths
in Florida and concluded that specific details were lack-
ing and that the complications were not specific to an
office setting or involved tumescent liposuction.
The association with systemic anesthesia was seen
95 liposuction deaths in a study of plastic surgeons
[41]. The survey of 1,200 plastic surgeons performing
a total of 496,245 procedures demonstrated a mortality
of 1 in 5,224 procedures, which was computed to a rate
of 19.1 per 100,000; 47.7% occurred after office-based
surgery and 16.9% after hospital-based surgery. The
primary cause of death was thromboembolism in
23.4% of cases. None of the patients succumbed to
lidocaine toxicity.
A survey of dermatologists was performed looking
at complications occurring from 1994 through 2000.
Data were obtained on a total of 66,570 liposuction
procedures. No deaths occurred and the serious
adverse-event rate was 0.68% [13]. In this review,
procedures had been performed in non-accredited
office settings, ambulatory surgical centers, and hospi-
tals. Adverse event rates were higher for tumescent
technique liposuction combined with intravenous or
intramuscular sedation than for tumescent technique
liposuction combined with oral or no sedation. Of the
45 adverse events recorded, only one is listed as
lidocaine toxicity. The conclusion was that tumescent
liposuction performed by dermatologic surgeons is
safe in an office setting [13].
Other studies have found that tumescent liposuction
as performed per the American Society of Dermatologic
B.I. Raskin and S. Iyer
Surgery (ASDS) guidelines is considered very safe
and should be differentiated from more aggressive
liposuction methods [1, 4244]. The ASDS data base
of over 300,000 procedures from 1995 to 2000 per-
formed according to ASDS guidelines demonstrates
no deaths [1].
Similarly, a 1988 survey encompassing 9,478 tumes-
cent liposuction procedures performed by dermatologists
without intravenous sedation documented no fatalities
[45]. A 1995 survey of 15,336 tumescent procedures as
performed by dermatologists showed no fatalities [12].
A 1999 analysis of malpractice claims from 1995 to
1997 showed that dermatologists performing liposuc-
tion in the office had fewer malpractice claims than
plastic surgeons performing liposuction in the hospi-
tal. The conclusion was attributed to the use of the
tumescent liposuction technique and the smaller vol-
umes of fat removed by dermatologic surgeons [46].
A more recent study published in 2009 assessed the
safety of liposuction exclusively with tumescent anes-
thesia in 3,240 consecutive cases in which there were
no deaths and no hospitalizations. The nine minor
complications encountered were liposuction related
and unrelated to anesthesia or lidocaine [49].
Fatality risk factors with liposuction may include
general or intravenous sedation, multiple surgeries per-
formed concurrently, removal of large volumes of fat
during one procedure, inpatient setting, administration
of toxic doses of lidocaine combined with general/intra-
venous anesthesia, and intravenous fluid overload [47].
Dermatologists commonly rely on tumescent anes-
thesia as the primary pain management method during
liposuction. When intravenous or general anesthesia
is added, a variety of drugs that are metabolized by the
same cytochrome enzymes or reduce hepatic blood
flow may be utilized resulting in diminished lidocaine
metabolism. Further, the subcutaneous tissue may be
underinfused, which means the tissue may not be
fully tumesced. It is thought that full tumescence pro-
tects blood vessels in the fibrous septae by compres-
sion making liposuction less traumatic. Intravenous
sedation and general anesthesia are more frequent
when larger-volume liposuction is planned or in con-
junction with other cosmetic procedures. The
combination of multiple forms of anesthesia and the
combination of drug effects and large-volume lipo-
suction may be the cause of the mortalities [41].
One issue of concern is deep venous thrombosis
leading to pulmonary embolism subsequent to liposuc-
tion and its relationship to hormonal therapy.
Butterwick [48] indicates that the incidence of deep
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique
venous thrombosis with true tumescent liposuction
without general anesthesia or deep intravenous seda-
tion appears no greater than the general incidence in
women on oral contraceptive or hormone replacement.
The conclusion is that these medications need not be
discontinued prior to surgery unless additional risk
factors are present, such as estrogen content greater
than 35 mg/day. One additional recommendation is
proper fitting of postoperative garments to avoid con-
stricting venous return and making sure women ambu-
late postoperatively. Graduated support hose were
recommended for women with increased risk factors
of deep venous thrombosis [48].
7.12 Guidelines for Maximum Volumes
of Lipoaspiration
Guidelines for safety establishing the maximum vol-
ume of aspirate have been set by the American
Academy of Dermatology as 4,500 mL of fat and by
the ASDS as 5,000 mL of total fluid/fat [1, 36]. The
authors remove no more than 45 Liters of fat during
each session. If patients have several areas requiring
treatment, multiple sessions must be planned. Safety
of the tumescent liposuction technique is maximized
when it is performed in compliance with these
guidelines.
7.13 Conclusions
Tumescent liposuction under local anesthesia with
the microcannula technique allows for very safe and
effective body sculpting and fat reduction entirely
under local anesthesia. Thorough understanding of the
pharmacology of lidocaine and implementation of the
infiltration and aspiration guidelines and techniques
associated with tumescent microcannula liposuction
are essential to achieve optimal outcomes.
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Chuang TY, Farmer ER, Lewis CW, Lowery BJ (2001)
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3. Fischer G (1976) First surgical treatment for modeling
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16. Lillis PJ (1988) Liposuction surgery under local anesthesia:
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cases of liposuction. J Am Acad Dermatol 62(6):988994
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traindicated in tumescent liposuction. Plast Reconstr Surg
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Olbrisch RR (2004) Prilocaine plasma levels and methemo-
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cent liposuction. Dermatol Surg 23(12):11311134
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specialty of the physician affect fatality rates in liposuction?
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patient surgical setting. Cosmet Dermatol 14:10
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a review of 9478 cases performed by dermatologists.
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(1999) Does the location of the surgery or the specialty of the
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Dermatol Surg 35(11):17281735
 Tumescent Technique
8
Melvin A. Shiffman

8.1 Introduction 2. For local tumescent anesthesia:

(a) Normal saline 1,000 mL
In the early days of liposuction, the dry technique was (b) Epinephrine 1 mg
used with general anesthesia. The technique used had no (c) Lidocaine 1,000 mg
fluids injected into the tissues, except perhaps local anes- The amount of tumescent solution compared to
thesia, and resulted in 2045% blood loss [16]. Liposuct- removal of aspirate was 1:1.
ion was limited to 2,0003,000 mL because of the blood Klein, in 1990 [16], showed that 35 mg/kg was a safe
loss, and patients were frequently given transfusions [2]. amount of lidocaine to use for local tumescent anesthe-
The wet technique relies on infusions of 100300 mL sia. The solution utilized at that time consisted of:
of normal saline into each site but has blood loss of 1. Normal saline 1,000 mL
1530% [711]. With epinephrine added to the fluid, 2. Epinephrine 1 mg
the blood loss is reduced to 2025%. 3. Lidocaine 500 mg
The tumescent technique has improved the problem 4. Sodium bicarbonate 12.5 mEq
of blood loss, reducing it to 17.8% [12, 13]. The term Klein, in 1993 [12], had changed the local tumes-
superwet anesthesia has been used to describe the cent anesthesia solution to:
same fluid injection as with the tumescent technique 1. Normal saline 1,000 mL
[14]. This technique consists of an infusion of saline 2. Epinephrine 0.50.75 mg
with epinephrine and lidocaine and an aspirate removal 3. Lidocaine 5001,000 mg
of approximately 1:1. Local tumescent anesthesia 4. Sodium bicarbonate 10 mEq
usually has a fluid infusion to aspirate of 2:1 or 3:1. 5. Triamcinolone 10 mg (optional)
The mean tumescent solution compared to total
aspirate was 4,609 mL:2,657 mL or almost 2:1.
8.2 Local Tumescent Anesthesia By 1995, Klein [17] had changed the tumescent
formula to:
Klein reported the use of local tumescent anesthesia in 1. Normal saline 1,000 mL
1987 [15]. The report described solutions used that 2. Epinephrine 0.50.65 mg
consisted of: 3. Lidocaine 5001,000 mg
1. For general anesthesia: 4. Sodium bicarbonate 10 mEq
(a) Normal saline 1,000 mL 5. Triamcinolone 10 mg
(b) Epinephrine 1 mg In 2000, Klein [18] described a variation of drugs in
the local tumescent solution according to the area
being liposuctioned. The basic solution to be changed
M.A. Shiffman
after checking for anesthesia completeness was:
Chair, Section of surgery Newport Specialty Hospital,
Tustin, CA, USA 1. Normal saline 1,000 mL
e-mail: shiffmanmdjd@gmail.com 2. Lidocaine 500 mg

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 101

DOI 10.1007/978-3-642-21837-8_8, Springer-Verlag Berlin Heidelberg 2013
102
3. Epinephrine 0.5 mg
4. Sodium bicarbonate 19 mEq
If the anesthesia was not adequate, then a variety of
formulations were proposed for each area of the body
areas and ranged from lidocaine of 7501,500 mg, epi-
nephrine from 0.5 to 1.5 mg [12, 1426], and sodium
bicarbonate of 10 mEq.
Local tumescent anesthesia is used as the anesthetic
for performing liposuction, especially with small
cannulas. The same fluid can be used with conscious
sedation to provide the necessary local anesthesia.
8.3 Tumescent Technique
Compared to local tumescent anesthesia, the tumescent
technique is used to diminish blood loss and bruising,
provide fluid replacement, and act as a local anesthetic
after surgery. The tumescent technique is used with con-
scious or deep sedation or general anesthesia. The solu-
tion utilized is a variation on local tumescent anesthesia
with the main elements being the fluid, either normal
saline or lactated Ringers (1,000 mL), and epinephrine
1 mg for vasoconstriction. There is some use for the
inclusion of lidocaine but not at the levels necessary for
local tumescent anesthesia. The expected tumescent
fluid to total aspirate is usually 1:1.
The authors formula for the tumescent technique
with general anesthesia or deep sedation consists of:
1. Lactated Ringers 1,000 mL
2. Epinephrine 1 mg
3. Lidocaine 250 mg
Sodium bicarbonate, 12.5 mEq, is added and lido-
caine increased to 350 mg if local tumescent anesthe-
sia with or without conscious sedation is utilized.
The total aspiration, except for rare cases, does not
exceed 5,000 mL. Tumescent fluid, with 250 mg lido-
caine in 1,000 mL, having a total of 5,000 mL admin-
istered gives a total of 1,250 mg lidocaine, which is
well under 35 mg/kg in most patients. This allows
5,000 mL total aspirate (1:1), and in a 70-kg (150 lbs)
patient, the lidocaine infused is 17.9 mg/kg. In con-
trast, local tumescent anesthesia using 500 mg lido-
caine per liter in a 70-kg patient requires 7,000 mL of
tumescent fluid to obtain 3,500 mL total aspirate (2:1),
and the total lidocaine is 3,500 mg or 50 mg/kg.
Cardenas-Camarena [27] reported the use of the
tumescent technique with the fluid consisting of
M.A. Shiffman
1,000 mL normal saline and 1 mg epinephrine in
patients having general anesthesia or peridural regional
block (with lidocaine). The volume of tumescent fluid
to extracted fluid was 1:1.
In the facial area, the total lidocaine should proba-
bly not exceed 7 mg/kg early in the injection since
absorption of the lidocaine peaks in 515 min until the
epinephrine takes effect at 15 min. The face is highly
vascular, and epinephrine takes 15 min to cause ade-
quate vasoconstriction. There is a second peak of lido-
caine in 8 to 14 h. Lidocaine in facial tumescence can
exceed a total of 490 mg in a 70-kg patient if infused
slowly. The more rapid the infusion, the lower the
blood level of lidocaine will need to be to result in
toxicity.
8.4 Discussion
Most patients in the authors practice prefer not to be
awake during the liposuction procedure. They are
frightened and anxious and have heard things from
friends or over the internet about the gross methods
used in liposuction. Watching or hearing the sounds
(machines and talking) with the liposuction procedure
is abhorrent to some patients. Just the thought of the
slightest discomfort during the procedure is enough for
some patients to prefer general anesthesia or deep
sedation. There have been instances of surgeons per-
forming liposuction with local tumescent anesthesia
where the patient has complained about pain and the
surgeon would not reinject tumescent fluid or avoid the
painful area since the procedure is almost done.
The use of the tumescent technique combined with
low vacuum [28] has resulted in minimal blood loss,
better patient satisfaction with the results of liposuc-
tion, and less bruising. The idea is to fill the areas to be
liposuctioned with enough fluid to swell the tissues but
not cause blanching. Injection of fluid begins with
tunnels in the deep subcutaneous tissues and ends in
tunnels in the superficial fat. Total aspirate usually
approximates the amount of infusate without con-
sciously attempting to get them equal.
Liposuction is stopped in any tunnel that produces
blood. It is possible to infuse more tumescent fluid
if the preliminary results are not satisfactory to the
surgeon, blood is beginning to appear in some of the
tunnels, and more liposuction is required.
8 Tumescent Technique 103

References 15. Klein JA (1987) The tumescent technique for lipo-suction.

Am J Cosm Surg 4(4):263267
16. Klein JA (1990) Tumescent technique for regional anesthe-
1. Dillerud E (1991) Suction lipoplasty: a report on complica-
sia permits lidocaine doses of 35 mg/kg for liposuction.
tions, undesired results, and patient satisfaction based on
J Dermatol Surg Oncol 16(3):248263
3511 procedures. Plast Reconstr Surg 88(2):239246
17. Klein JA (1995) Tumescent technique chronicles: local
2. Courtiss EH, Choucair RJ, Donelan MB (1992) Large-
anesthesia, liposuction, and beyond. Dermatol Surg 21:
volume suction lipectomy: an analysis of 108 patients. Plast
449557
Reconstr Surg 89(6):10681079
18. Klein JA (2000) Tumescent formulation. In: Klein JA (ed)
3. Ersek RA (1990) Severe and mortal complications.
Tumescent technique: tumescent anesthesia & microcannu-
In: Hetter GP (ed) Lipoplasty: the theory and practice of
lar liposuction. Mosby, St. Louis, pp 187195
blunt suction lipectomy, 2nd edn. Little, Brown, Boston, pp
19. Greco RJ (1997) Massive liposuction in the moderately obese
223225
patient: a preliminary study. Aesthet Surg J 17(2):8790
4. Drake LA, Ceilley RI, Cornelison RL, Dobes WL, Dorner W,
20. Hanke CW, Bernstein G, Bullock S (1995) Safety of
Goltz RW, Lewis CW, Salasche SJ, Chanco Turner ML,
tumescent liposuction in 15,336 patients. Dermatol Surg
Alt TH et al (1991) Committee on Guidelines of Care for
21:459462
Liposuction. J Am Acad Dermatol 24:489494
21. Kaplan B, Moy RL (1996) Comparison of room temperature
5. Hetter GP (1989) Blood and fluid replacement for lipoplasty
and warmed local anesthetic solution for tumescent liposuc-
procedures. Clin Plast Surg 16(2):245248
tion: a randomized double-blind study. Dermatol Surg 22:
6. Courtiss EH, Kanter MA, Kanter WR, Ransil BJ (1991)
707709
The effect of epinephrine on blood loss during suction
22. Lillis PJ (1990) Tumescent technique for liposuction surgery.
lipectomy. Plast Reconstr Surg 88(5):801803
Dermatol Clin 8(3):439449
7. Goodpasture JC, Bunkis J (1986) Quantitative analysis of
23. Narins RS, Coleman WP (1997) Minimizing pain for lipo-
blood and fat in suction lipectomy aspirates. Plast Reconstr
suction anesthesia. Dermatol Surg 23:11371140
Surg 78(6):765772
24. Ostad A, Kageyama N, Moy RL (1993) Tumescent anesthe-
8. Gargan TJ, Courtiss EH (1984) The risks of suction lipec-
sia with a lidocaine dose of 55 mg/kg is safe for liposuction.
tomy: their prevention and treatment. Clin Plast Surg 11(3):
Aesthet Plast Surg 17:205209
457463
25. Samdal F, Amland PF, Bugge JF (1994) Plasma lidocaine
9. Clayton DN, Clayton JN, Lindley TS, Clayton JL (1989)
levels during suction-assisted lipectomy using large doses of
Large volume lipoplasty. Clin Plast Surg 16(2):305312
dilute lidocaine with epinephrine. Plast Reconstr Surg
10. Dolsky RL (1990) Blood loss during liposuction. Dermatol
93(6):12171223
Clin 8(3):463468
26. Toledo LS (1991) Syringe liposculpture: a two-year experi-
11. Hetter GP (1990) Blood and fluid replacement. In: Hetter
ence. Aesthet Plast Surg 15:321326
GP (ed) Lipoplasty: the theory and practice of blunt suction
27. Cardenas-Camarena L, Tobar-Losada A, Lacouture AM
lipectomy, 2nd edn. Little, Brown, Boston, pp 191195
(1999) Large-volume circumferential liposuction with
12. Klein JA (1993) Tumescent technique for local anesthesia
tumescent technique: a sure and viable procedure. Plast
improves safety in large-volume liposuction. Plast Reconstr
Reconstr Surg 104(6):18871899
Surg 92(6):10851098
28. Elam MV, Packer D, Schwab J (1997) Reduced negative
13. Pitman GH (1996) Tumescent liposuction: operative tech-
pressure liposuction (RNPL): Could less be more? Int J
nique. Oper Tech Plast Reconstr Surg 3(2):8893
Aesthet Restor Surg 3(2):101104
14. Matarasso A (1997) Superwet anesthesia defines large-
volume liposuction. Aesthet Surg J 17(6):358364
 Anesthesia for Aesthetic Surgery
9
Gary Dean Bennett

Dedication
To my mother, Mary Ellen Bennett (19172009), whose enduring love, support, and
encouragement know no boundaries.

9.1 Introduction Regulatory agencies such as American Association

Nearly 75% of all elective surgery is performed in an
outpatient setting [1]. As much as 25% of all outpa-
tient surgeries are performed in physicians offices [2].
More than 50% of aesthetic plastic surgeons perform
most of their procedures in an office setting [3]. Clearly,
economic considerations play a major role in the shift
to ambulatory surgery. Because of greater efficiency,
these outpatient surgical units have greater cost-effec-
tiveness [4]. Also, these outpatient settings allow the
patient more convenient access to medical treatment
and provide a greater degree of privacy to the patient,
particularly when aesthetic procedures are performed.
Advances of monitoring capabilities and the adoption
of monitoring standards of the American Society of
Anesthesiologists (ASA) are credited for a reduction
of perioperative morbidity and mortality [5]. Advances
in pharmacology have resulted in a greater diversity of
anesthetic agents with rapid onset, shorter duration of
action, and reduced morbidity [6]. The advent of mini-
mally invasive procedures has further reduced the need
for hospital-based surgeries.
G.D. Bennett
Department of Anesthesiology, Chapman Medical Center,
Orange, CA, USA
e-mail: dasseen@cox.net
of Accreditation of Ambulatory Surgery (AAAASF)
and Accreditation Association for Ambulatory Health
Care (AAAHC) have helped establish minimum stan-
dards of care for surgical locations where anesthe-
sia is administered. Ambulatory anesthesia has even
become a formal subspecialty of anesthesia with the
establishment of the Society of Ambulatory Anesthesia
(SAMBA) in 1984. An evaluation of 1.1 million outpa-
tients revealed that the mortality rate after ambulatory
anesthesia was 1.5 per 100,000 cases [7]. No deaths
occurred in 319,000 patients who were monitored in
accordance with ASA standards [8, 9].
As a consequence of the shift away from hospital-
based surgery, the surgeon has adopted a more impor-
tant role in the medical decision making with respect
to anesthesia. Frequently, the surgeon decides on the
location of surgery, the extent of the preoperative eval-
uation, the type of anesthesia to be administered, the
personnel to be involved in the care and monitoring of
the patient, the postoperative pain management, and
the discharge criteria used. Therefore, it is incumbent
upon the surgeon to understand current standards of
anesthesia practice. If the surgeon chooses to assume
the role of the anesthesiologist, then he or she must
adhere to the same standards that are applied to the
anesthesiologist. While the morbidity and mortality of
anesthesia have decreased [10, 11], risk awareness of
anesthesia and surgery must not be relaxed.

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 105

DOI 10.1007/978-3-642-21837-8_9, Springer-Verlag Berlin Heidelberg 2013
106
9.2 The Surgical Facility
The surgeon is largely responsible for deciding which
facility the procedure is to be performed. Surgical
facilities may be divided into five main categories:
1. Hospital-based inpatient
2. Hospital-associated ambulatory surgical units
3. Freestanding surgical center with short-stay
accommodations
4. Freestanding surgical centers without short-stay
accommodations
5. Office-based operating rooms
Each of these choices has distinct advantages
and disadvantages. While convenient, economical, and
private, office-based surgery is associated with up to
four times the mortality as surgeries performed at cer-
tified freestanding ambulatory surgical centers [12].
Moreover, the types of complications that occur with
surgeries in office-based settings are more severe than
those that occur in the certified ambulatory surgical
centers. Domino reported that 21% of the complica-
tions that occurred as a result of procedures performed
in certified ambulatory surgical centers were fatal,
whereas 64% of the adverse outcomes that resulted
from procedures performed in office-based settings
were fatal. Forty-six percent of the complications that
occurred in the office-based settings were considered
to be avoidable, while only 13% of the complications
were considered avoidable in the certified ambulatory
surgical centers [13].
Grazer and de Jong [14] evaluated data of a survey
of 1,200 aesthetic surgeons pertaining to liposuc-
tions performed between 1994 and 1998. Of 496,245
procedures, 95 deaths were documented. Forty-six
percent of these deaths followed procedures performed
in office-based settings, while 26% followed hospital-
based procedures. Sedation of pediatric patients per-
formed in the office results in a greater incidence of
permanent neurological injury and death compared to
when sedation is administered in the hospital [15].
Patients with a risk of ASA III undergoing major
surgical procedures such as abdominoplasty should
preferentially be treated at hospital-based or hospital-
associated surgical units rather than an office-based
operating room [1618]. Ultimately, patient safety
should be the paramount factor in the final decision.
If the intended surgical procedure requires general
anesthesia or enough sedative-analgesic medication to
increase the probability of loss of the patients life
G.D. Bennett
preserving protective reflexes (LPPRs), then, accord-
ing to the law in some states of the USA, the surgical
facility must be accredited by one of the regulatory
agencies (AAAASF, AAAHC, or the JCAHO) [19, 20].
However, many states in the USA currently do not
have regulations pertaining to office-based proce-
dures. Regardless of which type of facility is selected
or the type of anesthesia planned, the standard of care
should be equivalent to the standards set for hospitals
[21]. Practice guidelines that specifically pertain to
office-based procedures have been developed by the
ASA and the American Society of Plastic Surgeons
[2224]. The American Society for Aesthetic Plastic
Surgery has decreed that its members only operate in
office-based settings that have been accredited by any
one of the three accrediting agencies.
The operating room must be equipped with the type
of monitors required to fulfill monitoring standards
established by the ASA [25], as well as proper resuscita-
tive equipment and resuscitative medications [26, 27].
The facility must be staffed by individuals with the
training and expertise required to assist in the care of
the patient [27, 28]. Emergency protocols must be estab-
lished and rehearsed [29]. Optimally, the surgical facil-
ity must have ready access to a laboratory in the event a
stat laboratory analysis is required. Finally, a transfer
agreement with a hospital must be established in the
event that an unplanned admission is required [26, 27].
9.2.1 Personnel
One of the most critical elements of a successful sur-
gical outcome is the personnel assisting the surgeon.
Qualified and experienced assistants may serve as
valuable resources, potentially reducing morbidity and
improving efficiency of the operating room [30, 31].
With an office-based operating room, the surgeon is
responsible for selecting the operating room personnel.
An anesthesiologist or a certified nurse anesthetist
(CRNA) may administer anesthesia. The surgeon may
prefer to perform the surgery using exclusively local
anesthesia without parenteral sedation, especially in
limited procedures such as liposuctions with the
tumescent technique [32]. However, many surgeons
add parenteral sedative or analgesic medications with
the local anesthetic. If the surgeon chooses to adminis-
ter parenteral sedative-analgesic medications, then
another designated, licensed, preferably experienced
9 Anesthesia for Aesthetic Surgery
individual should monitor the patient throughout the
perioperative period [33]. Use of unlicensed, untrained
personnel to administer parenteral sedative-analgesic
medications and monitor patients may increase the
risks to the patients. It is also not acceptable for the
nurse monitoring the patients to double as a circulating
nurse [34]. Evidence suggests that anesthesia-related
deaths more than double if the surgeon also adminis-
ters the anesthesia [35]. Regardless of who delivers
the anesthesia, the surgeon should preferably maintain
current Advanced Cardiac Life Support certification
(ACLS) and all personnel assisting in the operating
room and recovery areas must maintain Basic Life
Support certification [36]. At least one ACLS-certified
health provider must remain in the facility until the
patient has been discharged [37].
9.3 Preoperative Evaluation
The time and energy devoted to the preoperative prepa-
ration of the surgical procedure should be commen-
surate with the efforts expended on the evaluation and
preparation for anesthesia. The temptation to leave
preoperative anesthesia preparation of the patient as
an afterthought must be resisted. Even if an anesthesi-
ologist or CRNA is to be involved later, the surgeon
bears responsibility for the initial evaluation and prepa-
ration of the patient. Thorough preoperative evaluation
and preparation by the surgeon increase the patients
confidence, reduce costly and inconvenient last-minute
delays, and reduce overall perioperative risk to the
patient [38]. If possible, the preoperative evaluation
should be performed with the assistance of a spouse,
parent, or significant other so that elements of the
health history or recent symptoms may be more readily
recalled.
A comprehensive preoperative evaluation form is a
useful tool to begin the initial assessment. Information
contained in the history alone may determine the diag-
nosis of the medical condition in nearly 90% of patients
[39]. While a variety of forms are available in the
literature, a checklist format to facilitate the patients
recall is probably the most effective [40]. Regardless
of which format is selected, information regarding all
prior medical conditions, prior surgeries and types of
anesthetics, current and prior medications, adverse
outcomes to previous anesthetics or other medications,
eating disorders, prior use of antiobesity medication,
107
Table 9.1 Guidelines for preoperative testing in healthy
patients (ASA 111)
Age Test
1240a CBC
4060 CBC, EKG
Greater than 60 CBC, BUN, Glucose, ECG, CXR
a
Pregnancy testing for potentially childbearing females is
recommended
Adapted from Roizen et al. [52]
and use of dietary supplements which could contain
ephedra, should be disclosed by the patient.
A family history of unexpected or early health con-
ditions such as heart disease, or unexpected reactions,
such as malignant hyperthermia, to anesthetics or other
medications should not be overlooked. Finally, a com-
plete review of systems is vital to identifying undi-
agnosed, untreated, or unstable medical conditions
that could increase the risk of surgery or anesthesia.
Last-minute revelations of previously undisclosed
symptoms, such as chest pain, should be avoided.
Indiscriminately, ordered or routinely obtained pre-
operative laboratory testing is now considered to have
limited value in the perioperative prediction of mor-
bidity and mortality [4145]. In fact, one study showed
no difference in morbidity in healthy patients without
preoperative screening tests versus a control group
with the standard preoperative tests [46]. Multiple
investigations have confirmed that the preoperative
history and physical examination is superior to labora-
tory analysis in determining the clinical course of
surgery and anesthesia [4751]. Guidelines for the
judicious use of laboratory screening, particularly in
healthy patients, are now widely accepted (Table 9.1)
[52]. Additional preoperative tests may be indicated
for patients with prior medical conditions or risk fac-
tors for anesthesia and surgery (Table 9.2) [53].
Consultation from other medical specialists should
be obtained for patients with complicated or unstable
medical conditions. Patients with ASA III or VI risk
designations should be referred to the appropriate med-
ical specialist prior to elective surgery [33]. The consul-
tants role is to determine if the patient has received
optimal treatment and if the medical condition is stable.
Additional preoperative testing may be considered nec-
essary by the consultant. The medical consultant should
also assist with stabilization of the medical conditions
in the perioperative period if indicated. A complete
written report from the medical consultant regarding
108 G.D. Bennett

Table 9.2 Common indications for additional risk-specific testing

Electrocardiogram
History Coronary artery disease, congestive heart failure, prior myocardial infarction, hypertension, hyperthyroidism,
hypothyroidism, obesity, compulsive eating disorders, deep venous thrombosis, pulmonary embolism, smoking,
chemotherapeutic agents, chemical dependency, chronic liver disease
Symptoms Chest pain, shortness of breath, dizziness
Signs Abnormal heart rate or rhythm, hypertension, cyanosis, peripheral edema, wheezing, rales, rhonchi
Chest X-ray
History Bronchial asthma, congestive heart failure, chronic obstructive pulmonary disease, and pulmonary embolism
Symptoms Chest pain, shortness of breath, wheezing, unexplained weight loss, and hemoptysis
Signs Cyanosis, wheezes, rales, rhonchi, decreased breath sounds, peripheral edema, abnormal heart rate or rhythm
Electrolytes, glucose, liver function tests, BUN, creatinine
History Diabetes mellitus, chronic renal failure, chronic liver disease, adrenal insufficiency, hypothyroidism, hyperthy-
roidism, diuretic use, compulsive eating disorders, diarrhea
Symptoms Dizziness, generalized fatigue or weakness
Signs Abnormal heart rate or rhythm, peripheral edema, abnormal breath sounds, jaundice
Urinalysis
History Diabetes mellitus, chronic renal disease, and recent urinary tract infection
Symptoms Dysuria, urgency, frequency, and bloody urination
Adapted from Roizen et al. [53]

the patients medical status should be given to the
surgeon prior to scheduling the surgery. A hastily scrib-
bled note from the medical consultant stating cleared
for surgery is entirely inadequate and could potentially
delay the surgery or result in perioperative complica-
tions. If the surgeon has concerns about a patients
ability to tolerate anesthesia, a telephone discussion
with an anesthesiologist or even a formal preoperative
anesthesia consultation may be indicated.
Certain risk factors, such as previously undiagnosed
hypertension, cardiac arrhythmias, and bronchial asthma
may be identified by a careful physical examination.
Preliminary assessment of head and neck anatomy to
predict possible challenges in the event endotracheal
intubation is required may serve as an early warning to
the anesthesiologist or CRNA even if a general anes-
thetic is not planned. For most ambulatory surgeries, the
anesthesiologist or CRNA evaluates the patient on the
morning of surgery.
9.3.1 Preoperative Risk Assessment
The ultimate goals of establishing a patients level
of risk are to reduce the probability of periopera-
tive morbidity and mortality. As previously discussed,
the preoperative evaluation is the crucial component
of determining the patients preoperative risk level.
There is compelling evidence to suggest that the more
Table 9.3 The American Society of Anesthesiologists Physical
Status Classification
ASA CLASS I A healthy patient without systemic
medical or psychiatric illness
ASA CLASS II A patient with mild, treated, and stable
systemic medical or psychiatric illness
ASA CLASS III A patient with severe systemic disease
that is not considered incapacitating
ASA CLASS IV A patient with severe systemic,
incapacitating, and life-threatening
disease not necessarily correctable
by medication or surgery
ASA CLASS V A patient considered moribund and
not expected to live more than 24 h
coexisting medical conditions a patient has, the greater
the risk for perioperative morbidity and mortality [33,
54]. Identification of preoperative medical conditions
helps reduce perioperative mortality.
A variety of indexing systems have been proposed
to help stratify patients according to risk factors. One
such classification, first proposed in 1941 [55], later
modified in 1961 by Dripps et al. [56], and finally
adopted by the ASA in 1984 (Table 9.3) [57], has
emerged as the most widely accepted method of preop-
erative risk assessment. Numerous studies have con-
firmed the value of the ASA system in predicting which
patients are at a higher risk for morbidity [58] and mor-
tality [5961]. Goldman and Caldera [62] established a
9 Anesthesia for Aesthetic Surgery
multifactorial index based on cardiac risk factors. This
index has repeatedly demonstrated its usefulness in
predicting perioperative mortality [63, 64]. Physicians
should incorporate one of the acceptable risk classifica-
tion systems as an integral part of the preoperative
evaluation.
Multiple authors have documented the association
between morbidity and mortality and the type of surgery
[6568]. The consensus of these studies confirms the
increased risks of perioperative complications for more
invasive surgeries, surgeries with multiple combined
procedures, surgeries with prolonged duration, and sur-
geries with significant blood loss [69]. After reviewing
1,200 office-based facial plastic surgeries, 86% of which
exceeded 240 min, Gordon and Koch concluded that
increased morbidity or mortality was not associated with
the duration of surgery [70]. Nevertheless, the American
Society of Plastic Surgeons has recommended that pro-
cedures not exceed 6 h and that procedures should be
completed by 3:00 P.M. [23].
While studies correlating the amount of fat aspi-
rate during liposuction or the amount of tissue
removed during abdominoplasty with perioperative
morbidity and mortality have not been performed, it
would not be unreasonable to extrapolate conclusions
from the previous studies and apply them to abdomi-
noplasty and liposuction. Liposuction surgeries with
less than 1500 mL fat aspirate are generally consid-
ered less invasive procedures, while liposuctions
aspirating more than 3000 mL are considered major
surgical procedures [27]. As blood loss exceeds
500 mL [69] or the duration of surgery exceeds 2 h,
morbidity and mortality increase [58, 71]. Guidelines
presented by the American Society for Dermatologic
Surgery, the American Academy of Dermatology,
the American Society of Plastic Surgeons, and the
American Academy of Cosmetic Surgery have con-
cluded that for office-based liposuction, the total
supernatant fat and fluid should be limited to less
than 5000 mL [13].
9.4 Anesthesia in Patients
with Preexisting Disease
Over the past 30 years, the morbidity and mortality of
surgery have steadily declined [11]. One hypothesis to
explain this decline has been the greater recognition of
preoperative risk factors and the improved periopera-
tive medical management of patients with coexisting
109
diseases. Surgeons who perform outpatient surgery,
especially office-based surgery, and particularly those
surgeons who chose to administer sedative or analgesic
medication, must appreciate how these medical condi-
tions may increase the risk of anesthesia in the surgical
patient. Furthermore, the surgeon should maintain a
current working understanding of the evaluation and
treatment of these medical conditions.
9.4.1 Cardiac Disease
Cardiac-related complications, including myocardial
infarction and congestive heart failure, are the leading
causes of perioperative mortality [72, 73]. Most patients
with heart disease can be identified with a careful preop-
erative history and physical examination [51]. Since 80%
of all episodes of myocardial ischemia are silent [74, 75],
a high index of suspicion for silent ischemia must
be maintained when assessing asymptomatic patients
with risk factors for heart disease, such as smoking,
hypertension, diabetes mellitus, obesity, hyperlipidemia,
or family history of severe heart disease. Patients with
known cardiac disease must be evaluated by the internist
or cardiologist to ensure the medical condition is opti-
mally managed. When anesthesia is planned, patients
with significant heart disease should preferentially
undergo surgery at a hospital-based surgical unit rather
than a physicians office.
Most studies have consistently demonstrated that
patients who have suffered previous myocardial infarc-
tions have a dramatically greater risk of reinfarction
and death if surgery is performed less than 6 months
after the cardiac event [7678]. Subsequent studies
suggesting a lower rate of reinfarction [79, 80] involved
patients who were hospitalized in the intensive care
unit with invasive hemodynamic monitoring. These
studies may not have relevance to patients undergoing
elective ambulatory surgery. At this time, the prudent
choice remains to postpone elective surgeries for at
least 6 months after myocardial infarction.
Goldman et al. [62] established a cardiac risk index
which has been useful in identifying patients with
intermediate risk for cardiac complications in the peri-
operative period [63]. Patients with a score greater
than 13 should be referred to a cardiologist for preop-
erative evaluation. Dipyridamole thallium scanning
and dobutamine stress echocardiography have proven
useful in predicting adverse perioperative cardiac
events [81]. One reliable and simple screening method
110
to evaluate cardiac status is exercise tolerance. The
ability to increase the heart rate to 85% of the age-
adjusted maximal heart rate is a reliable predictor of
perioperative cardiac morbidity [82].
Despite years of investigation, no one anesthetic
technique or medication has emerged as the preferen-
tial method to reduce the incidence of perioperative
complications in patients with cardiac disease [83, 84].
Regardless of which anesthesia technique is selected,
scrupulous monitoring should serve as the framework
for safe anesthetic management. Wide hemodynamic
fluctuations and tachycardia must be avoided to prevent
ischemic episodes in the perioperative period.
9.4.2 Obesity
The prevalence of obesity (BMI > 30) in the USA is
estimated to be 34% of the population, while the preva-
lence of overweight and obesity combined (BMI > 25)
is estimated to be 68% [85]. It is reasonable to assume
that patients undergoing certain aesthetic surgical pro-
cedures such as major liposuction or abdominoplasty
have a greater incidence of obesity. The most widely
accepted method of quantifying the level of obesity is
the body mass index (BMI), which is determined by
weight (kg)/height (M) [2]. Patients with a BMI over 25
are considered overweight; those with a BMI over 30
are considered obese, while a BMI over 35 indicates
morbid obesity [86].
The risk factors associated with obesity such as
diabetes mellitus, hypertension, heart disease, sleep
apnea, and occult liver disease [87] should concern cli-
nicians administering anesthesia to patients with obe-
sity. A thorough preoperative evaluation must rule out
these occult risk factors prior to elective surgery.
Anatomical abnormalities make airway control chal-
lenging [88] and endotracheal intubation hazardous
[89]. The combination of a higher gastric volume and
lower pH with a higher frequency of esophageal reflux
results in a higher risk of pulmonary aspiration [90] in
the obese patient; pulmonary function can be severely
restricted even in an upright position [91]. In the supine
position, pulmonary function is even further reduced
[92]. Pulmonary function is further compromised in the
anesthetized patient. Because of these cardiopulmonary
abnormalities, obese patients develop hypoxemia more
quickly [93]. This respiratory impairment may persist
up to 4 days after surgery [94]. Even distribution and
G.D. Bennett
metabolism of medications vary significantly and often
unpredictably in the obese patient [95].
Given the increased risk of perioperative morbidity
and mortality of anesthesia, morbidly obese patients
(BMI > 35) undergoing major surgery and anesthesia
of any type should preferentially be restricted to a hos-
pital-based surgical facility. In general, these patients
should not be considered candidates for ambulatory
surgery. Anesthesia delivered in the office setting
should be restricted to patients with BMI less than 30.
While premedication with metaclopromide (Reglan,
Wyeth Pharmaceuticals), a dopamine-receptor antago-
nist, increases gastric motility and lowers esophageal
sphincter tone [96, 97], a troubling association between
single-dose metachlopromide and tardive dyskinesia
[98] has limited the routine use of this medication in
preoperative preparation of the patient. A histamine-
receptor blocking agent such as ranitidine (Zantac,
Glaxo) used with metaclopromide the evening before
and the morning of surgery reduces the risk of pulmo-
nary aspiration [99].
Because of the increased risks of deep venous throm-
bosis (DVT) [100] and pulmonary embolism (PE) in
the obese patient [101], prophylactic measures such as
lower extremity pneumatic compression devices and
early ambulation should be used.
An undetermined number of patients self-administer
herbal dietary supplements. Many of these supple-
ments contain ephedra alkaloids which may predispose
the patient to perioperative hypertension and cardiac
arrhythmias [102]. Some of these herbal products may
result in the increased incidence of bleeding as a result
of intrinsic anticoagulant properties of these herbal
supplements similar to warfarin. Antiobesity medica-
tions such as aminorex fumarate, dexfenfluramine
(Redux, Wyeth-Ayerst), fenfluramine (Pondimin,
AH Robins), and phenterimine (Ionimine, Adipex-P,
Fastin, Oby-Cap, Obenix, Oby-trim, and Zantryl,
various manufacturers) are associated with pulmonary
hypertension and valvular heart disease, even with as
little as 2 months of use. While most patients develop
symptoms such as palpitations, dyspnea, chest pain,
and irregular heart rate, murmur, and edema, some
patients remain asymptomatic [103].
Patients who have developed pulmonary hyper-
tension and valvular heart disease as a result of these
medications are predisposed to fatal cardiac arrhyth-
mias, congestive heart failure, and intractable hypoten-
sion. Some authors advocate a cardiac evaluation with
9 Anesthesia for Aesthetic Surgery
echocardiogram and continuous wave Doppler imag-
ing with color-flow examination for any patient who
has taken these antiobesity medications prior to sur-
gery. Sustained hypotension may not respond to ephed-
rine, a popular vasopressor. Phenylephrine is the
treatment of choice for hypotension occurring in these
patients [103].
9.4.3 Hypertension
Early studies revealed a significantly increased risk of
perioperative mortality in patients with untreated
hypertension [104, 105]. The reduction in mortal-
ity from cardiovascular and cerebrovascular disease
resulting from proper treatment of hypertension has
been widely accepted [106108]. Although still some-
what controversial, most authors concur that preopera-
tive stabilization of hypertension reduces perioperative
cardiovascular complications such as ischemia [109
111]. Patients with undiagnosed or poorly controlled
hypertension should be identified early in the preop-
erative preparation process and referred to the family
physician or internist for evaluation and treatment.
Physicians should not mistakenly attribute severe
hypertension to the patients preoperative anxiety.
Because of the risk of rebound hypertension, anti-
hypertension medications should be continued up to
and including the morning of surgery [112], except for
angiotensin-converting (ACE) inhibitors, which have
been associated with hypotension during induction of
general anesthesia [113].
Mild to moderate perioperative hypertension may
be a response to inadequate general or local anesthesia
or pain control. In these cases, pain is usually accom-
panied by other signs, such as the patients complaints,
tachycardia, and tachypnea. If hypertension persists
despite additional local anesthetic or analgesic medi-
cation, then treatment of the blood pressure is indi-
cated. Moderate to severe blood pressure elevations
occurring during the surgery or during recovery should
be treated using one or more of the antihypertensive
agents available.
Perioperative hypertension, especially if the hyper-
tension is accompanied by tachycardia, may be treated
with a beta-adrenergic blocking agent such propranolol
in judiciously administered, intravenous doses of 0.5 mg
iv at 1015 min intervals. Even small doses of a beta-
adrenergic blocking agent have been shown to reduce
111
the incidence of cardiac ischemia [111]. Labetolol
(Normodyne, Trandate), an antihypertensive agent
with combined alpha-adrenergic and beta-adrenergic
blocking properties, administered in 510 iv mg doses
every 10 min, is also a safe and effective alternative to
treat both hypertension and tachycardia [114].
Nifedipine (Procardia, Pfizer), 10 mg sl, a potent
systemic and coronary arteriolar dilator, effectively
reduces blood pressure and may be administered in a
conscious patient. The effect of nifedipine may be
additive if given with narcotics or inhalational anes-
thetic agents. Because nifedipine and lidocaine are
both highly protein bound, caution must be exercised
when administering nifedipine after high-dose lido-
caine tumescent anesthesia has been administered to
avoid possible toxic effects of the lidocaine [115].
For severe hypertension, hydralazine (Apresoline,
Novartis), a potent vasodilator, may be useful in
2.55 mg doses iv at 1015 min intervals. The effects
of hydralazine may be delayed up to 20 min and its
effects prolonged. Hydralazine may cause tachycar-
dia or hypotension, especially if the patient is hypov-
olemic [116].
9.4.4 Diabetes Mellitus
Although patients with diabetes mellitus have a sub-
stantially increased surgical mortality rate than nondia-
betic patients [117], these complications are more likely
to be a consequence of the end-organ disease such as
cardiovascular disease, renal disease, and altered wound
healing [54, 118, 119]. While evidence suggests that
tight control of blood sugar in insulin-dependent dia-
betics slows the progression of end-organ disease [120],
tight control is associated with additional risks such as
hypoglycemia and even death [121].
The preoperative evaluation should identify dia-
betic patients with poor control as well as medical con-
ditions associated with diabetes such as cardiovascular
disease and renal insufficiency. Diabetic patients have
a greater incidence of silent myocardial ischemia
[122]. Minimum preoperative analysis includes fasting
blood sugar, glycosylated hemoglobin, electrolytes,
BUN, creatinine, and EKG. If any doubt exists regard-
ing the patients medical stability, consultation should
be obtained from the diabetologist, cardiologist, or
nephrologist. Patients with brittle diabetes or with
other coexisting medical conditions should be referred
112
to a hospital-based surgical unit, especially if general
anesthesia is contemplated.
The goal of perioperative management of stable type
I or type II diabetic patients is primarily to avoid hypo-
glycemia. Although patients are generally NPO after
midnight prior to surgery, a glass of clear juice may be
taken up to 2 h prior to surgery to avoid hypoglycemia.
Patients with type I diabetes should not administer
insulin, and patients with type II diabetes should not
take oral hypoglycemia agents the morning of surgery.
Diabetic patients should be scheduled the first case in
the morning to minimize the risk of hypoglycemia dur-
ing the NPO period. After the patient arrives, a preop-
erative fasting glucose should be checked and then, an
infusion of 5% dextrose is generally initiated at 12 mL/
kg/h and continued until oral fluids are tolerated in the
recovery period. Usually, one half of the patients
scheduled dose of insulin is administered after the
intravenous dextrose is begun [123].
For surgeries longer than 2 h, at least one periph-
eral blood glucose should be measured, especially if
the patient is receiving general anesthesia. Blood glu-
cose above 200 mg/dL may be effectively managed
with a sliding scale of insulin [124]. Treatment regi-
mens directed toward tighter control of the blood
sugar, such as continuous insulin infusions, do not
necessarily improve the perioperative outcome [125,
126]. It is imperative that prior to discharge, patients
be able to tolerate oral intake without nausea and
vomiting. A final glucose level should be checked
prior to discharge.
9.4.5 Pulmonary Disease
Bronchial asthma, chronic bronchitis, chronic obstruc-
tive pulmonary disease, obesity, history of smoking,
and recent upper respiratory infection are the most
common medical conditions which may influence pul-
monary function in the perioperative period. An esti-
mated 4.5% of the population may suffer some form of
reactive airway disease [127]. If these medical condi-
tions are identified in the preoperative history, a thor-
ough evaluation of the patients pulmonary function
should ensure. As with other medical conditions, a
careful history may help separate patients with these
medical conditions into low- and high-risk groups,
especially since the degree of preoperative respiratory
dyspnea closely correlates with postoperative mortality
G.D. Bennett
Table 9.4 Grade of dyspnea while walking
Level Clinical response
0 No dyspnea
1 Dyspnea with fast walking only
2 Dyspnea with one or two blocks
walking
3 Dyspnea with mild exertion (walking around
the house)
4 Dyspnea at rest
Adapted from Boushy et al. [128]
[128]. Using a simple grading scale, the patients pre-
operative pulmonary function can be estimated
(Table 9.4).
Patients with level 2 dyspnea or greater should
be referred to a pulmonologist for more complete
evaluation and possibly further medical stabilization.
The benefits of elective surgery in patients with level
3 and 4 dyspnea should be carefully weighed against
the increased risks. Certainly, this group of patients
would not be considered good candidates for outpa-
tient surgery.
Since upper respiratory infection (URI) may alter
pulmonary function for up to 5 weeks [129], major
surgery requiring general endotracheal anesthesia
should be postponed, especially if the patient suffers
residual systems, such as fevers, chills, coughing, and
sputum production, until the patient is completely
asymptomatic.
While many studies confirm that patients who
smoke more than 12 packs of cigarettes daily have a
higher risk of perioperative respiratory complications
than non-smokers, cessation of smoking in the imme-
diate preoperative period may not improve patients
outcome. In fact, patients risk of perioperative com-
plications may actually increase if smoking is stopped
immediately prior to surgery. A full 8 weeks may be
required to successfully reduce perioperative pulmo-
nary risk [130].
If the physical examination of asthmatic patients
reveals expiratory wheezing, conventional wisdom dic-
tates that potentially reversible bronchospasm should
be optimally treated prior to surgery. Therapeutic
agents include inhaled or systemic, selective beta-
adrenergic receptor type-2 agonists such as albuterol
(Ventolin, Glaxo, Proventil, Proair, Teva) as a sole
agent or in combination with anticholinergic such
as ipratropium (Atrovent, Boehringer Ingelheim)
and locally active corticosteroid such as beclomethasone
9 Anesthesia for Aesthetic Surgery
dipropronate (Beclovent, Vanceril) medications [131].
Continuing the asthmatic medications up to the time
of surgery [132] and postoperative use of incentive
spirometry [133] have been shown to reduce postop-
erative pulmonary complications.
With regard to treated stable pulmonary disease,
there are no conclusive, prospective, randomized stud-
ies to indicate which anesthesia technique or medica-
tions would improve patient outcome.
9.4.6 Sleep Apnea Syndrome
Sleep apnea syndrome (SAS) may be a result of an
abnormality of the respiratory control center of the
brain in central sleep apnea or obstruction of the upper
airway in obstructive sleep apnea (OSA) which is the
most common cause of SAS. Many patients present
with a combination of central sleep apnea and OSA,
also referred to as mixed sleep apnea. According to the
National Commission on Sleep Disorders Research,
nearly 20 million Americans suffer with SAS. Unfor-
tunately, the majority of patients with SAS remain
undiagnosed [134]. The incidence of sleep apnea
increases among obese patients [134, 135]. Since the
target population for many aesthetic surgical proce-
dures such as major liposuction and abdominoplasty
includes patients with morbid obesity, SAS becomes a
more relevant concern.
OSA is a result of a combination of excessive
pharyngeal adipose tissue and inadequate pharyngeal
soft tissue support [136]. During episodes of sleep
apnea, patients may suffer significant and sustained
hypoxemia. As a result of the pathophysiology of OSA,
patients develop left and right ventricular hypertrophy
[137]. Consequently, patients have a higher risk of
ventricular dysrhythmias and myocardial infarction
[138].
Most medications used during anesthesia, includ-
ing sedatives such as diazepam and midazolam,
hypnotics such as propofol, and analgesics such as
fentanyl, meperidine and morphine, increase the risk
for airway obstruction and respiratory depression in
patients with SAS [139]. Death may occur suddenly
and silently in patients with inadequate monitoring
[140]. A combination of anatomical abnormalities
makes airway management, including mask ventila-
tion and endotracheal intubation, especially challeng-
ing in obese patients with OSA [141]. Perioperative
113
monitoring, including visual observation, must be
especially vigilant to avoid perioperative respiratory
arrest in patients with SAS.
For patients with severe SAS, particularly those with
additional coexisting medical conditions such as cardiac
or pulmonary disease, surgery performed on an outpa-
tient basis is not appropriate. For these high-risk patients,
monitoring should continue in the intensive care unit
until the patients no longer require parenteral analge-
sics. If technically feasible, regional anesthesia may be
preferable in patients with severe SAS. Postoperatively,
patients with any history of SAS should not be dis-
charged if they appear lethargic or somnolent [142].
During the preoperative evaluation of the obese
patient, a presumptive diagnosis of SAS may be made
if the patient has a history of loud snoring, long pauses
of breathing during sleep (more than 10 s), as reported
by the spouse, or daytime somnolence [143]. If SAS is
suspected, patients should be referred for a sleep study
to evaluate the severity of the condition.
9.4.7 Malignant Hyperthermia
Susceptibility
Patients with susceptibility to malignant hyperthermia
(MH) can be successfully managed on an outpatient
basis after 4 h of postoperative monitoring [144].
Triggering agents include volatile inhalation agents
such as halothane, enflurane, desflurane, isoflurane,
and sevoflurane. Even trace amounts of these agents
lingering in an anesthesia machine or breathing circuit
may precipitate an MH crisis. Succinylcholine and
chlorpromazine are other commonly used medications
which are known triggers of MH. However, many non-
triggering medications may be safely used for local
anesthesia, sedation-analgesia, postoperative pain con-
trol, and even general anesthesia [145]. Nevertheless,
anesthesia for patients suspected to have MH suscepti-
bility should not be performed at an office-based set-
ting. Standardized protocol to manage MH (available
from the Malignant Hyperthermia Association of the
United States, MHAUS), supplies of dantrolene
(Dantrium, Procter and Gamble Pharmaceuticals),
and cold intravenous fluids should be at the surgical
facility for all patients. Preferably, patients with MH
susceptibility should be referred to an anesthesiologist
for prior consultation. Intravenous dantrolene [146]
and iced intravenous fluids are still the preferred
114 G.D. Bennett

Table 9.5 Clinical pharmacology of commonly used local anesthetics infiltrative anesthesia in adults (70 kg)a
Maximum dose Maximum dose
(without epinephrine) Duration (with epinephrine)
Concentration Duration of Total Total of action Total Total
Agent (%) action (min) mg/kg mg mL (min) mg/kg mg mL
Lidocaine 1.0 3090 4 300 30 60120 7 500 50
Chloroprocaine 1.0 2030 10 700 70 3060 14 1000 100
Mepivacaine 1.0 4590 4 300 30 60120 7 500 50
Prilocaine 1.0 3090 5 350 35 60120 8 550 55
Etodocaimne 0.5 120180 4 300 60 180240 5.5 400 80
Bupivacaine 0.25 120240 2.5 175 70 180240 3 225 90
Ropivacaine 0.2 120240 2.7 200 80 180240 2.7 250 100
Levobupivicaine 0.25 120240 2.5 185 75 180240 3 225 90
a
Individual doses may vary depending on ethnic background, individual sensitivities, body habitus, or coexisting medical
conditions
Adapted from Covino and Wildsmith [147], and Berde and Struchartz [148]

treatment for MH. MHAUS may be contacted at 800 Table 9.6 Medications inhibiting cytochrome oxidase P450
3A4
98-MHAUS, and the MH hotline is 800-MH HYPER.
Amiodarone Fluoxetine Nifedipine
Atenolol Itraconazole Paroxetine
Carbamazepine Isoniazide Pentoxifylline
9.5 Anesthesia for Aesthetic Surgery
Cimetidine Labetolol Pindolol
Clarithromycin Ketoconazole Propofol
Anesthesia may be divided into four broad categories:
Chloramphenicol Methadone Propranolol
local anesthesia, local anesthesia combined with
Cyclosporine Methyprednisolone Quinidine
sedation, regional anesthesia, and general anesthesia. Danazol Metoprolol Sertraline
The ultimate decision to select the type of anesthesia Dexamethasone Miconazole Tetracyline
depends on the type and extent of the surgery planned, Diltiazam Midazolam Terfenidine
the patients underlying health condition, and the Erythromycin Nadolol Thyroxine
psychological disposition of the patient. Fluconazole Nefazodone Timolol
Flurazepam Nicardipine Triazola
Verapamil
9.5.1 Local Anesthesia Adapted from Shiffman [153]

A variety of local anesthetics are available for infiltra-

tive anesthesia. The selection of the local anesthetic
depends on the duration of anesthesia required and
the volume of anesthetic needed. The traditionally
accepted, pharmacological profiles of common anes-
thetics used for infiltrative anesthesia for adults are
summarized in Table 9.5 [147, 148].
The maximum doses may vary widely depending
on the type of tissue injected [149], the rate of admin-
istration [150], the age, underlying health, and body
habitus of the patient [151], the degree of competitive
protein binding [152], and possible cytochrome inhibi-
tion of concomitantly administered medications [153].
The maximum tolerable limits of lidocaine (Xylocaine)
have been redefined with the development of the
tumescent anesthetic technique [154]. Lidocaine doses
up to 35 mg/kg were found to be safe if administered
in conjunction with dilute epinephrine during liposuc-
tion [155]. With the tumescent technique, peak plasma
levels occur 624 h after administration [155, 156].
Doses up to 55 mg/kg have been found to be within
the therapeutic safety margin [157]. However, guide-
lines by the American Academy of Cosmetic Surgery
recommend a maximum dose of 4550 mg/kg [37].
Since lidocaine is predominantly eliminated by
hepatic metabolism, specifically cytochrome oxidase
P450 34A, drugs that inhibit this microsomal enzyme
may increase the potential of lidocaine toxicity [153,
158]. Table 9.6 [153] lists some of the more common
medications, which inhibit the cytochrome oxidase sys-
tem. Propofol and Versed, commonly used medications
9 Anesthesia for Aesthetic Surgery
for sedation and hypnosis during liposuction, are also
known to be cytochrome P450 inhibitors. However,
since the duration of action of these drugs is only
14 h, the potential inhibition should not interfere
with lidocaine at the peak serum level 612 h later.
Lorazepam is a sedative which does not interfere with
cytochrome oxidase and is preferred by some authors
[159].
Certainly, significant toxicity has been associated
with high doses of lidocaine as a result of tumescent
anesthesia during liposuction [155]. The systemic tox-
icity of local anesthetic has been directly related to the
serum concentration by many authors [32, 152, 155
157, 159, 160]. Early signs of toxicity, usually occur-
ring at serum levels of about 34 mg mL for
lidocaine, include circumoral numbness, lightheaded-
ness, and tinnitus. As the serum concentration increases
toward 8 mg/mL, tachycardia, tachypnea, confusion,
disorientation, visual disturbance, muscular twitching,
and cardiac depression may occur. At still higher serum
levels above 8 mg/mL, unconsciousness and seizures
may ensue. Complete cardiorespiratory arrest may
occur between 10 and 20 mg/mL [152, 159, 160].
However, the toxicity of lidocaine may not always cor-
relate exactly with the plasma level of lidocaine pre-
sumably because of the variable extent of protein
binding in each patient and the presence of active
metabolites [152] and other factors already discussed
including the age, ethnicity, health, and body habitus
of the patient, and additional medications.
Ropivacaine (Naropin, AstraZeneca) and levobupi-
vacaine are long-lasting local anesthetics with less car-
diovascular toxicity than bupivacaine and may be a
safer alternative to bupivacaine if a local anesthetic of
longer duration is required [148, 161]. The cardiovas-
cular toxicity of bupivacaine and etidocaine is much
greater than lidocaine [148, 161, 162]. While bupiva-
caine (Marcaine, Sensorcaine) toxicity has been
associated with sustained ventricular tachycardia and
sudden profound cardiovascular collapse [163, 164],
the incidence of ventricular dysrhythmias has not been
as widely acknowledged with lidocaine or mepiva-
caine (Carbocaine) toxicity. In fact, ventricular tachy-
cardia or fibrillation was not observed despite the use
of supraconvulsant doses of intravenous doses of lido-
caine, etidocaine, or mepivacaine in the animal model
[161].
Levobupivacaine (Chirocaine, AstraZeneca), an
S() isomer of the racemic bupivacaine, has emer-
115
ged as another alternative local anesthetic with
a prolonged duration of action for infiltrative anes-
thesia, peripheral nerve blocks, and central anesthesia,
including epidural and intrathecal anesthesia. Except
for a somewhat longer duration of the sensory block in
central anesthesia, the pharmacokinetics of levobupiva-
caine are virtually indistinguishable from bupivacaine.
However, levobupivacaine has a wider therapeutic
safety margin with less cardiotoxic potential and less
CNS and cardiac depressant effects compared to bupi-
vacaine [165, 166].
Indeed, during administration of infiltrative lido-
caine anesthesia, rapid anesthetic injection into a
highly vascular area or accidental intravascular injec-
tion leading to sudden toxic levels of anesthetics result-
ing in sudden onset of seizures or even cardiac arrest or
cardiovascular collapse has been documented [167,
168]. One particularly disconcerting case presented by
Christie confirms the fatal consequence of a lidocaine
injection of 200 mg in a healthy patient [169]. Seizure
and death occurred following a relatively low dose of
lidocaine and a serum level of only 0.4 mg/100 mL or
4 mg/mL. A second patient suffered cardiac arrest with
a blood level of 0.58 mg/100 mL or 5 mg/mL [170].
Although continued postmortem metabolism may arti-
ficially reduce serum lidocaine levels, the reported
serum levels associated with mortality in these patients
were well below the 820 mg/mL considered necessary
to cause seizures, myocardial depression, and cardio-
respiratory arrest. The 4 mg/mL level reported by
Christie [169] is uncomfortably close to the maximum
serum levels reported by Ostad et al. [157] of 3.4 and
3.6 mg/mL following tumescent lidocaine doses of
51.3 and 76.7 mg/kg, respectively. Similar near toxic
levels were reported in individual patients receiving
about 35 mg/kg of lidocaine by Samdal et al. [170].
Pitman and Klein [171] reported that toxic manifesta-
tions occurred 8 h postoperatively after a total dose of
48.8 mg/kg which resulted from a 12-h plasma lido-
caine level of 3.7 mg/kg. Ostad et al. [157] conclude
that because of the poor correlation of lidocaine doses
with the plasma lidocaine levels, an extrapolation of
the maximum safe dose of lidocaine for liposuction
cannot be determined. Given the devastating conse-
quences of lidocaine toxicity, physicians must exercise
extreme caution while attempting to push the accept-
able safe limits to ever-higher levels of tumescent
anesthesia. Physicians must consider the important
variables affecting susceptibility of individual patients
116
to lidocaine toxicity before boldly going where no
surgeon has gone before, especially since plasma
lidocaine levels typically peak after the patient is at
home.
Topical anesthetics in a phospholipid base have
become more popular as a technique for administering
local anesthetics. Application of these topical agents
may provide limited anesthesia over specific areas
such as the face for minor procedures including limited
laser resurfacing. EMLA (eutectic mixture of local
anesthetics), a combination of lidocaine and prilocaine,
was the first commercially available preparation. This
topical anesthetic preparation must be applied under
an occlusive dressing at least 60 min prior to the
procedure to develop adequate local anesthesia [172].
Even after 60 min, the anesthesia may not be com-
plete and the patient may still experience significant
discomfort. Many physicians prefer to use their own
customized formula, which they obtain from a com-
pounding pharmacy. Frequently, the patient is given
the topical anesthetic to be applied at home prior to
arrival to the office or surgical center. However, these
compounded formulas are not monitored by the FDA,
and compounding pharmacies may vary in the quality
control standards. Some of the formulas may contain
up to 40% local anesthetics in various combinations.
This type of preparation could deliver up to 400 mg per
gram of ointment to the patient. The application of
30 g of a compounded formula containing a total of
40% local anesthetic over a wide area with subsequent
occlusive dressing could expose the patient to
12,000 mg of local anesthetic. Studies have demon-
strated that systemic absorption of local anesthetic
after application of topical local anesthetic is limited to
less than 5% [173, 174]. Even with limited systemic
absorption, the development of toxic blood levels of
local anesthetic, with the ensuing catastrophic results,
would not be hard to envision if a large quantity of a
concentrated compounded anesthetic ointment were
applied under an occlusive dressing. There has been at
least one case report of death after application of a
compounded local anesthetic ointment while prepar-
ing for aesthetic surgery [175]. Physicians who pre-
scribe compounded topical local anesthetics to patients
prior to surgery should reevaluate the concentration of
these medications as well as the total dose of medica-
tion that may be delivered to the patient.
Patients who report previous allergies to anesthet-
ics may present a challenge to surgeons performing
G.D. Bennett
liposuction. Although local anesthetics of the aminoester
class such as procaine, chloroprocaine, tetracaine, or
cocaine are associated with allergic reactions, true
allergic phenomena to local anesthetics of the amino-
amide class, such as lidocaine, bupivacaine, ropivacaine,
and mepivacaine, are extremely rare [171, 176]. Allergic
reactions may occur to the preservative in the multidose
vials. Tachycardia and generalized flushing may occur
with rapid absorption of the epinephrine contained in
some standard local anesthetic preparations. The devel-
opment of vasovagal reactions after injections of any
kind may cause hypotension, bradycardia, diaphoresis,
pallor, nausea, and loss of consciousness. These adverse
reactions may be misinterpreted by the patient and even
the physician as allergic reactions [176]. A careful his-
tory from the patient describing the apparent reaction
usually clarifies the cause. If there is still concern about
the possibility of true allergy to local anesthetic, then
the patient should be referred to an allergist for skin
testing [177].
In the event of a seizure following a toxic dose of
local anesthetic, proper airway management and oxy-
genation maintenance are critical. Seizure activity may
be aborted with intravenous diazepam, 1020 mg intra-
venously (iv); midazolam, 510 mg iv; or thiopental,
100200 mg iv. Although the ventricular arrhythmias
associated with bupivacaine toxicity are notoriously
intractable [163, 164], treatment is still possible using
large doses of atropine, epinephrine, and bretylium
[178, 179]. Some studies indicate that lidocaine or
amiodarone should not be used during resuscitation of
local anesthetic-induced arrhythmias [148, 180].
Numerous case reports have emerged describing
successful resuscitation of intractable ventricular
arrhythmias and asystole which were induced by
acute bupivacaine, lidocaine, and ropivacane toxicity
using intravenous infusions of 20% lipid emulsions
(Intralipid, Baxter, Liposyn, Hospira) [181186].
Research in animals has confirmed the rescue effects
of intravenous lipid emulsions for local anesthetic
toxicity [187].
The recommended dosage of 20% lipid emulsion is
1.5 mL/kg iv over 1 min, repeated every 5 min until
adequate circulation is restored [188]. Marwick et al.
[186] reported recurrence of ventricular tachycardia
40 min after successful resuscitation with lipid infu-
sion. For surgical centers where local anesthetics are
routinely used for large cases or regional anesthesia,
having at least 1000 mL of a 20% lipid emulsion in
9 Anesthesia for Aesthetic Surgery 117

Table 9.7 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesiaa
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although
cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are
unaffected
Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients
respond purposefullyb to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained
Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but
respond purposefullyb following repeated or painful stimulation. The ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained
General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.
The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a
patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced
depression of neuromuscular function. Cardiovascular function may be impaired
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners
intending to produce a given level of sedation should be able to rescuec patients whose level of sedation becomes deeper than
initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescuec
patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescuec
patients who enter a state of general anesthesia
a
Monitored anesthesia care does not describe the continuum of depth of sedation, rather it describes a specific anesthesia service in
which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic
procedure
b
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response
c
Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway manage-
ment and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended
level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of seda-
tion. It is not appropriate to continue the procedure at an unintended level of sedation
Reproduced with permission from Wolters Kluwer [190]

reserve for emergency resuscitation of local anesthetic-
induced cardiac arrhythmias has been suggested as a
reasonable precaution [186].
Pain associated with local anesthetic administration
is due to pH of the solution and may be reduced by the
addition of 1 mEq of sodium bicarbonate to 10 mL of
anesthetic [189].
9.5.2 Sedative-Analgesic
Medications (SAM)
Many aesthetic surgical procedures are performed
with a combination of local anesthesia and supplemen-
tal sedative-analgesic medications (SAM) adminis-
tered orally (po), intramuscularly (im), or intravenously
(iv). Procedures performed under local or regional
anesthesia generally are accompanied with SAM. The
goals of administering supplemental medications are
to reduce anxiety (anxiolysis), the level of conscious-
ness (sedation), unanticipated pain (analgesia), and,
in some cases, to eliminate recall of the surgery
(amnesia).
Sedation may be defined as the reduction of the level
of consciousness, usually resulting from pharmacologi-
cal intervention. The level of sedation may be further
divided into four broad categories: minimal sedation
(anxiolysis), moderate sedation/analgesia (formerly
referred to as conscious sedation), deep sedation/
analgesia, and general anesthesia (Table 9.7) [190].
Conscious sedation, an outdated term, is occasionally
still used to distinguish a lighter state of anesthesia with
a higher level of mental functioning whereby the life-
preserving protective reflexes (LPPRs) are indepen-
dently and continuously maintained. Furthermore, the
patient is able to respond appropriately to physical and
verbal stimulation [191].
Life-preserving protective reflexes (LPPRs) may
be defined as the involuntary physical and physio-
logical responses that maintain the patients life which,
if interrupted, result in inevitable and catastrophic
physiological consequences. The most obvious exam-
ples of LPPRs are the ability to maintain an open air-
way, swallowing, coughing, gagging, and spontaneous
breathing. Some involuntary physical movements such
as head turning or attempts to assume an erect posture
118 G.D. Bennett

Table 9.8 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia
Minimal sedation Moderate sedation/analgesia Deep sedation/
anxiolysis (conscious sedation) analgesia General anesthesia
Responsiveness Normal response Purposeful response to Purposeful response Unarousable even
to verbal verbal or tactile stimulation following repeated or with painful stimulus
stimulation painful stimulation
Airway Unaffected No intervention required Intervention may be Intervention often
required required
Spontaneous Unaffected Adequate May be inadequate Frequently
ventilation inadequate
Cardiovascular Unaffected Usually maintained Usually maintained May be impaired
function
Committee of Origin: Quality Management and Departmental Administration (Approved by the ASA House of Delegates [190] on
October 27, 2004, and amended on October 21, 2009)
Reported with permission from Wolters Kluwer [187] 2/23/10

may be considered LPPRs if these reflex actions occur
in an attempt to improve airway patency such as expel-
ling oropharyngeal contents. The myriad of homeo-
static mechanisms to maintain blood pressure, heart
function, and body temperature may even be consid-
ered LPPRs.
As the level of consciousness is further depressed
to the point that the patient is not able to respond
purposefully to verbal commands or physical stimulation,
the patient enters into a state referred to as deep seda-
tion. In this state, there is a significant probability of loss
of LPPRs. Ultimately, as total loss of consciousness
occurs and the patient no longer responds to verbal com-
mand or painful stimuli, the patient enters a state of gen-
eral anesthesia [187, 188, 190, 191].During general
anesthesia, the patient most likely looses the LPPRs and
cardiovascular function may be impaired. Table 9.8
[190] summarizes the changes that occur during the four
stages of sedation analgesia.
In actual practice, the delineation between the lev-
els of sedation becomes challenging at best. The loss
of consciousness occurs as a continuum. With each
incremental change in the level of consciousness, the
likelihood of loss of LPPRs increases. Since the defini-
tion of conscious sedation is vague, current ASA
guidelines consider the term sedation-analgesia a more
relevant term [33]. Monitored anesthesia care (MAC)
has been generally defined as the medical management
by a qualified physician or certified registered nurse
anesthetist (CRNA) of a patient receiving local anes-
thesia during a diagnostic or therapeutic procedure
with or without the use of supplemental medications to
support the life of and provide comfort and safety to
the patient [192]. MAC usually refers to services pro-
vided by the anesthesiologist or the CRNA. The term
local standby is no longer used because it mischar-
acterizes the purpose and activity of the anesthesiolo-
gist or CRNA.
Surgical procedures performed using a combination
of local anesthetic and SAM usually have a shorter
recovery time than similar procedures performed under
regional or general anesthesia [193]. Using local anes-
thesia alone, without the benefit of supplemental medi-
cation, is associated with a greater risk of cardiovascular
and hemodynamic perturbations such as tachycardia,
arrhythmias, and hypertension particularly in patients
with preexisting cardiac disease or hypertension [194].
Patients usually prefer sedation while undergoing sur-
gery with local anesthetics [195]. While the addition of
sedatives and analgesics during surgery under local
anesthesia seems to have some advantages, the use of
SAM during local anesthesia is certainly not free of
risk. A study by the Federated Ambulatory Surgical
Association concluded that local anesthesia with sup-
plemental medications was associated with more than
twice the number of complications than with local
anesthesia alone. Furthermore, local anesthesia with
SAM was associated with greater risks than general
anesthesia [71]. Significant respiratory depression as
determined by the development of hypoxemia, hyper-
carbia, and respiratory acidosis often occurs in patients
after receiving minimal doses of medications. This
respiratory depression persists even in the recovery
period [196, 197]. Houseman determined that during
liposuction, the risk of serious complications is greater
when the procedures are performed with sedation than
when the procedures are performed under local anes-
thesia without sedation [198].
9 Anesthesia for Aesthetic Surgery
One explanation for the frequency of these com-
plications is the wide variability of patients responses
to these medications. Up to 20-fold differences in the
dose requirements for some medications such as
diazepam and up to fivefold variations for some nar-
cotics such as fentanyl have been documented in
some patients [199, 200]. Even small doses of fenta-
nyl as low as 2 mg/kg, considered by many physicians
as sub-clinical, produce respiratory depression for
more than 1 h in some patients [201]. Combinations
of even small doses of sedatives, such as midazolam,
and narcotics, such as fentanyl, may act synergisti-
cally (effects greater than an additive effect) in pro-
ducing adverse side effects such as respiratory
depression and hemodynamic instability [202]. The
clearance of many medications may vary depending
on the amount and duration of administration, a phe-
nomenon known as context-sensitive half-life. The
net result is increased sensitivity and duration of
action to medication for longer surgical cases [203].
Because of these variations and interactions, predict-
ing any given patients doseresponse is a daunting
task. Patients appearing awake and responsive may,
in an instant, slip into unintended levels of deep seda-
tion with greater potential of loss of LPPRs. Careful
titration of these medications to the desired effect
combined with vigilant monitoring are the critical
elements in avoiding complications associated with
the use of SAM.
Supplemental medication may be administered via
multiple routes including oral, nasal, transmucosal,
transcutaneous, intravenous, intramuscular, and rectal.
While intermittent bolus has been the traditional
method to administer medication, continuous infusion
and patient-controlled delivery result in comparable
safety and patient satisfaction [204, 205].
Benzodiazepines such as diazepam (Valium,
Hoffmann-La Roche Inc.), midazolam (Versed,
Hoffmann-La Roche Inc.), and lorazepam (Ativan,
Biovail and Baxter) remain popular for sedation and
anxiolysis. Patients and physicians especially appreci-
ate the potent amnestic effects of this class of medica-
tions, especially midazolam. The disadvantages of
diazepam include the higher incidence of pain on intra-
venous administration, the possibility of phlebitis
[206], and the prolonged half-life of up to 2050 h.
Moreover, diazepam has active metabolites which may
prolong the effects of the medication long after the
immediate postoperative recovery period [207, 208].
119
Midazolam, however, is more rapidly metabolized,
allowing for a quicker and more complete recovery
for outpatient surgery [207]. Because the sedative,
anxiolytic, and amnestic effects of midazolam are
more profound than other benzodiazepines and the
recovery is more rapid, patient acceptance is usually
higher [209]. Midazolam is an excellent choice as a
supplement to sedation, regional, or general anesthesia
to relieve concerns about potential recall after anesthe-
sia. However, the amnestic effect of midazolam or
other benzodiazepines may be an undesirable effect if
the patient actually chooses to have recall of the proce-
dure or if the patient cannot recall important instruc-
tions issued by the physician.
Since lorazepam is less affected by medications
altering cytochrome P459 metabolism [210], it has
been recommended as the sedative of choice for lipo-
suctions which require a large-dose lidocaine tumes-
cent anesthesia [159]. The disadvantage of lorazepam
is the slower onset of action and the 11 to 22-h elimi-
nation half-life, making titration cumbersome and
postoperative recovery prolonged [207, 210]. All ben-
zodiazepines are reversed by flumazenil (Romazicon,
Roche) [207].
Generally, physicians who use SAM, titrate a
combination of medications from different classes
to tailor the medications to the desired level of seda-
tion and analgesia for each patient. Typically, seda-
tives such as the benzodiazepines are combined with
narcotic analgesics such as fentanyl (Sublimaze,
Janssen), meperidine (Demerol, Sanofi Winthrop),
or morphine during local anesthesia to decrease pain
associated with local anesthetic injection or unan-
ticipated breakthrough pain. Fentanyl has the advan-
tage of rapid onset and duration of action of less
than 60 min. However, because of synergistic action
with sedative agents, even doses of 2550 mg can
result to respiratory depression [202, 211]. Other
medications with sedative and hypnotic effects such
as a barbiturate, ketamine, or propofol are often
added. Adjunctive analgesics such as ketorolac may
be administered for additional analgesic activity. As
long as the patient is carefully monitored, several
medications may be titrated together to achieve the
effects required for the patient characteristics and
the complexity of the surgery. Use of pre-packaged
combinations of medications defeats the purpose of
the selective control of each medication and is not
advised [33].
120
More potent narcotic analgesics with faster onset of
action and even shorter duration of action than fenta-
nyl include sufentanil (Sufenta, Janssen), alfentanil
(Alfenta, Akorn), and remifentanil (Ultiva, Glaxo-
SmithKline and Abbott). These narcotic analgesics
may be administered using intermittent boluses or con-
tinuous infusions in combination with other sedative
or hypnotic agents. However, extreme caution and
scrupulous monitoring are required when these potent
narcotics are used because of the risk of respiratory
arrest, particularly when used in combination with
other sedative or analgesic medications [212, 213].
Use of these medications should be restricted to the
anesthesiologist or the CRNA. A major disadvantage
of narcotic medication is the perioperative nausea and
vomiting [214]. All narcotic medications are reversed
by naloxone (Narcan, DuPont).
Many surgeons feel comfortable administering
SAM to patients. Others prefer to use the services of
an anesthesiologist or CNRA. Prudence dictates that
for prolonged or complicated surgeries or for patients
with significant risk factors, the participation of the
anesthesiologist or CRNA during procedures requiring
sedative-analgesia is preferable. Regardless of who
administers the anesthetic medications, the monitoring
must have the same level of vigilance.
Propofol (Diprivan, AstraZeneca), a member of
the alkylphenol family, has demonstrated its versa-
tility as a supplemental sedative-hypnotic agent for
local anesthesia and regional anesthesia. Propofol
may be used alone or in combination with a variety of
other medications. The rapid metabolism and clear-
ance of propofol result in faster and more complete
recovery with less postoperative hangover than other
sedative-hypnotic medications such as midazolam and
methohexital [193, 215]. The documented antiemetic
properties of propofol yield added benefits of this
medication [216]. The disadvantages of propofol
include pain on intravenous injection and the lack of
amnestic effect [217]. However, the addition of 3 mL
of 2% lidocaine to 20 mL of propofol reduces the
pain on injection with no added risk. If an amnestic
response is desired, a small dose of a benzodiazepine,
such as midazolam, 25 mg iv, given in combina-
tion with propofol, provides the adequate amnesia.
Rapid administration of propofol may be associ-
ated with significant hypotension, decreased cardiac
output [218], and respiratory depression [219].
Continuous infusion with propofol results in a more
G.D. Bennett
rapid recovery than similar infusions with midazolam
[220]. Patient-controlled sedation with propofol has
also been shown to be safe and effective [221].
Propofol has no known pharmacological antagonist.
Initially, the use of propofol was limited to anesthe-
siologists and nurse anesthetists primarily because of
the rapid and often unanticipated transition from mini-
mal to deep sedation. The frequent complication of
sudden apnea and hypotension associated with the
use of propofol requires airway management and
resuscitative skills. Because of its overall efficacy
during moderate sedation, propofol became attractive
to physicians of other specialties such as gastroin-
tenterology, pulmonology, and emergency medicine
for outpatient procedures [222]. However, the FDA
required the package labeling of propofol to include
the statement, should be administered only by per-
sons trained in the administration of general anesthesia
and not involved in the conduct of the surgical/diag-
nostic procedure [223].
Contending that propofol can be safely adminis-
tered by a registered nurse under physician supervi-
sion, these physician groups have advocated that
the FDA change the labeling requirements so that
the use of propofol for moderate sedation could be
expanded to include other medical specialties. How-
ever, the American Society of Anesthesiologists and
the American Association of Nurse Anesthetists issued
a joint statement urging adherence to the packaging
recommendations because of concerns of potential
complications which could occur during moderate and
deep anesthesia with the administration of propofol by
individuals not trained in the management of patients
under anesthesia [224]. Any physician who intends to
use propofol sedation must be proficient in the man-
agement of potential complications associated with
propofol, particularly the management of apnea and
airway obstruction [225229].
Fospropofol disodium (Lusedra, Eisai), a water-
based, phosphorylated prodrug of propofol, was
approved by the FDA in May of 2008 for use during
MAC by physicians trained in the administration of
general anesthesia. Fospropofol is rapidly metabolized
by alkaline phosphatases into propofol, formaldehyde,
and phosphate. Fospropofol shares the hypnotic, anxi-
olytic, sedative, and antiemetic properties of propofol.
However, because fospropofol is water-based, intrave-
nous administration is not associated with pain, a
significant advantage over propofol. The time to loss
9 Anesthesia for Aesthetic Surgery
of consciousness, time to peak effect, and duration of
action of fospropofol is longer compared to those of
propofol. Fospropofol shares the similar decreases
of mean arterial pressure, tachycardia, and respiratory
depression with propofol, although fospropofol
resulted is less apnea than propofol. The optimal dose
to induce moderate sedation during colonoscopies and
bronchoscopies was 6.5 mg/kg, while the dose to
induce deep sedation was 8 mg/kg. Subsequently, one
quarter of the original dose was administered every
4 min to maintain the level of sedation. The time to
discharge for patients who received either propofol or
fospropofol was significantly faster than for those
patients who received a midazolam and meperidine
combination. Most subjects who received fospropofol
experienced varying degrees of mild to moderate
perineal itching, burning, or paresthesias that were
resolved after a few minutes without treatment.
Transient myoclonus was also reported in some of the
participants. Like propofol, fospropofol has no known
pharmacological antagonist [230].
Barbiturate sedative-hypnotic agents such as
thiopental (Pentothal) and methohexital (Brevital),
while older, still play a role in some clinical settings.
In particular, methohexital, with controlled boluses,
1020 mg iv, or limited infusions, remains a safe and
effective sedative-hypnotic alternative with rapid recov-
ery. However, with prolonged administration, recovery
from methohexitial may be delayed compared to propo-
fol [231]. Barbiturate medications have no known phar-
macological reversing agent.
Ketamine (Ketalar, Pfizer), a phencyclidine
derivative, is a unique agent because of its combined
sedative and analgesic effects and the absence of
cardiovascular depression in healthy patients [232].
Because the CNS effects of ketamine result in a state
similar to catatonia, the resulting anesthesia is often
described as dissociative anesthesia. Although gag and
cough reflexes are more predictably maintained with
ketamine, emesis and pulmonary aspiration of gastric
contents are still possible [233]. Unfortunately, a
significant number of patients suffer distressing post-
operative psychomimetic reactions [234]. While con-
comitant administration of benzodiazepines attenuates
these reactions, the postoperative psychological seque-
lae limit the usefulness of ketamine for most elective
outpatient surgeries.
Droperidol (Inapsine, Janssen), a butyrophenone
and a derivative of haloperidol, an antipsychotic, acts
121
as a sedative, hypnotic, and antiemetic medication.
Rather than causing global CNS depression like
barbiturates, droperidol results in more specific CNS
changes similar to phenothiazines. For this reason, the
cataleptic state caused by droperidol is referred to as
neuroleptic anesthesia [235]. Droperidol has been
used effectively in combination with various narcotic
medications. Innovar is a combination of droperidol
and fentanyl. While droperidol has minimal effect on
respiratory function if used as a single agent, when
combined with narcotic medication, a predictable
dose-dependent respiratory depression may be antici-
pated [236]. Psychomimetic reactions such as dys-
phoria or hallucinations are frequent, unpleasant side
effects of droperidol. Benzodiazepines or narcotics
reduce the incidence of these unpleasant side effects
when used in combination with droperidol [237].
Extrapyramidal reactions such as dyskinesias, torti-
collis, or oculogyric spasms may also occur, even with
small doses of droperidol. Diphenhydramine usually
reverses these complications [238]. Hypotension may
occur as consequence of droperidols alpha-adrenergic
blocking characteristics. One rare complication of
droperidol is the neuroleptic malignant syndrome
(NMS) [239], a condition very similar to malignant
hyperthermia (MH), characterized by extreme tem-
perature elevations and rhabdomyolysis. The treat-
ment of NMS and MH is essentially the same.
While droperidol has been used for years without
appreciable myocardial depression [237], a surprising
announcement from the Federal Drug Administration
warned of sudden cardiac death resulting after the
administration of standard, clinically useful doses
[240]. Unfortunately, despite studies which refute
the FDA s conclusions [241] and an expert panels
opinion supporting the use of droperidol [242],
this potential complication makes the routine use of
this once very useful, cost-effective medication diffi-
cult to justify given the presence of other alternative
medications.
Butorphanol, buprenorphine (Buprenex, Reckitt
Benckiser), and nalbuphine (Nubain, Endo) are three
synthetically derived opiates which share the proper-
ties of being mixed agonistantagonist at the opiate
receptors. These medications are sometimes preferred
as supplemental analgesics during local, regional, or
general anesthesia because they partially reverse the
analgesic and respiratory depressant effects of other
narcotics. While these medications result in respiratory
122
depression at lower doses, a ceiling effect occurs at
higher dose, thereby limiting the respiratory depres-
sion. Still, respiratory arrest is possible, especially if
these medications are combined with other medica-
tions with respiratory depressant properties [243].
While the duration of action of butorphanol is 23 h,
nalbuphine has a duration of action of about 36 h and
buprenorphine up to 10 h with a peak effect occurring
after 3 h, making these medications less suitable for
surgeries of shorter duration. Finally, if a patient has
been taking narcotic analgesics for the treatment of a
chronic pain condition, the addition of an agonist
antagonist medication for the procedure could precipi-
tate withdrawal symptoms.
Dexmedetomidine (Precedex, Abbott), an alpha2-
adrenoreceptor agonist, with eight times the affinity
and the anxiolytic, sedative, and analgesic properties
of clonidine, is another recent addition to the available
medications for sedation-analgesia. [244]. Dexmedeto-
midine has also been shown to reduce the sympathetic
response to anesthesia and surgery. Several studies
have demonstrated the safety and effectiveness of
this medication for outpatient procedures [245247].
Although dexmedetomidine has less respiratory
depression when compared to other medications, the
delayed recovery time compared with other alterna-
tives, the relative expense of the medication, and
the potential adverse effects of hypotension and
bradycardia have led some authors to conclude that
the potential usefulness of this medication for outpa-
tient procedures requiring sedation-analgesia may be
limited [248].
Chloral hydrate, the first and oldest of the medica-
tions developed for sedation, was first synthesized in
1832. Chloral hydrate and nitrous oxide combina-
tions have been used for sedation, particularly in the
pediatric population for office-based procedures,
including dental work and diagnostic procedures,
for many years primarily because of the convenience
of the oral chloral hydrate dosing (70 mg/kg). Many
of these procedures have been performed in non-
accredited offices without the monitoring recom-
mended by the ASA Guidelines. As a result, this
combination of medications has resulted in complica-
tions in a significant number of patients primarily due
to hypoxemia [249]. Many of these complications
may have been avoided with proper patient monitor-
ing. Table 9.9 summarizes the recommended doses
for SAM [250252].
G.D. Bennett
9.5.3 General Anesthesia
While some authors attribute the majority of complica-
tions occurring during and after aesthetic procedures
to the administration of systemic anesthesia [32,
253], others consider sedation and general anesthesia
safe and appropriate alternatives in indicated cases
[27, 171, 254, 255]. In fact, Klein correctly acknowl-
edges that most of the complications attributed to
midazolam and narcotic combinations occurred as a
result of inadequate monitoring [32]. Although signifi-
cant advances have been made in the administration of
local anesthetics and supplemental medications, the
use of general anesthesia may still be the anesthesia
technique of choice for many patients undergoing
aesthetic surgical procedures. General anesthesia is
especially appropriate when working with patients suf-
fering extreme anxiety, high tolerance to narcotic or
sedative medications, or if the surgery is particularly
complex. The goals of a general anesthetic are a smooth
induction, a prompt recovery, and minimal side effects,
such as nausea, vomiting, or sore throat.
Older volatile inhalation anesthetic agents, halot-
hane, enflurane (Ethrane, Baxter), and isoflurane
(Forane, Baxter) [256] are still in use because of the
cost-effectiveness and the long-established safety,
reliability, and convenience of use in selected patient
populations. Because of the risk of halothane hepatitis
and MH, halothane should not be used in adults unless
there is a specific indication. Any halogenated volatile
inhalation anesthetic may cross-react and precipitate
hepatitis in patients who have previously suffered
halothane hepatitis [257]. Inhalation anesthetics should
not be used in patients who have experienced any
postoperative hepatotoxicity.
The newer inhalation agents, sevoflurane (Ultane,
Baxter) and desflurane (Suprane, Anaquest), share
the added benefit of rapid onset of action and emer-
gence [256, 258, 259]. However, these newer agents
are associated with higher costs, especially desflurane
due to the high total anesthetic consumption during
normal surgical procedures [259] and the requirement
of a heated vaporizer.
Nitrous oxide, a long-time favorite anesthetic inha-
lation agent, although popular because of its shorter
duration of action and low cost, is associated with post-
operative nausea and vomiting [260] and perioperative
hypoxemia. With the advent of the shorter-acting inha-
lation agents, sevoflurane and desflurane, the necessity
9 Anesthesia for Aesthetic Surgery 123

Table 9.9 Common medications and dosages used for sedative analgesiaa
Medication Bolus dose Average adult dose Continuous infusion rate
Opioid analgesics rapid onset, short duration of action (sedative, analgesic)
Alfentanil 57 mg/kg 3050 mg 0.20.5 mg/kg/min
Fentanyl 0.30.7 mg/kg 2550 mg 0.010.02 mg/kg/min
Remifentanil 0.250.5 mg/kg 1030 mg 0.0250.1 mg/kg/min
Sufentanil 0.050.15 mg/kg 2.57.5 mg 0.10.5 mg/kg/h
Opioid analgesics slower onset, long duration of action (sedative, analgesic)
Meperidine 0.2 mg/kg 1020 mg iv, 50100 mg im NA
Morphine 0.02 mg/kg 12 mg iv, 510 mg im NA
Opiate agonistantagonist analgesics long duration of action (sedative, analgesic)
Buprenorphine 25 mg/kg 0.10.3 mg NA
Butorphanol 27 mg/kg 0.10.5 mg NA
Nalbuphine 0.070.1 mg/kg 47.5 mg NA
Benzodiazepines (sedative, anxiolytic, hypnotic, amnestic)
Diazepam 0.050.1 mg/kg 57.5 mg NA
Lorazepam 0.010.02 mg/kg 12 mg NA
Midazolam 0.0300.075 mg/kg 2.55.0 0.501.0 mg/kg/min
a2-adrenergic agonists (sedative, hypnotic, analgesic)
Dexmedetomidine 1 mg/kg 2070 mg 0.20.7 mg/kg/min
Alkylphenols (sedative, antiemetic)
Fospropofol 6.5 mg/kg 120400 mg NA
Propofol 0.20.5 mg/kg 1050 mg 1075 mg/kg/min
Barbituate (sedative, hypnotic)
Methohexital 0.20.5 mg/kg 1020 mg 1020 mg/kg/min
Thiopental 0.51.0 mg/kg 2550 mg 2050 mg/kg/min
Phencyclidine (dissociative hypnotic, sedative, analgesic)
Ketamine 0.20.5 mg/kg 1020 mg 510 mg/kg/min
a
Based on an average weight of 70 kg. These doses may vary depending on age, gender, underlying health status, and other
concomitantly administered medications
Adapted from Philip [250], SaRego et al. [251], and Fragen [252]

of nitrous oxide is much less compelling. Table 9.10
[256259, 261, 262] summarizes the available inhala-
tion anesthetics and some of the significant clinical
characteristics.
The development of potent, short-acting sedatives,
opioid analgesics (Table 9.11) [250252, 262267],
and neuromuscular blocking agents (NMBAs)
(Table 9.12) [268270] has resulted in medication reg-
imens that permit the use of intravenous agents exclu-
sively for surgical procedures requiring general
anesthesia. Most of these medications can also be used
during general anesthesia in combination with other
sedative (Table 9.9) and inhalation agents (Table 9.10)
using modified doses for each type of combination
[263]. Sugammadex (Bridion, Schering-Plough), a
novel synthetic cyclodextrin neuromuscular relaxant
reversal agent, which acts by selectively binding the
steroidal neuromuscular blocking agents (rocuronium,
vecuronium, and pancuronium), may allow for faster
and more predictable recovery from neuromuscular
blockade [271]. The anesthesiologist or CRNA should
preferentially be responsible for the administration
and monitoring of a general anesthesia when these
medication regimens are being used.
9.5.4 Preoperative Preparation
Generally, medications which may have been required
to stabilize the patients medical conditions should be
continued up to the time of surgery. Notable excep-
tions include anticoagulant medications, monoaomine
oxidase inhibitors (MAO) [272, 273], and possibly
the angiotensin-converting enzyme (ACE) inhibitor
medications [274, 275]. It is generally accepted that
MAO inhibitors, isocarboxazid (Marplan, Oxford
124 G.D. Bennett

Table 9.10 Inhalation Agent MACa(%) Significant clinical considerations

anesthetics
Rapid onset and recovery
Desflurane 6.0 Fastest rate of recovery of all inhaled agents
Only volatile agent that does not reduce pulmonary resistance.
Induction by inhalation
poorly tolerated
Requires heated vaporizer
Most expensive inhalation agent
Increased risk of MH in susceptible patients
Nitrous oxide 105 Non-halogenated
May cause diffusion hypoxia and increase PONV
Megaloblastic bone marrow depression may occur after 12 h of
exposure
Sevoflurane 1.71 Induction by inhalation, well tolerated in adults and children
Potentially nephrotoxic only after prolonged exposure
No cases of renal failure have been reported
Increased risk of MH in susceptible patients
Slower onset and recovery
Enflurane 1.68 Rarely used in the USA
Increased risk of MH in susceptible patients
Halothane 0.76 Induction by inhalation in children, well tolerated
Hepatitis occurs in 1:10,000 adults
Should not be used in adults
Increased risk of MH in susceptible patients
Induction by inhalation in children, well tolerated
Isoflurane 1.12 Induction by inhalation poorly tolerated
Increased risk of MH in susceptible patients
a
Minimum alveolar concentration required for immobility in 50% of subjects exposed to a noxious
stimulus

Table 9.11 Common Average Continuous

intravenous medications and Medication Bolus dose adult dose infusion rate
dosages used for general
Opioids
anesthesiaa
Alfentanil 25100 mg/kg to 7 mg 0.52 mg/kg/min
Fentanyl 315 mg/kg 2001,000 mg 210 mg/kg/h
Remifentanil 12 mg/kg 70140 mg 0.11.0 mg/kg/min
Sufentanil 0.252 mg/kg 20160 mg 0.51.5 mg/kg/h
Alkylphenols (sedative, antiemetic)
Fospropofol 6.5 mg/kg 200450 mg NA
Propofol 13 mg/kg 75200 mg 50150 mg/kg/min
Barbituates
Methohexital 12 mg/kg 75150 mg 50100 mg/kg/min
Thiopental 34 mg/kg 200300 mg 70100 mg/kg/min
Imidazoles
Etomidate 0.20.6 mg/kg 1040 mg NA
Phencyclidines
Ketamine 0.52.0 mg/kg 35150 mg 15100 mg/kg/min
a
Based on an average weight of 70 kg. These doses are for sole use of the agent listed and may vary
depending on age, gender, underlying health status, and other concomitantly administered medi-
cations. Doses may change if additional medications are added
9 Anesthesia for Aesthetic Surgery 125

Table 9.12 Intubating Significant clinical characteristics

Neuromuscular Medication dosea
blocking agents for
Longer duration of action and slower onset of action
general anesthesia
d-tubocurarine 0.5 mg/kg Oldest agent. Causes hypotension through ganglionic
blockade and histamine release
Pancuronium (Pavulon) 0.1 mg/kg Causes tachycardia and hypertension through vagal
blockade
Intermediate duration of action with faster onset of action
Atacurium (Nimbex) 0.5 mg/kg Metabolized by ester hydrolysis and Hoffman
degeneration
Can be used in patients with kidney failure
Causes histamine release and hypotension and tachycardia
Cisatacurium (Nimbex) 0.2 mg/kg Metabolized by Hoffman degeneration
Can be used in patients with kidney failure
Less histamine release than atacurium
Rocuronium (Zemuron) 1.0 mg/kg The fastest onset of action of all non-depolarizing
NMBAs
Vecuronium (Norcuron) 0.1 mg/kg Not stable in solution. Requires mixing
Shorter duration of action with faster onset of action
Gantacurium 0.4 mg/kg Metabolized by ester hydrolysis and cysteine adduction
Cysteine may be used for reversal
Causes histamine release and hypotension and tachycardia
only at higher doses, less than atacurium
Not yet available in the USA
Succinylcholine 1.0 mg/kg The only depolarizing agent available
The fastest most reliable onset of action of all NMBAs
The shortest duration of action of all NMBAs
Most popular NMBA for rapid sequence induction
Causes skeletal muscle fasciculations and masseter rigidity
May result in severe postoperative myalgias
Causes hyperkalemia in some patients
Increases intracranial and intraocular pressure
May induce MH in susceptible patients
May result in prolonged block in patients
with pseudocholinesterase deficiency
a
Pertains to adults only. Doses may vary in patients depending on weight, body habitus, or medical condi-
tions or additional medications added

Pharmaceuticals Services), paragyline (Eutonyl,
Abbott), phenelzine (Nardil, Pfizer), selegiline
(Emsam Transdermal Patch, Bristol-Meyers Squibb,
Eldepryl, Deprenyl, Somerset Pharmaceuticals), and
tranylcypromine (Parnate, Glaxo Smith-Kline), be
discontinued 23 weeks prior to surgery, especially for
elective cases, because of the interactions with narcotic
medications, specifically hyperpyrexia, and certain
vasopressor agents, specifically ephedrine [272, 273].
Patients taking ACE inhibitors, captopril (Capoten,
Bristol-Myers Squibb), enalapril (Vasotec, Merck),
and lisinopril (Prinivil, Merck, Zestril, Zeneca), may
have a greater risk for hypotension during general
anesthesia [275]. Diabetics may require a reduction in
dosage of their medication. However, if the risks of
discontinuing any of these medications outweigh the
benefits of the proposed elective surgery, the patient
and physician may decide to modify the preoperative
medication regimen or to postpone, modify, or even
cancel the proposed surgery.
Previous requirements of complete preoperative
fasting for 1016 h are considered unnecessary by
many anesthesiologists [276, 277]. More recent inves-
tigations have demonstrated that gastric volume may
be less 2 h after oral intake of 8 oz of clear liquid than
after more prolonged fasting [278]. Furthermore, pro-
longed fasting may increase the risk of hypoglycemia
[279]. Many patients appreciate an 8-oz feeding of
their favorite caffeinated elixir 2 h prior to surgery.
Preoperative sedative medications may also be taken
126
with a small amount of water or juice. Abstinence
from solid food ingestion for 1012 h prior to surgery
is still recommended. Liquids taken prior to surgery
must be clear [280], e.g., coffee without cream or
juice without pulp.
Healthy outpatients are no longer considered at risk
for gastric acid aspiration, and therefore, routine use of
oral antacids, histamine type-2 (H2) antagonists, or
gastrokinetic medications is not indicated. However,
patients with marked obesity, hiatal hernia, or diabetes
mellitus have higher risks for aspiration. These patients
may benefit from selected prophylactic treatment
[281]. Sodium citrate, an orally administered, non-
particulate antacid, rapidly increases gastric pH.
However, its unpleasant taste and short duration of
action limit its usefulness in elective surgery [96].
Gastric volume and pH may be effectively reduced
by H2-receptor antagonists. Cimetidine (Tagamet,
Glaxo), 300 mg po 12 h prior to surgery, reduces
gastric volume and pH. However, cimetidine is also
a potent cytochrome oxidase inhibitor and may
increase the risk of reactions to lidocaine during
tumescent anesthesia [282]. Ranitidine (Zantac,
Glaxo), 150300 mg po 90120 min prior to surgery
[283], or famotidine (Pepcid, Merck), 20 mg po
60 min prior to surgery, are equally effective but have
a better safety profile than cimetidine [284].
Omeprazole (Prilosec, Astra Zeneca), 20 mg po,
which decreases gastric acid secretion by inhibiting the
proton-pump mechanism of the gastric mucosa, is a safe
and effective alternative to the H2-receptor antagonists
[284]. Metaclopramide (Reglan, Baxter and Schwarz
Pharma),1020 mg po or iv, a gastrokinetic agent, which
increases gastric motility and lowers esophageal sphinc-
ter tone, may be effective in patients with reduced gas-
tric motility, such as diabetics or patients receiving
opiates [97, 214]. However, extrapyramidal side effects,
such as permanent dystonic reactions, which have been
reported to occur with just one dose, limit the routine
use of the medication [97, 98, 214].
Postoperative nausea and vomiting (PONV) remains
one of the more vexing complications of anesthesia
and surgery [285]. In fact, patients dread PONV more
than any other complication, even postoperative pain
[286]. PONV is the most common postoperative com-
plication [287], the most important factor in determin-
ing length of stay after ambulatory anesthesia [288],
and the most common cause of postoperative patient
dissatisfaction [289]. Use of prophylactic antiemetic
medication has been shown to reduce the incidence of
G.D. Bennett
PONV [290]. Even though many patients do not suffer
PONV in the recovery period after ambulatory anes-
thesia, greater than 35% of patients develop PONV
after discharge [291]. A recent Cochrane review of all
medications to control PONV, prepared by Carlisle
and Stevenson, is the most comprehensive evaluation
of the safety and efficacy to date [292].
Droperidol (Inapsine, Akorn), 0.6251.25 mg iv,
an extremely cost-effective antiemetic [293], has been a
popular treatment for perioperative nausea and vomiting
for many years. However, troublesome side effects such
as sedation, dysphoria, and extrapyramidal reactions have
been described [294]. In 2001, the FDA issued a black
box warning concerning a fatal cardiac arrhythmia, tor-
sades de pointes, due to prolongation of the QT interval
after low doses of droperidol [240]. These complications
seemed to preclude the widespread use of droperidol alto-
gether. However, after a closer analysis of the reported
cases of cardiac complications following the use of dro-
peridol, one study refuted the FDAs determination that the
administration of droperidol, in doses less than 1.25 mg,
caused the reported cardiac complications [241]. The
FDAs conclusion has been further challenged following
a review of all the pertinent data by an expert panel from
Duke University Medical Center in 2003 [242].
Ondansetron (Zofran, Pfizer), a seratonin antago-
nist, 48 mg iv, one of the most effective antiemetic
medications available, is generally not associated with
sedative, dysphoric, or extrapyramidal sequelae [295,
296]. The antiemetic effects of ondansetron may
reduce PONV for up to 24 h postoperatively [297].
The effects of ondansetron may be augmented by the
addition of dexamethasone, 48 mg iv [298], or dro-
peridol, 0.6251.25 mg iv [299]. Ondansetron is avail-
able in a parenteral preparation and as orally
disintegrating tablets and oral solution. Other effective
serotonin antagonists, granisetron (Kytril, Roche),
1 mg iv, and dolasetron mesylate (Anzemet, Aventis
Pharmaceuticals), 12.525 mg iv, share the efficacy of
ondansterone but have half-lives twice that of ondan-
sterone [300, 301]. Granisetron is also available in a
transdermal preparation.
Promethazine (Phenergan, Baxter), 12.525 mg
po, pr, or im, a phenothiazine, one of the first H1-
receptor antagonists available for the treatment of
nausea and vomiting, is still in use today by many
physicians for prophylaxis of PONV, especially in
combination with narcotic analgesics. In 2009, the
FDA issued a warning regarding severe tissue damage
and gangrene following the use of intravenous or
9 Anesthesia for Aesthetic Surgery
Table 9.13 Antiemetic Antiemetics Dose (mg)
medications
Aprepitant 4080
Dexamethasone 410
Dimenhydrinate 2550
Diphenhydramine 2550
Dolasetron 12.525
Droperidol 0.6252.5
Fosaprepitant 115
Granisetron 1 iv
Hydroxyzine 2550
Metachlopromide 1020
Ondansterone 48
Prochlorperazine 510/25
Promethazine 12.525
Scopolamine 0.2
subcutaneous promethazine administration. Because
of the anticholinergic properties, promethazine use in
patients with prostatic hypertrophy may result in uri-
nary retention. Prochlorperazine (Compazine, Glaxo
Smith Kline), 510 mg po or im and 25 mg pr, is
another older antiemetic phenothiazine that is still in
use for PONV. Once again, sedation and extrapyrami-
dal effects may complicate the routine prophylactic
use of these medications [98, 214].
Dexamethasone is another safe, cost-effective alter-
native for the prevention and treatment of perioperative
nausea and vomiting with an efficacy equal to
droperidol and ondansterone [284, 302]. A single iv
dose of 10 mg dexamethasone has rare reported side
effects and may be combined with other antinauseant
and antiemetic medications [298]. Because of its
delayed onset of action, dexamethasone should be
administered early in the perioperative period [301].
Preoperative atropine, 0.4 mg im; glycopyrrolate,
0.2 mg im; and scopolamine, 0.2 mg im, anticholinergic
agents once considered standard preoperative medica-
tions because of their vagolytic and antisialogic effects,
are no longer popular because of side effects such as dry
mouth, dizziness, tachycardia, and disorientation [303].
Transdermal scopolamine (Scopoderm TTS, Novartis
Pharma) applied 90 min prior to surgery effectively
reduces PONV. However, the incidence of dry mouth
and drowsiness is high [304], and toxic psychosis is
a rare complication [305]. Urinary retention may
result from anticholinergic in patients with prostatic
hypertrophy. Antihistamines, such as diphenhydramine,
127
Route Significant adverse effects
po Headache
iv, im Slow onset, fluid retention
po, iv, im Sedation, hypotension
po, iv, im Sedation, hypotension
iv Headache, possible arrhythmia
iv Sedation, dysphoria, extrapyramidal
symptoms, cardiac arrhythmias
iv Injection site pain
Headache, tachycardia
po, iv, im Sedation, hypotension
po, iv Tardive dyskinesia, dystonic reactions
iv, im, sl Headache, tachycardia
po, im, pr Dysphoria, extrapyramidal symptoms,
oculogyric crisis
po, im, pr Sedation, extrapyramidal symptoms,
dystonic reactions, vascular necrosis
im, iv, tc Sedation, disorientation, dry mouth,
blurred vision, tachycardia, psychosis
(Benedryl, McNeil), 2550 mg po, im, or iv; dimenhy-
dranate (Dramamine, Pfizer), 25 50 mg po, im, or iv;
and hydroxyzine (Atarax or Visaril, Pfizer), 50 mg
po or im [306], may also be used to treat and prevent
PONV with few side effects except for possible rare
hypotension and postoperative sedation [307].
A very a simple, effective and often overlooked
method of nausea control in the perioperative period is
the use of inhaled isopropyl alcohol, the type contained
in widely available single-use alcohol prep pads [308].
While this method has developed as a popular folk
remedy for nausea, recent studies have confirmed its
safety and efficacy. This treatment seems to be most
effective for nausea associated with vasovagal reactions.
Recent advances in the control of nausea and
vomiting have focused on the neurokinin type 1 (NK1)-
receptor antagonists such as aprepitant, 40 mg po, for
oral dosing and fosaprepitant, 115 mg iv, the lyo-
philized prodrug of aprepitant, for intravenous dosing
(Emend, Merck). NK1 receptors are highly concen-
trated in the chemoreceptor trigger zone (CTZ) of the
emetic center of the brainstem. Substance P, a pain-
mediating neurotransmitter, is a member of the family
of NK peptides [309]. A recent study concluded that
40 mg of aprepitant resulted in a significant reduction
of nausea and vomiting in the first 24 h after balanced
anesthesia compared to ondansterone [310]. Table 9.13
summarizes these antiemetic medications.
The selection of anesthetic agents may also play
a major role in PONV. The direct antiemetic actions
of propofol have been clearly demonstrated [311].
128
Anesthetic regimen utilizing propofol alone or in com-
bination with other medications is associated with sig-
nificantly less PONV [264]. Although still controversial,
nitrous oxide is considered by many authors a prime
suspect among possible causes of PONV [260, 312,
313]. Use of opiates is also considered a culprit in the
development of PONV and the delay of discharge after
outpatient surgery [214, 314316]. Adequate fluid
hydration has been shown to reduce PONV [317].
One goal of preoperative preparation is to reduce
patients anxiety. Many simple, non-pharmacological
techniques may be extremely effective in reassuring
both patients and families starting with a relaxed,
friendly atmosphere and a professional, caring, and
attentive office staff. With proper preoperative prepa-
ration, pharmacological interventions may not even be
necessary. However, a variety of oral and parenteral
anxiolytic-sedative medications are frequently called
upon to provide a smooth transition to the operative
room. Diazepam, 510 mg po, given 12 h preopera-
tively, is a very effective medication, which usually
does not prolong recovery time [318]. Parenteral diaz-
epam, 510 mg iv or im, may also be given preopera-
tively. However, because of a long elimination half-life
of 2448 h and active metabolites with elimination
half-life of 50120 h, caution must be exercised
when using diazepam, especially in shorter cases, so
that recovery is not delayed [208]. Pain and phlebitis
with iv or im administration also reduces the popular-
ity of diazepam [206].
Lorazepam, 12 mg po or sl, 12 h preoperatively,
is also an effective choice for sedation or anxiolysis.
However, the prolonged duration of action may prolong
recovery time after shorter cases [319]. Midazolam,
510 mg im 30 min preoperatively or 25 mg iv
minutes prior to surgery, is a more potent anxiolytic-
sedative medication with more rapid onset and shorter
elimination half-life compared to diazepam [320].
While midazolam is available in an oral syrup prepara-
tion for children because of unpredictable results, it is
not considered a useful alternative for preoperative
medication in adults [321]. Oral narcotics, such as
oxycodone, 510 mg po, may help relieve the patients
intraoperative breakthrough pain during cases under
sedative-analgesic anesthesia with minimal potential
perioperative sequelae. Parenteral opioids, such as
morphine, 510 mg im or 12 mg iv; meperidine,
50100 mg im or 1020 mg iv; fentanyl, 1020 mg iv; essential component of the perioperative management.
or sufentanil, 12 mg iv, may produce sedation and
G.D. Bennett
euphoria and may decrease the requirements for other
sedative medication. The level of anxiolysis and seda-
tion is still greater with the benzodiazepines than with
the opioids. Premedication with narcotics has been
shown to have minimal effects on postoperative recov-
ery time. However, opioid premedication may increase
PONV [322, 323].
Antihistamine medications, such as hydroxyzine,
50100 mg im or 50100 mg po, and diphenhydramine,
50 mg po, im or 25 mg iv, are still used safely in com-
bination with other premedications, especially the opi-
oids, to add sedation and to reduce nausea and pruritis.
However, the anxiolytic and amnestic effects of these
antihistamines are not as potent as the benzodiazepines
[306]. Barbiturates, such as secobarbital and pentobar-
bital, once standard premedications, have largely been
replaced by the benzodiazepines and other agents.
Postoperative PE is an unpredictable and devastat-
ing complication with an estimated incidence of
0.15%, depending on the type of surgical cases, and
a mortality rate of about 15% [324]. Risk factors for
thromboembolism include prior history or family
history of DVT or PE, obesity, smoking, hyperten-
sion, use of oral contraceptives or hormone replace-
ment therapy, and patients over 60 year of age [325].
Estimates for the incidence of postoperative DVT
vary from 0.8% for outpatients undergoing hernior-
rhaphies [326] to as high as 80% for patients under-
going total hip replacement [324]. Estimates of fatal
PE also vary from 0.1% for patients undergoing
general surgeries to up to 15% of patients undergo-
ing major joint replacement [324]. While a recent
national survey of physicians performing tumescent
liposuction in a total of 15,336 patients indicated
that no patient suffered DVT or PE [327], only 66
physicians who perform liposuction responded out of
1,778 questionnaires sent, which is a mere 3.7%
response rate. A review of 26,591 abdominoplasties
revealed nine cases of fatal PE, or 0.03%, but gave no
information regarding the incidence of non-fatal PE
[328]. Other reports suggest that the incidence of pul-
monary embolism after tumescent liposuction and
abdominoplasty may be more common than reported
[329333]. One study revealed that unsuspected PE
may actually occur in up to 40% of patients with who
develop DVT [333].
Prevention of DVT and PE should be considered an
Although unfractionated heparin reduces the rate of
9 Anesthesia for Aesthetic Surgery
fatal PE [334], many surgeons are reluctant to use this
prophylaxis because of concerns of perioperative
hemorrhage. The low-molecular-weight heparins,
enoxaparin (Lovenox or Clexane, Sanofi-Aventis),
dalteparin (Fragmin, Pfizer), and ardeparin
(Normiflo, Wyeth-Ayerst), are available for prophy-
lactic indications. Graduated compression stockings
and intermittent pneumatic lower extremity compres-
sion devices applied throughout the perioperative
period until the patient has become ambulatory are
considered very effective and safe alternatives in the
prevention of postoperative DVT and PE [335, 336].
Even with prophylactic therapy, PE may still occur up
to 30 days after surgery [337]. Physicians should be
suspicious of PE if patients present postoperatively
with dyspnea, chest pain, cough, hemoptysis, pleuritic
pain, dizziness, syncope, tachycardia, cyanosis, short-
ness of breath, or wheezing [325].
9.5.5 Airway Management
Maintaining a patent airway, ensuring adequate
ventilation, and prevention of aspiration of gastric con-
tents are the goals of successful airway management.
Because the consequences of complications related to
airway management misadventures are so potentially
devastating, this important topic warrants special focus.
Indeed, an analysis of closed claims confirms that
complications due to airway mismanagement generate
one of the highest numbers of legal claims [338].
Because of the inherent pathology associated with
many aesthetic surgery patients, such as cleft palate,
hypoplastic facial malformations, post-traumatic or
post-neoplastic resection deformities, reconstruction
deformities, or morbid obesity, many patients under-
going various aesthetic surgical procedures should be
classified as higher risk due to airway abnormalities.
Physicians administering anesthesia to patients under-
going aesthetic surgery should study the difficult
airway algorithm published by the American Society
of Anesthesiologists (ASA) [339].
Surgeons who perform procedures without the
assistance of an anesthesiologist are obligated to
understand these critical airway issues as well. In the
majority of cases, simple airway obstruction during
moderate or deep sedation may be easily relieved by
gently elevating the anterior mandible with one finger,
a maneuver aptly described as the finger of life.
129
Table 9.14 Anatomical characteristics that identify a
potentially difficult airway
1 Prodigious upper incisors
2 Prominent overbite
3 Space between incisors with maximum oral opening less
than 3 cm (less than 2 finger widths)
4 Inability to completely visualize uvula (Mallampati class
III or IV)
5 Thyromental mental distance less than 3 finger widths
6 Short or thick neck anatomy (circumference great
than 60 cm)
7 Reduce cervical range of motion (i.e., due to degenera-
tive joint disease or trauma)
8 Inability to voluntarily prognath mandible
9 Limited mandibular joint compliance
10 Narrow or highly arched palate
Table 9.15 Critical decisions during the management of a
difficult airway
1 Awake intubation (with or without fiber-optic devices)
versus intubation after induction of general anesthesia
2 Maintenance or suppression of spontaneous ventilation
(i.e., with muscular paralysis)
3 Use of ventilation aids (e.g., LMA or Combitube
esophageal/tracheal airway)
4 Call for help from another physician qualified in airway
management
5 Invasive intubation (e.g., retrograde wire intubation,
cricothyrotomy, tracheostomy)
6 Abandon intubation attempts and awaken the patient
A critical element of airway management is the preop-
erative airway assessment. Proper crisis preparation
is critical to the avoidance of airway management
disasters. One consideration often acknowledged by
experienced anesthesiologists is that the presence of
full facial hair often conceals potential facial anoma-
lies that could make intubation more challenging.
Table 9.14 summarizes important anatomical charac-
teristics that identify a potentially difficult airway dur-
ing the preoperative airway assessment modified from
the ASA Task Force on Management of the Difficult
Airway [339]. These abnormalities could legitimately
be referred to as the terrifying ten traits.
Table 9.15 summarizes critical decisions during the
management of a difficult airway modified form the
ASA Difficult Airway Algorithm [340].
In general, for airways that could potentially present
a serious challenge to the physician, the awake, fiberop-
tic-assisted approach with sedation is the initial prefer-
ential course of action. Maintenance of spontaneous
130
ventilation is usually a safer alternative than suppres-
sion of spontaneous ventilation with very difficult air-
ways. When airway trauma is evident due to multiple
unsuccessful attempts at direct laryngoscopy or intuba-
tion, or there is an inability to ventilate the patient with
an occlusive mask or ventilatory assist devices (LMA:
LMA North America, Inc. San Diego, California or
Combitube Esophageal/Tracheal Airway: Tyco-
Kendall, Mansfield, MA), it is always advisable to
awaken the patient and proceed on another day. Invasive
airway management should be reserved for emergency
situations that may otherwise result in significant mor-
bidity or mortality. The anesthesiologist should have a
pre-prepared difficult intubation tray or cart available
for every case.
It would not be an exaggeration to state that the
laryngeal mask airway (LMA) has transformed airway
management for elective and emergency airway con-
trol. The LMA can be a life-saving alternative to main-
tain an open airway during difficult intubations. The
LMA may also serve as airway support for cases that
may not require full endotracheal intubation during
both adult [341] and pediatric procedures [342].
LMAs of various sizes should be available within easy
reach during any surgical procedure regardless of the
type of anesthesia used. Facial aesthetic surgeries that
require unrestricted access to the oral cavity and lower
facial regions often require nasotracheal intubation.
Obviously, this procedure requires an anesthesiologist
with extensive training and experience to avoid serious
complications to the upper airway. Techniques that
facilitate safe nasotracheal intubation are:
1. Pretreatment of the nasopharynx with a vasocon-
strictor (oxymetolosine 0.05%, Afrin, Schering)
2. Nasotracheal tube one size smaller than the size
normally used for orotracheal intubation
3. Prewarming the endotracheal tube to 45C
4. Progressively dilating the nasopharynx with lubri-
cated rubber nasopharyngeal tubes after induction
5. Copious lubrication of the endotracheal tube with a
dental anesthetic lubricant (with benzocaine 10%)
6. Preflexing the tip of the endotracheal tube just prior
to intubation to negotiate the nasopharyneal curve
7. Using curved intubating forceps (Magill) to direct
the endotracheal tube through the larynx
When these preparations are employed, compli-
cations related to nasotracheal intubation, such as peri-
operative nasopharyngeal bleeding or nasopharyngeal
trauma, are rare [343].
G.D. Bennett
9.5.6 Perioperative Monitoring
The adoption of standardized perioperative monitoring
protocol has resulted in a quantum leap in perioperative
patient safety. The standards for basic perioperative
monitoring were approved by the ASA in 1986 and
amended in 1995 [25]. These monitoring standards are
now considered applicable to all types of anesthetics,
including local with or without sedation, regional, or
general anesthesia, regardless of the duration or com-
plexity of the surgical procedure, regardless of whether
the procedures are performed in the office or the hospital
setting, and regardless of whether the surgeon or anes-
thesiologist is responsible for the anesthesia. Vigilant,
continuous monitoring and compulsive documentation
facilitates early recognition of deleterious physiologi-
cal events and trends, which, if not recognized promptly,
could lead to irreversible pathological spirals, ulti-
mately endangering a patients life.
During the course of any anesthetic, the patients
oxygenation, ventilation, circulation, and temperature
should be continuously evaluated. The concentration
of the inspired oxygen must be measured by an oxygen
analyzer. Assessment of the perioperative oxygenation
of the patient using pulse oximetry, now considered
mandatory in every case, has been a significant
advancement in monitoring. This monitor is so critical
to the safety of the patient that it has earned the nick-
name the monitor of life. Evaluation of adequate
ventilation includes observation of skin color, chest
wall motion, and frequent auscultation of breath
sounds. During general anesthesia with or without
mechanical ventilation, a disconnect alarm on the
anesthesia circuit is crucial. Capnography, a measure-
ment of respiratory end-tidal CO2, is required not only
when the patient is under moderate sedation, deep
sedation, or general anesthesia but also during the
postoperative recovery period. Capnography provides
the first alert in the event of airway obstruction,
hypoventilation, or accidental anesthesia circuit dis-
connect, even before the oxygen saturation has begun
to fall. The use of capnography should also be applied
to patients recovering from sedation-analgesia or gen-
eral anesthesia because of the potential for respiratory
arrest during recovery. All patients must have continu-
ous monitoring of the electrocardiogram (ECG)
and intermittent determination of blood pressure (BP)
and heart rate (HR) at a minimum of 5-min inter-
vals. Superficial or core body temperature should be
9 Anesthesia for Aesthetic Surgery
monitored. Of course, all electronic monitors must
have preset alarm limits to alert physicians prior to the
development of critical changes.
While the availability of electronic monitoring
equipment has improved perioperative safety, there is
no substitute for visual monitoring by a qualified,
experienced practitioner, usually a CRNA or an anes-
thesiologist. During surgeries using local anesthetics
with SAM, if a surgeon elects not to use a CRNA or an
anesthesiologist, a separate, designated, certified indi-
vidual must perform these monitoring functions [33].
Visual observation of the patients position is also
important in order to avoid untoward outcomes such as
peripheral nerve or ocular injuries.
Documentation of perioperative events, interven-
tions, and observations must be contemporaneously
performed and should include BP and HR every 5 min
and oximetry, capnography, ECG pattern, and temper-
ature at 15-min intervals. Intravenous fluids, medica-
tion dosages in mg, patient position, and other
intraoperative events must also be recorded. Proper
documentation may alert the physician to unrecog-
nized physiological trends that may require treatment.
Preparation for subsequent anesthetics may require
information contained in the patients prior records,
especially if the patient suffered an unsatisfactory out-
come due to a previous anesthetic regimen. Treatment
of subsequent complications by other physicians may
require information contained in the records, such as
the types of medications used, blood loss or fluid totals.
Finally, compulsive documentation may help exoner-
ate a physician in many medical-legal challenges.
When local anesthesia with SAM is used, monitor-
ing must include an assessment of the patients level of
consciousness as previously described. For patients
under general anesthesia, the level of consciousness
may be determined using the bispectral index (BIS), a
measurement derived from computerized analysis of
the electroencephalogram. When used with patients
receiving general anesthesia, BIS improves control of
the level of consciousness, rate of emergence and
recovery, and cost control of medication usage [344].
Given that 18% of malpractice claims against anes-
thesiologists are related to peripheral nerve injuries
occurring in the perioperative period [345], scrupulous
attention to patient positioning during anesthesia is
critical, especially for prolonged cases under general
anesthesia. Elbows, knees, and feet should be carefully
padded and the extremities should be placed in a neutral
131
position avoiding extreme abduction, extension, or
flexion to prevent traction on peripheral nerves. A pillow
under the knees in the supine position may reduce the
pressure on the low back and avoid postoperative back
pain. Prolonged immobilization of the head may result in
localized alopecia from follicular pressure necrosis.
Maintaining neutral head position during laryngoscopy
may reduce postoperative neck pain. Documentation of
proper positioning and frequent checks of positioning
may be helpful in the defense in the event of a legal claim
due to an unanticipated perioperative nerve injury.
Patients eyes should be protected from inadvertent con-
tact to avoid ocular injuries such as corneal abrasions.
Hypothermia should be avoided during extended surgi-
cal procedures using FDA-approved warming devices
such as the Bair-Hugger, Arizant Healthcare Inc. Make-
shift warming devices such as heated IV bags, heated
water bottles, electric blankets, warming lights, or forced
heated air are absolutely contraindicated due to the high
likelihood of severe burn injuries [346, 347].
9.5.7 Perioperative Fluid Management
Management of perioperative fluids probably gener-
ates more controversy than any other anesthesia-related
topics. Generally, the typical, healthy, 60-kg patient
requires about 100 mL of water per hour to replace
metabolic, sensible, and insensible water losses. After
a 1012 h period of fasting, a 60-kg patient may be
expected to have an approximately 1 L volume deficit
on the morning of surgery. This deficit should be
replaced iv over the first few hours of surgery. In addi-
tion to the fluid deficit, induction of general anesthesia
is usually accompanied by vasodilatation which
requires compensatory iv fluid administration of
approximately 0.5 mL/kg, or 300 mL. The patients
usual maintenance fluid needs may be met during sur-
gery with an iv crystalloid solution such as lactated
Ringers solution.
Replacement fluids may be divided into crystalloid
solutions, such as normal saline (0.9% NaCl) or bal-
ance salt solution (lactated Ringers solution); colloids,
such as fresh frozen plasma, 5% albumin, plasma pro-
tein fraction, or hetastarch; and blood products contain-
ing red blood cells, such as packed red blood cells.
Generally, balanced salt solutions may be used to
replace small amounts of blood loss. For every mL of
blood loss, 3 mL of fluid replacement is usually required
132
[348]. However, as larger volumes of blood are lost,
attempts to replace these losses with crystalloid reduces
the serum oncotic pressure, one of the main forces sup-
porting intravascular volume. Subsequently, crystalloid
rapidly moves into the extracellular space. Intravascular
volume cannot be adequately sustained with further
crystalloid infusion [349]. At this point, many authors
suggest that a colloid solution may be more effective in
maintaining intravascular volume and hemodynamic
stability [350, 351]. Given the ongoing crystalloid-
colloid controversy in the literature, the most practi-
cal approach to fluid management is a compromise.
Crystalloid replacement should be used for estimated
blood losses (EBL) less than 500 mLs, while colloids,
such as hetastarch, may be used for EBLs greater than
500 mLs. One milliliter of colloid should be used to
replace 1 mL of EBL [348]. However, not all authors
agree on the benefits of colloid resuscitation. Moss and
Gould concluded that isotonic crystalloid replacement,
even for large EBLs, restores plasma volume as well as
colloid replacement [352].
For patients undergoing liposuction with less than
1500 mL of fat extraction using the tumescent tech-
nique, studies have determined that postoperative
serum hemoglobin remains essentially unchanged
[353]. Therefore, intravenous fluids beyond the deficit
replacement and the usual maintenance amounts are
generally not required [27, 171, 353, 354]. As the vol-
ume of fat removed approaches or exceeds 3000 mL,
judicious iv fluid replacement, including colloid, may
be considered depending on the patients hemodynamic
status [27]. Fluid overload with the possibility of pul-
monary edema and congestive heart failure following
aggressive administration of infusate and intravenous
crystalloid solutions has become a legitimate concern
[18, 171, 354357]. Using the tumescent technique
during which subcutaneous infusion ratios of 23 mL
for 1 mL of fat is aspirated, significant intravascular
hemodilution has been observed [355]. A 5-L tumes-
cent infusion may result in a hemodilution of 10%.
Plasma lidocaine near toxic levels, combined with an
increased intravascular volume, may increase the risk
of cardiogenic pulmonary edema, even in healthy
patients [152, 355, 357].
While crystalloid replacement regimen during lipo-
suction may vary, Pitman et al. [356] advocate limiting
iv replacement to the difference between twice the vol-
ume of total aspirate and the sum of iv fluid already
G.D. Bennett
administered intravenously and as tumescent infusate.
This replacement formula presumes a ratio of infusate
to aspirate of greater than 2 to 1. If the ratio is less than
one, more generous replacement fluids may be required
since hypovolemia may occur [18]. The determination
of fluid replacement is still not an exact science, by any
means. Because of the unpredictable fluid require-
ments in patients, careful monitoring is required,
including possible laboratory analysis such as CBC
and BUN [18]. To avoid hypothermia, particularly dur-
ing longer or more extensive surgical procedures, all
intravenous or tumescent fluids should be prewarmed
to 40C (104F). During prolonged surgical proce-
dures under sedation-analgesia, care must be taken not
to administer too much fluid to avoid patient discom-
fort due to a distended urinary bladder.
The estimation of perioperative blood and fluid loss
during surgical procedures is not a trivial task.
Observers in the same room frequently have wide dis-
crepancies in the estimated blood loss. In some surgi-
cal procedures, unrecognized blood loss may occur.
Substantial amounts of blood can seep around and
under the patient, unnoticed by the surgeon, only to be
discovered later as the nurses apply the dressing.
Because of subcutaneous hematoma formation and the
difficulty of measuring the blood content in the aspi-
rate during large-volume liposuction, estimating the
EBL during liposuction may be a particularly daunting
task. Fortunately, the development of tumescent tech-
nique has dramatically reduced perioperative blood
loss during liposuction surgeries [32, 358].
The blood content in the aspirate after tumescent
liposuction has varied between less than 1% [355, 358]
and 8% [356]. To underscore the difficulty of estimat-
ing the EBL, the range of the determined blood loss in
one study was 01002 mL or 041.5% of the aspirate
for liposuctions removing 10005500 mL of fat [356].
Samdal et al. [358] admitted that the mean fall of post-
operative hemoglobin of 5.2% (4.9%) was higher
than anticipated. The authors suggested that previous
estimates of continued postoperative blood extravasa-
tion into the surgical dead space may be too low and
may be greater than the EBL identified in the aspirate.
Mandel [359] concluded that unappreciated blood loss
continues for several days after surgery, presumably
due to soft tissue extravasation, and that serial postop-
erative hematocrit determinations should be used,
especially for large-volume liposuctions.
9 Anesthesia for Aesthetic Surgery
The decision to transfuse a patient involves multiple
considerations. Certainly, the EBL, health, age, esti-
mated preoperative blood volume of the patient, and
the hemodynamic stability of the patient are the pri-
mary concerns. The potential risks of transfusions,
such as infection, allergic reaction, errors in cross
matching, and blood contamination should be consid-
ered. Finally, the patients personal or religious prefer-
ences may play a pivotal role in the decision to
transfuse. Cell-saving devices and autologous blood
transfusions may alleviate many of these concerns.
Healthy, normovolemic patients, with hemodynamic
and physiologic stability, should tolerate hemoglobin
levels down to 7.5 g/dL [360]. Even for major surgical
procedures or large-volume liposuction using the
tumescent technique, transfusions are rarely necessary
[27]. Once the decision to transfuse is made, 1 mL of
RBCs should be used to replace every 2 mL of EBL
along with replacement colloid or crystalloid [348].
Serial hematocrit determination, although sometimes
misleading in cases of fluid overload and hemodilu-
tion, is still considered an important diagnostic tool in
the perioperative period to assist with decisions regard-
ing transfusion. An estimate of the patients volume
status and possibly hemoglobin content of the blood
may be routinely determined by newer, non-invasive
pulse oxygenation-type monitors in the future.
During longer, extensive surgical procedures and
large-volume liposuction monitoring, the urine output
using an indwelling urinary catheter is a useful guide
to the patients volume status. Urinary output should
be maintained at greater than 0.5 mL/kg/h. However,
urinary output is not a precise method of determining
the patients volume status since other factors, includ-
ing surgical stress, hypothermia, and the medications
used during anesthesia, are known to alter urinary
output [361]. Therapeutic determinations based on a
decreased urinary output become even more chal-
lenging since oliguria may be a result of either hypov-
olemia or fluid overload and congestive heart failure.
In general, use of loop diuretics, such as furosemide,
to accelerate urinary output makes everyone in the
operating room feel better but does little to elucidate
the cause of the reduced urinary output, and in cases of
hypovolemia, may worsen the patients clinical situa-
tion. However, a diuretic may be indicated if oliguria
develops in the course of large-volume liposuction
where the total infusate and intravenous fluids is
133
several liters more than the amount of aspirate [357]
or in cases with minimal blood loss with adequate
hydration.
9.6 Recovery and Discharge
The same intensive monitoring and treatment which
occurs in the operating room must be continued in the
recovery room under the care of a designated, licensed,
and experienced person for as long as is necessary to
ensure the stability and safety of the patient, regardless
of whether the facility is a hospital, an outpatient
surgical center, or a physicians office. During the ini-
tial stages of recovery, the patient should not be left
alone while hospital or office personnel attend to other
duties. Vigilant monitoring including visual observa-
tion, continuous oximetry, continuous ECG, and inter-
mittent BP and temperature determinations must be
continued. Because the patient is still vulnerable to
airway obstruction and respiratory arrest in the recov-
ery period, continuous visual observation is still the
best method of monitoring for this complication. Sup-
plemental oxygenation should be continued during the
initial stages of recovery and continued until the patient
is able to maintain an oxygen saturation above 90% on
room air.
The most common postoperative complication is
nausea and vomiting. The antiemetic medications pre-
viously discussed, with the same consideration of
potential risks, may be used in the postoperative period.
Because of potential cardiac complications, droperi-
dol, one of the most commonly used antiemetic, is now
considered by the FDA unsafe unless the patient has
no cardiac risk factors and a recent 12-lead ECG was
normal without prolongation of the QT interval [240].
Ondansetron, 48 mg iv or sl, is one of the most effec-
tive and safe antiemetics [295299]. Postoperative sur-
gical pain may be managed with judiciously titrated iv
narcotic medication such as meperidine, 1020 mg iv
every 510 min; morphine, 12 mg iv every 510 min;
butorphanol, 0.10.2 mg iv every 10 min; or hydro-
morphone, 0.10.2 mg iv every 510 min. However,
when using narcotic medications to control postopera-
tive pain, scrupulous monitoring in accordance with
the ASA Guidelines [25] must be maintained because
of the risk of delayed respiratory depression which
could result in respiratory or cardiac arrest.
134
Following large-volume liposuction, extracellular
fluid extravasation or third spacing may continue for
hours postoperatively leading to the risk of hypoten-
sion, particularly if the ratio of tumescent infusate to
aspirate is less than one [357]. For large-volume lipo-
suction, blood loss may continue for 34 days [359].
Crystalloid or colloid replacement may be required in
the event of hemodynamic instability.
The number of complications that occur after dis-
charge may be more than twice the complications
occurring intraoperatively and during the immediate
recovery period combined [362]. Accredited ambula-
tory surgical center must have established discharge
criteria. While these criteria may vary, the common
goal is to ensure the patients level of consciousness
and physiological stability. It is usually not necessary
to urinate prior to discharge for most patients. The fol-
lowing is one example of discharge criteria that may be
used (Table 9.16).
Use of medications intended to reverse the effects
of anesthesia should be used only in the event of sus-
pected overdose of medications. Naloxone, 0.10.2 mg
iv, a pure opiate-receptor antagonist, with a therapeutic
half-life of less than 2 h, may be used to reverse the
respiratory depressant effects of narcotic medications,
such as morphine, demerol, fentanyl, and butorphanol.
Because potential adverse effects of rapid opiate rever-
sal of narcotics include severe pain, seizures, pulmo-
nary edema, hypertension, congestive heart failure,
and cardiac arrest [364], naloxone must be adminis-
tered by careful titration. The effective half-lives of
many narcotics exceed the half-life of naloxone.
Naloxone has no effect on the actions of medications,
such as the benzodiazepines, the barbiturates, propo-
fol, dexmedetomidine, or ketamine.
Flumazenil, 0.10.2 mg iv, a specific competitive
antagonist of the benzodiazepines, such as diazepam,
midazolam, lorazepam, may be used to reverse exces-
sive or prolonged sedation and respiratory depression
resulting from these medications [365]. The effective
half-life of flumazenil is 1 h or less [366]. The half-
lives of the benzodiazepines exceed the half-life of flu-
mazenil. The benzodiazepines have effective half-lives
greater than 2 h and, in the case of diazepam, up to
50 h. Many active metabolites unpredictably extend the
putative effects of the narcotics and benzodiazepines.
Because the effective half-lives of most of the ben-
zodiazepines and many of the narcotics exceed that of
flumazenil and naloxone, a major risk associated with
G.D. Bennett
Table 9.16 Ambulatory discharge criteria
1 All life-preserving protective reflexes, i.e., airway,
cough, gag, must be returned to normal
2 The vital signs must be stable without orthostatic
changes
3 There must be no evidence of hypoxemia 20 min after
the discontinuation of supplemental oxygen
4 Patients must be oriented to person, place, time, and
situation (4 times)
5 Nausea and vomiting must be controlled, and patients
should tolerate po fluids
6 There must be no evidence of postoperative hemorrhage
or expanding ecchymosis
7 Incisional pain should be reasonably controlled
8 The patient should be able to sit up without support and
walk with assistance
9 Patients should be discharged in the care of a responsible
adult
10 Patients should not drive for at least 24 h if sedatives or
analgesics were used
Modified from Mecca [363]
the use of flumazenil and naloxone is the recurrence of
the effects of the benzodiazepine or narcotic after 12 h.
If the patient has already been discharged to home after
these effects recur, the patient may be at risk for over
sedation or respiratory arrest [364, 367]. Therefore,
routine use of reversal agents, without specific indica-
tion, prior to discharge is ill advised. Patients should be
monitored for at least 2 h prior to discharge if these
reversal agents are administered [33].
Physostigmine (Antilirium, Forest), 1.25 mg iv, a
centrally acting anticholinesterase inhibitor, functions
as a non-specific reversal agent which may be used to
counteract the agitation, sedation, and psychomotor
effects in the central nervous system caused by a vari-
ety of sedative, analgesic, and inhalation anesthetic
agents [368, 369]. Neuromuscular blocking drugs, if
required during general anesthesia, are usually reversed
by the anesthesiologist or CRNA prior to emergence in
the operating room with anticholinesterase inhibitors
such as neostigmine (Prostimine, ICN) or edropho-
nium (Enlon, Bioniche Pharma, Tensilon, Valeant
Pharmaceuticals, or Reversol, Organon) [270].
Occasionally, a second dose may be required when the
patient is in the recovery room.
In the event patients fail to regain consciousness dur-
ing recovery, reversal agents should be administered. If
no response occurs, the patient should be evaluated
for other possible causes of unconsciousness, including
hypoglycemia, hyperglycemia, hyponatremia, cerebral
9 Anesthesia for Aesthetic Surgery
vascular accidents, or cerebral hypoxia. If hemody-
namic instability occurs in the recovery period, causes
such as occult hemorrhage, hypovolemia, pulmonary
edema, congestive heart failure, or myocardial infarc-
tion must be considered. Access to laboratory analysis
to assist with the evaluation of the patient is crucial.
Unfortunately, stat laboratory analysis is usually not
available if the surgery is performed in an office-based
setting.
The above text is meant to serve as an overview
of the extremely complex subject of anesthesia. It is
the intent of this chapter to serve as an introduction to
the physician highlighting salient considerations in the
perioperative management of patients and should not
be considered a comprehensive presentation. The phy-
sician is encouraged to seek addition information on
this broad topic through the other suggested readings.
At least one authoritative text on anesthesia should
be considered a mandatory addition to the physicians
office references.
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major liposuction procedures. Aesthetic Plast Surg
14:187191
360. Leone BJ, Spahn DR (1992) Anemia, hemodilution, and
oxygen delivery. Anesth Analg 75(5):651653
361. Kaye AD, Grogono AW (2000) Fluid and electrolyte phys-
iology. In: Miller RD (ed) Anesthesia, 5th edn. Churchill
Livingstone, Philadelphia, p 1601
362. Natof HE, Gold B, Kitz DS (1991) Complications. In:
Wetcher BV (ed) Anesthesia of ambulatory surgery, 2nd
edn. Lippincott, Philadelphia, pp 374474
363. Mecca RS (1992) Postoperative recovery. In: Borash PG,
Cullen BF, Stoelting RK (eds). J.B. Lippincott, Philadelphia,
pp 15171518
364. Bailey PL, Egar TD, Stanley TH (2000) Intravenous opioid
anesthetics. In: Miller RD (ed) Anesthesia, 5th edn.
Churchill Livingstone, Philadelphia, pp 273376
365. Jensen S, Knudsen L, Kirkegaard L, Kruse A, Knudsen EB
(1989) Flumazenil used for antagonizing the central effects
of midazolam and diazepam in outpatients. Acta Anaes-
thesiol Scand 33(1):2628
366. Klotz U (1988) Drug interactions and clinical pharma-
cokinetics of flumazenil. Eur J Anaesthesiol 2(Suppl):
103108
367. McCloy RF (1995) Reversal of conscious sedation by flu-
mazenil: current status and future prospects. Acta Anaes-
thesiol Scand Suppl 108:3542
368. Bourke DL, Rosenberg M, Allen PD (1984) Physostigmine:
effectiveness as an antagonist of respiratory depression and
psychomotor effects caused by morphine or diazepam.
Anesthesiology 61(5):523528
369. Hill GE, Stanley TH, Sleutker CR (1977) Physostigmine
reversal of postoperative somnolence. Can Anaesth Soc J
24:707711
Additional Recommended Reading
Miller RD (2010) Millers anesthesia, 7th edn. Churchill
Livingstone Elsevier, Philadelphia
Roizen MF, Fischer SP, White PF (eds) (1997) Ambulatory
anesthesia and surgery. WB Saunders, Philadelphia,
pp 155172
 Part III
Head and Neck
 Facial Peels
Niti Khunger
10.1 Introduction
Facial peeling with chemicals or chemical peeling is a
procedure, where a chemical agent or combination of
agents of defined strength is applied to the skin, causing
a controlled destruction of the layers of the skin. This is
followed by regeneration and remodeling leading to
improvement of texture and surface abnormalities.
The concept of skin peeling to beautify the skin by
the use of chemicals and natural products has been
used since the time of Cleopatra. She used sour milk,
containing lactic acid whereas French women used
old wine containing tartaric acid for beauty baths.
The modern era of chemical peeling began with
MacKee [1] who used phenol as a peeling agent to
treat facial scars. Peeling procedures attracted wide
interest at that time because of the remarkable results
they achieved, and peeling formulas were closely
guarded secrets. Finally, scientific investigations were
undertaken, and various agents are now being used for
chemical peeling with newer agents being added day
to day.
The objective of chemical peeling is to cause
destruction at the required depth without scarring.
Chemical peels are divided according to the depth as
very superficial, superficial, medium depth, and deep
peels. The depth of peeling is controlled by many
factors: the most important being the strength and
characteristics of the peeling agent. Every physician
N. Khunger
Department of Dermatology, V.M. Medical College
& Safdarjang Hospital, New Delhi, India
e-mail: drniti@rediffmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_10, Springer-Verlag Berlin Heidelberg 2013
10
performing chemical peels should aim to standardize
their peeling procedures in order to eliminate the
maximum number of variables that can affect depth of
facial peels.
The introduction of nonablative lasers and light
therapy systems initially led to a decline in the use of
chemical peels, but lasers are still very expensive to
acquire and maintain. Till these newer nonablative
light therapies become more predictable, affordable,
and widely available, chemical peels continue to be an
extremely useful armamentarium in the treatment of
common conditions such as skin rejuvenation, photoa-
ging, hyperpigmentation, and acne. Newer, safer, and
more effective peeling agents, such as mandelic acid,
lactic acid, pyruvic acid, phytic acid, etc., and current
peeling options such as combination peels, sequential,
segmental, and switch peels have led to resurgence in
the use of chemical peels [2]. Sound knowledge of
peeling agents, peeling procedures, and experience are
still essential to achieve cosmetically pleasing results.
Hence, chemical peeling is a versatile tool that can
help build a good aesthetic practice.
10.2 Basic Principles and Mechanism
of Action
Chemical peels have a sound scientific, histological,
chemical, and toxicological basis. The basic principle
of chemical peeling is to cause injury to the skin at a
required depth and allow regeneration and remodeling
to take place, without causing permanent scarring.
Various peeling agents are available. It is essential to
understand basic chemistry of these agents, anatomy
147
148
of the skin, and the skinchemical interactions, in
order to optimize treatment [3]. Peeling agents basically
act by either of three mechanisms:
1. Metabolic
2. Caustic
3. Toxic
Alpha hydroxy acids (AHAs) are weak acids and
include common peeling agents such as glycolic acid,
mandelic acid, pyruvic acid, lactic acid, citric acid,
etc. They act by metabolic action by interfering with
the functioning of enzymes such as kinases, sulfo-
transferases, and phosphotransferases, which attach
sulfate and phosphate molecules to the corneocytes.
This causes desquamation of corneocytes, leading to
epidermal desiccation and shedding, followed by
regeneration. A single light AHA peel can replace the
epidermis in 2 weeks [4]. In higher concentrations of
free acid, they act as caustic agents that cause epider-
molysis or skin necrosis. In the dermis, there is an
induction of inflammatory response with deposition
of glycosaminoglycans and new collagen formation.
Salicylic acid is a beta hydroxy acid and has kera-
tolytic properties. It causes dissolution of the intercel-
lular cement substance and hence reduces corneocyte
adhesion. It is lipophilic and easily penetrates the
sebaceous follicles and hence is useful in acne. It also
has comedolytic and anti-inflammatory properties.
When applied over large areas, it can be absorbed in
the systemic circulation and cause salicylism.
Trichloroacetic acid (TCA) is a strong acid and has
a caustic action. It causes coagulation of proteins,
which is seen visually as frosting. TCA causes destruc-
tion of cells, the depth depending on the concentration,
with stimulation of collagen in the dermis. Regeneration
of dermal collagen starts within 23 weeks whereas
the increase in papillary dermal collagen and the pro-
duction of elastic fibers continue for 6 months [5]. It is
self-neutralizing and is not absorbed into the systemic
circulation.
Phenol and resorcinol have a toxic action on the
cells. They cause enzyme inactivation and protein
denaturation and increase permeability of cell mem-
branes leading to cell death. Resorcinol has a weaker
action as compared to phenol. Phenol is absorbed in
the systemic circulation and can cause cardiac, renal,
and hepatic toxicity.
At the same, pH and concentration applying a
greater volume of acid on the skin of course induce
greater necrosis.
N. Khunger
10.3 Histological Classication
of Peels and Peeling Depths
Chemical peels are divided according to the depth of
necrosis as very superficial, superficial, medium depth,
and deep peels (Table 10.1). Superficial peels are more
frequently used, whereas deep peels have been sup-
planted by lasers and light devices to a greater extent.
There are many variables that can modify the depth
of the peel.
10.3.1 Peeling Agent
The peeling agent and its concentration is the most
important factor in determining the peel depth.
Generally, the higher the concentration of the peeling
agent, the greater is the depth. However, in combina-
tion peels, peeling agents can be combined at lower
concentrations to achieve greater depths. In addition,
concentration of the peeling agent can vary, with dif-
ferent brands and formulations of the same peeling
agent. Hence, while peeling a patient, one must not
interchange the brand of the peeling agent, even if it
indicates the same concentration.
10.3.2 Duration of Contact
This is important with AHA peels, particularly glycolic
acid. The longer the duration of contact, the greater is
the depth achieved. This is not significant with TCA
and salicylic acid, where concentration is important.
10.3.3 Availability of Free Acid
The availability of free acid in the formulation is
important. The pKa of the solution is the pH at which
half is in acid form. A lower pKa means that more free
acid is available for action. Though many products
advertise the acid percentage, the pKa is a more accu-
rate determinant of strength of the peeling agent.
10.3.4 Method of Degreasing the Skin
Vigorous degreasing of the skin can increase penetra-
tion and cause hotspots to develop.
10 Facial Peels 149

Table 10.1 Histological classification of chemical peels

Type of peel Histological level
Very superficial Exfoliation of the stratum
corneum, without any
epidermal necrosis
Superficial Necrosis of part or entire
epidermis, not below
the basal layer
Medium Necrosis of the epidermis,
papillary dermis up
to the upper one third
of the reticular dermis
Deep Necrosis of the epidermis, papillary
dermis up to mid-reticular dermis
Agents Indications
Glycolic acid 3050% applied for 12 min Active acne
TCA 10% applied as one coat Skin brightening
Jessners solution one to three coats
Resorcinol 2030% applied for 510 min
Glycolic acid 5070% applied for 210 min, Ephelides
depending on the type and thickness of the skin
TCA 1030% Epidermal melasma
Jessners solution four to ten coats
Resorcinol 4050% applied for 3060 min
Glycolic acid 70% applied for 315 min, Lentigines
depending on the type and thickness of the skin
TCA 3550% Dermal melasma
Glycolic acid 70% plus TCA 35% Superficial acne scars
Jessners solution plus TCA 35%
Phenol 88% Superficial wrinkles
BakerGordon phenol formula

10.3.5 Technique of Application
If the peeling agent is rubbed when applying on the
skin, it achieves a greater depth than if it is painted on
the skin. The number of coats applied as in Jessners
solution and the degree of frosting as with salicyclic
acid peel can cause variations in the peel depth.
papulosa nigra, and lentigo all affect penetration of
the peeling agent.
Hence, it is essential to standardize the peeling
agents used, procedure of priming the patient, cleaning
and degreasing the skin, and method of application so
as to maintain the required depth of the peel.

10.4 Peeling Agents

10.3.6 Priming Agents
The application of low concentrations of glycolic acid,
tretinoin or salicylic acid during the period of pre-peel
priming causes thinning of the stratum corneum. This
leads to greater penetration of the chemical agent.
10.3.7 Location of Peel
A facial peel will have greater depth as compared to a
non-facial peel, where the skin is thicker at the same
concentrations.
10.3.8 Characteristics of Patients Skin
Currently, a wide and often confusing variety of peel-
ing agents are available. For beginners, it is better to
start chemical peeling with a few tried and tested prod-
ucts from reputed manufacturers, where the strength of
the peeling agent is standardized. The learning curve
for aesthetic peels should begin with fewer peels and
lower concentrations. Once experience is gained, higher
strengths and deeper peels can be more safely and con-
fidently used. It should be remembered that there can
be tremendous variability between formulations and
brands, even at the same concentration, which can lead
to unexpected outcomes and complications.
A comparison of the common peeling agents is
given in Table 10.2.

If the patient has thick oily skin, penetration is less 10.4.1 Newer Peels and Combination Peels
as compared to thin dry skin. The level of photodam-
age, actinic damage, and presence of irregular superfi- Many newer peels have been introduced that are gen-
cial lesions such as seborrheic keratoses, dermatoses tler, with lower concentrations, and available singly as
150 N. Khunger

well as in combinations. Many of these patented
peels have added antioxidants and humectants to
make them potent, with improved tolerance and less
irritant potential. These newer peels include mandelic
acid, lactic acid, pyruvic acid, phytic acid, polyhydroxy
acids, citric acid, malic acid, and various agents in
combination [6].
Combination peels have the benefit of increased
efficacy, without increased risk of complications. The
action of individual agents at lower concentrations

Table 10.2 Comparison of the common peeling agents

End point/
Agent Indications Precautions neutralization Advantages Disadvantages
Alpha Photoaging Timing is Timing begin Long shelf life Great variability in
hydroxy Skin freshening important with 3 min and Well tolerated reactivity and
acids Fine wrinkling Watch out for gradually Do not produce efficacy
Rough-textured skin erythema and hot increase time systemic Sometimes difficult
Epidermal melasma spots or endpoint toxicity to judge the end
Pigmented acne Grayish erythema point
Superficial acne scars discoloration due Neutralization Wounds and scarring
to epidermolysis with sodium can occur in higher
Do not leave the bicarbonate 15% concentrations
room while doing or water Have to be
the peel neutralized
Expensive
Can cause PIH in
darker skin types
Salicylic Comedonal acne Do not apply Concentration, Safe in all type Causes burning
acid Inflammatory acne over large surface begin with 20%, of skins IVI when applied
Pigmented acne scars areas to avoid gradually Inexpensive Can be absorbed
Superficial acne scars absorption increase Predictable when applied over
Oily skin Adequate amounts concentration response large areas and
Enlarged facial pores of water to be Endpoint Causes a cause salicylism
Superficial given after the pseudofrosting pseudofrost Contraindicated in
pigmentation peel Neutralization End point is patients allergic to
As sequential peels not required, easy to judge aspirin
to increase penetration washed with Lipophilic Cannot be used in
of other peeling water Anti-inflammatory pregnancy and
agents Comedolytic lactation
Photoaging Limited depth of
Skin texture peeling
abnormalities
TCA Acne scars Use with Concentration, Inexpensive Highly hydrophilic
photoaging precaution begin with Stable Can lose efficacy
Textural changes in darker skin 1015%, No systemic when repeatedly
Freckles types gradually toxicity exposed to air
Lentigines increase Peel depth Can cause prolonged
Plain warts concentration correlates with PIH
Endpoint the intensity Can cause scarring
frosting of the frost
Neutralization End point is
not required, easy to judge
washed with No need for
water neutralization
Retinoic Acne Do not use in Well tolerated Yellow in color
acid hyperpigmentation patients with without burning Has to be left on for
Photoaging sensitive skin Comedolytic at least 4 h
Safe in darker skin Can cause excessive
types peeling
10 Facial Peels 151

Table 10.2 (continued)

End point/
Agent Indications Precautions neutralization Advantages Disadvantages
Phenol In skin type III Monitor cardiac Endpoint frosting Deep peel useful for Can cause systemic
Photoaging activity Neutralization not deep wrinkles and toxicity cardiac,
Moderate to severe with pulse oximeter required post-acne scars renal, hepatic
wrinkles Give adequate Dramatic results with High risk of cardiac
Moderate to severe hydration during the a single peel arrhythmias
post-acne scars procedure to Has anesthetic effect Requires an OT
Adjunct to other reduce systemic setup
aesthetic procedures toxicity Presence of
such as blepharoplasty Peeling is completed anesthetist
In darker skin type in one zone before Not an office
IIIIV, with extreme proceeding to procedure
caution the next, carried out Prolonged downtime
Mild to moderate over 90 min Can cause perma-
dyschromias nent hypopigmenta-
Mild wrinkles tion in darker skins
Post-acne scars

complements each other, without increasing their
concentration.
Some of the popular combination peels are:
1. Jessners solution: Lactic acid 14 g, salicylic acid
14 g, resorcinol 14 g with ethanol added to make
100 mL. Useful for acne, photoaging, dyschromia.
2. Modified Jessners solution: Lactic acid 17%,
salicylic acid 17 g, citric acid 8% with ethanol
added to make 100 mL. Less toxic as resorcinol is
replaced by citric acid.
3. Melaspeel KH (Sesderma peels, Spain): Lactic
acid 10%, citric acid 10%, kojic acid 5%, hydro-
quinone 2%, salicylic acid 2%. Useful for hyper-
pigmentation.
4. Glicopeel K (Sesderma peels, Spain): Com-
bination of glycolic acid 33%, citric acid 10%,
kojic acid 10%, lactic acid 9%, salicylic acid 5%,
willow herb extract, and bearberry extract. Useful
for hyperpigmentation and photoaging.
5. SM Peel (Timpac Engineers, India): Salicylic acid
20%, mandelic acid 10% in gel form. Useful in acne.
6. Easy Phytic Peel (Skin Tech, USA): Slow release
AHA combination peel with phytic acid, glycolic
acid, lactic acid, and mandelic acid that does need
neutralization. Useful for hyperpigmentation,
acne, and photoaging.
7. Cosmelan (Mesoestetic, Spain): Azelaic acid,
kojic acid, phytic acid, ascorbic acid, arbutine,
titanium dioxide. Useful for hyperpigmentation
including melasma.
8. Mandelic acid 15% + lactic acid 15%: A low-
strength peel for sensitive skin, useful for acne and
photoaging.
9. Mandelic acid 30% + lactic acid 40%: Useful for
sensitive skin.
10. Fluor-Hydroxy pulse peel: A combination of
5-fluorouracil 5% and glycolic acid 70% lotion
(Drogaderma, Brazil). It is useful for actinic
keratoses and disseminated actinic porokeratoses.
10.4.2 Choosing the Correct Peel
Facial peeling is a useful technique in the treatment of
common cosmetic disorders such as photodamage,
facial pigmentation including melasma, post-inflam-
matory hyperpigmentation (PIH), acne and post-acne
scars, mild facial scarring, and for skin rejuvenation
(Table 10.3).
Some peels are more appropriate for certain condi-
tions and for particular skin types. The choice of the
peeling agent should be individualized, and a patient
may require different peeling agents at different
periods of time for maximum benefit. Thus, it is
important to choose the right peel at the right time for
the right patient. The choice of the peeling agent
depends on two important factors: the depth of the
treating condition and the skin type of the patient.
A guide to initial selection of peeling agents is given
in Table 10.4.
152 N. Khunger

Table 10.3 Indications and contraindications of chemical 10.5 Patient Management

peeling
Indications 10.5.1 Counseling
A. Pigmentary disorders
1. Resistant melasma Adequate counseling before treatment is very essential
2. Post-inflammatory hyperpigmentation (PIH) to avoid disappointment and potential legal problems
3. Pigmented cosmetic dermatitis
at a later stage. Explanations about the nature of
4. Lichen planus pigmentosis, ashy dermatosis
treatment, expected outcomes, time taken for recovery
5. Freckles
of normal skin, and the importance of maintenance
6. Lentigines
B. Acne
regimens are essential components of a counseling
1. Comedonal acne program. It is always advisable to downplay the degree
2. Macular hyperpigmented post-acne scars of improvement expected. Discussion of side effects,
3. Superficial mild post-acne scarring likely and unlikely complications, particularly on pig-
4. Ice-pick scars mentary changes and alternative treatments available
5. Acne excorie should be done prior to starting facial peeling. If need
C. Cosmetic be repeated consultations are done, utilizing the inter-
1. Photoaging vening period for starting home care products. This
2. Fine wrinkling breathing space also helps in judging the ability of the
3. Actinic keratoses patient to follow prescribed skin care.
4. Seborrheic keratoses
5. Dilated pores
Contraindications 10.5.2 Consent Forms, Documentation,
A. Active infection in the area to be peeled
and Photographs
B. Herpes simplex
C. Folliculitis, furuncles
Informed consent is a legal document whereby a person
D. Open wounds
gives consent to perform a procedure based upon an
E. Preexisting inflammatory conditions
1. Seborrheic dermatitis
understanding of the facts given by the treating physician.
2. Photosensitive dermatitis The patient should be explained the need for treat-
3. Atopic dermatitis ment, expected outcomes, duration of the procedure,
4. Contact dermatitis number of sittings that may be required, approximate
5. Psoriasis cost of treatment, likely complications, consequences
6. Rosacea of nontreatment, and modes of alternative treatments.
F. Drug ingestion Signing the consent form should not be a casual affair
1. History of taking photosensitizing medications like getting signature on a dotted line and should be
G. Patient characteristics signed by an informed patient. In the case of teenagers
1. Uncooperative patient (1318 years), it is better to take the signatures of both
2. Patient with unrealistic expectations the minor and the parent. The patient should feel free to
3. Patients with body dysmorphophobic disorders ask questions, and sufficient time should be devoted to
4. Occupations with extensive sun exposure expectation alignment between the patient and physi-
H. Allergy
cian. The patient should also be given written instruc-
1. Allergic to contents of peeling agent
tions detailing pre- and post-peel care.
I. Heavy smoking
Photographic records are very important since patients
J. Pregnancy
often do not remember the initial condition. Every effort
K. For medium depth and deep peels, in addition to the
above should be made to standardize the photographs, includ-
1. History of abnormal scarring ing three views, front, right, and left side, distance, light-
2. Keloids ing, and background. The progress should be monitored
3. Atrophic skin regularly at every peel. Consent for photographs should
4. Isotretinoin use in the last 6 months be incorporated in the consent form. Proper records of
10 Facial Peels 153

Table 10.4 Selection of peeling agents for common indications and expected response
Expected
Indication Depth Peeling agents response
Facial pigmentation
Melasma Epidermal SA, MA, combination peels Good
Dermal/mixed Combination peels Fair/poor
Freckles Epidermal SA, MA, TCA Good
Lentigines Mixed TCA Fair
Pigmented cosmetic dermatitis Dermal Combination peels Fair/prolonged
PIH Epidermal/dermal SA, MA Good/fair
Acne
Comedonal acne Epidermal SA, MA, low-strength TCA 1015% Good
Pigmented scars Epidermal MA, combination peels Good
Mild atrophic scars Upper 1/3 dermis SA, GA, PA, phytic acid Good/fair
Ice-pick scars Deep dermis CROSS 50100% TCA Good/fair
Aesthetic
Rejuvenation Epidermal SA, GA Good
Dilated pores CROSS 50100% TCA Good/fair
Fine wrinkles Upper dermis GA, combination peels Good
Moderate wrinkles Upper 1/3 dermis Phenol Fair/poor
Photoaging
Dyschromia Epidermal Very carefully Good/fair
SA, MA
Actinic/seborrheic keratoses Epidermal Fluorouracil Good/fair
GA glycolic acid, MA mandelic acid, PA pyruvic acid, SA salicylic acid

the procedure, peeling agent used, concentration, and
details of treatment given pre-peel and post-peel should
be maintained. Occurrence of any complications and
their treatment should also be recorded.
10.5.3 Patient Evaluation
The patient should be thoroughly evaluated at the first
visit. It is easier to fill a pro forma so that no issues are
missed. Occupation, hobbies, and level of sun expo-
sure are important. Patients on photosensitizing drugs
or suffering from photosensitive disorders are at higher
risk of PIH, particularly in darker skin types. If there is
a history of herpes simplex, prophylactic acyclovir
or valacyclovir should be given to avoid scarring.
Conditions that can cause delayed healing such as
chronic smoking, immunosuppression, and radiation
over the area to be peeled should be ruled out as such
patients are at high risk of complications, particularly
with deeper peels. Patients who have undergone recent
facelifts or any surgery where extensive undermining
of the face has been done that compromises blood
supply and delays wound healing should avoid deep
chemical peels for at least 612 months.
Contraindication of chemical peeling in patients
using isotretinoin is controversial. Though there
have been reports of abnormal scarring in patients
on isotretinoin, following resurfacing procedures,
practically, it is hardly seen with chemical peels.
Precautions may be required when performing deep
phenol peels.
Assessment of skin phototype, tendency to
post-inflammatory hyperpigmentation (PIH), thick
oily skin, thin dry skin, sensitive skin, wound heal-
ing use of facial scrubs, retinoids, AHAs can all
affect penetration of peeling agents and should be
asked for.
10.5.4 Pre-peel Care
Pre-peel care is called priming the skin prior to peel-
ing. It is the first step towards performing safe and
effective peels. Priming is ideally started at least
24 weeks before the peel. The goal of priming the
154
skin is to assist in producing uniform penetration
of the peeling agent, accelerate wound healing, and
reduce risk of complications.
Retinoic acid and alpha hydroxy acids like glycolic
acid cause thinning of the stratum corneum and help
to achieve increased uniform penetration of the peel-
ing agent. Retinoic acid applied for at least 2 weeks
prior to peeling has been reported to reduce re-
epithelialization time after peeling. In addition, any
agent that is likely to be used immediately post-peel
or for maintenance therapy should be applied as a
priming agent to detect intolerance. This is especially
important with regard to sunscreen use and hydroqui-
none, which can have devastating effects if reactions
develop after a peel.
In darker skinned patients and in those at risk of
PIH, the use of hypopigmenting agents like hydro-
quinone, kojic acid, arbutin, etc., before the peel
greatly reduces the chances of PIH. Priming also
helps to enforce patient compliance. Patients who
do not follow instructions are at risk for poor
results post-peel and should not be taken up for facial
peeling.
Broad spectrum sunscreens against UVA, UVB,
and visible light, with minimum SPF 30 should be
given. In patients with sensitive skin, the physical sun-
screens containing zinc oxide or titanium dioxide are
safer than chemical sunscreens.
10.6 Peeling Technique
Chemical peeling is a simple technique that can be
performed as an office outpatient procedure, with
very few requirements (Table 10.5). However, deep
phenol peels should be carried out in a fully equipped
surgical suite.
The patient should be adequately counseled and
primed. A consent form is signed, and photographs
are taken. Contact eye lenses are removed, and the
patient is asked to wash the face with soap and water
to remove makeup, dirt, and grime. The hair is pulled
back with a hair band or cap. The patient is made to
lie down with head elevated to 45 and eyes closed.
The skin is inspected for abrasions or inflammation
that should be avoided. Sensitive areas where the
peeling agent can collect, like the inner canthus of the
eye and nasolabial folds, are protected with petrola-
tum or Vaseline. The skin is cleaned with alcohol
and then degreased with acetone, using 2 2 gauze
pieces.
N. Khunger
Table 10.5 Reagents and equipment for facial peels
Reagents
Chemical peeling agents with varying concentrations
correctly labeled
Glycolic acid 20%, 35%, 70%
TCA 10%, 15%, 25%, 100% (for CROSS technique)
Salicylic acid 20%, 30%, 50%
Mandelic acid 40%
Combination peels for acne, dyschromia, rejuvenation,
according to choice and availability
Neutralizing solutions
Cold water
Syringe filled with normal saline to irrigate the eyes, in
case of accidental spillage of reagent in the eyes
Alcohol or spirit for cleansing
Acetone for degreasing
Equipment
Cap or headband to pull back the patients hair
Glass cups to hold the peeling agent
Cotton tip applicators, ear buds, small brush or fine
toothpicks for application
2 2 gauze pieces
Timer for glycolic acid peels
Handheld fan for patient comfort
Gloves
The required peeling agent is poured in a glass bea-
ker, and neutralizing agent is also kept ready. The
label should be carefully checked. The peeling agent
is then applied either with a brush or cotton-tipped
applicator without dripping of the agent. The chemical
agent is applied quickly on the entire face divided into
cosmetic units beginning from the forehead in an
upward direction, then the right cheek, nose, left
cheek, and chin in that order. The perioral, upper and
lower eyelids, if required, are treated last (Fig. 10.1).
Feathering strokes are applied at the edges to blend
with surrounding skin and prevent demarcation lines.
A handheld cooling fan helps to reduce burning of the
skin. The patient should not be left alone, and a strict
watch should be kept for redness, hot spots, and
epidermolysis. The peel is neutralized as required
according to the peeling agent. AHA peels require
neutralization with sodium bicarbonate but can also
be washed away with copious amounts of water. While
other peels like TCA peel and salicylic acid peels are
self-neutralizing and can be washed away with water.
The skin is gently dried with gauze, and the patient
is asked to wash with cold water till the burning
subsides. The patient is then asked to apply a sun-
screen, before leaving the clinic, along with post-peel
instructions.
10 Facial Peels
Fig. 10.1 Cosmetic units of the face and order of application of
a chemical peel
10.7 Post-peel Care
Facial peeling makes the skin very sensitive to sunlight
and heat. This can lead to sunburn, erythema, and post-
inflammatory hyperpigmentation. Hence, adequate sun
protection is most important in the immediate post-peel
period till re-epithelialization is complete. Broad spec-
trum sunscreens that have been started in the priming
period should be applied ideally every 2 h. Light mois-
turizers may be used in case of excessive dryness and
desquamation. The patient should be warned to avoid
picking at the exfoliating lesions, which can lead to
excessive erythema and PIH. In darker-skinned indi-
viduals, who are prone to PIH, hypopigmenting agents
should be started as soon as possible. Retinoids and
glycolic acid should be started only after complete re-
epithelialization. In the post-peel period, the barrier
function of the skin is compromised, and topical agents
can penetrate more easily. This is an advantage, and
appropriate creams should be applied according to the
condition being treated; e.g., in the treatment of
melasma, hypopigmenting agents like hydroquinone,
glabridin, arbutin or kojic acid along with topical
155
Fig. 10.2 Pseudofrost on application of salicylic acid due to
crystallization
ascorbic acid have better permeability. Maintenance
treatment is an important component of any peeling
regimen and should be continued to maintain results.
10.8 Acne and Post-acne Scars
Acne is one of the most common skin diseases in
clinical practice. Topical and systemic therapies are
the mainstay of treatment. Patients frequently have poor
self-image, depression, and anxiety due to acne, and it
can affect the quality of life. Hence, effective manage-
ment of acne can have a relevant positive impact on
the acne patient. Chemical peeling in active acne is
an adjuvant therapeutic technique that can help in early
resolution of lesions. It is indicated in comedonal acne
and mild to moderate inflammatory acne. Superficial
and ice-pick post-acne scars can also be treated with
peeling agents.
Salicylic acid 2030% is the peeling agent of choice
in acne as it has keratolytic and anti-inflammatory
properties. The advantage is that since it is lipophilic in
nature, it can easily penetrate the pilosebaceous appara-
tus. It is effective in all grades of active acne because of
its comedolytic and anti-inflammatory properties. It is
also safer in darker skin phototypes IVVI. A pseudof-
rost is formed which is easy to visualize; hence, it can
be applied evenly, without skip areas (Fig. 10.2).
Glycolic acid in low strengths, 2035%, TCA 1015%,
156
Fig. 10.3 (Left) Active acne with persistent pigmented macules. (Right) Following treatment with 40% mandelic acid peels, six
peels at two weekly intervals
and Jessners solution are other agents that can be used
for acne. Newer peeling agents in acne include man-
delic acid 3050%, tretinoin 15%, lactic acid 4090%,
and pyruvic acid 4050%.
10.9 Comedonal Acne
If there are many comedones, comedone extraction is
done first followed by a 20% salicylic acid peel. This
allows better penetration of the peeling agent and has-
tens improvement. Closed comedones are first pierced
with a No. 26 needle; contents are extracted out with
a comedone extractor, and then, the peel is applied.
The peels can be repeated weekly in thick oily skins
or every 24 weeks in dry skins. Tretinoin peels con-
taining 15% retinoic acid are also effective.
10.10 Inammatory Papulopustular Acne
Salicylic acid 2030% and mandelic acid 40% are
the peeling agents of choice. They can also be
combined for greater efficacy. The advantage of this
N. Khunger
combination is that salicylic acid is lipophilic and
anti-inflammatory, whereas mandelic acid also has
antibacterial properties. Glycolic acid 2050% and
pyruvic acid 4070% are alternative peeling agents
and are useful when there is less inflammation but
more superficial scars.
10.11 Post-acne Pigmentation
For post-acne pigmentation, combination peels are
more effective and safer as compared to single agents.
Low-strength glycolic acid 20%, kojic acid, lactic acid,
citric acid, and salicylicmandelic peels repeated every
2 weeks are safer, particularly in darker skin types
(Fig. 10.3).
10.12 Supercial Post-acne Scars
Sequential peels with salicylic acid 30% followed
by glycolic acid 5070%, or salicylic acid 2030%
followed by TCA 1535%, depending on the skin type
are effective but should be used cautiously in patients
10 Facial Peels
prone to PIH. Combination peels containing glycolic
acid, pyruvic acid, and lactic acid are safer, though
they require larger number of sessions [7].
10.13 Ice-Pick Acne Scars CROSS
Technique
Ice-pick acne scars are deep and difficult to eradicate,
even with lasers. A technique using high strength of
the peeling agent TCA called CROSS technique (chem-
ical reconstruction of skin scars) has been found to be
useful as a simple office procedure [8]. In this technique,
Fig. 10.4 Application of 100% TCA by the CROSS technique,
by stretching the skin, and using a fine wooden toothpick
Fig. 10.5 (Left) Ice-pick post-acne scars. (Right) After treatment with the CROSS technique using 100% TCA
157
65100% TCA is applied to the bottom of the ice-pick
scar with a wooden toothpick, which leads to destruc-
tion of the epithelial tract. This is followed by col-
lagenization in the healing phase and filling up of the
depressed ice-pick scar. It causes momentary, mild, tol-
erable burning on application, and no anesthesia is
required. After cleaning and degreasing the skin with
acetone, the acid is carefully applied up to the depth of
the scar, using a fine pointed wooden tip of a toothpick,
taking care to avoid spillage on the surrounding skin
(Fig. 10.4). The skin is stretched to reach the bottom of
the scar. There is immediate blanching with an intense
white frost due to coagulation of epidermal and dermal
proteins. A sunscreen is then applied. Within 13 days,
crusts are formed which fall off in 35 days. Collagen
formation may take 23 weeks and can continue up to
46 weeks. A sunscreen is applied in the daytime, and
0.05% tretinoin and 5% hydroquinone cream are
applied at night for a minimum of 4 weeks to prevent
post-inflammatory hyperpigmentation. On an average
of about 25% improvement of scars takes place with
one session. The procedure may be repeated two or
three times at intervals of 24 weeks. The advantage of
the CROSS technique is that since the adjacent normal
tissue and adnexal structures are spared, healing is more
rapid with a lower complication rate than conven-
tional full-face medium to deep chemical resurfacing
(Fig. 10.5). However, PIH can commonly occur in
patients with darker skins; hence, the patient should be
primed adequately with hypopigmenting agents prior
to the procedure, and these should be continued till
improvement [9].
158
Table 10.6 Common causes of facial pigmentation
Epidermal Dermal
Melasma Melasma
Freckles Post-inflammatory hyperpigmentation
Lentigines Pigmented cosmetic dermatitis
Post-inflammatory Drug-induced
hyperpigmentation melanoses
Epidermal nevi Actinic lichen planus
Lichen planus pigmentosus
Periocular melanoses
Nevus of Ota
Pigmentary demarcation lines
10.14 Facial Pigmentation
Facial pigmentation can be due to various disorders,
which should be identified before treatment so as to
select the appropriate peeling agent (Table 10.6).
Therapy should be selected according to the etiology
and depth of the pigmentation. The primary approach
to the treatment of facial pigmentation is topical
hypopigmenting agents, which inhibit synthesis of
melanin and photoprotection with sunscreens that
inhibit activity of the melanocyte. Chemical peels are
adjuvant measures that remove excess melanin and
hasten improvement. The Q-switched Nd:YAG laser
causes disruption of melanin and is primarily useful in
nevus of Ota, freckles, lentigines, and epidermal nevi.
Melasma is one of the commonest causes of facial
pigmentation and often recalcitrant to treatment. It
requires a combination of agents to improve melasma,
along with prolonged maintenance therapy. The main-
stay of treatment of facial pigmentation is topical
therapy, which should also be used for priming the
skin of at least 46 weeks before chemical peeling.
Hydroquinone 25% as tolerated is the gold standard
for hyperpigmentation. If the pigmentation worsens,
the possibility of ochronosis must be kept in mind.
A biopsy will confirm the diagnosis, and hydroqui-
none must be stopped. Ochronosis is seen more
commonly with high concentrations like 10%, and it
is not very common in lower concentrations up to 5%.
If hydroquinone causes irritation, alternative agents
such as azelaic acid 1020%, kojic acid 2%, arbutin
5% can be used. Sun protection is very important as it
is a common aggravating factor in facial pigmentation,
and a combination of physical methods such as hats
and umbrellas and chemical agents like broad spec-
trum sunscreens, including physical sunscreens, should
N. Khunger
be repeatedly advocated, particularly in patients with
outdoor occupations. Glycolic acid 612% is also
useful as a priming agent in patients with thick uneven
skin. Topical retinoids should be used cautiously to
avoid retinoid dermatitis and inflammation, which
can aggravate pigmentation. Low strengths such as
tretinoin 0.025% or adapalene 0.1% applied for short
durations initially are preferred. The strength and dura-
tion of application of the priming agent should be
increased gradually if the patient has sensitive skin.
Facial peeling should also be done cautiously in darker
skin types due to the increased risk of PIH. It is always
safer to use lower strength of peeling agents either
sequentially or in combination to achieve desired
results. E.g., applying 20% salicylic acid followed by
1015% TCA or 35% glycolic acid is safer as com-
pared to 70% glycolic acid or 35% TCA used alone.
Various combinations of peeling agents are available
for facial pigmentation and found to be quite effective
for long term use, even in darker skins (Fig. 10.6).
Peels may give variable responses for hyperpigmenta-
tion; hence, a small test peel may be done in the
postauricular or temple area to detect unpredictable
responses. This is particularly common with glycolic
acid, TCA, and resorcinol. A low concentration of
the peeling agent should be used first, and the concen-
tration should be increased gradually, depending on
response. All precautions should be undertaken to
avoid excessive inflammation. It is safer to combine
peels in lower concentrations to increase depth rather
than increase concentration of a single agent. One can
also customize the peel to the individual face to get
optimum results and vary the peeling agents according
to response. Areas with thick, oily, damaged skin may
require a deeper peel, while thinner, dry skin zones
may only require a superficial peel. Following a peel,
the area of hyperpigmentation and scaling can show
increased pigmentation initially that can alarm the
patient. The skin may become more sensitive post-peel
and lower strengths of retinoids or glycolic acid should
be used if this happens.
In a study of 40 Indian patients with melasma, with
Fitzpatrick skin types IIIV, the group of 20 patients who
were treated with serial 3040% glycolic acid peels along
with a modified Kligmans formula showed a signifi-
cantly better response as compared to 20 patients who
were treated with the modified Kligmans formula alone
[10]. Adverse events were minimal in both groups, with
two patients in the peel group developing PIH. Similar
results were observed in another study of recalcitrant
10 Facial Peels
Fig. 10.6 (Left) Pretreatment persistent melasma. (Right) Three years after treatment with mandelic acid 40%, eight peels at two
weekly intervals, with maintenance of improvement
melasma treated with serial glycolic acid peels [11].
Focal TCA has also been safely used in benign pig-
mented facial lesions in darker skin types [12].
Inflammation plays a key role in causing PIH due to
release of cytokines that stimulate activity of melano-
cytes. Hence, controlling inflammation with topical
and, if required, systemic steroids is an essential part
of post-peel care when treating hyperpigmentation.
Bleaching agents like hydroquinone, kojic acid or aze-
laic acid combined with tretinoin or glycolic acid are
useful for PIH. Re-peeling with very superficial peels
may give good response if PIH persists, in spite of
therapy beyond 24 weeks [13]. Chemical peels can
also improve dermal pigmentation by causing a con-
trolled low-grade inflammation that can stimulate
phagocytosis of excess dermal melanin (Fig. 10.7).
10.15 Photoaging and Facial
Rejuvenation
Photoaging is defined as the superimposed effects of
photodamage due to chronic ultraviolet light exposure
on intrinsically aging skin. It is characterized by wrin-
kles, mottled pigmentation, laxity of the skin, sallow
159
complexion, dilated pores, vascular lesions, and tex-
turally rough skin. Ultraviolet light exposure activates
matrix degrading metalloproteinase enzymes includ-
ing collagenase. Cytokines are released from keratino-
cytes. The cumulative effect of these changes is chronic
dermal inflammation. The features of photoaging vary
with the skin types. In individuals with lighter skin
color, Fitzpatrick IIII, wrinkles are more common
and appear early along with an increased occurrence of
premalignant and malignant skin lesions including
actinic keratoses, basal cell carcinoma, squamous cell
carcinoma, and melanoma. In contrast, in darker skin
individuals, there is less wrinkling and reduced inci-
dence of malignancy, whereas pigmentary abnormali-
ties are more common.
Topical therapy using broad spectrum sunscreens,
retinoids, polyhydroxy acids, salicylic acid along
with hypopigmenting agents such as hydroquinone or
azelaic acid and cosmeceuticals containing arbutin,
licorice, unsaturated fatty acids, soy extracts, ide-
benone, copper peptides, serine protease inhibitors,
resveratrol, etc., is useful for treatment as well as
priming the skin [14]. Due to changes in lifestyle
and depletion of ozone layer in the atmosphere, the
exposure to harmful UV rays of the sun has increased,
160
Fig. 10.7 (Left) Pretreatment dermal pigmentation due to lichen planus pigmentosis. (Right) Two years posttreatment with a series
of combination peels, 12 combination peels at two weekly intervals and maintenance of improvement
leading to skin aging becoming more common and
evident in younger individuals in their twenties and
thirties. Being a regenerative organ, the skin can be
stimulated to repair and renew itself. Hence, skin
rejuvenation techniques are becoming very popular,
with a marked preference for minimally invasive
techniques with reduced downtimes. The physician
should evaluate the nature of skin and the degree of
photodamage, techniques available, and active cos-
meceutical agents that work for skin rejuvenation
before management.
Facial peeling is a good technique to hasten
response in photoaging. The physician should be
aware that mature skin is generally dry, thinner, sen-
sitive, and intolerant to many products, and many
geriatric patients are on systemic medications that
can cause photosensitivity or pigmentation. These
factors should be taken into account while selecting
patients for chemical peels. Superficial peels are use-
ful for pigmentary changes, whereas medium depth
and deeper peels are indicated for wrinkling. If there
are any growths like seborrheic keratoses, dermatoses
N. Khunger
papulosa nigra, these should be treated prior to peel-
ing. Young patients with minimal skin damage often
respond best to a series of light superficial peels
(lunch time peels) in combination with a good skin
care program. The alpha hydroxy acids are particu-
larly good agents for photoaging because of their
dermal effects. Glycolic acid 3570%, pyruvic acid
50%, and lactic acid 90% are peeling agents of choice.
Pyruvic acid is an a-keto acid which is converted
physiologically to lactic acid. Ghersetich et al. [15]
treated 20 patients with Glogaus photoaging types I
and II, with pyruvic acid 50% in a series of four peels
at monthly intervals. A smoother texture, reduction in
fine wrinkles, and lightening of areas of hyperpig-
mentation were observed, with minimal side effects.
Salicylic acid has also shown to be effective for pho-
toaging. In a study of 50 women with mild to moder-
ate photodamage, salicylic acid reported improvement
in pigmented lesions, surface roughness, and reduc-
tion in fine lines [16]. Medium depth peeling is more
useful to treat photodamage, but it should be used
cautiously in darker skin types [17]. Combination
10 Facial Peels
peels with 70% glycolic acid and 35% TCA are effec-
tive. The use of deep phenol peels has declined due to
the availability of safer and effective modalities such
as fractional ablative and nonablative lasers.
10.16 Customizing Peels and Techniques
Various peeling agents with differing mechanisms
of action are available, making peeling a very versa-
tile procedure for different skin types and skin condi-
tions. The cosmetic units of the face often differ in
the same patient and may have different requirements.
Application of the peeling agents can thus be custom-
ized to optimize outcomes. Various formulations are
available in combination peels, and the precise formula
may be adjusted to meet each patients needs [2].
Patients with oily thick skins and acne will require
higher concentrations of salicylic acid, while patients
a b
Fig. 10.8 Dermal melasma after 2 weeks single sequential peel. (a) Before treatment. (b) After salicylic acid peel. (c) Application
of glycolic acid, hydroquinone. (d) Two weeks after single sequential peel
161
with predominant hyperpigmented lesions benefit from
higher concentrations of hydroquinone, kojic acid, and
citric acid along with glycolic acid. Patients with sen-
sitive skin can tolerate lactic acid and mandelic acid
safely and benefit from lower strength peeling agents
in combination.
Sequential peels use more than one peeling agent at
a time in a sequential manner. They are deeper peels
and indicated for conditions that have a dermal compo-
nent such as mixed melasma, lichenoid pigmentation,
and PIH (Fig. 10.8).
Facial peeling can also be combined with other
techniques to increase the penetration or a comple-
mentary effect [18]. Techniques such as micro-
dermabrasion [19], sandabrasion [20, 21], nonablative
lasers [22], botulinum toxin [23], fillers [23], bleph-
aroplasty, and face lifts can be effectively combined.
Each facial concern is customized and addressed indi-
vidually with the appropriate modality.
162
c d
Fig 10.8 (continued)
10.17 Complications
Every physician performing chemical peels must have
adequate knowledge about prevention, early detection,
and management of complications [2426].
10.17.1 Prevention
The first step in prevention is identifying patients that
are at a higher risk of complications. These include
skin types IIIVI who are at a higher risk of PIH,
patients with thin, dry, sensitive skin with a reddish
hue, poor wound healing and those with outdoor occu-
pations, on photosensitizing drugs, and a history of
sunburn. Peeling should also be performed cautiously
in patients who are uncooperative and have unrealistic
expectations. Counseling the patient regarding
expected results and emphasizing the importance of
post-procedure precautions and treatment is essential
in preventing complications. The physician should
communicate to the patient early warning signs of
N. Khunger
adverse events as most complications can be minimized
when detected early and treated promptly. Prolonged
erythema, crusting, vesiculation painful erosions, and
pruritus are early signs and should be treated immedi-
ately. Pre-peel priming regimens should be religiously
followed, and the patient should avoid scrubs and pro-
cedures immediately before peels as it can lead to
uneven peeling. Any facial skin disorder such as sebor-
rheic dermatitis, atopic dermatitis, contact dermatitis,
etc., should be treated before peeling.
The physician should not use too many peels of dif-
ferent manufacturers as peels from different sources,
even with the same labeled concentrations, can have
varying results. It is better to be familiar with fewer
peels on a regular basis and develop safe procedures.
When trying out a new peel, or peeling an apprehensive
patient, it is preferable to do a test peel on the preau-
ricular area, or a small area on the lesion on the fore-
head or temple area, rather than a full-face peel. Ideally,
one should start with the lowest concentration and
gradually titrate upwards. For the beginner, it is better
to combine different agents at lower concentrations and
10 Facial Peels 163

Table 10.7 Complications of chemical peels

Topical Systemic Ocular
Pigmentary changes post-inflammatory Toxicity resorcinol, salicyclic acid, and phenol, Chemical conjunctivitis
hyperpigmentation and hypopigmentation when applied over large areas Corneal abrasions
Lines of demarcation Laryngeal edema it is a rare complication, with
Infection bacterial (Staphylococcus, symptoms of stridor, hoarseness of voice, and
Streptococcus, Pseudomonas), viral tachypnea developing within 24 h of chemical peeling
(herpes simplex), and fungal (Candida)
Persistent erythema
Scarring
Allergic reactions
Milia
Acneiform eruptions
Textural changes

use superficial peels rather than use a high concentra-

tion of a single peeling agent or deeper peels. The phy-
sician must have a thorough knowledge of selecting the
right peeling agent at the right concentration. The label
and concentration should be checked before applica-
tion. The neutralizing agent should be kept ready, in
case termination of the peel is required before the
scheduled time.
To avoid ocular complications, the head must be ele-
vated during the peel. The inner and outer canthi of the
eyes must be protected with Vaseline, especially when
performing a periocular peel. The peel should never be
passed over the eyes, and a syringe filled with saline
should be at hand in case of accidental spillage in the
eye. If TCA or GA enters the eye, it should be flooded
with normal saline, and for phenolic compounds, the
eye should be flooded with mineral oil [27].
While applying the peel, vigorous scrubbing should
be avoided as it can lead to patchy and deeper peeling
than required.

10.17.2 Management
Fig. 10.9 Hyperpigmentation following peeling

The potential complications that can occur are given in

Table 10.7. Hyperpigmentation is the commonest com-
plication occurring after peels (Fig. 10.9). It can occur
any time after the peel and can be persistent if inade-
quately treated. It is important to educate the patient
about avoiding sun exposure and use of broad spec-
trum sunscreens before and indefinitely after the peels.
Priming the patient with suitable topical hypopigment-
ing agents such as hydroquinone, kojic acid, and arbu-
tin is an important part of the peeling regimen and
should be strictly enforced in the post-peel period.
When hyperpigmentation occurs, triple combination
creams containing hydroquinone, tretinoin, and ste-
roids are useful. Hypopigmentation is commonly seen
immediately after a superficial peel and is due to
removal of excess melanin and sloughing off of the
epidermis. In medium depth peels, the hypopigmenta-
tion can be more prolonged till melanocytes migrate
from the surrounding skin and adnexae. In deep peels,
permanent hypopigmentation is common. This may
not be noticeable in fair types I and II skins but can
164
Fig. 10.10 Epidermolysis, vesiculation, and edema in the peri-
ocular region following 50% glycolic acid peel, without signifi-
cant erythema
have disastrous consequences in darker skins. In addi-
tion, phenol has a direct toxic effect on the melano-
cytes and can cause a permanent hypopigmentation
with a peculiar alabaster look. Hence, deep peels are
better avoided in darker skin types.
Bacterial infection is uncommon, but if it occurs, it
should be treated aggressively with oral and topical
antibiotics to prevent scarring. Herpetic outbreaks pres-
ent with painful erosions and should be treated with
antiviral therapy. Prophylactic antiviral therapy should
be given preferably to all patients undergoing medium
depth and deep peels and continued till complete re-
epithelialization. For superficial peels, it should be
given in those patients with history of herpes simplex.
Candidial infection may occur in immunocompromised
patients, diabetics, and patients with oral thrush. It
presents with superficial pustules with a background of
erythema and is treated with topical clotrimazole 1%
cream and systemic antifungals such as fluconazole
50 mg or ketoconazole 200 mg per day. Post-peel ery-
thema generally fades in 35 days after superficial
peels, 1530 days after medium peels, and 6090 days
after deep peels. However, prolonged erythema may be
a sign of inadvertent deeper peeling and impending
scarring and should be treated promptly with short
duration potent topical steroids. Edema in the periocu-
lar region can occur and is managed with application of
ice. In severe cases, a short course of systemic steroids
may be given. Epidermolysis causing vesiculation and
blistering may be seen, particularly with AHA peels
(Fig. 10.10). Prolonged burning can occur particularly
if topical retinoid or glycolic acid is applied immedi-
ately after peels or there is prolonged sun exposure.
Application of bland emollients and sunscreens are
effective, and in severe cases, topical steroids like
hydrocortisone or fluticasone may be required. Pruritus
may occur after peeling. If it is severe and occurs with
N. Khunger
development of papules and erythema, it may be a sign
of contact dermatitis to a topical application. It is very
important to recognize and treat this as soon as possi-
ble, as a delay in treatment can lead to worsening in the
outcome of the peel. Hence, no new topical agents
should be introduced in the maintenance regime after a
peel to avoid this complication. Scarring is a dreaded
complication and fortunately very uncommon after
superficial peels but can occur with medium depth and
deep peels. Patients with a history of poor wound heal-
ing, keloid formation, and developing post-peel infec-
tion are at a higher risk of scarring. The temple area,
mandibular area, upper lips, and the chin are areas
prone to developing scars. Abnormal scarring has been
reported with patients on isotretinoin. In severe cases,
there can be ectropion or eclabion.
10.18 Systemic Complications
Systemic complications are more common with deep
phenol peels. When applied over large areas over a
short period of time or under occlusion, phenol can
cause systemic toxicity by absorption. The most com-
mon adverse effect is cardiotoxicity that presents in the
form of arrhythmias [28]. Hence, cardiac status must
be continuously monitored, and intravenous hydration
be given along with the peel. Peeling must be done in
small segments and completed before moving to the
next cosmetic unit to reduce systemic absorption. If
arrhythmia develops, the peel must be stopped, and
intravenous (IV) lignocaine should be administered.
Since phenol is metabolized in the liver and excreted
by the kidney, it should not be used in patients with
hepatic or renal disease.
Resorcinol can also produce toxicity if applied in
excess. Diarrhea, vomiting, severe headache, dizzi-
ness, drowsiness, bradycardia, dyspnea, and paralysis
are presenting features. The best way to avoid resor-
cinism is to restrict the area of application or limit the
concentration of resorcinol.
Toxicity with salicylic acid is not observed when it
is applied on the face but has been reported when large
amounts of 50% salicylic acid paste are applied to 50%
or more of the body surface, under occlusion. Salicylism
is characterized by tinnitus, dizziness, abdominal
cramps, and deafness.
Though peels can cause complications, they are
uncommon in well-trained hands if done with proper
precautions following safety guidelines for different
types of skins [29].
10 Facial Peels
10.19 Conclusions
There has been a tremendous increase in procedural
techniques for skin rejuvenation, and the trend is
increasing for procedures that are noninvasive or mini-
mally invasive, requiring little downtime. The majority
of chemical peeling procedures fit into this category.
The advantage of chemical peeling is that it is flexible,
effective, and safe with minimal complications. It is a
simple office procedure, requiring no machines, afford-
able to every physician, and easy to learn and practice.
There is a wide variety of chemical agents available,
and treatment can be individualized, according to skin
type and requirement of the patient. The downside to
peeling is that it is a slower process. Multiple sessions
are required with superficial peels to achieve accept-
able cosmetic results. Results are not permanent, and
maintenance peels are often required. Post-peel, pig-
mentary changes are common in inexperienced hands,
especially in darker skins.
Facial peeling results in removal of superficial skin
lesions, reducing excess pigmentation, regeneration of
new tissue with improvement of the skin texture, and
long lasting therapeutic and cosmetic benefits. There is
a tremendous variability of response to chemical peels;
hence, physicians must standardize their peeling agents
and techniques in order to maintain results. A patient
may require different peeling agents at different concen-
trations over a period of time, and these should be cus-
tomized and selected accordingly for maximum benefit.
The mix and match options and customizing techniques
give chemical peeling a newer dimension for treating
patients optimally, with greater versatility and satisfac-
tion, and enhanced safety at the same time. Hence,
chemical peeling is a versatile tool that can help build a
good aesthetic practice, with minimal investment.
References
1. Brody H (1997) History of chemical peels. In: Baxter S (ed)
Chemical peeling and resurfacing, 2nd edn. Mosby Year
Book, St. Louis, pp 15
2. Khunger N, Arsiwala S (2009) Combination and sequential
peels. In: Khunger N (ed) Step by step chemical peels,
1st edn. Jaypee Brothers Medical Publishers Ltd, New Delhi,
pp 202218
3. Dewandre L (2006) The chemistry of peels and a hypothesis
of action mechanisms. In: Rubin MG (ed) Chemical peels,
1st edn. Elsevier Inc., Philadelphia, pp 112
4. Deprez P (2007) Alpha-hydroxy acids: histology and factors
influencing penetration. In: Deprez P (ed) Textbook of
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5. McCollough EG, Langsdon PR, Maloney BP (1996)
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Indian J Dermatol Venereol Leprol 74(Suppl):S5S12
 Facial Resurfacing with
the Ultrapulse Laser
Bernard I. Raskin
11.1 Introduction
While ablative fractional systems are the current choice
for significant results, ablative laser skin resurfacing
with the Ultrapulse laser represents the gold standard
for facial skin modification and enhancement [1, 2].
This chapter may appear solely of historical interest to
many; however, laser surgeons with many years of
experience recognize the superior results possible with
full ablative CO2 lasering. The author has considerable
expertise with ablative laser resurfacing and fraction-
ated CO2 systems. Definitely the new technology of
fractionated ablative lasers offers distinct advantages.
However, there exists a subset of patients with rela-
tively fair complexion, moderate or severe elastosis and
rhytides, or substantial acne scars in which the ultra-
pulse CO2 is beneficial. These patients often have
accompanying loose skin and would not typically
improve sufficiently with fractionated treatments due
to the lack of skin tightening compared to the ultra-
pulse full ablative resurfacing. Thus, the original ultra-
pulse laser is still effective for an array of skin conditions
and circumstances when used on the right patient. The
laser primarily reviewed in this chapter is the ultrapulse
system on which most literature is based.
B.I. Raskin
Division of Dermatology, Department of Medicine,
UCLA Geffen School of Medicine, Los Angeles,
California, USA
Advanced Dermatology & Cosmetic Care,
28212 Kelly Johnson Parkway, Suite 245,
Valencia, California, USA
e-mail: braskin@CreatingBeauty.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_11, Springer-Verlag Berlin Heidelberg 2013
11
This chapter will focus on CO2 treatment of photoa-
ging and acne scars. Other conditions may effectively
be treated such as certain localized skin cancers, xan-
thelasma, epidermal nevi and possibly in skin cancer
prevention [36]. Benefits of CO2 and Er:YAG resur-
facing in reducing p53 gene expression have recently
been documented [7].
11.2 History
Skin resurfacing was accomplished in a relatively satis-
factory manner before lasers with deep chemical peels
or specialized machine dermabrasion with either a dia-
mond wheel or wire brush [8]. For strong chemical
peels, phenol was commonly used by plastic surgeons
while dermatologists preferred trichloroacetic acid regi-
mens [9]. Phenol peels were considered to be the deepest
peeling agent, and interestingly postoperative late-onset
hypopigmentation with this agent was well recognized.
Post-inflammatory hypopigmentation with trichloroa-
cetic acid was also seen but was less problematic than
with phenol. Dermabrasion was also popular, but was
more technique and practitioner dependent, the learning
curve was substantial, and results variable [10]. Further
dermabrasion as performed with a motorized device
spread microscopic skin particles, blood, and infectious
debris widely into the air and those microscopic particles
remained in the local room air for hours. Neither peels
nor dermabrasion resulted in collagen tightening [11].
Ultrapulse laser resurfacing of nonacne scars on the face
compares favorably to dermabrasion [12]. However,
peels and dermabrasion suffered from variable efficacy,
lack of consistent reproducibility, and depth control
issues [13].
167
168
Continuous wave CO2 lasers were problematic for
skin resurfacing and were primarily effective for spot
lesion ablation. The ultrapulse technology was the first
to utilize a high powered short duration pulse of energy.
The ultrapulse laser was introduced in the early 1990s,
[14] and once the clinical benefits were elucidated, the
technique gained popularity quickly [15]. Over time
this type of laser became immensely popular through
the mid-1990s. The Ultrapulse (the actual name is
Ultrapulse 5000C) was produced by Coherent Laser
which through various iterations is now Lumenis
Corporation. Ultrapulse lasering has been available as
part of the ActiveFx and Deep Fx line of fractionated
CO2 lasers produced by Lumenis. (The author has
no financial relationship with the manufacturer.)
Competitors utilizing a scanning technology had
entered the market for full face resurfacing lasers
shortly after the Ultrapulse was introduced although
the ultrapulse prevailed in the marketplace even though
clinical equivalence was established [16]. The initial
Ultrapulse lasers utilized a 3-mm spot and surgeons
became adept at treating a full face in a tedious fash-
ion. The next technological achievement was the emer-
gence of the scanner handpiece (computer pulse
generator) with a 2.25-mm spot size which made this
system practical and increased the accuracy of the spot
pattern affording the surgeon a number of choices in
spot placement and density along with size options for
the patterns chosen. This allowed efficient lasering
with a high degree of accuracy and predictability. A
subsequent model produced by Lumenis was the
Ultrapulse Encore which had a smaller spot size and
thus somewhat different numerical settings to achieve
equivalent energies delivered to the skin. However,
most literature cited on this subject was written before
the Ultrapulse Encore entered the marketplace, and
thus settings and descriptions noted in this chapter
reflect the Ultrapulse 5000C.
The ultrapulse system was the first laser that pro-
vided substantial clinical improvement with a true
wow factor. This afforded laser surgeons the oppor-
tunity to modify acne scars, substantially reduce
rhytides, provide improved skin tone, and reduce facial
redundancy by tightening collagen.
The ultrapulse system was a major technological
innovation literally advancing laser surgery by light
years. The technology was embraced rapidly and with
great enthusiasm. This laser was unlike any previously
on the market and initially did not appear to require a
significant learning curve. A great many physicians of
B.I. Raskin
differing skill levels and qualifications entered the
market. Ultrapulse full face resurfacing evolved almost
overnight into a highly requested cosmetic treatment
prompted by media publicity. Articles featuring physi-
cians and their Ultrapulse were in leading newspapers
and demonstrations shown on national TV shows [17].
A cosmetic market was created and the laser was being
widely utilized before solid clinical studies were pub-
lished. Much of the first couple years use was empiri-
cal based on anecdotal observations. Eventually the
complexity in producing consistent results became
apparent. Pain management during the procedure was
an issue and only later were methods such as tumes-
cent anesthesia introduced for this surgery. Also this
laser caused significant down time with concomitant
issues in the postoperative period and problems such
as delayed healing and wound infections. The risk of
scar induced by the laser was not appreciated early on,
and only later did a conservative approach become the
standard technique. Early hyperpigmentation was frus-
trating to patients and late-onset hypopigmentation
was not initially considered to be problematic but sub-
sequently became a troubling issue [18].
Over time the popularity waned. Part of this reduc-
tion involved physicians recognizing that the ultrapulse
technology simply was not effective in a number of the
conditions in which it was being utilized, such as
melasma. The ultrapulse system was introduced when
there were only two other cosmetic lasers: the original
pulse dye laser and the Q switched YAG both of which
had limited benefit. Botox was not yet available, and
the only filler was Collagen. The ultrapulse became the
workhorse for various conditions in which it was sub-
optimal. Eventually the erbium laser was introduced
making more superficial resurfacing possible and then
the first nonablative technologies entered the market.
More to the point, popularity of the Ultrapulse suc-
cumbed to the same media fervor that created it: a sub-
stantial media outpouring of laser catastrophes with
associated stories relating to substandard physician
training through short weekend conferences. Botox
morphed into the media darling and the IPL photofa-
cial became the must have technology for noninva-
sive rejuvenation although CO2 resurfacing induces
significantly more rhytid reduction than IPL [19, 20].
Subsequently fractionated technology utilizing nonab-
lative 1,440 and 1,540 wavelengths attained promi-
nence. Lumenis introduced the first CO2 fractionated
device known as the ActiveFX in 2005 and this was
followed by the microfractional CO2 DeepFX in 2007.
11 Facial Resurfacing with the Ultrapulse Laser
The current platform combines the ActiveFX and
DeepFX and original ultrapulse laser capability.
That being said, the author is of the opinion that the
original Ultrapulse technology offers a substantial ben-
efit to a limited group of patients whose skin is some-
where between the fractionated CO2 and a facelift, or
have substantial acne scars. For this laser, a conserva-
tive approach is now recognized as the preferred method
[21]. Patients must not be risk averse and they need a
clear understanding of the procedures limits along
with the fact that full improvement may take months. In
general, patients should be relatively fair complected.
They must be capable of carefully following postopera-
tive protocols. And importantly patients must tolerate a
common frustrating time early in the postoperative
period where their face is crusted and edematous. These
issues will be discussed further in the chapter.
11.3 Laser Technology and Tissue
Interaction
Laser tissue interactions are complex. In general, tissue
effects occur only when light is absorbed. The light
carries its energy as a photon. Absorption occurs when
the photon interacts with a chromophore (also known
as an absorbing molecule). Many chromophores are
specific for certain light wavelengths and energies.
Once the photon is absorbed by the chromophore, the
photon ceases to exist and all the energy is transferred
resulting in an excited state. Different types of excited
states occur depending on the wavelength and energy.
For instance, ultraviolet leads to an electronic excita-
tion of the chromophore resulting in a different type of
damage which impacts the DNA. Infrared rays cause
vibrational excitation leading to heating. In the epider-
mis, absorption is the dominant process over the spec-
trum of 20010,600 nm. However, in the dermis,
wavelength-dependent scattering by collagen fibers
prevails. Therefore, penetration of light into the dermis
is attenuated by this scattering, thus reducing the lasers
impact [22]. Different technologies have been devel-
oped to address chromophores in the epidermis or der-
mis while minimizing impact on adjacent structures.
In dermatologic applications, either visible or infra-
red light predominates and most laser tissue interac-
tions produce heat. When the temperature is raised
substantially, essential structures within the cells dena-
ture resulting in loss of function by protein unfolding
and by coagulation of macromolecules. Thermal coag-
169
ulation at high temperatures as occurs from CO2 laser
causes cell necrosis and ultimately a clinical burn.
However, lower heat levels in the adjacent tissue cause
thermal damage rather than necrosis. Depending on the
temperature reached, the thermal damage may be revers-
ible and new proteins production is stimulated. As an
interesting aside, physiological defensive responses
exist to increased temperature. Normal protein synthesis
is inhibited and specific proteins known as heat shock
proteins are induced and these specific proteins provide
relative resistance to additional thermal injury. Most
human cells withstand temperatures up to 40C. Survival
at higher temperatures depends on exposure time and
temperature. The rate of thermal denaturation is tem-
perature dependent, and heat increases the rate of dena-
turation. Laser-induced thermal injury follows the
Arrhenius model which documents that the rate of dena-
turation is exponentially related to temperature and pro-
portionally to time [23]. Small temperature changes
result in more substantial denaturation rates while
increased time at a particular temperature causes only a
proportional change. Thus, small increases in heat dra-
matically increase the speed of protein denaturation.
Therefore, laser systems for resurfacing must be
designed to achieve specific temperature ceilings so that
the rate of damage is controlled.
Near a critical temperature which varies depending
on the tissue type there is a rapid coagulation event
this means the effect on tissue at a given temperature
varies depending on the tissue type. This accounts for
the well-established histologic boundaries of dermal
coagulation in laser or burn injuries. For instance, in
the dermis, elastin is extremely thermally stable and
survives boiling without evidence of injury. Type 1
collagen which is the predominant collagen subtype in
the dermis has a sharp melting point transition to a
fibrillar form at between 60C and 70C. At or above
these temperatures, collagen denaturation occurs and
scars become more likely. Thus, the goal of CO2 abla-
tive laser therapy is to vaporize the epidermis, and
minimize an underlying zone of necrosis where colla-
gen has been heated above 70C, and yet create a
deeper thermal injury zone within the dermis where a
temperature maximum of 6070C has occurred.
Minimizing the zone of necrosis occurs by reducing
bulk dermal heating by preventing dermal tempera-
tures in excess of 6070C.
Reducing the probability of additional bulk dermal
heating requires maintaining the laser pulse at approxi-
mately equal to or shorter than the thermal relaxation
170
time (TRT) of the target. When a pulse longer than the
TRT is used, heat is not confined to the target structure
and may dissipate beyond the target into surrounding
tissues causing collateral damage. To clarify this con-
cept, in CO2 resurfacing, the epidermis is vaporized in
under 1 ms and most of the heat imparted to the epider-
mis is carried away into the air as steam when the tis-
sue water reaches boiling within that 1 ms. The
remaining heat is in the char and this heat dissipates in
all directions. If the epidermis were to be heated slower
for instance over several milliseconds, vaporization
temperature would still be reached but while being
heated a portion of that heat would be dissipating in all
directions at the same time, resulting in overheating
adjacent tissue. Thus, the concept of TRT is extraordi-
narily important. These concepts have been further
refined with the advent of fractionated systems.
The target TRT is related to its size and shape, with
the TRT proportional to the square of its size. The TRT
for epidermis is about 1 ms; therefore pulsed systems
must deliver large energy boluses in a maximum of
1 ms. For CO2 systems, achieving selective ablation of
skin with minimal collateral thermal injury occurs
when approximately 5 J/cm squared is delivered in
under 1 ms to the surface [24].
Different lasers variably affect the skin at the sur-
face and deeper levels. Visible light lasers emanate in
the 500700 nm wavelength and have variable targets
based on size and chromophore absorption the pulse
dye laser is an example of a visible light system. These
lasers can penetrate the skin in the right conditions
without adversely affecting the surface. Infrared lasers
range from the mid-700 nm wavelength through the
10,600 nm CO2 laser wavelength. Low wavelength
infrared lasers are beneficial for treating chromophores
that are subsurface such as hair and vessels due to good
beam penetration into the skin which is usually accom-
plished by protecting the epidermis with cooling.
Shortening the beam duration by Q switching a midin-
frared laser such as the 1,064 nm wavelength makes it
suitable for small targets such as tattoo pigment which
has an extremely short TRT. The CO2 laser creates a
wavelength of 10,600 nm. The beam is generated by a
gas-filled laser tube using CO2 as the emission source,
and thus the name CO2 laser.
As the infrared wavelength is increased, water
becomes the main target. The most efficient water
absorption occurs at the 2,940 wavelength of the
erbium yag laser. With a purely pulsed erbium yag
B.I. Raskin
laser water absorption is so substantial and efficient
that almost all laser heat is contained within the vapor-
ized water and minimal heat transfers to the adjacent
tissue. The 10,600 nm wavelength is well absorbed by
water although not quite as efficiently as the erbium
laser. However, the water absorption precludes the
laser beam from penetrating into the skin, and there-
fore CO2 is effective primarily at the skin surface
(although fractional lasers do penetrate further due to
the technology of the equipment). Because water
absorption is not nearly as efficient as the erbium yag
laser, part of the beams heat is in the vaporized water
from the skin surface and the remainder of the heat dif-
fuses into the underlying tissue creating collagen dam-
age. The penetrating heat creates a zone of tissue
necrosis and another zone of collagen injury. The zone
of collagen injury is a necessary component to create
tissue tightening and rejuvenation. The key to under-
standing and utilizing the pulsed CO2 laser was to
maximize the zone of injury while minimizing the
zone of necrosis. Overutilizing laser energies would
cook the skin causing substantial necrosis and sub-
optimal results.
The theory of the ultrapulse CO2 system relied on
heating and vaporizing epidermal tissue before the tis-
sues natural thermal relaxation time allowed heat to
dissipate into deeper levels. To create this effect, a
laser pulse required enough energy to vaporize and this
was established to be about 5 J/cm2 and yet be deliv-
ered within the 1 ms thermal relaxation time of the epi-
dermis [25]. With these energies, skin temperature
reaches 120200C. In this way, the heat was removed
from the tissue as steam from the vaporized water,
leaving behind a thin layer of desiccated collagen, pro-
teins, cellular debris, thin underlying layer of necrosis
and below that was a zone of injury. Therefore, a rapid
increase in skin temperature causes a rapid tissue vapor
pressure to develop by boiling water within the cells
and instantaneous tissue vaporization occurs. The
superficial layer has most of the energy deposited and
is instantly vaporized. This results in measurably
reproducible tissue ablation with each pass. With the
ultrapulsed CO2 laser, this has been established to be
80150 mm [26].
Physiologically, three events occur: epidermal abla-
tion due to vaporization of tissue, immediate dermal
collagen contraction in the zone of injury, and delayed
long-term dermal collagen remodeling which may
require months.
11 Facial Resurfacing with the Ultrapulse Laser
The biological benefits of ablative resurfacing are
primarily in the dermis [27]. Acute tissue contraction
occurs with 1 or 2 passes and derives from thermal
denaturation of collagen. Collagen formation in the
superficial dermis has been correlated with thermal
denaturation and acute tissue tightening [28]. The
exact role of immediate contraction on long-term skin
tightening and collagen formation is not well under-
stood. Regardless delayed collagen remodeling and
new collagen synthesis along with extracellular matrix
production occur as a result of tissue wounding, wound
healing reaction, fibroblast activation, and resorption
of elastotic collagen fibers although the mechanisms of
action are obscure.
Biochemical events in the postoperative process
have recently been reviewed by Orringer [29]. While a
detailed discussion is beyond the intent of this chapter,
in summary, the production of type 1 procollagen and
type 3 procollagen messenger RNA peaks at about 89
times baseline levels at approximately 21 days post
laser and remain elevated for at least 6 months. These
changes are preceded or accompanied by alterations in
messenger RNA levels of cytokines including interleu-
kin 1B, tumor necrosis factor-alpha, and transforming
growth factor-beta-one. Increases were also identified
in messenger RNA levels of several MMP variants
with levels of fibrillin and tropoelastin elevations
delayed for several weeks. These biochemical changes
proceed through a well-organized wound healing
response with alterations in dermal structure. The
quantitative changes may be helpful for future com-
parisons of other therapeutic modalities.
In summary, then, how does carbon dioxide resur-
facing work? CO2 resurfacing is effective because
first and foremost the laser creates a precise, predict-
able, uniform superficial thermal injury. The thermal
nature of the injury stimulates greater collagen depo-
sition than nonthermal ablative wounds of equivalent
depth [30].
11.4 Patient Selection
Ablative CO2 laser treatment is currently utilized
primarily for facial skin and can be problematic if used
on the neck due to the risk of hypertrophic scars [31, 32].
Ablative lasers are the gold standard, yet in many ways
are far from ideal. Optimal benefits occur with appropri-
ate patient candidates [33]. Epidermal wounding results
171
in downtime, healing issues, postoperative discomfort,
and potential permanent skin color changes. Extrafacial
applications are severely limited due to scarring although
long-term resolution of epidermal nevi has been reported
[6, 34]. Be that as it may, ablative resurfacing remains a
powerful tool for rejuvenation of the aging face and can
be effective in treatment of other conditions such as
actinic chelitis [35] and scar resurfacing [36].
Because of issues with potentially permanent post-
treatment hyper- and hypopigmentation, lighter com-
plected patients tend to do better overall. Fitzpatrick
skin color significantly limits treatment opportunities;
however success has been reported in darker com-
plected individuals using lower laser settings [37, 38].
With olive or Fitzpatrick 24 complected ethnic groups
such as from Mediterranean areas, South America, or
Asia a posttreatment period of hyperpigmentation may
result, although this usually improves over time [39]. In
a report on treating Fitzpatrick type 4 patients, postin-
flammatory hyperpigmentation was the most common
complication and lasted about 4 months although true
hypopigmentation was not encountered [40]. Treating
darker than Fitzpatrick 4 may be performed but carries
significant risk for color anomalies. Other technologies
have evolved that are more specialized or more effec-
tive in differing conditions, including nonablative tech-
nologies, fillers, and neuromodulators. Many conditions
are now treated with multiple modalities in combina-
tion programs to maximize improvement with reduced
downtime.
Full face ablative procedures should be considered
as a major cosmetic surgery because of the nature of
the procedure, healing process, and risks. As such
patients should have a significant cosmetic problem.
The cosmetic issue should not otherwise be amenable
to more conservative treatments or where only limited
improvement would occur with less invasive modali-
ties. Examples of appropriate problems include severe
or substantial acne scars of the face, significant perio-
ral static creases or rhytides, and patients with moder-
ate-to-severe facial rhytides. Nondynamic periocular
lines may significantly improve. Patients with non-
melasma pigmentation may experience an excellent
result. Patients with somewhat loose facial skin and
mild-to-moderate jowl formation will also benefit.
However, patients clinically requiring a face lift
procedure often have skin that is too loose for ablative
laser to help them. Similarly patients with severe der-
matochalasis or significant lower lid herniated fat may
172
not sufficiently improve to warrant the time, expense,
and risk of ablative lasering. The author has seen mild-
to-moderate dermatochalasis and lower lid bulges sig-
nificantly improve although bulging should not be the
main reason laser is chosen.
In the authors opinion, patients fixated on one
particular problem such as a single line or one small
anatomical area are poor candidates because the
improvement may be less than desired leading to an
unhappy person. Patients who are most satisfied in the
authors experience typically suffer from a number of
related cosmetic issues and are happy if they can
appreciate global improvement: The more satisfied
individuals have a number of problems such as actinic
dyspigmentation, areas of rhytides, mild jowl forma-
tion, and static perioral creases. That type of patient will
experience reasonable or significant improvement in all
areas although no single region will be perfect. But the
combination of improvements provides a much more
youthful vigorous image with brighter appearing skin.
Acne scars are another area where substantial
improvement often occurs [41, 42]. However, higher
laser settings may be necessary; so those with the fair-
est complexion are the most appropriate candidates.
Often acne scar patients are women in their 50s with
the complaint that the scars did not bother them until a
few years previously and had become difficult to con-
ceal. These scars appear worse with age due to sagging
skin. In the authors experience, this group of patients
achieves considerable satisfaction due to improvement
in the scars and tightening of the skin. However, acne
scars never completely resolve; so in selecting patients
for acne scars, care must be exercised to avoid those
with unreasonable expectations of a complete cure.
Surgeons should be aware of other medical and
social issues in the patient selection process. Patients
with significant underlying illness may be poor candi-
dates. Those with infectious processes that pose risk to
the operator such as Hepatitis B, C, or HIV may not be
appropriate. Patients with high alcohol consumption
may be problematic. Importantly smokers, even recent
former smokers, may be suboptimal candidates or can
expect increased postoperative problems and healing
issues.
Unreasonable expectations are a major problem
with ablative resurfacing. These individuals are under-
going a substantial procedure with significant down-
time, costs, and require considerable postoperative
care. If those individuals expectations are unmet,
intense frustration and anger may result.
B.I. Raskin
In terms of patient selection, this procedure requires
detailed counseling regarding the nature of the proce-
dure, downtime, healing process, and risks. Patients
should exhibit the capacity to understand the concepts
of this type of surgery. Various laser procedures in the
current marketplace are widely advertised as mini-
mally invasive, so substantial counseling is necessary
in the authors opinion to be certain that patients under-
stand the procedure, risks, and dynamic aspects of
healing and final results. Typically, the author has an
initial consultation and arranges a second visit before
the laser procedure for a more complete discussion and
review.
Importantly, patients should be able to tolerate frus-
tration, anxiety, and waiting for final results. There is a
period during early healing when the face often looks
terrifying to the patient or family and patients incapa-
ble of coping do not handle this period well. The author
has found that patients tolerance of this interim phase
determines their overall satisfaction and happiness.
A patient fixated on the fear they felt during that early
stage healing may never get past that aspect mentally
and measures the overall results by the impact of those
early anxieties.
More than with any other laser, this procedure
requires that the patient and surgeon communicate and
work well together primarily due to issues in the peri-
operative and prolonged postoperative time. The author
typically discusses full face ablative laser procedures
as a journey that the surgeon and patient undertake
together. In this regard, the surgeon needs to be aware
that not all apparently good candidates are appropriate
for this laser treatment, and the physicians staff can be
helpful in elucidating awareness of issues that might
result in a problem patient.
Postoperative anxiety and depression after major
cosmetic surgery is well recognized. This is the type of
procedure where postoperative anxiety or depression
may occur. Patients should be counseled in advance of
the procedure about this common problem.
11.5 Contraindications
The most significant contraindication is isotretinoin
(Accutane) use within the prior 612 months.
Isotretinoin is felt to increase the risk of scar forma-
tion. Most physicians feel a 6-month period after
isotretinoin is sufficient, but some advocate waiting
an entire year. Another contraindication is a face lift
11 Facial Resurfacing with the Ultrapulse Laser
procedure within 3 months before or after laser resur-
facing. Laser resurfacing increases the metabolism
and a recent prior rhytidectomy may temporarily
compromise adequate blood flow for current demand.
Similarly most physicians wait about 3 months after
laser before a rhytidectomy is contemplated [43].
However, performing a blepharoplasty at the same
time is not problematic [44, 45].
Treating the neck may be contraindicated [46].
However, a published study of 1,851 patients treated
on the neck with conservative settings demonstrated
only 2 focal pigmentary areas of depigmentation and
both of those were sites of herpes infections [47].
Newer modalities are available such as IPL or fraction-
ated nonablative or ablative systems to address this
challenging area.
Patients with a history of radiation therapy to the
area, or diseases such as scleroderma are not candidates.
Keloid formers on the face area should be excluded.
Koebnerizing entities such as psoriasis or vitaligo are
relative contraindications because they could worsen in
the affected area after laser. Similarly lupus and discoid
lupus would be relative contraindications.
Patients should be in need of a significant cosmetic
procedure and understand the consent and ramifications
of the lasering. Caution should be exercised with smok-
ers. Hepatitis and HIV patients are considered a con-
traindication in terms of staff exposure. Patients with
underlying conditions such as immune-compromised
states or on mediations which interfere with healing
response such as prednisone are relative contraindica-
tions. Darker complected patients, especially those with
documented histories of postinflammatory pigmenta-
tion, are relative contraindications. Patients with facial
keloids or hypertrophic scars would not be considered
candidates depending on the cause of the scarring.
Pulmonary status may be a relative contraindication if
conscious sedation is anticipated as patients with pul-
monary limitations such as smokers may require oxy-
gen during the procedure and the fire hazards of oxygen
during laser surgery should be appreciated.
Another contraindication is patients who cannot
wear a metal protective contact lens. Active Herpes
type I is an absolute contraindication due to the
risk of a herpes infection suffusing the lasered skin
over the entire face. A current MRSA infection would
also contraindicate surgery in the authors opinion,
although there are no specific guidelines for address-
ing nasal carriers. Unanswered questions include
whether to proceed if any close family exhibits an
173
MRSA infection although delaying surgery would
probably be advised.
11.6 Preoperative Evaluation
and Instructions
Because of the plume, it is recommended that appro-
priate laboratory studies for Hepatitis C, HIV, and
Hepatitis B are obtained. As this is a significant cos-
metic procedure, routine laboratory evaluation should
encompass CBC, renal and hepatic status to avoid
medical problems manifesting in the immediate post-
operative time. Female patients of childbearing age
should be pregnancy tested.
Patient medications list should be accurate. There is
minimal bleeding, but it is recommended to discon-
tinue agents such as aspirin appropriately in advance.
Preoperative photographs should be of high quality
and a backup made as these photos are necessary in
determining the improvement achieved.
Many physicians perform ablative lasering under
conscious sedation and parameters in that regard must
be adhered to as necessary in the preoperative stage. If
tumescent anesthesia is to be utilized, the surgeon
should be familiar with any medications that may inter-
fere with lidocaine metabolism. The planned preopera-
tive and postoperative medications should be discussed
and prescriptions given to avoid miscommunication.
Whether oral or injected, sedatives, anxiolytics, or
analgesics of some type are generally utilized and
therefore transportation needs and assistance at home
should be addressed in advance. Postoperatively, the
face is covered with dressings and anxiolytics and nar-
cotics are often necessary in the immediate postopera-
tive setting, so discussing these aspects at the
preoperative evaluation is beneficial. The author typi-
cally tries to answer all questions and have patients
sign consent at the preoperative evaluation, and then
again on the day of surgery.
Patients are also given a list of items they need to
have, such as ice bags for post-op care (the author likes
bags of frozen peas or corn), towels for placement over
the pillow at night, and ibuprofen.
11.7 Preoperative Medications
There has been in general a uniform opinion that her-
pes prophylaxis is necessary before a substantial CO2
174
resurfacing procedure [48]. Typically medications are
initiated at least the night before with treatment level
dosing of acyclovir 400 mg QID or equivalent dosing
with valcyclovir or famciclovir [49]. Even patients
with no clinical history of herpes may harbor the virus.
The medications are commonly continued 57 days or
until significant healing has occurred [50].
Preoperative antibiotics have been commonly uti-
lized typically with cephalosporins. In a study of 356
patients, prophylactic intranasal mupirocin was inef-
fective but ciprofloxacin was advocated as advanta-
geous because of prevention of both gram-positive and
gram-negative infection [51]. Candida infections can
occur after laser and diflucan dosing preoperatively or
in the postoperative period has been advocated by
some practitioners [52]. In the current environment,
MRSA could be anticipated as an infectious agent and
use of doxycycline may be appropriate. In general,
antibiotics are continued by most surgeons for a num-
ber of days depending on preference. Decisions on
antibiotics and antifungals must be individualized and
are best left to individual physician judgment.
If the procedure is to be under local anesthesia,
lorazapam 12 mg can be beneficial. Because of the
long half-life, a dose at night before surgery can last
through the surgical period. The author advocates clo-
nidine 1 mg orally about an hour before surgery as this
drug has both anxiolytic and analgesic benefits. If
strictly local anesthesia is utilized, surgeons can con-
sider an oral narcotic before surgery.
11.8 Consent
Consent should include cautions about scarring and
dyspigmentation which may be temporary or perma-
nent, and the need for sun protection during the first
months of healing to help avoid hyperpigmentation.
Specifically the high probability of permanent hypop-
igmentation should be noted. Risks of anesthesia
should be discussed. Even with eye shields, the author
counsels about potential eye damage. Fire risk exists
with this laser and should be mentioned as a risk.
Infections should be listed on the consent including
MRSA and herpes. Delayed healing may occur. It is
important to note that there can be no guaranty of
results and additional procedures or other modalities
of treatment are often necessary. Consent should
include that late development of hypertrophic scars
may occur.
B.I. Raskin
11.9 The Day Prior to Laser
Patients should be instructed to shampoo vigorously
the night before or the morning of surgery. Antiviral
and antibiotics should be started at least the night
before. Patients should purchase several bags of frozen
peas or frozen corn to treat the face after surgery the
unopened packages are used to soothe the burning
sensation in the hours after surgery. Any specific
dressing components should be prepurchased.
Postoperative prescriptions should be filled. Calling
the patient the day before to review the medications,
verify transportation issues, and answer last minute
questions will make the procedure and immediate
aftermath smoother.
11.10 Treatment Protocol: Safety
Precautions and Preoperative
Preparation
Surgeons must take appropriate safety precautions for
themselves and staff, and this is the first step in
treatment. Protective specialized sub-micrometer filter
laser face masks for laser procedures must be worn.
Appropriate eye shields for CO2 laser are necessary.
The suction must be a specialized HEPA smoke evacu-
ation unit with adequate vacuum and the correct filter-
ing system. The filters on these units must be replaced
regularly and there is generally an indicator on the
suction device. The assistant should be previously
trained to maintain the suction tip within 1 cm of the
laser. Keeping the suction tip within 1 cm is 98.6%
efficient in removing the plume; however, with the
suction tip 2 cm from the treatment site, efficiency
drops to 50% [53].
Fire is always a risk, and paper gowns and towels
should be avoided. In general cloth drapes are pre-
ferred, and these can be moist to additionally reduce
risks. A soaking wet towel is recommended to be
within hand reach so that any spontaneous fire may
be immediately blotted. Alcohol should never be uti-
lized in the immediate preoperative period as ignited
alcohol burns with an invisible flame and can widely
spread before being recognized. Plastic materials
can also be ignited. Leaving the laser in active mode
may result in an inadvertent laser discharge. Laser-
ignited plastic endotracheal tube fires can result in
release of toxic fumes directly into the airway and
death [54].
11 Facial Resurfacing with the Ultrapulse Laser
Facial skin preparation is at the surgeons discre-
tion. The author prefers normal saline as a surgical
prep. Eye protection is best accomplished with metal
protective contact lenses, which should be designed
for laser use. Plastic contact lenses can transfer heat
to the cornea and are contraindicated. Eye protection
methods commonly used with the IPL such as opaque
tape eye coverings are not appropriate for ablative
CO2 lasers. While lasering around the eyes, addi-
tional protection is afforded by covering the eye with
a moist tongue blade. Opaque goggles can be utilized
in the alert patient but caution is necessary to keep
the goggles over the eyes at all times. However, metal
contact lenses designed for laser use allow for laser
treatment of both upper and lower lids and rhytides
laterally.
When patients lay supine, the anatomy changes and
determining which areas to laser can be challenging.
Therefore, all areas should be pre marked on the skin
while sitting. This will help establish which areas will
be treated at different laser settings. Marking deep
rhytides is helpful in determining subsequently during
surgery if additional passes are necessary.
11.11 Treatment Protocol: Anesthesia
Lasering may be accomplished under conscious seda-
tion or with local anesthesia. The author prefers con-
scious sedation in an ambulatory surgical center
environment for enhanced patient comfort although
the procedure is equally well performed under local
anesthetic. The primary issues with conscious sedation
involve supplemental oxygen and the increased fire
hazard conferred. Some surgeons utilize minimal con-
scious sedation without oxygen and others prefer
delivering O2 via an LMA tube. Wrapping the LMA
with aluminum foil or wet gauze has been advocated to
prevent combustion [55].
Even with conscious sedation, local infiltration of
anesthesia is helpful. Infiltrating lidocaine reduces the
need for deeper sedation and thus minimizes O2 sup-
plementation. The author has found that approximately
2025 cc of xylocaine 1% with epinephrine 1:100,000
is the minimum necessary for full facial local infiltra-
tion including regional blocks. This amount is below
the 7 mg/kg toxicity level (approximately one 50 cc
bottle of 1% xylocaine with 1:100,000 epinephrine for
the average sized patient). Caution should be utilized if
a 2% xylocaine is used because the toxicity level
175
begins at about 25 cc of infiltrated xylocaine. If per-
formed completely under local, the xylocaine is fur-
ther modified by adding bicarbonate to reduce injection
discomfort.
Regional blocks are initiated first by injecting the
supraorbital, infraorbital, and mental nerves. Other
injection sites are at the superior aspect of the phil-
trum at the base of the nose, and along the lateral
aspect of the proximal nasal sidewall from the nasal
root to the nasal cheek sulcus. However regional
blocks alone are insufficient for total face anesthesia,
which requires routine skin infiltration over a wide
area. While most of the forehead blocks nicely with
the supraorbital blocks, the central portion often
requires additional skin infiltration. Similarly the lat-
eral forehead and temple is best blocked by infiltrat-
ing from the midbrow to the temple hairline in the
deep subcutaneous tissue. The upper and lower eye-
lids must be infiltrated. The preauricular regions are
particularly uncomfortable and require infiltration, as
does the region along the mandible. For diffuse infil-
tration, the author typically injects in the superficial
fat in a fan-like distribution. Anesthesia occurs slower
due to infiltration in the fat but less anesthetic is
required.
Alternatively, a tumescent anesthesia mixture can
be suffused into the subcutaneous fat using a .1% lido-
caine mixture (lidocaine, epinephrine, bicarbonate
mixture as described in the chapter on tumescent lipo-
suction) [56]. While this is effective, patients appear
quite edematous postoperatively which can be disturb-
ing to them. Tumescing the tissue can impair visual
aspects allowing rhytides that might need an additional
pass to be overlooked in treatment.
Laser resurfacing has benefited from the advent of
effective topical agents [57]. However eye damage in
the form of corneal abrasions has occurred [58].
Topical anesthetics have been incorporated with con-
scious sedation to avoid the need for local infiltration
[59]. Cold air cooling combined with oral analgesia
has been used without injecting xylocaine for localized
single-pass treatment of the periorbital and perioral
regions [60].
In the authors experience, local anesthesia works
effectively for one laser pass but supplemental infiltra-
tions may be necessary for any area treated with a sec-
ond pass. Areas that have been lasered are often
uncomfortable until final dressings are applied but this
can be ameliorated by spraying the lasered area with a
50-50 mixture of lidocaine 1% and saline.
176
11.12 Treatment Protocol: Laser Settings
The Ultrapulse laser allows adjustment of laser energy
output, the density of the pulse pattern, the shape of the
pattern of pulses on the skin, and the size of that shaped
pattern. The pulse duration is a preset 1 ms and each
individual pulse in the pattern is about 2 mm in
diameter.
The setting for the shape of the pattern of pulses is
at the discretion of the surgeon as pattern shape makes
no difference in treatment. The main issue is to treat
the entire face or specific region and not overlap
because overlap can cause tissue burn. The size of the
pattern chosen is relevant because a smaller size is
considerably less painful if the procedure is performed
under local. Treating with a larger pattern size makes
the procedure more efficient, but if patients complain
of pain the discomfort diminishes when the pattern
size is reduced.
The laser output is measured in millijoules.
Commonly 250 or 300 mJ is optimal for the rapid skin
heating necessary to reach the critical immediate tissue
vaporization stage. Eyelids are treated at a maximum
of 250 mJ. 175 mJ is often utilized just inferior of the
mandible for feathering to reduce an abrupt color
change postoperatively.
The most important setting is the density value. The
density determines spacing between dot pattern of
pulses and settings vary from complete separation to
varying degrees of overlap. Surgeons have become
more conservative over the years. While in the past set-
tings of 6 or 7 were common (2030% overlap), typi-
cally density settings now are 5 or 6 (1020%) for
treatment. Density settings of 3 or 4 are used for the
feathering zone. The problem with high density is that
Fig. 11.1 (a) Preoperative markings showing areas to be
emphasized, feathered, and avoided. Deeper creases are indi-
vidually marked. The area along the mandible will be treated at
a lower setting due to increased risk of scar formation. Patient
had upper and lower blepharoplasty at the time of surgery. (b)
Smoke evacuation (amber colored) is held very close to laser.
All drapes outside the surgery area are moist to reduce the risk
of fire. (c) Partial treatment. The lasered area should appear even
and white. Small areas of honey-colored crusts are a result of
stacked pulses from laser overlap when the edge of one pattern
of pulses overlaps onto another. Focal overlap is unavoidable
and not problematic, but larger areas of overlapping pulses can
result in burns. Areas must be wiped clean with wet saline gauze
B.I. Raskin
excessive heat is delivered to the skin beyond that
required for immediate vaporization leaving the skin to
act as a heat sink. This caused deep zones of necrosis
and bulk heating resulting in skin burns or scars.
11.13 Treatment Protocol: Laser
Technique
Before treatment, the laser is tested on a wet tongue
blade to assess the settings (Figs. 11.111.5). Treatment
may begin on any area of the face. The assistant must
keep the suction tip within 1 cm of the laser area to
aspirate the splatter. The laser is properly positioned
for the immediate area to be treated, and once trig-
gered, the handpiece is held in place until the dot pat-
tern has been laid down on the skin. The handpiece
should be held so that the laser beam hits the skin in a
perpendicular direction in order to maintain the proper
overlap pattern of the generated laser pulses. The oper-
ator can quickly see by the pattern laid down if the
laser was in proper position as all the pulses will be
perfectly symmetrically arranged. This is sometimes
challenging because of the size of the handpiece and
natural curvature of the areas to be treated. Using a
smaller sized arrangement of pulses often minimizes
problems in difficult areas. A fine white char is seen in
the pattern of pulse dots.
The most important aspect of treatment is to avoid
overlap of treated areas [61]. Overlap is identified by
a black char on the skins surface. The white char
acts as a heat sink since there is no water left for
vaporization in that area. High peak temperatures
approaching 400C can occur with pulse stacking
[62]. Therefore overlapping treated areas may result
between laser passes to avoid laser burns. (d) Metal contact
lenses are in place. Plastic lenses are contraindicated. In addi-
tion, a wet tongue blade can be held just below the lid margin to
cover the eyelashes and help in stretching the skin. The laser
beam is safe on a wet tongue blade and allows the laser to be
used immediately adjacent to the lid margin without damaging
eyelashes. (e) Wiping face with saline gauze between passes. In
many cases, the char slides off easily, but often vigorous rubbing
is necessary for removal. The char must be removed between
passes, because the desiccated debris of the char acts as a heat
sink when lasered, reducing vaporization and causing signifi-
cantly higher heat buildup in tissue
11 Facial Resurfacing with the Ultrapulse Laser 177

a b

c d

e
178 B.I. Raskin

a b

c d

Fig. 11.2 (a) Preoperative. Notice deep perioral creases and
prominent nasolabial fold. (b) Day 3: After dressing removal.
Crusting is present in areas at edge of bandages. (c) Day 5: Once
the skin begins epithelializing, the process proceeds quickly. (d)
Day 8: The skin has epithelialized completely. At this stage,
patients can begin applying makeup but should begin with small
test sites for any product used to avoid irritation. Sunscreen and
sun avoidance are particularly important during early healing.
Moderately intense erythema may persist but usually begins to
improve within weeks. (e) Day 20: In many patients, the redness
improves relatively quickly leaving a persistent pink tone that is
easily covered with cosmetics. Any areas of persistent intense
erythema need to be carefully followed as this may be indicative
of early scar formation. (f) Day 60: Mild hyperpigmentation is
present and a subtle erythema persists, although both issues are
easily covered with cosmetics. Topical steroids and hydroquino-
nes are helpful, and sun avoidance is mandatory. (g) Day 88:
Erythema and mild hyperpigmentation are improved
11 Facial Resurfacing with the Ultrapulse Laser 179

e f

Fig. 11.2 (continued)

in skin burns. After some practice and experience
with the laser, the operator develops the ability to lay
the pulse pattern down next to the previously treated
site without overlap. However, not uncommonly
small spaces between pulse patterns may be dis-
cerned and these do not necessarily need to be treated.
Or alternatively, after the first pass is completed and
the char removed, these spaces can be touched up
with a smaller pattern of pulses.
Typically larger size patterns are used for the
cheeks and forehead while smaller pattern sizes are
necessary for around the eyes and nose. When work-
180 B.I. Raskin

a b

c d

Fig. 11.3 (a) Preoperative. (b) Day 2: After removal of nonoc-
clusive dressings. (c) Day 3: Crusting is still present in areas of
deeper laser treatment. (d) Day 4: The patient has now epitheli-
alized in most areas although crusts persist in the perioral region.
(e) Day 7: Well epithelialized. Notice focal area of persistent
erythema on right upper lip just superior to vermilion. Author
uses high potency steroids for a short time for any area suspi-
cious for early scar formation. (f) Day 9: Patient now wearing
makeup but redness still apparent. Skin is significantly brighter.
(g) Day 53: Well healed. She requires only small application of
makeup to cover the erythema. (h) Day 74: No makeup. Overall
redness has resolved, and patient has dramatically improved
skin tones and softening. The laser lift from collagen contrac-
tion helps reduce the nasolabial folds and provide for a more
volumized appearing face
11 Facial Resurfacing with the Ultrapulse Laser 181

e f

g h

Fig. 11.3 (continued)

182 B.I. Raskin

a b

c d

Fig. 11.4 (a) Day 1: Preoperative. Notice irregular pigmenta- ness still apparent. Skin is significantly brighter. (f) Day 53:
tion on cheek. (b) Day 2: Areas of the right cheek already have Erythema easily covered with cosmetics. (g) Day 74: Without
epithelialized. (c) Day 4: (d) Day 7: This patient has a relatively cosmetics. Face tones are now even and brighter. Lip creases
mild erythema. (e) Day 9: Patient now wearing makeup but red- substantially reduced
11 Facial Resurfacing with the Ultrapulse Laser
e f
Fig. 11.4 (continued)
ing around the eyes, the eyelashes can be swept aside
and protected using a wet tongue blade allowing
treatment very close to the lash line. Care must be
taken to avoid the eyebrows as those hairs may take
months to regrow if lasered. Treatment may be car-
ried up to the vermilion. A wet gauze should be
inserted in the mouth over the teeth as laser energy
destroys enamel. The earlobes should be included on
183
full face treatments. The mandibular line should be
marked prior to surgery and this represents the most
inferior part of the face to be treated. Once on the
neck, the risk of scar is significantly increased and
only a low energy lower density feathering should be
used in a thin strip immediately below the mandibular
line. The goal of feathering is to smooth the color
transition since the lasered area heals lighter. Other
184
Fig. 11.5 (a) Day 3: After removal of dressings. Patients fre-
quently have crusting around mouth and eyes in areas at edge of
dressings. The next several days require frequent follow-up vis-
its for emotional support. At this stage, patients wash frequently
and cover with thin layers of emollients to avoid crust buildup.
Antibiotic ointments are avoided to reduce the complication of
contact dermatitis slowing epithelialization
more current technologies provide superior results on
the neck at lower risk.
Evaluating color of the tissue while lasering is nec-
essary to determine depth of penetration. After wiping
with moist saline, the rehydrated papillary dermis
appears pink due to the presence of an intact papillary
dermal plexus. Additional laser passes extends dam-
age into the deeper papillary dermis and a tan color is
noticeable and at this point distinct tissue contraction
should be obvious. Most surgeons rarely proceed
beyond a tan coloration. After an additional pass or
passes, a yellowish hue analogous to a wet chamois
cloth is noted. This represents the upper reticular der-
mis, and proceeding beyond this depth with additional
passes is not recommended due to the risk of thermal
damage to adnexal structures from which reepithelial-
ization develops [63]. Yellow brown discoloration that
is persistent after wiping indicates thermal necrosis
and should be considered an absolute contraindication
to further laser passes in that area.
End points of laser treatment are when wrinkles or
scars are no longer visible, or no further skin tighten-
ing is noted, or when yellowish discoloration is present.
B.I. Raskin
Areas of thicker skin often require more passes as do
areas of greater photodamage. Because of increased
healing times and risk, many laser surgeons no longer
treat to maximum end points, preferring to compro-
mise between extent of benefit, risk of scar, and poten-
tial postoperative hypopigmentation.
Optimal results will be achieved if the operator
sees the skin tightening while lasering. This can be
quite dramatic and is primarily noticeable on the
cheeks, malar areas, and lids although can be seen on
other areas as well. The author prefers to choose set-
tings that demonstrate tightening on the first laser pass
and thus if possible avoid the risks of deeper laser
treatment with a second pass. Alternatively, one must
avoid lasering too deep with the first pass, and thus in
some individuals a second pass is necessary to induce
immediate tissue contraction. As a test, after starting
an area, a small amount of the white char is gently
removed with saline-soaked gauze and moist pink skin
should be visualized similar to superficially denuded
skin or superficial second degree burns. A tan or buff
color means the deeper collagen has been impacted
and settings should be reconsidered depending on the
clinical circumstance. It is not uncommon while doing
a touch up second or third pass on individual rhytides
to see a buff colored area and this is considered a cau-
tion point although patients generally heal without
noticeable problems. Seeing a wide area of buff color-
ation after removing the char signifies a deeper laser-
ing. A deep procedure may provide enhanced results
but at increased risk. Many patients who need the sub-
stantial tightening that can occur with second or third
passes also share the highest risk due to thin elastotic
skin with poor physiologic reserve. Physician judg-
ment and experience are the determining factors.
In many patients, a single pass will complete the
procedure [64]. Single-pass laser resurfacing can yield
beneficial results with faster healing and reduced
adverse events [65]. In a study of 50 patients treated
with one pass, there were no episodes of hypopigmen-
tation or scar [66]. With a single-pass treatment, the
char does not need to be removed because vigorous
wiping with saline-soaked gauze may result in addi-
tional injury [67]. Post-op care can be initiated as
described subsequently and the patient discharged.
The number of laser passes to perform is individu-
alized. Factors that determine additional passes include
the surgeons judgment of the effect of the first pass,
Fitzpatrick skin color type, and extent of rhytides or
acne scars, character of the skin, and whether the
11 Facial Resurfacing with the Ultrapulse Laser
patient is a smoker. Second and/or third passes can be
localized to individual areas or even select rhytides.
Acne scars generally require additional sculpting with
second or third passes and the location determines how
deeply areas can be treated with tolerance greater on
the central face than the lateral cheeks or forehead as
areas with sebaceous skin are more forgiving. Keep in
mind that those who are fair with fine-pored skin and
fewer apparent adnexa tend to be at a higher risk for
late-onset hypopigmentation [68].
If a second pass is intended, then the face is cleaned
with saline-soaked gauze. In some patients, the char is
adherent and vigorous wiping is necessary while in
others, the char slides off easily. The author advises
iced saline since heat is retained in the skin and may
cause further damage as is well established in burn
injuries. Under local anesthesia, the patient often com-
plains of heat and burning rather than pain after a treat-
ment. After removal of char, chilled saline-soaked
gauze is applied to the entire face for a few moments
until the burning sensation subsides.
The face is evaluated from several angles and resid-
ual scars or rhytides are identified. Energy settings for
second passes may be the same or lower than the ini-
tial setting. The face must be wiped dry before laser-
ing because the laser photons are then simply absorbed
by water on the skins surface. The author typically
uses the same millijoule setting but reduces the den-
sity by 1 setting except in the immediate periocular
region where both density is reduced by 1 and the mil-
lijoule setting diminished by 50 (for example from
300 to 250 mJ). A second pass may be performed over
the entire face although the author does not usually
find benefit from doing the forehead twice. Or the sec-
ond pass may be on an area such as portions of the
cheeks to enhance tightening, or just on individual
scars or lines. It is recommended to avoid extensive
second passes in the immediate preauricular area or
along the jaw line because those areas are more prone
to hypertrophic scar formation. Treating just scars or
lines on a second or third pass slows epithelialization
in those areas which is noticeable over the next several
days but only rarely results in additional long-term
hypopigmentation. The surgeon must recognize that
rhytides or scars may not be amenable to complete
resolution with laser and thus avoid multiple passes.
Examples of difficult areas are individual upper lip
lines, deeper cheek lines, and focal scars. The author
recommends that three passes is the maximum to uti-
lize for any specific site.
185
11.14 Laser Protocol: Localized Areas
In some patients only a regional treatment is planned,
such as the perioral or periocular region for rhytides.
Regional areas should be designed around normal ana-
tomical boundaries encompassing a complete cosmetic
unit, for example, extending to the nasolabial fold for
treating the upper lip [69]. When treating the periocu-
lar area the tear trough serves as the lower margin;
however, the lateral margin can be more difficult to
determine. The problem with localized treatment is
that the skin may ultimately heal lighter than the
untreated adjacent skin. This can result in an owl eye
look or a white upper lip and/or chin. If treating local-
ized acne scars on a cheek, a white circle may form.
Patients with the lightest colored skin tolerate local-
ized treatments since the contrast post surgery is not as
noticeable. Female patients who regularly wear
makeup may be unconcerned about discoloration if
advised in advance. Some surgeons treat the entire face
with a lower setting such as 250 mJ at a density 4 or 5
and then focus higher energies on the regional site to
try and avoid color anomalies. If treating the neck,
very conservative settings are necessary and details on
this aspect were addressed in the contraindications
section above.
11.15 Laser Protocol: Postoperative
Dressings and Subsequent
Wound Care
CO2 laser is the precise application of heat to the skin.
The end result is a defined skin burn creating a thin
layer of necrosis and an adjacent region of injury. In the
immediate moments after the procedure has been com-
pleted, patients complain of both pain and an uncom-
fortable burning sensation. Residual heat in the skin is
known to continue resulting in additional injury.
Therefore the patients skin should be covered in chilled
saline gauze, and the author keeps the skin chilled for
10 min or until patients indicate the skin feels cold.
Some surgeons do not utilize dressings feeling that
the risk of infection is reduced compared to occluded
skin [70]. However, patients often find the experience
unpleasant and pain is more difficult to manage. More
commonly is a nonstick dressing regimen [71, 72].
Various occlusive dressing types have been utilized
[73, 74]. In a recent comparative study of available
dressings, Flexzan was considered most efficacious,
186
and this is consistent with the authors approach [75].
Among the various dressings available the author pre-
fers Flexzan. This dressing usually adheres to lasered
skin but is easy to remove. The dressing is cut to fit and
applied over all areas including as much of the eyelid
as possible and up to the lips. A mesh stockinette is
applied over the head to hold it in place.
Use of occlusive dressings for 48 h followed by
open wound care with occlusive ointments achieves
the benefits of occlusive dressings while minimizing
additional costs and the increased risks of infection
from prolonged occlusion [76]. The author covers the
skin with Aquaphor Healing Ointment or similar oint-
ment. Antibiotic preparations are avoided to reduce
irritation and contact dermatitis. Among the various
dressings available the author prefers Flexzan. This
dressing usually adheres to lasered skin but is easy to
remove. The dressing is cut to fit and applied over all
areas including as much of the eyelid as possible and
up to the lips. A mesh stockinette is applied over the
head to hold it in place.
The most common complaint in the hours after sur-
gery is a persistent burning sensation and feelings of
anxiety. It is not known if this is just residual damaged
nerve endings, or persistent heat in the skin. Diazapam
is effective postoperatively, and frozen corn or frozen
pea bags can be held against the skin. Narcotics in the
immediate postoperative period do not seem to reduce
the symptoms of heat or anxiety. Most patients then take
a narcotic at night and the usual stated reason is to avoid
being woken up in pain. Overall pain management is not
problematic for most patients, and hydrocodone or
codeine at routine dosing is sufficient although most
patients do well on acetaminophen or ibuprofen.
The patient is typically followed up the next day, at
which time the dressing has commonly come loose
around the eyes and mouth and developed superficial
crusting in those areas because they have dried out. The
patient is instructed to apply aquaphor frequently with a
cotton applicator to the crusted areas on the periphery.
On the second or third postoperative day, the patient
is instructed to remove the dressing in the shower. The
Flexzan dressing loosens from the skin easily when it
becomes soaked. The patient is instructed to cleanse
the face with water or a very mild soap and blot dry.
Aquaphor should be applied in a very thin layer hourly
or as needed whenever the face skin feels dry or gritty,
but only very thin layers are necessary to avoid buildup
that may look like infection. Patients at this time find
B.I. Raskin
their appearance frightening and should be counseled
in advance. Over the next few days the face is washed
several times daily, and the hair shampooed to avoid
crust buildup which may harbor bacteria. Aquaphor
use will be hourly initially but then decrease as the
skin heals. Some physicians recommend acetic
acid applications to reduce the chance of Candida
infection.
Generally, with a single-pass laser treatment, epi-
thelialization occurs within 57 days, and after
710 days, patients are resuming normal activities and
wearing makeup. Additional time to epithelialize is
required if lasering was deeper. Infections may occur
before epithelialization and these must be treated early
and aggressively both topically and orally. If an abnor-
mal area is identified, the skin must be cultured for
bacteria, fungi, and herpes.
The skin has a bright pink-red appearance once it has
epithelialized. This diminishes over the next several
weeks. Some surgeons advocate vitamin C applications
or steroid creams during this time period. Patients must
wear sun screens. The skin is still friable once it has
epithelialized, and patients often complain of small ero-
sions over the next several days after the skin appears
healed. These erosions generally heal without problems.
Surgeons must be aware of any persistently red area or
region of firmness as this often indicates early hypertro-
phic scar formation, and these areas must be aggres-
sively treated early with high potency steroid creams.
Posttreatment erythema may be prolonged for a
duration of 34 months. A persistent erythema may
sometimes lead to hyperpigmentation. The author treats
erythema lasting longer than a few weeks with a short
course of topical steroids and vitamin C creams [77].
Commonly patients undergo a period of hyper pig-
mentation, especially if they have sun exposure. This
can be managed with high potency steroids and hydro-
quinone. Most hyperpigmentation gradually resolves
but may require months.
11.16 Results
Wrinkles and sun damage do well with CO2 resurfacing
[78]. Improvement with full face ablative laser resur-
facing can be dramatic with substantial improvement in
rhytides, good skin tightening, and a brighter skin color
bereft of dull brown hues (Figs. 11.611.9). Considerable
tightening due to collagen shrinkage may be obtained [79].
11 Facial Resurfacing with the Ultrapulse Laser 187

a b

Fig. 11.6 (a) Preoperative. Patient has dull sallow appearing
skin, jowl formation, and irregular dyspigmentation. Perioral
creases and prominent nasolabial folds are present. (b) Six
months posttreatment. Patient declined fillers and neurotoxins.
She has achieved smoothing of the nasolabial fold and reduction
in the jowl. The cheeks appear lifted and more full due to the
laser lift effect of collagen contraction, and the tear trough is
reduced. Pigmentation is more even and skin tones brighter.
Mild hyperpigmentation persists

a b

Fig. 11.7 (a) Preoperative 56-year-old female with solar elas- and acne scars less apparent. Dull brown tones are no longer
tosis, dyspigmentation, mild acne scars, and dullness of the skin. present, and nasolabial fold is softened
(b) Seven weeks posttreatment, skin is brighter and more vibrant
188 B.I. Raskin

a b

Fig. 11.8 (a) Preoperative patient with significant sun damage, youthful complexion. Skin tones are even and creases dimin-
mottled pigmentation, early jowl formation, and creased areas ished. Jowls are tightened and the laser lift effect of collagen
on chin. (b) Eight weeks post laser, patient has brighter, more contraction gives the face a more volumized appearance

a b

Fig. 11.9 (a) Preoperative 57-year-old female with dyspig- ened. Face appears more full and eyebrows lifted from the laser
mentation and jowl formation. (b) Six months after laser, skin lift of collagen contraction. Skin tones are brighter and more
color is brighter and jowls reduced. Perioral creases have soft- vibrant. Overall patient appears years younger

However residual rhytides often remain, especially on
upper lip smokers lines and around the perioral area.
Deep creases around the eyes persist, although static
and dynamic lines show improvement. Dermatochalasis
may improve significantly [80]. Final improvement
occurs over months and the maximum benefit may not
be seen for 6 months or longer [81]. Overall improve-
ment of wrinkles can be 5090% [8284]. Fine lines
especially those around the eyes improve substantially
more than deep rhytides and creases.
11 Facial Resurfacing with the Ultrapulse Laser
a b
Fig. 11.10 (a) Area of delayed healing at day 12. Any slow
healing site must be cultured for both bacteria and herpes. The
site should be debrided gently and frequently. Most persistent
superficial incompletely epithelialized areas eventually heal
without problems. Areas not healing because of localized deep
The initial substantial improvement often appears
to diminish after 2 or 3 months leading to patient dis-
satisfaction. However, the collagen remodeling so
important to the final result is only just beginning and
patients need to be counseled about the healing
process.
Overall acne scars improve moderately, and severe
acne scars are less responsive than mild or moderate
scars although improvement of about 80% in moderate
atrophic acne scars has been reported [85]. In a study
of fractional CO2 lasers for acne scars, after two or
three treatments, a 2550% benefit was shown in atro-
phy, texture, and overall improvement [86]. Therefore,
ultrapulse ablative resurfacing is the superior tech-
nique for acne scars and the difference in the two stud-
ies cited is reflective of clinical experience although in
the authors impression, acne scar improvement is
variable and not always consistently predictable with
either modality. Acne scar patients continue to improve
for up to 18 months with 11% improvement noted
between months 6 and 18, which are longer than for
patients with photoaging [87]. Patient skin color clearly
is a determining factor in laser choice and the nonabla-
tive fractional laser may be a viable option [11].
189
laser treatment may go on to heal with discoloration or scar. (b)
Six months later, skin color is brighter and jowls reduced. Perioral
creases have softened. Face appears more full and eyebrows
lifted from the laser lift of collagen contraction. Skin tones are
brighter and more vibrant. Overall patient appears years younger
However, fractionated lasers, either ablative or nonab-
lative, offer additional alternatives beyond the scope of
this chapter [88].
11.17 Complications
Complications and problems have been discussed
throughout this chapter (Fig. 11.10). Complications
may occur because of the patients overall health or lack
thereof and also additional factors such as excessive
sunlight during the postoperative period or smoking.
Many complications are avoidable with proper commu-
nication and patient selection based on the patients
underlying status and by avoiding excessive lasering.
Proper preoperative skin preparation, postoperative
wound management, adequate physician training, and
physicians awareness reduce the frequency and severity
of complications [89]. Be that as it may, complications
are a fact of surgery exacerbated by patient behavior,
underlying clinical status and unknown factors.
Acute complications include infections. Bacteria
and fungi must be considered. Poor or slow epithelial-
ization may indicate infection. Reactivation herpes can
190
spread through the entire lasered area. Obviously
infection can lead to scar formation or persistent dis-
coloration [90]. In a study of 354 patients treated with
occlusive dressings, the infection rate was 1.13%, and
three of the infections occurred 35 weeks after the
procedure, thus delayed infections can occur [91].
Common problems include acne flares and milia.
Contact dermatitis may occur. Short-term issues include
hyperpigmentation that generally resolves with treat-
ment but may persist months [92]. Erythema is expected
after laser resurfacing, and generally resolves after sev-
eral weeks. However prolonged erythema becomes a
complication because of patient unhappiness. Prolonged
erythema may last for months. Erythema is thought to
represent the effects of epidermal immaturity, reduced
melanin absorption of light, reduced dermal optical
scattering, and increased blood flow due to injury [93].
Operator influence may occur from use of tretinoin pre-
or postoperatively and from mechanical trauma from
excessive rubbing with wet gauze intraoperatively [94].
Persistent erythema can eventually result in hyperpig-
mentation, and therefore should be treated with steroid
preparations and vitamin C creams.
Other less frequent problems include prolonged
nonhealing where an area of the skin simply does not
reepithelialize. Often these are culture negative and
poorly responsive to antibiotics. Delayed wound heal-
ing may lead to hypertrophic scar and the pulsed dye
laser may be beneficial [95].
Short-term issues include hyperpigmentation that
generally resolves with treatment but may persist months
[92]. Frequency of hyperpigmentation is variable but
has been reported to occur in 2535% with the higher
percentage in darker skin [96, 97]. In a mouse study,
both prelaser and postlaser UV exposure correlated with
postoperative hyperpigmentation and also adversely
impacted texture changes and fibrosis [98]. Pigmentation
can be very distressing to patients. Various pre- and
posttreatment therapy combinations have been advo-
cated but results are inconsistent. The most effective
treatment combines topical steroids and hydroquinone
with an emphasis on sun prevention and protection.
Delayed-onset scar formation is relatively rare, but
must be treated early. As noted above, this will often pres-
ent as a persistent red often somewhat indurated area and
at an early stage often improves within a couple of weeks
with super high potent steroids such as clobetesol.
Deep lasering can cause slow healing and scar for-
mation. Unfortunately when this occurs around the
B.I. Raskin
lips or eyes, there can be contraction forces causing
anatomical distortion.
Late-onset hypopigmentation is considered both
a complication and expected result. Hypopigmentation
is relatively uncommon with an incidence of
approximately 16% and is seen more frequently in
patients with significant actinic bronzing with scattered
lentigines [33]. This may occur months after treat-
ment often a year later. In fact the lightening of the
skin is part of the benefit in making people appear
more youthful and vigorous and certainly women
typically require less makeup application. Skin light-
ening is not specific to laser since it is seen with deep
chemical peels also. However the hypopigmentation
is disturbing to many patients and often precludes
men from having the procedure. Younger females in
particular find the color difference between the neck
and face to be problematic, probably because in gen-
eral they do not wear as much makeup as older
women. Repigmentation has been accomplished with
topical photochemotherapy [99].
Eye damage from the laser is possible if eyes are
inadequately protected. Other unusual complications
reported include a granulomatous reaction and a case
of parapharyngeal abscess from a postoperative skin
staph infection [100]. Multiple warts after a CO2 resur-
facing have been described [101].
Occasionally severe complications supervene
beyond the capabilities of the treating surgeon. In a
report on 50 CO2 laser resurfacing patients treated at a
burn center over a 5-year period, wounds that had not
epithelialized within 1421 days were debrided and
treated with split skin graft or bioengineered skin sub-
stitute [102]. Late complications include hyperemia,
pigmentation issues, and hypertrophic scars. Ultraviolet
light avoidance was critical and hyperpigmentation
was treated with 810% hydroquinone, with hypertro-
phic scars treated by injection and acrylic plastic face
masks used for pressure therapy. Fortunately this level
of complication is extremely rare and is probably even
more infrequent as resurfacing protocols have become
more conservative.
11.18 Conclusion
Full face ablative CO2 laser treatments have been
superseded in most patients with new modalities and
combination treatments of less invasive technologies.
11 Facial Resurfacing with the Ultrapulse Laser
However for a segment of people with significantly
damaged skin or substantial acne scars, this laser
method can be very beneficial, especially in those who
otherwise can only achieve a similar improvement after
months and repeated treatments with less aggressive
therapy at ultimately a higher financial cost. Even uti-
lizing multiple treatments sessions of less aggressive
therapy, results often do not achieve the gold standard
of ultrapulse fully ablative CO2 laser therapy. The risks
of the procedure and ability of the patient to understand
and comply with the protocol must be evaluated in
determining which patient is a candidate.
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11 Facial Resurfacing with the Ultrapulse Laser
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carbon dioxide laser resurfacing of photoaged facial skin.
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 Capacitive Radiofrequency
Skin Rejuvenation
Manoj T. Abraham and Joseph J. Rousso
12.1 Introduction
Skin rejuvenation procedures, particularly those that
deal with rhytids and skin tightening, are a necessary
skill set in the arsenal of the aesthetic clinician. In
general, plastic surgical techniques provide the most
dramatic improvement. Resurfacing lasers (traditional
or fractionated), dermabrasion, deep chemical peels,
and coblation are considered standard ablative nonsur-
gical tools for skin-rejuvenating procedures. However,
longer duration of recovery, scarring, pigmentary changes,
and other complications are more common with surgi-
cal and ablative procedures due to the very nature of
these treatments. As a result, noninvasive methods
have become increasingly popular, and there is signifi-
cant demand for effective, proven methods of nonabla-
tive skin rejuvenation. The senior author has found
nonablative capacitive radiofrequency to be a success-
ful and well-received approach for nonsurgical skin
tightening in his private practice.
M.T. Abraham (*)
Facial Plastic, Reconstructive & Laser Surgery, PLLC,
Poughkeepsie, NY, USA
Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology
Head & Neck Surgery,
New York Medical College,
Valhalla, NY, USA
e-mail: info@nyfacemd.com
J.J. Rousso
Department of Otolaryngology Head & Neck Surgery,
The New York Eye & Ear Infirmary,
New York, NY, USA
e-mail: joe.rousso@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_12, Springer-Verlag Berlin Heidelberg 2013
12
Radiofrequency (RF) energy is electromagnetic radi-
ation in the range of 3300 GHz. Solta Medical, Inc.
(formerly Thermage, Inc.), based in Hayward, California,
has pioneered the aesthetic application of nonablative
RF skin tightening. Thermage, Inc., was initially granted
FDA regulatory clearance for treatment of periorbital
wrinkles and rhytids in November 2002. This was
followed by clearance for full-face treatment in June
2004. In January of 2006, the FDA expanded its clear-
ance to treatment of all skin surface wrinkles and
rhytids. Although there are a growing number of other
devices and technologies available for nonablative skin
tightening, none of these have the accumulation
of published studies reporting efficacy compared to
Thermage [138]. In addition, Thermage treatment
protocols have had time to evolve through several gen-
erations, ensuring safety and more consistent and
effective results [32, 34, 37].
Thermage systems utilize the companys proprietary
technology, incorporating large monopolar capacitive
electrodes to deliver RF energy into the skin while
concurrently protecting the skin surface with a cryo-
gen cooling spray. Current flows from the device via
the treatment tip, through the skin and out through a
grounding pad applied to the patient. This creates a
reverse thermal gradient in the skin, with cooling of
the epidermis while simultaneously achieving precise
volumetric heating of the deeper dermis. As a result,
there is partial denaturation of the collagen within the
dermis without injury to the skin surface [1, 19]. Initial
contraction of the skin collagen network in the dermis
occurs immediately as the collagen fibrils reanneal.
Tightening continues as a healing response is triggered
within the dermis, leading to an overall increase in skin
collagen content [12, 30].
195
196
12.2 Indications
Nonablative capacitive RF treatment is most appropriate
for patients with mild to moderate aging and wrinkling
of the skin. The treatment is best suited to address deeper
rhytids (such as the nasolabial folds and marionette
creases in the face) rather than fine, superficial crepe
papertype wrinkles along the skin surface. This relates
to the epidermis being protected during the treatment
(fine skin surface wrinkles and dyschromias are best
treated by fractionated or more traditional ablative
methods of skin resurfacing).
Patients with significant skin laxity or those with
noticeable underlying structural ptosis are not ideal
candidates for the procedure, but those who are not
interested in surgical options for rejuvenation may still
obtain a theoretical antiaging benefit from collagen
stimulation in the skin. Similarly, patients who have
had a surgical lift may benefit from this maintenance
effect. It is the senior authors experience that patients
with thinner skin typically achieve a more dramatic
result. Patient with thicker, more sebaceous skin may
require more than one treatment session.
Capacitive RF skin rejuvenation is nonablative and
depends on energy delivery based on tissue resistance
rather than absorption of laser light energy, and can
therefore be used with all Fitzpatrick sun-reactive skin
types. It follows that since RF energy is not light-
based, pigmentary dyschromias, hair, and capillary
and vascular ectasias are all relatively unaffected by
capacitive RF treatment (it is possible that there is
some reduction in capillary dilation due to the increased
skin collagen content). Nonablative lasers and intense
pulsed light systems are more effective for these appli-
cations, and can be packaged and performed in con-
junction with capacitive RF skin rejuvenation.
Thermage treatment can also be combined with
other minimally invasive office-based or surgical pro-
cedures to obtain a cumulative result (Table 12.1) [24,
29]. Of note, animal histology studies have shown
inflammatory changes associated with tissue fillers in
the skin after capacitive RF treatment, but a clinical
study by Alam et al. indicated that there was no signifi-
cant morphological change in the filler material or sur-
rounding tissue when RF treatment was performed in
patients 2 weeks after deep dermal injection with
hyaluronic acid derivatives or calcium hydroxylapatite
[21, 29, 38].
M.T. Abraham and J.J. Rousso
Table 12.1 Minimally invasive procedures that can be
combined effectively with capacitive RF skin rejuvenation
Surgical procedures
Facial and neck liposuction
Blepharoplasty
Percutaneous suture techniques
Nonsurgical treatments
Chemodenervation
Tissue fillers
Intense pulsed light and nonablative lasers
Microdermabrasion and superficial chemical peels
Table 12.2 Contraindications to capacitive RF skin rejuvenation
Absolute contraindications
Metallic skin art or tattoo that cannot be removed
Implanted medical device
(Pacemaker, defibrillator, etc.)
Pregnancy
Relative contraindications
Dermatologic conditions
Collagen-vascular or autoimmune diseases
Impaired collagen production (radiation, metabolic, etc.)
It is essential that patients have realistic expecta-
tions of the subtle improvements expected with capacitive
RF skin rejuvenation. Patients must understand that
dramatic surgical- or ablative-type results are not pos-
sible currently with this technology. Patients must
also understand that although there is some initial con-
tour change, skin texture and tone will continue to
improve gradually for several months after the treat-
ment. Depending on each patients individual biology
and reaction to the treatment, additional treatments
may be necessary. Adequate periprocedure patient
counseling is a key component of ensuring patients
satisfaction with the procedure [4, 10].
When performed alone, there are few contraindica-
tions to Thermage treatment (Table 12.2).
12.3 Treatment Considerations
12.3.1 Analgesia
Despite newer multiple-pass treatment algorithms that
require less energy to be delivered at one time, capaci-
tive RF treatment is uncomfortable. There is an initial
12 Capacitive Radiofrequency Skin Rejuvenation
cooling sensation as the cryogen cooling spray is
applied, overcome by a burst of heat as RF energy is
delivered, followed by cooling again. The most recent
generation of Thermage systems (the CPT system)
utilizes an enhanced energy delivery algorithm weav-
ing microbursts of RF energy and cryogen cooling
within each treatment pulse, combined with a vibrating
handpiece to reduce discomfort. According to internal
studies by the manufacturer, patients uniformly toler-
ated treatment better even though the newer treatment
tips are four times more effective in heating tissue to
the target temperature.
Since a typical full-face and upper neck treatment
with the 1.5-cm2 tip involves 600 RF pulses and can
take an hour to perform, some form of anesthesia can
help optimize patient comfort. Most patients with
appropriate temperament are able to tolerate treat-
ment using oral narcotic analgesics (oxycodone, hydro-
codone) and short-acting anxiolytics (lorazepam,
alprazolam). Topical anesthetics are counterproductive
as they numb the epidermis and the cooling sensation,
but are not effective in alleviating the discomfort of
penetrating RF heat [30]. Local injection anesthetics
can alter skin resistance and interfere with proper RF
energy delivery [9, 12, 32]. Sedation or general anes-
thesia should only be utilized by experienced pro-
viders, since the additional safety measure of patient
feedback is removed.
12.3.2 Tip Selection
A variety of Thermage treatment tips are available
depending on the treatment site and treatment goals
(Fig. 12.1). The appropriate tip is selected based on the
size of the treatment tip and the depth of penetration of
the RF energy. Face procedures are commonly per-
formed with the 1.5-cm2 medium-depth treatment tip,
although a 3-cm2 tip is also available (Table 12.3). For
eyelid procedures, the smaller 0.25-cm2 superficial-
depth treatment tip is appropriate. The much larger
deep tip is suited for large surface area procedures on
the body (abdomen, flanks, arms, buttocks, thighs)
this tip has a surface area five times larger than the
1.5-cm2 face tip and penetrates 79% deeper according
to the manufacturer. This uniform, deeper volumetric
penetration of the RF energy may help with cellulite
treatment.
197
12.3.3 Disposable Costs
All Thermage treatment tips are disposable. They are
designed for single use per patient and are electroni-
cally programmed to stop firing after a preset num-
ber of pulses. Other Thermage system disposable item
costs are listed in Table 12.4.
12.4 Technique
12.4.1 Site Preparation
It is ideal if Thermage treatment is performed in a pri-
vate procedure room, with the patient positioned on a
comfortable adjustable chair or procedure table. The
provider is typically seated on a supportive surgeons
stool. Playing soft music can help the patient relax.
Patients are instructed to arrive with the areas to be
treated clean and free of any makeup or other skin care
product. If hair bearing skin is to be treated, it is best if
the hair is shaved or trimmed in advance. The treat-
ment area is exposed and, if necessary, cleansed with
mild soap and water. All metal accoutrements are removed.
The grounding pad is applied to an area distant from the
treatment site.
12.4.2 Energy Settings
Studies by Zelickson et al. [1] have revealed that mul-
tiple treatment passes over the same area using lower-
energy settings creates more collagen change compared
to a single treatment at a higher-energy level. Avoiding
very high energy settings has the additional benefit of
making the treatment more tolerable, and decreasing
the likelihood of potential complications [1, 34, 37].
Coupling fluid is liberally applied throughout treat-
ment to ensure uniform energy delivery. Complete,
even contact of the electrode with the skin surface is
necessary to initiate cooling and RF delivery. An initial
test pulse is performed prior to beginning treatment to
allow the machine to calibrate skin resistance.
The patient is asked to provide feedback using a
04-point scale (0 nothing, 1 warm, 2 hot, 3 very
hot, 4 burning), with treatment settings calibrated to a
22.5 level. With the 1.5-cm2 tip, this usually translates
to a setting of 6196 J/cm2 in most areas.
198 M.T. Abraham and J.J. Rousso

Fig. 12.1 Components of the Thermage CPT nonablative RF handpiece which vibrates to provide improved patient comfort is
skin rejuvenation system (Solta Medical, Inc., Hayward, CA). pictured in the middle, and some of the various disposable treat-
The computer-controlled RF generator unit with integrated ment tips are seen at bottom right. The use of the treatment grid
cryogen cooling unit is seen on the left, the ergonomic treatment to guide delivery of each treatment pulse is depicted in the inset

Table 12.3 Algorithm rules and clinical premises. Typical number of firings using the 1.5-cm2 tip to treat the face
Rule
First XY Cover maximum surface
pass area in a contiguous
region of desired
tightening/toning.
Addl. XY Additional Passes along
passes vectors of tightening,
similar to facelift vectors.
Isolate by physical
manipulation of the skin.
Final Z Final passes to correct
passes excessive tissue laxity or
contour change due to fat
and/or fibrous septae laxity.
Courtesy of manufacturer
Clinical premise
Every square centimeter treated has
5-20% of collagen volume denatured
(setting dependent). More contiguous
surface area achieves greater tightening
of XY plane.
Additional passes achieve incremental
correction through tightening of the
more easily mobilized tissue adjacent
to the targeted area of correction.
Tightening in the Z-axis, particularly
in the mid and lower face, creates a
narrowing and lifting effect
incremental to XY axis tightening.
Evidence
Published article demonstrating
the relationship between
collagen volume affected
and the treatment setting.
Clinical observations led
to published histology work
showing cumulative collagen
damage with multiple passes.
Observations if Z-axis contour
changes during treatment. Pilot
histology suggests both fibrous
septae and fat involvement

Table 12.4 Thermage system disposable costs Energy levels are reduced where needed. For instance,
RF treatment tips when treating the face, lower energy (4461 J/cm2) is
Cryogen canisters utilized in areas of thinner skin (around the orbital rim
Grounding pads and lower neck), over vulnerable superficial fat pads
Coupling fluid (temporal, malar), and over sensory nerve trunks (greater
Treatment grid auricular, supraorbital, infraorbital, mental). Visible
12 Capacitive Radiofrequency Skin Rejuvenation
Fig. 12.2 Schematic
indicating 3D volumetric 3-D Tightening along X,Y & Z Planes
tightening of the dermis.
Tightening of the fibrous
septa in the subcutaneous
tissue helps contour in the
Y
Z-plane (Graphic courtesy
of the manufacturer)
Z Septae
Visualize tightening in 3 dimensions
tightening, erythema of the skin, and excessive patient
discomfort are all subjective clinical end points of treat-
ment for each specific area on the skin.
12.4.3 Treatment Planning
The manufacturer-supplied ink grid is used to guide
treatment topography (Fig. 12.1). The grid is useful in
knowing exactly where to position the treatment tip for
each RF pulse, adjacent to the previous treatment site,
without skipping areas or causing undue overlap. After
the initial pass of RF treatment has been completed,
when making the next pass over the same area, the
intersection of the grid lines is used. In this manner, by
switching back and forth on the grid on each subse-
quent pass, an even application of RF energy is ensured
throughout.
The treatment plan is best visualized in 3D
(Figs. 12.212.4) (Table 12.5). One or two initial
passes are performed to cover the entire treatment area
to achieve uniform contraction of the collagen skin
scaffold in the X-Y plane. Additional passes are then
performed along vectors perpendicular to the relaxed
skin tension lines of the skin to achieve maximal lift-
ing and tightening in the direction desired. In the
face, superior and lateral vectors are targeted to lift,
tighten, and stretch the skin around the lips, nasola-
bial folds, and marionette creases, similar to a surgi-
cal face-lift.
199
Volumetric Heating:
Epidermis
Dermis
Fat Cells
Muscle
RF energy is known to conduct through collagen-based
fibrous septa that surround fat locules in the subcuta-
neous tissue [11]. Additional shrinkage and definition
can be accomplished by targeting the fibrous septa in
this 3D Z-plane. This strategy works well in areas
of fullness such as the submental and jowl regions.
Stacking of treatment pulses on top of each other
without at least 2 min in between pulses is generally
not recommended due to concerns of excessive heat
buildup, but can be used effectively in experienced
hands to achieve further tissue sculpting in this
Z-plane [25].
The total number of treatment pulses required for
different zones of the face and neck is tabulated in
Table 12.3 (Figs. 12.3 and 12.4). It is usually not nec-
essary to treat skin that is densely adherent (over the
nasal dorsum, ear, and scalp, for instance).
Upper lid skin is distracted onto the orbital rim and
away from the globe prior to treatment when using the
medium-depth tip, although the eye lid skin can be
treated directly with the superficial-depth treatment tip
(haptic plastic corneal shields are placed to protect the
entire globe) [35].
12.5 Aftercare
If other complementary procedures are to be done
concurrently (Table 12.2), they should be performed
after Thermage treatment is completed [9, 11, 18, 28].
200 M.T. Abraham and J.J. Rousso

Fig. 12.3 Computer graphic

depicting treatment algorithm 1st Two Passes = 80 160 REPs
for the upper face *XY Pass = 20 40 REPs

Total = 100 - 200 REPs

Periorbital Wrinkles Vector Passes

*Based on using 1.5 cm2
FAST Tip
*Only one pass over temple region

Fig. 12.4 Computer graphic

1st Two Passes = 300 - 400 REPs
depicting treatment algorithm
for the mid/lower face. XY Pass = 40 - 80 REPs
The first two treatment passes Z Passes = 60 -120 REPs
(purple) cover all of the areas Total = 400 - 600 REPs
depicted. The XY treatment
pass (red) overlaps the purple
areas, and the Z treatment
pass (green) overlaps both the
red and purple areas. REP
radiofrequency energy pulse
(Images courtesy of
manufacturer)

Mid & Lower Face and Neck: Contour Passes

*Based on using 1.5 cm2 FAST Tip

If Thermage is performed alone, aftercare is minimal. recommended. Patients are instructed to avoid using ice
Most patients can resume normal activities immedi- or anti-inflammatory medications which may blunt the
ately after the procedure. Routine sun protection is healing response and impede collagen stimulation.
12 Capacitive Radiofrequency Skin Rejuvenation 201

Table 12.5 Treatment Treatment area (all units 1st XY Additional Final Z
algorithm to achieve in square centimeters) pass XY passes passes Total
tightening in 3D
Periorbital/ Wrinkles 100 50 N/A 150
forehead Brow effect 24 N/A 124
Mid and lower/ Nasolabial fold 240 50 20 310
face and neck Jawline 90 20 350
Neck alone 100 50 N/A 150
Full face and neck 340 120 40 500
Courtesy of manufacturer
The numbers shown above are to provide guidance as to the number of firings required for an
average size face and shouldnt be taken as absolute Always use as many firings as needed to
complete the algorithm

12.6 Results 12.7 Complications

Initial skin tightening due to thermally mediated
collagen tightening is seen as the treatment end point.
Results are most impressive in patients with thin skin
and moderate laxity. Gradual thickening, toning, and
lifting of the skin peaks a few weeks after treatment
and continues for 4 months or longer, as a result of
increased collagen production in the skin [210].
Contour changes seen in the face typically include
24 mm of brow elevation, smoothing of the nasola-
bial folds and marionette creases, and better definition
of the jaw line and cervicomental angle (Fig. 12.5 and
12.6) [215, 17, 18, 2427].
Intrinsic characteristics of the skin, such as pore size,
acne, and tone, are also improved [2, 16, 17]. The patient
is spared the incisions, complications, and recovery time
associated with traditional plastic surgery procedures.
Collagen stimulation in the skin may also provide a
theoretical antiaging benefit by replenishing collagen
lost during aging.
A single Thermage treatment is sufficient in most
patients, especially those with thinner skin who do not
have significant underlying structural ptosis. Additional
treatments can provide cumulative results. Results
typically last several years in patients who adhere to
a healthy lifestyle. The senior author has re-treated
patients with Thermage 35 years after initial treatment,
with very good patient satisfaction, perhaps because of
continually improved technology and treatment algo-
rithms. As with any procedure, setting realistic patient
expectations is crucial to achieving patient satisfaction
[4, 10].
Compared to invasive surgical procedures and ablative
methods of skin rejuvenation, the incidence of compli-
cations following capacitive RF treatment is extremely
low [2, 410, 13, 1822, 26, 27, 32]. Clinically notice-
able asymmetry is unlikely if treatments are performed
uniformly and treatment guidelines are followed. A
mild amount of transient erythema and edema is com-
mon after the procedure, and resolves within a few
days. On rare occasion, low-dose oral steroid therapy
may be useful, but it is avoided unless necessary since
the inflammatory and healing response is what is felt
to trigger new collagen formation.
There can be some numbness of the skin (in the face
and neck often in the distribution of the greater auricular
nerve), possibly as a result of perineural inflammation.
Numbness may take a few weeks to recover, but perma-
nent nerve injury has not been reported [24]. Localized
inflammation of superficial muscles like the platysma
in the neck can cause temporary ridging or lumping,
which may take a month or two to dissipate. Anecdotally,
patients who have the greatest evidence of inflammation
appear to get the most amount of skin tightening.
If the treatment tip is not kept completely flat against
the skin surface, arcing of RF energy can occasionally
cause a small <5-mm superficial burn [4, 6, 32]. In the
senior authors experience, these are self-limited and
can be treated with topical antibiotic ointment. The
treatment tip has built-in sensors which continuously
monitor temperature and surface pressure. RF energy
delivery is aborted if measurements are outside a safe
threshold, making significant skin burns unlikely.
202 M.T. Abraham and J.J. Rousso

Figs. 12.5-12.6 Typical patient results 9 months after nonabla- ThermaCool system. Lifting and stabilization of the brow,
tive capacitive RF treatment of the face and neck using a 900- tightening of the eyelid ski, and improvement in the jaw line and
pulse 1.5-cm2 medium-depth tip and eyelid treatment with the midface profile are evident. (Left) Pretreatment. (Right)
225-pulse 0.25-cm2 shallow-depth tip with the original Following treatment
12 Capacitive Radiofrequency Skin Rejuvenation
The complication of greatest concern with capacitive
RF treatment is localized over tightening of subcutane-
ous collagen-based fibrous septa or possible fat atro-
phy resulting in skin surface irregularity [22]. This
complication was more common initially when single-
pass high-energy regimens were being followed, often
with the patient under profound anesthesia [4, 22, 32].
The senior author has found in two patients with this
complication, the indentations improved over the
course of a few months without any additional inter-
vention, most likely as a result of new collagen forma-
tion. Other treatments including autologous fat transfer
have been advocated [22]. With current lower-energy
multiple-pass treatment algorithms and in experienced
hands, complications in general are rare.
12.8 Conclusions
Capacitive RF skin treatment provides an additional
avenue of skin rejuvenation, especially for patients not
interested in invasive surgical options. Candidates for
treatment must be made aware of the limitations of the
procedure and the gradual nature of the changes seen.
Patients with significant skin laxity or underlying
structural ptosis should be counseled that capacitive
RF treatment does not currently achieve the dramatic
changes provided by traditional surgery, although there
is a theoretical antiaging benefit to stimulating colla-
gen formation in the skin. Combining RF treatment
with other nonsurgical or minimally invasive proce-
dures can achieve a more significant result. Future
developments and refinement of RF technology will
undoubtedly expand the role of capacitive RF treat-
ments for facial and body rejuvenation.
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ultrastructural evaluation of the effects of a radiofrequency-
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3. Koch RJ (2004) Radiofrequency non-ablative tissue tighten-
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noninvasive, nonsurgical approach to tissue tightening in
facial skin using nonablative radiofrequency. Dermatol Surg
29(4):325332
14. Hsu TS, Kaminer MS (2003) The use of non-ablative radiof-
requency technology to tighten the lower face and neck.
Semin Cutan Med Surg 22(2):115123
15. Iyer S, Suthamjariya K, Fitzpatrick RE (2003) Using a
radiofrequency energy device to treat the lower face: a treat-
ment paradigm for a nonsurgical facelift. Cosmet Dermatol
16:3740
16. Ruiz-Esparza J, Gomez JB (2003) Nonablative radiofre-
quency for active acne vulgaris: the use of deep dermal heat
in the treatment of moderate to severe active acne vulgaris
(thermotherapy): a report of 22 patients. Dermatol Surg
29(4):333339
17. Fisher GH, Jacobson LG, Bernstein LJ, Kim KH, Geronemus RG
(2005) Nonablative radiofrequency treatment of facial lax-
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18. Finzi E, Spangler A (2005) Multipass vector (mpave) tech-
nique with nonablative radiofrequency to treat facial and
neck laxity. Dermatol Surg 31(8 Pt 1):916922
19. Meshkinpour A, Ghasri P, Pope K, Lyubovitsky JG, Risteli J,
Krasieva TB, Kelly KM (2005) Treatment of hypertrophic
scars and keloids with a radiofrequency device: a study of
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20. England LJ, Tan MH, Shumaker PR, Egbert BM, Pittelko K,
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21. Shumaker PR, England LJ, Dover JS, Ross EV, Harford R,
Derienzo D, Bogle M, Uebelhoer N, Jacoby M, Pope K
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(2006) Effect of mono-polar radiofrequency treatment over
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Med 38(3):211217
22. Narins RS, Tope WD, Pope K, Ross CE (2006) Overtreatment
effects associated with a radiofrequency tissue-tightening
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autologous fat transfer. Dermatol Surg 32(1):115124
23. Kushikata N, Negishi K, Tezuka Y, Takeuchi K,
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(2005) Non-ablative skin tightening with radiofrequency in
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25. Lack EB, Rachel JD, DAndrea L, Corres J (2005)
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a review of radiofrequency and combined radiofrequency
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quency nonsurgical skin tightening. Clin Plast Surg 36(2):
261268
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tive radiofrequency for rejuvenation. Clin Dermatol 26(6):
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(2007) Radiofrequency and 585-nm pulsed dye laser
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Monopolar radiofrequency facial tightening: a retrospective
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36. Biesman BS, Pope K (2007) Monopolar radiofrequency
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236243
 Mesotherapy in Aesthetic Medicine
13
Maya Vedamurthy

13.1 Introduction 13.2 Common Applications

of Mesotherapy
Mesotherapy is a technique of delivering small quanti-
ties of vitamins, minerals, amino acids, conventional Mesotherapy is used in the treatment of:
medications, and preparations directly into the meso- 1. Cellulite
derm to promote a biological response and reverse 2. Weight loss and body sculpting
pathology in the treated area [1, 2]. 3. Local fat deposits xanthelasma, lipoma
Mesotherapy was invented by Michel Pistor in 1952 4. Alopecia
to treat conditions in rheumatology, sports traumatol- 5. Facial rejuvenation wrinkles, skin tightening
ogy, infectious diseases, vascular diseases and mainly 6. Hyperpigmentation
as a pain-relieving technique [3]. Pistor described Other dermatologic conditions purported to benefit
mesotherapy as smallest dose, infrequently in the using mesotherapy [1]:
correct location. The proposed mechanism of action 1. Acne
of mesotherapy is that solutions injected intracutane- 2. Melasma
ously remain in the area longer than they would by 3. Eczema
deeper injection as these solutions continually pene- 4. Hypertrophic or keloid scars
trate into the deeper tissues. Mesotherapy therefore 5. Leg ulceration
appears to be a unique technique to administer medi- 6. Photoaging
cines local to the pathology while the skin serves as a 7. Pruritus
natural time release system. 8. Psoriasis
Traditional Mesotherapy has now evolved into a 9. Striae distensae
new era of aesthetic medicine where it is employed 10. Telangiectasias
in cosmetic applications such as removal of fat and 11. Venous stasis
cellulite, and body contouring. The North American 12. Vitiligo
experience began when Bissoon learned the technique
in France and later popularized it in America.
13.3 Candidate Selection

Adults between the ages of 18 and 75 years in good

M. Vedamurthy
Consultant Dermatologist, Department of Dermatology,
Apollo Hospitals, Chennai, TN, India
e-mail: mayavedamurthy@gmail.com
physical and medical health and with realistic expecta-
tions are candidates for mesotherapy. A detailed medi-
cal history and physical examination is mandatory to
administering mesotherapy.

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 205

DOI 10.1007/978-3-642-21837-8_13, Springer-Verlag Berlin Heidelberg 2013
206 M. Vedamurthy

13.4 Contraindications to Mesotherapy 13.5.3 Chemicals That Act as Antioxidants

and Are Claimed to Decrease
1. Pregnancy and lactation Pigmentation
2. Insulin-dependent diabetes
3. History of strokes 1. Glutathione
4. History of cancer 2. Ascorbic acid
5. History of thromboembolic phenomena 3. Glycolic acid
6. Patients on medications like aspirin, warfarin, hepa- 4. Pyruvate
rin, etc.
7. Severe heart disease
8. Active kidney or hepatic diseases 13.5.4 Chemicals That Stimulate
9. Allergy to one of the components Hair Growth

1. Buflomedil
13.5 Products Commonly Used 2. Minoxidil
in Mesotherapy 3. Finasteride

The products selected for mesotherapy are based on

the pharmacology. There is a wide range of products
for various indications. Sometimes a combination of
these products is used to achieve desired results. When
the ingredients are reconstituted, they must be used
within 24 h or discarded [4].
13.5.1 Fat/Cellulite
13.5.5 Vitamins
1. Vitamin C is used for hyperpigmentation and
melasma. It acts as an antioxidant and helps in col-
lagen and elastin production.
2. Vitamin A is used in antiaging treatment to improve
fine lines.
3. Biotin is used in treatment of alopecia.

1. Phosphatidylcholine
(a) Polyunsaturated phosphatidylcholine extracted 13.5.6 Minerals
from soy bean lecithin
(b) Increases cholesterol solubility Minerals like copper, zinc, magnesium, and chromium
(c) Modifies cholesterol and triglyceride metabo- are used to improve skin elasticity.
lism excellent fat burner
2. Organic silicium
(a) Increases lipase production
3. l-Carnitine 13.6 Equipment and Materials
(a) Vehicles used to transform fat into energy Required
within the cell
1. Mesotherapy Products (Fig. 13.1)
(a) All ingredients must be water soluble, isotonic,
13.5.2 Skin Rejuvenation nonallergenic, and sterile.
2. Syringes
1. CRP 1000 (a) Usually 1 mL, 5 mL, 10 mL, and 20 mL syringes
(a) Has multivitamins, cytokines, and copper pep- depending on the indication.
tides for cellular stimulation and improving col- 3. Needles
lagen and elastin synthesis Meso needles or the so-called Lebel needle
2. Hyaluronic acid (Fig. 13.2) is commonly used for face and neck rejuve-
(a) Improves hydration nation, 4-mm 30-gauge mesotherapy needles and for
3. Organic silicium fat and cellulite treatment, 6-mm 30-gauge mesother-
(a) Increases collagen production apy needle or inch 30-gauge needles.
13 Mesotherapy in Aesthetic Medicine 207

Fig. 13.1 Mesotherapy products

Fig. 13.2 Lebel needles

13.7 Multi-injectors (Fig. 13.3) 13.9 Mesopen (Fig. 13.5)

A practical process is using sterile multi-injectors with Mesopen is a device used to inject small areas more
needles ready to be used with Luer tip in different effectively and quickly.
diameters, i.e., 27 gauge30 gauge. Circular multi-
injectors can be used for all body parts with 5 or 7
needles. Linear or right multi-injectors with 3 or 5 13.10 Micromesotherapy Device
needles can be used for all body parts. (Fig. 13.6)

A one-use system in micromesotherapy is an evolution

13.8 Mesogun (Fig. 13.4) of conventional mesotherapy. Here, the use of skin
injection therapy in the form of a shallow cone with an
The Mesogun can be used for all body parts and allows ultra thin 2-mm needle of 23 gauge in the middle
for different injection techniques. allows injection in the superficial layer of the dermis
208 M. Vedamurthy

Fig. 13.3 Meso needle

multi-injectors

Fig. 13.4 Mesogun

(papillary layer). This micro therapy will overcome the

undesirable risks and effects on the surface area treated
with conventional mesotherapy.
Fig. 13.5 (a) Mesopen. (b) Needle tip

13.11 Needle-Less Mesotherapy

(Fig. 13.7)

This device sends an electrical wave that pushes meso-
therapy ingredients painlessly through the skin without
needles through a technology known as isophoresis.
1. Uses ultrasound and/or iontophoresis technology
2. Probably about 20% efficiency compared to tradi-
tional mesotherapy
3. Less traumatic and painless
13.12 Mesotherapy Injection
Techniques
Mesotherapy involves injecting microquantities of
mesoproducts in the right place using one of the
following techniques as it determines the quality of the
results obtained (Fig. 13.8).
13 Mesotherapy in Aesthetic Medicine
Fig. 13.6 Micromesotherapy device
13.12.1 Intraepidermal
First described by Perrin, intraepidermal is the most
superficial of the techniques. Here, the basal layer is
not penetrated.
1. Depth: 1 mm within the epidermis
2. Simples, painless, no bleeding
3. Large surfaces covered
4. Ideal for patients with low pain threshold
5. Ideal for facial rejuvenation
13.12.2 Papular (Fig. 13.9)
1. Depth: 2 mm dermoepidermal junction
2. Painful
3. Useful for treatment of wrinkles and hair loss
4. MesoBotox
13.12.3 Nappage (Fig. 13.10)
With the syringe held at 3060 angle from the skin
and while applying light and constant pressure on the
syringes plunger, the physician flicks the wrist to
infuse a drop of the solution [5].
209
Fig. 13.7 Needle-less mesotherapy
1. Depth: 24 mm at an angle of 3060 into superfi-
cial dermis
2. Less pain, pinpoint bleeding
3. Large surfaces covered
4. Ideal for scalp and rejuvenation treatment
13.12.4 Point by Point (Fig. 13.11)
First described by Dr. Pistor, point by point is an injec-
tion of 0.02 mL to 0.05 mL of solution made by per-
pendicularly inserting the entire length of a 4 mm or
6 mm needle, its entire length.
Depth of 4 mm with precise single injection is into
deep dermis. This is ideal for fat reduction.
13.13 Getting Started for Mesotherapy
1. Patient selection
2. Evaluation of the patient physical and mental
health
210 M. Vedamurthy

Fig. 13.8 Mesotherapy

injection slides

Intra-epidermal - 1mm
Epidermis
Papular - 2 mm

Dermis
Nappage - 2 - 4mm

Point by Point - 4 mm
Hypodermis
Mesoperfusion - >4 mm

excessive fat. Sodium deoxycholate is a major fea-

ture of an injectable phosphatidylcholine formulation
used for localized fat dissolution [7]. The injected
formula helps to break the existing fat cells which
the body naturally flushes out. The detergent action
of this treatment may be used for post liposuction
irregularities. However, this treatment cannot replace
liposuction.

13.15 Ingredients: Fat-Burning

Mixture/Formula

1. Phosphatidylcholine: 5 mL
Fig. 13.9 Papular method 2. Organic silicium: 5 mL
3. Rutin and Melilot: 2 mL
4. Artichoke extract: 5 mL
3. Explain position of mesotherapy in current clinical 5. l-Carnitine: 5 mL
practice
4. Education of patient
5. Discuss treatment alternatives 13.16 Injection Technique
6. Obtain an informed written consent
7. Photographic documentation 1. Perform procedure with the patient lying down.
2. Map the area to be treated and disinfect with iodized
product.
13.14 Indications and Their 3. Topical anesthesia/ice may be used to minimize
Protocols pain discomfort.
4. No gun used because injection should go deep. Use
Localized fat reduction [6] for abdomen, hips, a long 30-gauge needle.
buttocks, thighs, love handles, and upper arms, also 5. Ideal depth: 1 cm.
known as mesolipo, lipodissolve, and flab jab, has 6. Pinch the fatty area and inject perpendicular to the
attracted a lot of interest from physicians and the skin.
general public as body-contouring technique. It can 7. Injection spacing point: every 23 cm.
target specific areas or spots where the body stores 8. Injection amount: 0.20.8 mL.
13 Mesotherapy in Aesthetic Medicine 211

Fig. 13.10 (a) Nappage manual method. (b) Nappage using Mesogun. (c) Immediately after treatment

Dose usually not to exceed 500 mg per session at

13.17 Post Treatment least initially to see side effects if any.
Lipomas [8], Buffalo hump, double chin
Start massage 72 h later and continue daily between (Fig. 13.12).
treatments to decrease incidence of nodules.

13.18.1 Formula
13.18 Treatment Schedule
1. Phosphatidylcholine: 5 mL
1. 1 session per week for 610 sessions 2. Organic silicum: 2 mL
2. 1 session every 2 weeks till results Inject directly into the area 0.1 mL/point every
3. 1 session per month up to 5 months 1 cm2 cm.
212 M. Vedamurthy

Fig. 13.11 Point by point

13.18.2 Treatment Schedule

b
1. 1 session per week for 45 sessions
2. Good indication

13.19 Eyebags/Xanthelasma [9]

Lower eyelid bags have been treated using phosphati-

dylcholine [10]

13.19.1 Formula Eyebags

1. Phosphatidylcholine: 5 mL
2. Organic silicum: 5 mL

Fig. 13.12 (a) Double chin patient before treatment. (b) After
13.19.2 Formula Xanthelasma treatment

1. Phosphatidylcholine: 2 mL
2. Saline solution: 1 mL 13.20.1 Formula
3. Procaine/Lidocaine: 0.5 mL
Exercise extreme caution. Dose is 0.1 mL every 2 cm 1. 10 mL syringe volume
2. Hyaluronidase: 4 mL
3. Phosphatidylcholine: 2 mL
13.19.3 Treatment Schedule 4. Aminophylline: 2 mL
5. Artichoke: 1 mL
1 session every 2 weeks until disappearance 6. Procaine 2%: 1 mL

13.20 Cellulite (Fig. 13.13) 13.20.2 Injection Technique

One of the most popular indications for mesotherapy is 1. Manual application using 5-mL syringe with 6-mm
cellulite treatment [11]. 30-gauge meso needle or multi-injectors.
13 Mesotherapy in Aesthetic Medicine
a 13.20.4 Side Effects
b 1. Antiwrinkle
Fig. 13.13 (a) Cellulite patient before treatment. (b) After
treatment
2. Mesogun application using 5-mL syringe with
6-mm 30-gauge meso needle.
3. Perform procedure with patient lying down.
4. Map and disinfect the area to be treated.
5. Inject the drugs smoothly and slowly.
6. Ideal depth: 46 mm.
7. Injection spacing: 12 cm part.
8. Injection amount: 0.2 mL per injection.
9. Injection method: Nappage or point by point.
13.20.3 Treatment Schedule
1. 1 session per week for 610 sessions
2. Maintenance: 1 session per month
213
1. Local: Bruising, swelling, redness, infection, skin
necrosis
2. Systemic: Liver toxicity, demyelination of nerves
13.21 Skin Rejuvenation
13.21.1 Mesolift, Mesoglow (Fig. 13.14)
One of the simplest formulations of mesotherapy is
used for skin rejuvenation [12]. Mesotherapy with
hyaluronic acid is found to be an effective treatment
for skin photoaging as confirmed by ultrasound [13].
Sites included face, neck, hands, and dcollet
(Fig. 13.15). Other indications are:
2. Hydration, tightening
3. Acne scars
13.21.2 Formula
13.21.2.1 Antiwrinkle
1. CRP 1000: 5 mL
2. Hyaluronic acid 2 mL or MesoBotox
13.21.2.2 Hydration, Tightening
1. Multivitamins: 1 mL
2. Hyaluronic acid: 1 mL
3. Retin A 0.01%: 1 mL
4. Glycolic acid 1%: 1 mL
5. Procaine 2%: 1 mL
6. Multritrace 5: 1 mL or IAL system
13.21.2.3 Injection Technique
1. Position the patient lying down
2. Disinfect area to be treated
3. Topical anesthesia is useful
4. Manual or Mesogun application with 6-mm
30-gauge meso needle
5. Ideal depth: 24 mm
6. Injection spacing: 0.52 cm apart
7. Injection amount: 0.150.2 mL
8. Injection method: Nappage or point by point
13.21.2.4 Post Treatment
Mesomask (Fig. 13.16) may be used after each treat-
ment. This allows all products to penetrate deeper in
the skin to give a better effect. Mesomask (Fig. 13.17)
214 M. Vedamurthy

a 13.21.2.5 Treatment Schedule

1. One session per month for 3 months
2. Maintenance: every 34 months

13.21.2.6 Acne Scars (Fig. 13.18)

1. Hyaluronic acid 2% or 3.5%: 5 mL
2. Saline solution: 2 mL

13.21.3 Injection Technique

1. Patient lying down position

2. Topical anesthesia
3. Subcision followed by injection gives best
results

13.21.4 Treatment Schedule

b One session per month for 3 months

13.22 Alopecia (Pattern Baldness)

Mesotherapy can be useful in hair loss by supplying

nutrition, restoring microcirculation, and inhibiting
5-alpha reductase.

13.22.1 Ingredients

1. Biotin
2. Zinc
3. Minoxidil
4. Finasteride
5. Dutasteride
6. Buflomedil

Fig. 13.14 (a) Skin rejuvenation patient before treatment. 13.22.2 Formulas Commonly Used
(b) After skin rejuvenation
1. Biotin 10 mg/ml: 4 ml
2. Minoxidil 0.2%: 2 ml; or Biotin 10 mg/mL: 4 ml
3. Dutasteride/Finasteride: 2 ml
contains a mixture of calcium sulfate, talc, and orange
oil. One hundred fifty grams of powder is mixed with
room-temperature water to form a paste that is applied 13.22.3 Injection Techniques
for 15 min as a mask over a gauze on the face.
Mesomask is usually applied after every mesolift 1. Patient lying down position
procedure. 2. Disinfect area to be treated
13 Mesotherapy in Aesthetic Medicine 215

a b

Fig. 13.15 (a) Mesomask product for rejuvenation. (b) Hand rejuvenation. (c) Neck, decollate

3. Topical anesthesia 6. Injection depth: 14 mm

4. Manual application: 3 mL syringe with 4-mm 7. Injection spacing: 1 cm apart
30-gauge meso needle 8. Injection amount: 0.2 mL per injection
5. Mesogun: 5 mL syringe with 6-mm 30-gauge 9. Injection method: Nappage
meso needle 10. Total volume injected: 68 mL
216 M. Vedamurthy

Fig. 13.16 Mesomask application

Fig. 13.18 (a) Acne scars patient before treatment. (b) After
treatment

13.22.6 Formula

1. Glutathione: 5 mL
2. Vitamin C: 2 mL
3. 1% Glycolic acid: 1 mL

13.22.7 Injection Techniques

1. Patient lying down

Fig. 13.17 Mesomask product
13.22.4 Treatment Schedule
1. One session per week for 1 month
2. One session per month till results
3. Maintenance: 1 session every 13 months
2. Disinfect the area
3. Topical anesthesia desirable
4. Manual or Mesogun application with 30-gauge
6-mm meso needle
5. Injection depth: 24 mm
6. Injection spacing: 0.51 cm apart
7. Injection amount: 0.10.2 mL
13.22.8 Injection Method

Nappage or papular
13.22.5 Melasma/Pigmentation
(Fig. 13.19)
13.22.9 Treatment Schedule
Melanin is produced form tyrosine. If glutathione is
1. 1 session per week for 1 month
available, the metabolism produces more phaeomela-
2. 1 session per month till results
nin which is lighter in color.
13 Mesotherapy in Aesthetic Medicine 217

a b

Fig. 13.19 (a) Hyperpigmentation patient before treatment. (b) After treatment

Table 13.1 Common mesotherapy formulations for specific 13.23.1 Actions of MesoBotox
conditions
Conditions Formulations 1. Reduction in fine wrinkles
Alopecia Minoxidil, finasteride, multivitamins 2. Shrinkage of open pores
Cellulite Pentoxiphylline, hyaluronidase or 3. Reduction in sebaceous secretions
collagenase, carnitine, calcium, 4. Skin tightening
pyruvate, aminophylline or caffeine,
coumarin, artichoke, melilot, or
5. Reduction in sweating
ginko biloba
Facial rejuvenation Lipoic acid, DMAE, multivitamins,
hyaluronic
acid, tretinoin 13.24 Mechanism of Action
Herpetic neuralgia Lidocaine, acyclovir, corticosteroids
Hyperpigmentation Vitamin C, Glutathione, Glycolic 1. Superficial muscle fibers are paralyzed leading to
acid compensatory contraction of deeper fibers giving
There are no standardized dosages or ingredients rise to tightening effect.
2. Chemodenervation of sebaceous glands.
There are dosages and ingredients may vary common 3. Tissue edema from paralysis of lymphatic vessel
mesotherapy formulations for specific conditions smooth muscle.
(Table 13.1).

13.25 Injection Technique

13.23 MesoBotox or Intradermal Botox
1. Dilution: 1:10 with normal saline
Developed by Koreans. 2. Injection method: papular
218 M. Vedamurthy

13.26 Treatment Schedule References

1. Once a month for 36 months 1. Rotunda AM, Kolodney MS (2006) Mesotherapy and
phosphatidylcholine injections: historical clarification and
review. Dermatol Surg 32(4):465480
2. Pistor M (1976) What is mesotherapy? Chir Dent Fr
13.27 Complications of Mesotherapy 46(288):5960
3. Brown SA (2006) The science of mesotherapy chemical
13.27.1 Local anarchy. Aesthet Surg J 26(1):9598
4. Matarasso A, Pfeifer TM (2005) Mesotherapy for body
contouring. Plast Reconstr Surg 115(5):14201424
1. Tenderness
5. Mrejen D, Perrin JJ (2003) Mesotherapie et Rachis, Editions.
2. Bruising S.F.M CERMIIe de France, CRM Champagne
6. Hexsel D, Serra M, Mazzuco R, Dal Forno J, Zechmeister D
3. Burning or itching (2003) Phosphatidylcholine in the treatment of localized fat.
4. Urticaria [14] J Drugs Dermatol 2(5):511518
5. Pain 7. Rotunda AM, Suzuki H, Moy RL, Kolodney MS (2004)
6. Swelling Detergent effects of sodium deoxycholate are a major
feature of an injectable phosphatidylcholine formulation
7. Skin necrosis used for localized fat dissolution. Dermatol Surg 30(7):
8. Ulcers [15] 10011008
9. Abscess [16] 8. Bechara FG, Sand M, Sand D et al (2005) Ultrasound controlled
10. Hyperpigmentation injection lipolysis of lipomas with phosphatidylcholine in
patients with familial multiple lipomatosis. In: American
11. Non-tuberculosis mycobacterial infection [17] Society for Dermatologic surgery and American College of
12. Rare granulomatous panniculitis [18], koebner- Mohs Micrographic Surgery and Cutaneous Oncology,
ization, granuloma annulare Combined Annual Meeting, Atlanta, 2730 October 2005
9. Maggie S (1988) Treatment of xanthelasma with phosphati-
dylcholine. In: 5th international meeting of mesotherapy,
13.27.2 Systemic Paris, 1988
10. Ablon G, Rotunda AM (2004) Treatment of lower eyelid
1. Flushing pads using phosphatidylcholine: clinical trial and review.
2. Vagal response Dermatol Surg 30(3):422427
11. Rotunda AM, Avram MM, Avram A (2005) Cellulite; is
3. Allergy there a role for injectable? J Cosmet Laser Ther 7(34):
4. Dizziness, Nausea 147154
5. Liver toxicity 12. Amin SP, Phelps RG, Goldberg DJ (2006) Mesotherapy
6. Demyelination of nerves for facial skin rejuvenation: a clinical, histologic and electron
microscopic evaluation. Dermatol Surg 32(12): 14671472
13. Lacarrubba F, Tedeschi A, Nardone B, Micali G (2008)
Mesotherapy for skin rejuvenation: assessment of the sub-
13.28 Conclusions epidermal low-echogenic band by ultrasound evaluation
with cross sectional B-mode scanning. Dermatol Ther
21:S1S5
Although mesotherapy sounds like a new technique, 14. Urbani CE (1994) Urticarial reaction to ethylene diamine in
dermatologists have been using similar injection tech- aminophylline following mesotherapy. Contact Dermatitis
niques to treat keloids and hypertropic scars with ste- 31(3):198199
roids. Physicians practicing mesotherapy should 15. Al Khenaizan S (2008) Facial cutaneous ulcers following
mesotherapy. Dermatol Surg 34(6):832834
possess a good knowledge of the products used to 16. Garcia-Navarro X, Barnadas MA, Dalmau J, Coll P,
ensure safety to the patients. Products whose mecha- Gurgu M, Alomar A (2008) Mycobacterium abscessus
nism of action is well understood and whose adverse infection secondary to mesotherapy. Clin Exp Dermatol
effects and doses are well studied should be chosen. 33(5):658659
17. Sanudo A, Vallejo F, Sierra M, Hoyos JG, Yepes S, Wolff
Until more controlled and published studies are avail- JC, Correa LA, Montealegre C, Navarro P, Bedoya E,
able in the literature, dermatologists should exercise Sanclemente G (2007) Nontuberculosis mycobacteria infec-
caution. However, the future of this technique depends tion after mesotherapy. Preliminary report of 15 cases. Int J
on the clinical and experimental studies to establishing Dermatol 46(6):649653
18. Davis MD, Wright TI, Shehan JM (2008) A complication of
the safety and efficacy of mesotherapy, also known as mesotherapy. Non infectious granulomatous panniculitis.
intradermotherapy. Arch Dermatol 144(6):808809
 Upper Blepharoplasty
Morris E. Hartstein
14.1 Introduction
The goal of upper blepharoplasty is to create an
aesthetically pleasing upper lid and brow complex. In
recent years, we have come to appreciate that aging
changes in the lid can reflect volume loss, and rejuve-
nation of the upper eyelid reflects volume restoration
and not just a simple removal of tissue.
When evaluating the potential blepharoplasty patient,
it is important to determine whether or not there is also a
ptosis component in the eyelid examination, and if so,
whether or not this will be addressed during the bleph-
aroplasty surgery. For instance, patients may suffer from
mild ptosis, but are really much more bothered by the
dermatochalasis and thus would only need to undergo
blepharoplasty. Alternatively, marked dermatochalasis
may mask significant ptosis which may become more
apparent postoperatively if not corrected. Even if you are
not surgically addressing the ptosis, it should certainly
be pointed out to the patient preoperatively with a mirror
or photos so there are no surprises postoperatively. As
always, preoperative counseling and discussion is key.
The state of the cornea is very important to exam-
ine with regards to dry eye symptoms. The patient
should be questioned about dry eye symptoms and
M.E. Hartstein
Department of Ophthalmology,
Assaf Harofeh Medical Center, Zerifin, Israel
Clinical Associate Professor
of Ophthalmology and Plastic Surgery,
Saint Louis University School of Medicine,
St. Louis, MO 63104, USA
e-mail: mhartstein@earthlink.net
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_14, Springer-Verlag Berlin Heidelberg 2013
14
whether or not they use artificial tear supplements.
Schirmer testing, though not completely reliable, is
still one objective way of measuring tear quantity and
should be performed on every patient. A quicker mea-
surement can be obtained using Zone-Quick (Oasis,
Glendora, CA) in which the threads are placed in the
inferior fornix of the eyelid for only 15 s. Some bleph-
aroplasty patients may note functional symptoms such
as a tired look, may actually complain of reduced
visual field especially when reading, and/or headaches
from chronic brow elevation.
The eyelid is a dynamic structure which provides
protection to the globe as well as conveys facial expres-
sion. When considering a patient for upper blepharo-
plasty, it is helpful to go through the following anatomic
checklist.
14.2 Brows
Brow ptosis can contribute to fullness in the upper lid.
Most patients will show some degree of brow asym-
metry, and this should be pointed out to the patient pre-
operatively. It is also important to note where the true
border of brow is located (this may be obscured by
plucking of the brow hairs).
14.3 Bony Orbits
Smaller orbits result in crowding and fullness of the
superior sulcus. Larger orbits result in a deeper and
more hollow sulcus. These differences in orbit size
will affect what is achievable in surgery.
219
220
14.4 Eyelid Skin
The amount and quality of skin in the lids should be
noted. If there is swelling of the lid, this may be a
sign of thyroid disease or other inflammatory eyelid
conditions. This should be worked up and treated
preoperatively.
14.5 Orbital Fat
The location and prominence of the fat pockets should
be noted. Laterally, what appears to be fat may indeed
be a prolapsed lacrimal gland.
14.6 Procedure
A basic set of instruments used in blepharoplasty is in
Fig. 14.1. The author prefers having bipolar cautery
available as well as monopolar unit. The procedure
begins with marking the lid crease, and I prefer using
a fine-tipped marking pen (Devon, fine tip, #61,
Cardinal Health), as this is much more precise
Fig. 14.1 Basic set of instruments for blepharoplasty
M.E. Hartstein
(Fig. 14.2). This is a crucial step for the procedure
and needs to be precise. I use the patients own creases
if they are readily apparent and symmetrical
(Fig. 14.3). If there is a faint or nonexistent crease,
then markings are made 810 mm centrally in women
and 78 mm central height in men, with the medial
and lateral ends tapering about 1 mm lower. In Asian
individuals, the crease runs lower an important fac-
tor to keep in mind when performing eyelid surgery
on these patients. At the medial aspect, care should
be taken not to extend the marking past the punctum.
If it is necessary to carry the incision further, once the
punctum is reached, the marking should flare superi-
orly for about 2 mm to reduce the chance of develop-
ing of medial canthal web postoperatively (Fig. 14.4).
Laterally, the incision can flare superiorly once the
lateral canthus is reached. The upper line of the inci-
sion is determined by how much skin is to be removed.
Using a forceps, the tissue can be pinched while the
lid margin is observed for rotation. Usually, more tis-
sue is excised laterally than medially (Fig. 14.5). A
useful guideline is to try and leave approximately
20 mm from the brow to the lid margin after pinching
the skin to be removed (Fig. 14.6).
14 Upper Blepharoplasty 221

a b

Fig. 14.2 (a, b) Fine-tip surgical marking pen is crucial for accurate marking of lid creases and area to be excised

Fig. 14.3 The eyelid crease is marked in the preexisting crease

of the patient using the fine-tip marking pen

Fig. 14.4 The medial aspect of the incision reaches the

It is the authors preference to first mark, then inject,
to allow time for the epinephrine to take effect while
the patient is prepped. A variety of different local
anesthetic solutions may be employed; however, a
50:50 mixture of 2% lidocaine with epinephrine and
0.5% or 0.75% bupivacaine (with or without epineph-
rine) is preferred. The final epinephrine concentration
should be 1:100,0001:200,000. The local anesthetic
punctum where it then curves superiorly for 12 mm in order to
avoid medial canthal webbing
solution may be buffered with sodium bicarbonate in
order to increase the comfort of injection by changing
the pH. Hyaluronidase is usually not necessary. The
local anesthetic is infiltrated just beneath the skin.
222 M.E. Hartstein

Fig. 14.5 The pinch technique demonstrates the amount of

tissue which can be excised without causing eversion of the lid
margin

Fig. 14.7 The 15c blade is smaller and finer and better suited to
eyelid surgery than a standard 15 blade

Fig. 14.6 From the edge of the true brow to the lid, margin
should measure approximately 200 mm after substrating the
amount of excised tissue. This is a helpful guideline in order to
avoid postoperative lagophthalmos

Intravenous sedation may be used well and in some

cases even general anesthesia. Following injection,
topical proparacaine or tetracaine is instilled in the
eyes, and the patient undergoes a full face prep with a
head drape and split sheet leaving the entire face
exposed. Most patients feel more comfortable with the
entire face left open, and both eyes can be compared
Fig. 14.8 The 15c blade is used to incise just through the skin
during the procedure. After additional topical anesthe- along the demarcated line. Alternatively, a sharp Wescott scis-
sia with proparacaine or tetracaine, a rigid corneal sors, CO2 laser, Ellman, or Colorado needle may be used
(or eye) shield is placed to protect the globe during the
procedure.
The incision is made with a #15c blade (smaller radiofrequency unit (Ellman International, Inc,
profile than a standard #15) along the demarcated Oceanside, NY), or CO2 laser. A skin or skin-muscle
line(s) (Figs. 14.7 and 14.8). Alternatively, one may flap is excised. Previously, many blepharoplasty sur-
use a sharp Wescott scissors, Colorado needle, Ellman geries included automatic removal of the skin and
14 Upper Blepharoplasty
Fig. 14.9 In most cases, removing a skin flap only is sufficient
to achieve the desired effect. Even if the orbicularis is to be
removed as well, it is safer to do it in stages so as not to inadver-
tently penetrate deeper and injure the levator muscle
orbicularis together (Fig. 14.9). For the beginning
surgeon, it is recommended to excise a skin flap first
and then consider orbicularis removal. While some
patients need to have both layers removed, skin removal
alone can achieve most of the desired effects of bleph-
aroplasty sparing the orbicularis muscle is more
protective of the eye in terms of maintaining the blink
as well as creating a volume in the upper lid.
Hemostasis is obtained with bipolar or monopolar
cautery (Fig. 14.10). With an assistant retracting the
superior skin edge and applying gentle pressure to the
globe, the fat pockets are made to bulge anteriorly.
Currently, it is recommended to debulk/excise the
medial fat pad if indicated and, more rarely, excise
the central fat pad so as not to create a hollow appear-
ance or so-called A-frame deformity. Once in the
suborbicularis plane, as the fat bulges, the overlying
capsule is divided and the fat allowed to prolapse.
Additional local anesthetic may be necessary at this
point. The fat is excised/debulked using the clamp
and cut method, CO2 laser, or monopolar cautery
(Fig. 14.11). Laterally, care should be taken not to con-
fuse the lacrimal gland with a lateral fat pad (the lacri-
mal gland tends to be whiter in color and firmer in
texture). Lacrimal gland prolapse can contribute to the
lid fullness, and the gland may need to be repositioned
into the lacrimal gland fossa. Also, previously the
ROOF fat was routinely sculpted or excised, which
would only contribute to deflation of the temporal
223
Fig. 14.10 Following removal of the skin flap and hemostasis,
the orbicularis muscle layer is intact
brow region. The ROOF fat should be left intact or at
most repositioned if there is significant descent.
At this point, the awake patient can be asked to
open their eyes and the lids are examined for symmetry.
If this is satisfactory, them incision closure is
performed. The lid crease may be reformed, if desired,
and this helps to control the precise level of the crease.
This may be accomplished by passing a few inter-
rupted 60 absorbable sutures, through one or both
edges of the wound while incorporating a bite of
the edge of the levator aponeurosis or the pretarsal
orbicularis (Figs. 14.12 and 14.13). Alternatively,
these sutures may be passed from inferior orbicularis
to levator edge to superior orbicularis. These sutures
also can serve to imbricate the orbicularis muscle
thereby creating more volume for the upper lid. The
skin incision is closed with a running suture, using
60 plain gut or a nonabsorbable suture such as 60
silk or polypropylene. Antibiotic ointment is applied
(Fig. 14.14).
Cold compresses are placed immediately after
surgery and then continued at frequent intervals for the
next 48 h. The patient is advised to keep his/her head
elevated, such as sleeping on several pillows, in order
to minimize postoperative edema. Antibiotic ointment
is applied up to 3 times daily for a week with artificial
tears used as needed for possible dry eye symptoms.
Patients are usually seen in the office at 57 days
postoperatively, and at this point, any nonabsorbable
sutures may be removed.
224
Fig. 14.11 The orbicularis may be button-holed medially in
order to sculpt or excise the fat pocket, in this case with the
Colorado needle. The central fat pocket is rarely removed
Fig. 14.12 The lid crease is reformed by passing a suture
through both edges of wound while incorporating a bite of the
edge of the pretarsal orbicularis
14.7 Complications
Retrobulbar hemorrhage is a rare but devastating com-
plication of eyelid surgery. Patients should be instructed
to call their surgeon for significant eyelid swelling.
Preoperative screening and counseling for potential
anticoagulants is a necessity.
M.E. Hartstein
Fig. 14.13 When the crease suture is tied, it sets the crease at
the desired height. By imbricating the orbicularis muscle poste-
riorly, the crease suture also serves to augment the volume of the
upper lid. Several crease sutures can be placed but I usually
place them medially and centrally while laterally just closing
skin to skin
Fig. 14.14 (a) Preoperative. (b) Postoperative following upper
blepharoplasty
Mild lagophthalmos and exposure keratitis (dry
eye) are probably the most common complications.
Usually these are self-limiting in most cases. The
patient may need to use artificial tear supplements for
a short period postoperatively. In more severe cases of
14 Upper Blepharoplasty
dry eye, patients may be required to frequently instill
lubricating drops and ointments and place punctal
plugs. In addition, oral doxycycline may be helpful to
correct meibomian gland dysfunction which can con-
tribute to dry eye after surgery. In rare cases, a corneal
ulcer may develop, requiring the eyelids be closed
temporarily with a tarsorrhaphy.
Asymmetric eyelid creases may result from poor
incision marking or from lack of crease fixation
sutures. In general, it is easier to raise a low crease than
to lower a high crease. If the patient is unhappy with
crease asymmetry, one should discuss using the higher
crease as a guide.
Oversculpted deep superior sulcus may result from
over-aggressive skin/orbicular removal and/or fat
removal. To correct this deformity, residual fat pads
may be mobilized and advanced or fat/filler injections
may be performed [13].
225
14.8 Conclusions
Upper blepharoplasty can be a highly rewarding pro-
cedure. It is critical to understand the relevant eyelid
anatomy. Previous concepts of simply removing as
much tissue as possible have yielded to a greater
appreciation of what constitutes a youthful and
aesthetic upper eyelid.
References
1. Hartstein ME, Kikkawa D (2009) How to avoid blepharo-
plasty complications. Oral Maxillofac Surg Clin North Am
21(1):3141
2. Older JJ (1995) Ptosis repair and blepharoplasty in the adult.
Ophthalmic Surg 26(4):304308
3. Pacella SJ, Codner MA (2010) Minor complications after
blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and
scleral show. Plast Reconstr Surg 125(2):709718
 Lower Blepharoplasty
Morris E. Hartstein
15.1 Introduction
The cookie-cutter approach is to be discouraged in any
cosmetic procedure but nowhere more so than in lower
blepharoplasty. It is crucial to evaluate the patient and
discuss with them preoperatively what exactly bothers
them about their lower lids. For example, is it the bags?
The wrinkles? The dark circles? All of the above?
A standard ocular exam is part of the standard pre-
operative evaluation for lower blepharoplasty, espe-
cially checking for dry eye and previous LASIK surgery.
In addition, the following checklist can be helpful.
The quality and amount of excess skin are noted.
Redundant or lax skin can also be a function of attenu-
ated orbicularis muscle. The fat pockets are then
observed while the patient looks straight ahead and in
upward gaze. Gentle pressure on the globe can make
these areas bulge further. Chronic eyelid edema may be
a sign of thyroid disease, and the presence of festoons
should be noted. If there is a prominent lateral fat pad,
this should be noted as it is sometimes overlooked intra-
operatively. Hypertrophic orbicularis along the lid mar-
gin can lead to fullness in this area. Finally, it is important
to note the relationship of the lower lid to the midface,
noting if there is malar fat lad descent or prominent tear
trough deformity. Negative vector patients, where the
M.E. Hartstein
Department of Ophthalmology,
Assaf Harofeh Medical Center, Zerifin, Israel
Clinical Associate Professor
of Ophthalmology and Plastic Surgery,
Saint Louis University School of Medicine, St. Louis,
MO 63104, USA
e-mail: mhartstein@earthlink.net
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_15, Springer-Verlag Berlin Heidelberg 2013
15
globe protrudes anterior to the rest of the lower lid and
midface, may be at higher risk for lid malposition post-
operatively if not addressed properly.
Lower lid laxity is evaluated by the distraction test
and the snapback test. The lid should be able to be
distracted not more than 68 mm from the globe. In the
snapback test, the lid is pulled downward and allowed to
snapback to the globe. With significant laxity, the lid
will not return to the globe until the next blink. These
are lids which are at risk for postoperative lower lid mal-
position if not addressed surgically. In addition, address-
ing the laxity can enhance the result of the surgery.
In lower lid blepharoplasty, it is crucial to address
each of the layer of the lid complex: skin, muscle, fat,
vector, and the canthus. Properly addressing each of
these aspects of the lid will ensure a great chance of
success in lower lid rejuvenation.
15.2 Procedure
Topical proparacaine is placed in the eye, a corneal
shield is placed, and the lower lid is digitally retracted
by the assistant. Local anesthetic 50:50 mixture of 2%
lidocaine and .75% bupivacaine with epinephrine
(1:100,0001:200,000) is injected subconjunctivally
(Fig. 15.1). The needle is then directed into the fat
pockets as well as the infraorbital nerve. A cotton-
tipped applicator is used to ballott the globe, and this
causes the inferior fornix to prolapse. An incision is
made several millimeters beneath the inferior tarsal
border from the caruncle to the lateral canthus
(Figs. 15.2 and 15.3). A traction suture is placed through
the superior aspect of the incision to enhance exposure
and to protect the globe (5-0 Vicryl, 4-0 silk). Dissection
227
228
Fig. 15.1 With the assistant everting the lid, local anesthetic is
given subconjunctivally. Additional local anesthetic is given into
the fat pockets as well as to the infraorbital nerve
Fig. 15.2 With the lid everted and with gentle pressure on the
globe, an incision is made several millimeters below the inferior
tarsal border. Note the corneal shield
Fig. 15.3 The transconjunctival incision is carried out from the
caruncle to the lateral canthus
M.E. Hartstein
Fig. 15.4 (a) Dissection is carried out along the lower lid
retractor until (b) the fat pads are easily visible. Additional local
anesthetic can be given at this point
is carried out inferiorly, staying close to the conjunctiva
and lower lid retractors (Fig. 15.4). Blunt dissection
with a cotton-tip can be helpful as well. A Desmarres
retractor is then used to retract and placed over the
inferior orbital rim, causing the fat pockets to prolapse.
Additional local anesthetic can be given at this time
prior to opening up the capsule surrounding the fat
pockets. The capsule is gently divided across the length
of the incision, and the fat should easily prolapse. At
this point, it is helpful to take a cotton-tipped applicator
and use it to bluntly dissect between the nasal and cen-
tral fat pads in order to indentify the inferior oblique
muscle (Fig. 15.5). Once the muscle is visualized, the
fat pockets can be safely addressed. After opening the
capsules surrounding the fat, the fat can be teased out
15 Lower Blepharoplasty
Fig. 15.5 The overlying capsules are gently divided to allow
the fat to prolapse. A cotton-tipped applicator is placed between
the nasal and central fat pad to identify the inferior oblique
muscle
Fig. 15.6 The nasal fat pad is debulked/resected using the
coagulation setting on the Colorado needle
using a forceps and cotton-tipped applicator. If the goal
is to excise the fat, it can be removed using a Colorado
needle on the coagulation setting (Figs. 15.615.8). It is
often necessary to supplement the anesthesia with addi-
tional injections into the fat. Fat is usually removed
down to the level of the inferior orbital rim.
In a more fat-conserving blepharoplasty, the fat can
also be repositioned in the intra-SOOF plane [1]. A
pocket is created by dissecting just over the perios-
teum under the orbicularis muscle for a distance of not
more than 10 mm inferior to the rim so as not to dis-
rupt the orbicularis nerve fibers. This can be done with
an elevator or by spreading with scissors just anterior
229
Fig. 15.7 The fat may also be removed by the clamp and cut
method
Fig. 15.8 Special attention must be paid to the lateral or temporal
fat pad. This pad is sometimes overlooked until it is noticed
postoperatively
to the periosteum (Fig. 15.9). The prolapsed fat pads
can be gently sculpted. A suture (e.g. 6-0 Prolene) is
then passed through the skin side in a previously
marked area just beneath the tear trough, coursing
along the anterior inferior orbital rim (Fig. 15.10).
The suture needle is then weaved through the fat pads,
passed over the anterior rim again to exit through the
skin alongside just the first suture. Sometimes, the
medial and central fat pad can be weaved using the
same suture needle, or separate sutures and needles
may be passed for each compartment. The temporal
pad in these cases is usually removed. When the suture
is tied, the repositioned fat is advanced over the infe-
230
Fig. 15.9 If fat repositioning is to be carried out, a pocket is
developed in the preperiosteal plane using a scissors to spread
bluntly or an elevator
Fig. 15.10 A suture is passed from the skin side, over the
inferior rim where it is weaved through the fat and then passed
back out through the skin
rior rim (Figs. 15.11 and 15.12). This maneuver may
also create some elevation of the midface after the
orbicularis is freed. The conjunctival incision is not
closed. Additional fat may be injected as well for fur-
ther volume enhancement.
Once the fat is taken care of, attention can now be
directed to the anterior lamella. If there is lid laxity,
this should be addressed, and several options are avail-
able. Suture canthopexy provides tightening of the lid
during at least the postoperative period. Technically
M.E. Hartstein
Fig. 15.11 When the suture is tied over a bolster, the fat is
redraped over the inferior orbital rim
Fig. 15.12 Bolster in place. Repositioning the fat in this fash-
ion may also provide midrace elevation
easier to perform than a full canthoplasty, the can-
thopexy is also less powerful. Still, a simple suture
canthopexy procedure can be very effective when
combined with a transconjunctival approach. When
the lower lid retractors are released, this allows the lid
to migrate upward, and when combined with the can-
thopexy, this can ensure a stable lid position during the
healing phase. In cases of severe laxity or in cases
15 Lower Blepharoplasty
Fig. 15.13 Blunt dissection through a buttonhole incision in
the orbicularis down the lateral rim
Fig. 15.14 A 5-0 Vicryl suture is passed through the periosteum
over the lateral orbital rim
combined with a translid subperiosteal midface lift, a
full canthoplasty, i.e. tarsal strip procedure, may be
warranted [2].
It is useful to address the orbicularis muscle. Atten-
uation of the orbicularis may be partly responsible for
the tear trough deformity and for some of the aging
effects seen in the lower lid region. Tightening the
orbicularis laterally can also help to support the lid
without altering the canthal appearance which may
occur with a tarsal strip canthoplasty. This is also use-
ful in patients with a significant distraction test of the
lid. A lateral incision is made just lateral to the lateral
231
Fig. 15.15 Pulling on the 5-0 Vicryl to ensure a proper
periosteal bite is taken
Fig. 15.16 The 5-0 Vicryl suture is passed through the orbicularis
in a mattress fashion
canthal angle, and blunt dissection is carried out to the
orbital rim. By making a buttonhole incision and
bluntly spreading, there is less chance of orbicularis
denervation (Fig. 15.13). A 5-0 Vicryl suture is passed
through the periosteum of the lateral rim (Figs. 15.14
and 15.15). The suture is then hitched (Little JW
personal communication) to the orbicularis muscle
in a mattress fashion (Fig. 15.16). When tied, this
elevates the lid, and may help efface the tear trough.
Excess skin can be resected in the form of a skin
pinch, and with the underlying orbicularis support,
a large amount of skin can be safely resected
232
Fig. 15.17 Excess skin is now addressed through a skin pinch
using Adson forceps. The skin may also be addressed with laser
resurfacing
Fig. 15.18 Only the pinched skin is excised no orbicularis is
taken
(Figs. 15.1715.19). Closure is with 6-0 Prolene or
6-0 plain gut sutures, closing from the medial to
temporal direction to decrease chances of a dog-ear
laterally (Figs. 15.2015.22). Alternatively, the skin
can be tightened with a laser.
Postoperatively, the patient uses eye drops and
ointment to be placed in the eye. Often an antibiotic/
steroid combination can be used. Cold compresses are
applied for 48 h and the patient is instructed to call if
there is significant swelling. Some patients may report
diplopia immediately postoperatively as a result of
M.E. Hartstein
Fig. 15.19 Following skin excision, the skin easily redrapes
Fig. 15.20 The 5-0 Vicryl is tied down, elevating and securing
the orbicularis and supporting the lower lid and canthus
anesthesia injection around the inferior oblique, but
this is usually transient.
15.3 Complications
Similar to upper blepharoplasty, patients undergoing
lower blepharoplasty may develop dry eyes, persistent
edema/chemosis, allergic reactions, etc. Sometimes,
residual fat may be noted especially laterally. Con-
versely, patients may have too much fat removed and
15 Lower Blepharoplasty
Fig. 15.21 Excess skin at the lateral canthus is removed
Fig. 15.22 Skin pinch and lateral incision are closed using
interrupted 6-0 Prolene or 6-0 plain gut sutures
suffer from a hollow-appearing lid. More conservative
fat removal or repositioning can help avoid this prob-
lem. If it does occur, it can be corrected with filler
injections; however, the periorbital area is one of the
least forgiving on the face, so care should be taken.
One of the most common and distressing complica-
tions of lower blepharoplasty is eyelid malposition in
the form of lid retraction ectropion or both. This com-
plication is most often associated with the subciliary
approach, lack of attention to lid laxity, and/or nega-
233
Fig. 15.23 (a) Preoperative. (b) Postoperative
tive vector eyes [3]. Careful preoperative assessment
and intraoperative attention can help to easily avoid
this complication.
15.4 Conclusions
Lower blepharoplasty can be a challenging procedure.
However, with careful preoperative planning and by
addressing each layer of the lid complex, one can
achieve successful rejuvenation of the lower lid region
(Fig. 15.23).
References
1. Hartstein ME, Kikkawa D (2009) How to avoid blepharo-
plasty complications. Oral Maxillofac Surg Clin North Am
21(1):3141
2. Jordan DR, Anderson RL (1989) The lateral tarsal strip revis-
ited. The enhanced tarsal strip. Arch Ophthalmol 107(4):
604606
3. Mohadjer Y, Holds JB (2006) Cosmetic lower eyelid bleph-
aroplasty with fat repositioning via intra-SOOF plane.
Ophthal Plast Reconstr Surg 22(6):409413
4. Shorr N, Fallor MK (1985) Madame Butterfly procedure:
combined cheek and lateral canthal suspension procedure for
post-blepharoplasty, round eye, and lower eyelid retraction.
Ophthal Plast Reconstr Surg 1(4):229235
 Blepharoptosis: The Check
Ligament Technique
Antonio Stanizzi
16.1 Introduction
This technique was pioneered by Holmstrm and
Santanelli in 2002 [1, 2] and provides for the use of the
suspensor ligament of the conjunctival fornix or check
ligament which, once suitably insulated, is attached to
the tarsus. It is a flexible structure due to laxity of the
capsule of Tenon in this area. Originally Holmstrom
proposed its use in the treatment of congenital bleph-
aroptosis [3], which it is not the levator aponeurosis,
but it is the levator muscle to have functional deficits.
Under these conditions, traditional techniques of
resection and shortening of the levator aponeurosis
were subject to frequent and early recurrences, and the
techniques of suspension to the frontalis muscle,
reserved for otherwise intractable cases, have several
problems, not least having to make adjustments in sub-
jects with secondary growth [48].
The check ligament technique has interesting
advantages:
1. The check ligament is a flexible structure indepen-
dent of the levator muscle and therefore can be used
in all conditions with an intrinsic deficit of this
muscle.
2. The check ligament is a vascularized structure, so it
is not necessary to use grafts of autologous or syn-
thetic material as it is required in the techniques of
suspension to the frontalis muscle.
3. No adjustment is necessary in subjects in secondary
growth.
A. Stanizzi
Cl. of Plastic Surgery, Ospedali Riuniti, Ancona, Italy
e-mail: astanizzi@tiscali.it
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_16, Springer-Verlag Berlin Heidelberg 2013
16
4. Can be implemented early, unlike other traditional
techniques, even under 1 year of age, when it is
more important to operate in severe cases to prevent
amblyopia [9].
5. This technique has no substantially recurrences.
The main disadvantages of this technique are essen-
tially the following believes:
1. The author believes that it is not so easy to find it
and make a correct check ligaments isolation.
2. The determination of the correction has no objec-
tive parameter of evaluation, and it depends on the
sensitivity of the surgeon, who must evaluate a
number of variables such as the type of ptosis, its
severity, the characteristics of the ligament which
may vary from individual to individual, as it has
been managed and isolated, etc.
This involves a subjective final evaluation by the
surgeon that can predispose to hypo or hyper correc-
tion. It seems reasonable to expect 30% of minor revi-
sions to change the level of correction obtained in the
first instance. When the secondary correction is
required, there are some advantages in performing it
within the first week when the scar is not yet consoli-
dated, and all plans and structures can be isolated more
easily again. It is not always possible to have a full
aesthetic result, but in almost all cases, you can get a
good functional result. For all these reasons, the appli-
cation of this technique can be extended to all cases,
congenital or acquired, characterized by a poor func-
tion of the levator muscle [1013].
Another indication is the treatment of acquired
involutional blepharoptosis early onset, at a young age,
where the quality of levator aponeurosis does not offer
guarantees on maintaining the level of correction in the
time after its shortening [14].
235
236
In all these cases, the check ligament technique is
now the treatment of choice.
16.2 Description of the Technique
It begins with an incision at the level of upper eyelid
crease, with removal of a small amount of skin and
orbicularis muscle. Then the levator aponeurosis is
separated from the tarsus, in its central third, and the
tarsal plate cartilage exposed. The dissection proceeds
in a plan between the conjunctiva, in depth, and levator
aponeurosis and Mller muscle on the surface. The
dissection continues until the superior conjunctival
fornix, the capsule of Tenon is reached. In this area, it
presents a laxity, so it can be hung and, with a gentle
traction, protruded. At this point, you proceed with its
carefully isolation, separating the conjunctiva from the
check ligament until the correct amount needed is
obtained. Hemostasis must be very accurate.
After completing its isolation, the check ligament is
attached to the tarsus with 3 nonabsorbable 6-0 inter-
rupted suture. At this stage, the surgeon must decide,
subjectively, the amount of correction to be made. If the
operation is conducted under local anesthesia and the
patient can cooperate, an initial reference may be to ask
the patient to open their eyes and place the lid margin
between the pupil and the iris margin, but each case must
be assessed individually. Established the degree of cor-
rection the dissected plans are simply repositioned with-
out requiring any resection of the levator aponeurosis.
The operation ends with the skin suture with 6-0
nylon, interrupted sutures. This kind of suture offers
the advantage of getting a scar concave, to better recre-
ate the fold of the supratarsal crease, and to allow in
Fig. 16.1 This 17-years-old male had right congenital secondary
blepharoptosis. When he was 6 years old, he was treated by
levator aponeurosis resection (other surgeon), and there was
recurrence after a few months. (a) Preoperative. (b) Preoperative
planning. The incision is made at level of the superior supra-
tarsal crease. In this case, the incision is to be the same as the
previous surgical treatment. (c) Infiltration of local anesthe-
sia (45 mL of lidocaine 2% with epinephrine 1:100.000).
(d) Incision. (e) A small amount of skin and orbicularis muscle
is removed. (f) The levator aponeurosis is exposed. (g) Detach-
ment of the levator aponeurosis from tarsus. (h) Dissection starts
following the plane between the conjunctiva on the deep side
and the levator and Mller muscles on the superficial side. Note
the tip of the scissor under the conjunctival plane. (i) The dissec-
tion reaches the superior conjunctival fornix. (j) The check liga-
ment, represented by a laxity of the capsule of Tenon, can be
A. Stanizzi
the early hours, the drainage of a part of the exudates
through the wound, with less postoperative edema.
The dressing consists in the application of ophthal-
mic ointment with steroids and antibiotics and wet
gauze (saline solution), to be renewed several times
during the day. Ice is also applied at intervals during
the first two days. In this way, the wound is kept clean
because the wet gauze absorbs exudates, and the ice
helps to reduce postoperative edema.
The level of correction obtained is checked within
the first 24 days, and if its not satisfactory, its pos-
sible to proceed to a revision. In any case, whatever the
degree of correction obtained, it must always leave
possible the normal obstruction of the eyelid in both
the waking and sleep. A small fissure during sleep may
residual for the first weeks or even be permanent but
must be limited (12 mm) and not create any discom-
fort to the patient.
16.2.1 Case 1
This 17-years-old male had right congenital secondary
blepharoptosis.
When he was 6 years old, he was treated by levator
aponeurosis resection (other surgeon), and there was
recurrence after few months. A check ligament repair
was performed (Fig. 16.1).
16.2.2 Case 2
This 18-month-old male had congenital blepharoptosis
of the left side. A check ligament repair was performed
(Fig. 16.2).
hung and gently pulled. (k) The check ligament is fixed to a
suture to make its management easier. (l) The check ligament is
pulled over the tarsal plate, ready to be sutured on it. (m) The
first suture is placed in the middle. (n) Another two sutures are
placed on later and medial side of the check ligament. Be careful
the sutures remain in the tarsal plate and do not reach the con-
junctiva of the eyelid. (o) The suture of the check ligament to the
tarsus has been completed. (p) Note the three sutures (Nylon
6-0) over the check ligament. (q) The levator and Mller mus-
cles are replaced without any resection. (r) Level of correction
obtained is verified. (s) Suture of the skin with interrupted
sutures. It allows a better definition of the supratarsal crease and
the drainage of part of the exudation, with less postoperative
edema. (t) (1) Application of ophthalmic ointment with antibi-
otic and steroid. (2) Dressing with wet gauze. (u) Two days post-
operative. (v) Two weeks postoperative
16 Blepharoptosis: The Check Ligament Technique 237

a b

c d

e f
238 A. Stanizzi

g h

i j

k l

Fig. 16.1 (continued)

16 Blepharoptosis: The Check Ligament Technique 239

m n

o p

q r

Fig. 16.1 (continued)

240 A. Stanizzi

s t1

t2

Fig. 16.1 (continued)

16 Blepharoptosis: The Check Ligament Technique 241

a b

c d

Fig. 16.2 (a) Preoperative 18-months-old male with congenital right blepharoptosis. (b) Ten days postoperative after check ligament
procedure. (c) Eight months postoperative. (d) Note normal closure of the eyelids. (e) Good elevation of the eyelid
242 A. Stanizzi

16.2.3 Case 3 16.2.7 Case 7

Congenital right blepharoptosis in a 2 years-old male A 22-years-old male with acquired posttraumatic
(Fig. 16.3). blepharoptosis of the right side with complete paraly-
sis of the levator muscle (Fig. 16.7).

16.2.4 Case 4
16.2.8 Case 8
A 18-years-old female with acquired bilateral bleph-
aroptosis (Fig. 16.4). A 72-years-old female with congenital bilateral asym-
metrical blepharoptosis. Familial disease with her
mother and sister affected as well (Fig. 16.8).
16.2.5 Case 5

A 42-years-old male with acquired right blepharoptosis 16.2.9 Case 9

for 15 years (Fig. 16.5).
16.2.6 Case 6
A 54-yeasr-old female with acquired blepharoptosis of
the left side for 20 years (Fig. 16.6).
A 64-years-old male with acquired bilateral bleph-
aroptosis (Fig. 16.9).
Acknowledgments My personal thanks to Prof. Hans Holmstrm
whose teaching have allowed me to learn and implement this
technique.
16 Blepharoptosis: The Check Ligament Technique 243

a b

c d

Fig. 16.3 (a) Preoperative 2-years-old male with right con- closure of the eyelid. (d) Good elevation of the eyelid. (e) Six
genital blepharoptosis. (b) Three years postoperative. Aesthetic years postoperative and the result is maintained
result is not perfect but the functional result is good. (c) Normal
244 A. Stanizzi

a a

Fig. 16.4 (a) Preoperative 18-years-old female with acquired

bilateral blepharoptosis. (b) Two years postoperative

Fig. 16.5 (a) Preoperative 42-years-old male with acquired right

blepharoptosis for 15 years. (b, c) and (d) One year postoperative
16 Blepharoptosis: The Check Ligament Technique 245

a b

d
c

Fig. 16.6 (a) Preoperative 54-years-old female with acquired blepharoptosis of the left side for 20 years. (b) Preoperative poor function
of the levator muscle. (c) One year postoperative. (d) Good elevation of the eyelid

a b

c d

Fig. 16.7 (a, b) Preoperative 22-years-old male with acquired posttraumatic blepharoptosis of the right side with complete paralysis
of the levator muscle. (c) One year postoperative (d) Normal closure
246 A. Stanizzi

a a

b b

Fig. 16.8 (a) Preoperative 72-years-old female with congenital

bilateral asymmetrical blepharoptosis. Familial disease with her
mother and sister affected as well. (b, c, d) One year postopera-
tive. Normal closure and good elevation of the eyelids

Fig. 16.9 (a) Preoperative 64-years-old male with acquired

bilateral blepharoptosis. (b, c, d) One year postoperative. Good
elevation and normal closure of the eyelids.
16 Blepharoptosis: The Check Ligament Technique 247

References 7. Philandrianos C, Galinier P, Salazard B, Bardot J, Magalon G

(2010) Congenital ptosis: long-term outcome of frontalis
suspension using autogenous temporal fascia or fascia lata in
1. Holmstrm H, Santanelli F (2002) Suspension of the eyelid
children. J Plast Reconstr Aesthet Surg 63(5):782786
to the check ligament of the superior fornix for congenital
8. Wasserman BN, Sprunger DT, Helveston EM (2001)
blepharoptosis. Scand J Plast Reconstr Surg Hand Surg
Comparison of materials used in frontalis suspension. Arch
36(3):149156
Ophthalmol 119(5):687691
2. Holmstrm H, Bernstrm-Lundberg C, Oldfors A (2002)
9. Lin LK, Uzcategui N, Chang EL (2008) Effect of surgical
Anatomical study of the structures at the roof of the orbit with
correction of congenital ptosis on amblyopia. Ophthal Plast
special reference to the check ligament of the superior fornix.
Reconstr Surg 24(6):434436
Scand J Plast Reconstr Surg Hand Surg 36(3):157159
10. Wagner RS (1990) Surgical options for congenital ptosis
3. Iljin A, Zielinska A, Karasek M, Zielinski A, Omulecka A
with poor levator muscle function. Semin Ophthalmol 5(4):
(2007) Structural abnormalities in the levator palpebrae
176182
superioris muscle in patients with congenital blepharoptosis.
11. Whitehouse GM, Grigg JR, Martin FJ (1995) Congenital
Ophthalmic Surg Lasers Imaging 38(4):283289
ptosis: results of surgical management. Aust N Z J Ophthalmol
4. Scuderi N, Chiummariello S, De Gado F, Alfano C, Scuderi
23(4):309314
G, Recupero SM (2008) Surgical correction of blepharopto-
12. Dayal Y, Crawford JS (1966) Evaluation of the results of
sis using the levator aponeurosis-Mllers muscle complex
surgery to correct congenital ptosis of the upper eyelid. Can
readaptation technique: a 15-year experience. Plast Reconstr
Med Assoc J 94(22):11721177
Surg 121(1):7178
13. Deenstra W, Melis P, Kon M, Werker P (1996) Correction of
5. Park DH, Choi WS, Yoon SH, Shim JS (2007) Comparison of
severe blepharoptosis. Ann Plast Surg 36(4):348353
levator resection and frontalis muscle transfer in the treatment
14. Carraway JH (1988) Cosmetic and functional considerations
of severe blepharoptosis. Ann Plast Surg 59(4):388392
in ptosis surgery. The elusive perfect result. Clin Plast
6. Fan J (2001) Frontalis suspension technique with a tempo-
Surg 15(2):185193
ral-fasciae-complex sheet for repairing blepharoptosis.
Aesthetic Plast Surg 25(3):147151
 Aesthetic Rhinoplasty Utilizing
Various Techniques Depending 17
on the Abnormality

Fernando D. Burstein

17.1 Introduction

The nose is the central and most prominent aesthetic

facial landmark. It divides the face into two halves and
defines many of the common measures of facial pro-
portions (Fig. 17.1). When in balance with the rest of
the face, it is an important component of perceived
facial beauty. When it is too prominent, too short, too
wide, or off center, it can contribute to facial dishar-
mony. Rhinoplasty can be an important adjuvant pro-
cedure when combined with surgery of the jaws or
surgery for facial aging. There have been many books,
articles, and seminars on the subject with ardent opin-
ions as to the merits of a particular philosophy or sur-
gical technique. It is apparent that many different
approaches can yield gratifying results in the proper
hands. The following is a personal approach to aes-
thetic rhinoplasty based on the authors experience
with over 5,000 procedures over 25 years. This is the
basic approach that the author has demonstrated and
taught to the plastic surgery residents. This chapter is a
brief synopsis of a methodology that has provided con-
sistent good results with a minimum of aesthetic, func-
Fig. 17.1 Measuring ideal facial proportions using Ricketts
tional, or postoperative problems.
Golden Rule

17.2 Consultation

The initial consultation for a patient requesting primary

F.D. Burstein
Division of Plastic and Reconstructive Surgery,
Emory University, Atlanta, GA, USA
Center for Craniofacial Disorders, Childrens Healthcare
of Atlanta, Atlanta, GA, USA
e-mail: fburstein@aol.com
aesthetic rhinoplasty should include a detailed medical
history, review of any previous nasal procedures, and
careful attention to the patients stated aesthetic goals.
The nose should be examined externally, and with a
nasal speculum, any anatomic or functional anomalies

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 249

DOI 10.1007/978-3-642-21837-8_17, Springer-Verlag Berlin Heidelberg 2013
250
should be documented and brought to the patients
attention. A speculum examination of the nasal cavity
can give important clues to potential functional problems
that could be aggravated by aesthetic nasal surgery.
These concerns should be discussed with the patient
and, if necessary, addressed at the time of aesthetic sur-
gery. Overall facial aesthetics should be discussed with
particular emphasis on the underlying bony anatomy of
the face. A patient with what appears to be a dispropor-
tionately large nasal pyramid may, in fact, have a small
chin which is amplifying the disharmony. An overly
projected nasal tip may be more prominent in a patient
with maxillary retrussion and so forth. A lateral cepha-
lometric radiograph can be useful in verifying the clini-
cal impression in cases of skeletal disharmony.
In addition to external examination, photographic
documentation is essential for documentation and treat-
ment planning. At a minimum anterior posterior and
right and left profile views are recommended. A worms
eye view can be helpful in patients with a wide nasal
base. Computerized imaging is an essential part of my
surgical preparation and an important tool for enhancing
communication with the patient. The staff images the
patient, and a written consent is obtained documenting
that the images are potential results and may vary. The
author is very wary of the patient that demands a nose
that she or he sees in a movie magazine. The computer-
ized images are used as a real-time guide during the
procedure. In formulating a surgical plan, the author
considers the patients desires, the relevant anatomy,
and the results of computerized images. This plan is
presented to the patient and discussed in detail to insure
that their expectations are realistic. An outlined plan
based on these factors may look something like this:
1. Dorsal hump bony and cartilaginous. Reduce dor-
sum with slight concavity. Reduce supra tip septum.
2. Wide bony pyramid. Bilateral lateral osteotomies
with infracture.
3. Amorphous wide nasal tip. Cephalic trim, intradomal
sutures, and graft tip. Reduce alar base width.
17.3 Anesthesia
The author performs all aesthetic nasal surgery under
a general endotracheal anesthetic supervised by a
board-certified anesthesiologist. Only minor revisions
are done under local with oral sedation. The proper
topical and infiltrative anesthetic administration will
F.D. Burstein
greatly decrease operative and postoperative bleeding.
Along with better visualization during the procedure,
the patients postoperative discomfort will be greatly
reduced. Pledgets impregnated with 4% cocaine are
placed between the inferior and middle turbinate to
anesthetize and constrict the mucosa. The supratro-
chlear, supraorbital, infraorbital, and anterior ethmoidal
nerves are blocked with 0.25% mepivacaine with epi-
nephrine, and the subcutaneous nasal tissues are infil-
trated (Fig. 17.2). If septal work is to be done, the septal
mucosa is also infiltrated. Less than 10 cm3 is used for
all injections. It is useful to allow 15 min for maximal
vasoconstriction to occur before starting the operation.
17.4 Surgery
An external rhinoplasty approach is used in nearly
all of the aesthetic nasal operations, and the author
has done so for nearly 20 years. There are advantages
and disadvantages to both the external and internal
approaches to rhinoplasty, but on balance, the author
much prefers the external approach. The exposure
afforded by this approach is wonderful for teaching
purposes since cause and effect of various maneuvers
can be easily demonstrated. Important technical points
that will minimize undesirable results include meticu-
lous closure of the columellar incision and careful reat-
tachment of suspensory and connecting ligaments that
are taken down for exposure. It is important to let the
patient know that there will be numbness of the nasal
skin for several weeks and that often the nose will feel
indurated during the healing process. These conditions
are temporary, but in cold climates, care must be taken
to avoid nasal frostbite until sensation returns.
For purposes of clarity, the author has divided the
operative procedure into several distinct steps. These
are described in the order that the author recommends
performing, which is a logical progression that avoids
repetition and redundancy, allowing an orderly and
predictable procedure. There are countless variations
on every step of the rhinoplasty procedure based on
anatomic factors, the surgeons preferences and experi-
ence, and surgical goals. The basic technique employed
is broken down into several logical progressive stages
from which creative variations can be added according
to the surgeons experience. These steps are illustrated
for instructive purposes for reductive rhinoplasty with
tip modification.
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 251

Fig. 17.2 Administration Supraorbital n.

of infiltrative and topical
anesthetic in preparation for
rhinoplasty. Note that block
of all sensory innervation and
mucosal vasoconstriction are Supratrochlear n.
key to successful surgery and
recovery

Infraorbital n.

Anterior ethrnold n.

Cocainized pledgett

17.4.1 Exposure

The location and design of the columellar incision is

critical. Placing the incision in the distal third of the
columella hides it from the frontal view and makes dis-
section easier (Fig. 17.3). A stair-step incision breaks
up the incision line thus camouflaging it since no seg-
ment is more than 34 mm in length. Alignment of the
incision is facilitated by simply fitting the right angles
back together at the end of the procedure. The nasal
skin is quite adherent in this area, and a fine #69 beaver
blade is recommended for the initial dissection. Using
a thumb hook, the nasal vestibular skin is everted dem-
onstrating the edge of the lower lateral cartilages. The
incision is carried from the columella along the edge of
the cartilages from medial to lateral leaving a 5-mm rim Fig. 17.3 Location and design of external rhinoplasty incision.
of intact vestibular skin. Leaving this rim will prevent Note right angles. This hides scar and makes accurate reapproxi-
visible scars and distortion of the rim. Sharp scissor mation possible
252
Fig. 17.4 Septal harvesting.
Note that both dorsal and
caudal septal struts are
maintained. Approach is
through external incision
going between footplates
Vomer
dissection of the lower lateral cartilages is carried out
until they are fully exposed. The rest of the dissection
over the dorsum is easily carried out with blunt scis-
sors, protecting the skin with an elevator. At this stage,
the entire external nasal anatomy will be visible. I take
a moment to correlate the actual anatomy with my sur-
gical plan at this stage and modify it as necessary.
Important anatomic points are the amount of cartilagi-
nous versus bony dorsal hump, thickness of the skin,
intradomal fat versus cartilage width.
17.4.2 Dorsum
After exposure has been achieved, the dorsal component
can be addressed. If septal grafts are required, they are
obtained at this point by dissecting between the medial
crura and carefully separating the mucoperichondrium
F.D. Burstein
Ethmoid
Nasal septum
(1.5 cm. intact)
Harvest
1 cm. intact
from the septum (Fig. 17.4). A 1-cm caudal strut and a
12-cm dorsal strut are left intact as the central septum
is harvested with a swivel knife. The septal mucoper-
ichondrium is then sutured back together with a mat-
tress suture of 4-0 gut (Fig. 17.5). This obliterates a
potential dead space and hematoma formation making
packing unnecessary. Next, the periosteum of the dor-
sum is elevated with a Joseph elevator; this allows the
rasp to work without interference. Coarse to fine rasps
are used to bring the bony dorsum down to the desired
level; no osteotomes are used. This allows gradual,
controlled contouring of the bony dorsum under direct
visualization (Figs. 17.6 and 17.7). The cartilaginous
component is then trimmed using either septal right
angle scissors or a #11 scalpel blade. The nasal skin
flap is frequently returned to its original position, and
the dorsum is palpated as well as visually inspected
several times as the profile is adjusted a millimeter at
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
Fig. 17.5 Resorbable
mattress sutures placed
between septal
mucoperichondrium flaps
obliterating dead space.
No packing is used
a time until the profile matches the patients desires.
The computerized imaging photos are invaluable in
this step. In some instances, the upper lateral cartilages
may need to be trimmed along their juncture with the
septum to reduce projection of the dorsum. The mucosa
should be carefully dissected prior to trimming to
avoid penetrating into the nasal cavity. Reduction of
the nasal dorsum will almost always result in a flatten-
ing of the dorsum or open roof as the peak of the
bony cartilaginous dorsum is removed (Fig. 17.7).
Lateral osteotomies can minimize this effect while at
the same time reducing the apparent nasal bony width
which is often desirable. A 2-mm straight osteotome
is often used for the lateral osteotomies. No tunnels
are necessary before introducing the osteotome at the
level of the pyriform aperture. The tip of the osteot-
ome should be flush with the maxilla and follows
the juncture of the nasal bones and maxilla to the level
of the medial canthus, where it is turned at a right
angle, to the long axis of the nasal bones, continuing
the osteotomies toward the nasal dorsum (Fig. 17.8).
The 2-mm osteotome produces a perforated paper
effect by leaving the periosteum attached along the
253
Remnant of
nasal septum
Mucoperiosteum
lines of the osteotomy-enhancing stability. Care should
be taken to control the osteotome to avoid perforat-
ing the nasal mucosa, which can result in bleeding.
This technique results in an osteotomy that is flush
with the maxilla preventing a visible or palpable
rocker deformity and is inherently stable. No pack-
ing is necessary to hold the nasal bones in place. Once
the osteotomies are complete, attention is turned to the
nasal tip.
17.4.3 Tip
The plethora of variations of nasal tip anatomy makes
tip work a creative part of rhinoplasty. There are many
maneuvers that can be performed to achieve the desired
nasal tip results. The particular techniques employed
will depend on the patients goals, the quality and
thickness of the overlying nasal skin, and the available
graft material. Most often, the lower lateral cartilages
will be too wide, and initial trimming is required. The
cartilages are incised with a micro tip coagulator nee-
dle cautery sparing the mucosa and remove the desired
254
Fig. 17.6 Exposure of dorsum. Bony dorsum modified with coarse to fine rasps. The cartilaginous dorsum is reduced with #11
scalpel. Insert shows flattening of dorsum with open roof being created
Fig. 17.7 Open roof as result of bringing down nasal bones and
septum. This creates a flattened dorsum that should be addressed
F.D. Burstein
segment with sharp scissors (Fig. 17.9). Care is taken
not to damage the lower border of the upper lateral
cartilage especially at its juncture with the septum to
preserve the internal nasal valve. A minimum of 4 mm
of rim cartilage should be left intact to provide airway
support to the external valve.
For patients requiring only minimal narrowing of
the nasal tip with reasonably thin skin, this cephalic
trimming may be all that is required to achieve the
desired aesthetic result. It can be coupled with suturing
of the footplates and domes to further narrow and proj-
ect the tip. Only resorbable 5-0 PDS sutures are used
for this. It is important that the tip-defining point be the
lower lateral cartilages and not the septum to prevent a
poly-beak deformity. It may be necessary to trim the
distal septum if it projects beyond the most distal point
of the dome. If the tip is still too wide or the lateral
aspect of the domes too rounded, a simple bruising
using a cartilage crusher, while protecting the mucosa,
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 255

Fig. 17.8 Lateral osteotomy

technique. A perforated
paper effect is achieved.
Periosteal attachments also
help with the stability of the
osteotomies Lateral osteotomies

Periosteal bridges

can soften this curve while insuring nasal airway

support (Fig. 17.10).
In cases where the tip is bifid or under projected
or the skin is too thick to show the desired highlights
tip, grafting may be indicated. Autologous tissues
in rhinoplasty are used only to avoid problems with
rejection, infection, and extrusion that can occur with
prosthetic materials. In primary rhinoplasty, the septum
and other cartilaginous trimmings provide a plethora
of materials that can be sculpted to achieve an aestheti-
cally pleasing tip. Some basic graft types are the
cephalic trim materials, septal columellar, shield and
button grafts (Figs. 17.1017.13). In almost all cases,
the edges of the grafts should be softened or bruised Fig. 17.9 Nasal tip. Lower lateral cartilage is trimmed leaving
to prevent an edge effect. The degree of softening a 4-mm rim of intact cartilage to support external nasal valve
256 F.D. Burstein

Fig. 17.10 Composite

of various tip-modifying
techniques. Note bruising
of lateral crura to reduce
nostril convexity. Tip grafts
to define and project tip can
be stacked if necessary

Bruised
alar cartilages

Tip grafts

Fig. 17.11 (a) Submental

vertex view of nasal tip
showing broad bifid tip with
lack of projection. (b) Tip Tip grafts
projection increased by
suturing domal cartilages.Tip
definition improved with
onlay grafts

a b

required will depend on how thick the nasal skin is and
how thick the graft is. If the skin is very thick, requir-
ing a more substantial graft to show highlights, the
edges of the grafts can be beveled with a scalpel rather
than bruised with a cartilage crusher to retain stiffness.
The cephalic trimmings are thin supple grafts that can
be doubled over and stacked to fine tune nasal tip
projection; care should be taken to preserve the thin
perichondrium to maintain structural integrity. The
graft should be placed on top of the native lower lateral
cartilages exactly where the tip-defining points are
desired. The placement can be checked by simply
unfurling the nasal skin flap and inspecting the effect.
The septal cartilage can be used for a variety of grafts
including shield shapes and button shapes. These grafts
are fairly substantial and relatively rigid making them
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
Fig. 17.12 Shield type tip graft being applied. Note that the
highest point of graft will be tip-defining point
Fig. 17.13 Columellar strut graft between lower lateral carti-
lages. It will provide support allowing for tip narrowing and
rotation
ideal for patients having thicker skin. Columellar grafts
are used to provide tip support and projection as well
as to rotate the tip-defining point to the desired angula-
tion (Fig. 17.14). In cases of a hooked or droopy tip,
they are often combined with trimming of the distal
dorsal septum to shift the tip in an upward direction
257
(Figs. 17.15 and 17.16). A small pocket is created at
the level of the nasal spine, and the graft is inserted
contacting the spine. The medial crura and footplates
are secured to the strut graft with mattress sutures and
then walked to the tip. As the dome is reached, nasal
tip width is converted to tip projection. The angle of
the strut relative to the medial crura and footplates of
the graft insertion will help to determine the nasolabial
angle. The strut should not project beyond the domes.
Additional grafts can then be added as required. After
the tip work has been completed, the skin is closed
with 5-0 Prolene at the stair-step incision and 5-0 chro-
mic for the intranasal portion.
17.4.4 Base Width
After closing all incisions, the base width is evaluated
and compared to the desired width on the imaging pho-
tographs. This step is undertaken only after all tip and
dorsal modifications have been completed. Columellar
grafts, intradomal sutures, and other maneuvers that
increase tip projection will tend to narrow the nasal
base. A diamond-shaped pattern of skin and mucosa
is removed from the floor of nose just medial to the
alar attachments to the facial skin (Fig. 17.17). This
hides the incision intranasally while allowing signifi-
cant width reduction. In addition, it preserves the natu-
ral curvature of the lateral crura avoiding a grafted look
seen with alar excision techniques. Absorbable sutures
are used for closure.
17.5 Special Situations in Primary
Aesthetic Rhinoplasty
Surgery of the non-European ethnic nose can seem
intimidating. In the USA, the most common ethnic
groups seeking aesthetic nasal improvement are those
of African American and Asian lineage (Fig. 17.18).
Most commonly, the tip width and projection are the
primary concerns. Occasionally, the dorsum is also an
issue. The first step is, as always, communicating with
the patient as to realistic goals and expectations. The
imaging computer is a valuable adjuvant in this regard.
Keep in mind that almost all patients wish to keep
their ethnic nasal identity and simply desire improve-
ment in terms of proportions, tip definition, or dorsal
height (Fig. 17.19). The authors preference is to only
258 F.D. Burstein

a c

b1 b2

Fig. 17.14 (a) Male complaining of hooking of nose with a decrease plunging. (c) Postoperative following columellar strut
plunging tip and prominent hump. He desires a natural appear- graft. Note decrease in dorsal hump and increased nasal labial
ance. (b) Columellar strut graft used to rotate tip upward and angle as tip rotates upward
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 259

Fig. 17.15 (a) Young

a b
woman with large nasal
dorsal hump and resulting
plunging tip. Plunging made
worse with facial animation.
(b) Postoperative after bony
and cartilaginous dorsum
reduction, columellar strut
and tip grafting

a b

Fig. 17.16 (a) Patient desiring aesthetic improvement. Note plunging tip, dorsal hump, and amorphous tip. (b) Postoperative after
dorsal hump reduction, cephalic tip trimming, columellar strut, and shield grafting to tip improve aesthetics
260 F.D. Burstein

a1

a2

b c

Fig. 17.17 (a) Technique used to decrease nasal base width. wide tip. (c) Postoperative following cephalic trim, intradomal
Incisions are well hidden. (b) Preoperative young woman desir- sutures, and small crushed round cartilage graft to tip. Nasal
ing aesthetic improvement of nose. Complains of amorphous base narrowed
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 261

Fig. 17.18 (a) Preoperative

woman complaining of
a
excessive tip and alar width
as well as lack of tip
definition. Note shortened tip
on lateral view. Wants to
maintain ethnic characteristics
and look natural.
(b) Postoperative after alar
base reduction, cephalic trim,
dome placation, and stacked
septal shield grafts to
lengthen tip

use autologous tissues to augment the tip or dorsum.
The most frequent complaint is an amorphous wide
tip. In these cases, the standard external approach is
used.
Often a fibro fatty collection between the domes is
present, splaying the tip. This tissue is removed, the
septum is exposed between the footplates, and the
cartilage is harvested. Next, the cephalic margins of
the lower lateral cartilages are trimmed, and the lat-
eral crura remnant is often bruised to convert the cur-
vature from convex to slightly concave. This maneuver
will help in refining the tip. If tip support is deficient,
the septal cartilage can be used as a columellar graft
advancing the medial crura on this pillar of support.
262 F.D. Burstein

a b

Fig. 17.19 (a) Preoperative young man complaining of overall width of nose, dorsal hump, and wide nostrils. (b) Postoperative
following takedown of hump, alar base reduction, cephalic trim, and small shield graft to tip

These septal and/or cephalic trimmings are then used
to create a tip-defining point. If modest dorsum aug-
mentation is desired, a stacked septal graft is ideal.
Alternatively, a bruised conchal graft can be used.
For the rare cases of extreme dorsal deficiency, a
carved costal cartilage graft is preferred to prosthetic
materials. Great caution should be used in contem-
plating lateral narrowing osteotomies if the nasal
bones are short since the osteotomies may be quite
unstable and result in less dorsal projection if they
collapse into the nasal vault. Finally, after all inci-
sions have been closed, the alar base is addressed.
The diamond excision can be carried right to the junc-
ture of the nares and facial skin allowing a marked
narrowing of the nasal base without visible scars. This
maneuver can also soften nares flaring. I have not had
either hypertrophic or keloid scars form from the
nasal incisions.
17.5.1 Dressings and Postoperative
Care
No intranasal packing is used. The nose is dressed with
steri-strips and a thermoplastic dressing. Oral analge-
sics, 3 days of oral antibiotics, and a Medrol dose pack
are prescribed. Cold packs and head elevation are rec-
ommended. Showering is allowed the next day. The
columellar sutures and splint are removed in 57 days,
and normal activity, including exercise, can be resumed.
This regimen results in minimal postoperative discom-
fort and swelling. Most patients take little if any of the
prescribed narcotics and report minimal discomfort.
The patient can see an approximation of the final result
as soon as the dressings are removed. As part of the
preoperative preparation, written instructions and edu-
cation on perioperative care are given to the patient and
verbally reviewed before and after the procedure. Mild
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 263

swelling and numbness can be expected for 46 weeks.
The final result will take 912 months to see as grafts
heal and residual skin edema gradually resolves.
17.6 Revisional Surgery
Despite the surgeons best efforts, minor revisions may
be necessary. In the authors experience, a 4% revision
rate has been consistent from year to year. At least 9
and preferably 12 months is waited before considering
revisional surgery. Most of the revisions involve minor
dorsal rasping, scar revision, or alar width adjustment.
Almost all can be done in an office setting under local
with oral sedation.
obtuse cervical mental angle can benefit from HOM
(Fig. 17.21). Most often, advancement is indicated in
order to improve the profile, in conjunction with reduc-
tive rhinoplasty, but vertical reduction or lengthening
is also possible. In older patients, an additional benefit
of HOM with advancement is improvement in the neck
profile. HOM is done through an intraoral approach
using pre-bent titanium plates available in 2 mm incre-
ments. This allows fairly precise correlation to the
patients computerized imaging profile. Care is taken
to avoid the inferior alveolar nerve as it exits the men-
tal foramen and to keep the osteotomy at least 5 mm
below the cuspid roots. The mentalis muscle is reat-
tached with resorbable sutures, and supporting tape is
placed on the chin for 5 days.

17.7 Adjuvant Procedures 17.8 Conclusions

Genioplasty (Horizontal Osteotomy of the Mandible,
HOM)
HOM is often performed in conjunction with
aesthetic rhinoplasty. Most frequently, it is done to
balance facial proportions (Fig. 17.20). Patients with
retromicrogenia, vertical midface hyperplasia, or an
Aesthetic rhinoplasty can seem daunting to the young
plastic surgeon starting practice. A simple, systematic
approach to rhinoplasty will help link cause and effect
for the surgeon. The use of the external direct approach
allows immediate feedback on the operating table
improving the consistency of results.

a
a1 a2

Fig. 17.20 (a) Technique for

HOM. Note osteotomy well
below mental foramen and
tooth roots. Leaving muscles
attached to the inner cortex of
the advanced chin will tighten
the neck improving cervical
mental area in older patients.
(b) Preoperative young
woman complaining of
having a nose that is too Digastric and platysma
prominent. Note retrusive placed under stretched
chin increasing perceived after advancement
disproportion of nose.
(c) Postoperative after HOM,
5-mm straight advancement,
and reduction of nasal
dorsum. Note improvement in
overall facial proportions
264 F.D. Burstein

b c

Fig. 17.20 (continued)

a b

Fig. 17.21 (a) Preoperative

patient with retrussive long
chin and dorsal hump before
and after surgery. (b)
Postoperative after HOM
designed to move forward
7 mm and upward 3 mm,
nasal dorsum reduced
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 265

References 9. Johnson C, Toriumi D (eds) (1990) Open structure rhino-

plasty. W.B. Saunders Co, Philadelphia
10. Kamer F, Churukian M (1984) Shield graft for the nasal tip.
1. Bronz G (1999) The role of the computer imaging system in
Arch Otolaryngol 110(9):608610
modern aesthetic plastic surgery. Aesthetic Plast Surg 23(3):
11. Kamer F, Pieper P (2004) Nasal tip surgery: a 30 year
159163
experience. Facial Plast Surg Clin North Am 12(1):8192
2. Cardenas-Camarena L, Guerrero M (1999) Use of cartilagi-
12. Kawamoto H (2000) Osseous genioplasty. Aesthetic Surg J
nous autografts in nasal surgery: 8 years of experience. Plast
20:509516
Reconstr Surg 103(3):10031014
13. Ortiz-Monesterio F, Olmedo A, Oscoy L (1981) The use of
3. Correa A, Sykes J, Ries W (1999) Considerations before
cartilage grafts in primary aesthetic rhinoplasty. Plast
rhinoplasty. Otolaryngol Clin North Am 32(1):714
Reconstr Surg 67(5):597605
4. Daniel R (1992) The nasal tip: anatomy and aesthetics. Plast
14. Rees T (ed) (1980) Aesthetic plastic surgery. W.B. Saunders
Reconstr Surg 89(2):216224
Co, Philadelphia, pp 51387
5. Daniel R, Lessard M (1984) Rhinoplasty: a graded aesthetic-
15. Rohrich R, Muxaffar A, Janis J (2004) Component dorsal
anatomical approach. Ann Plast Surg 13(5):436451
hump reduction: the importance of maintaining dorsal
6. Fruscella P (1997) Cephalometric analysis and postopera-
aesthetic lines in rhinoplasty. Plast Reconstr Surg 114(5):
tive results in aesthetic rhinoplasty. Aesthetic Plast Surg
12981308
21(2):7985
16. Sheen J, Sheen A (1998) Aesthetic rhinoplasty, 2nd edn.
7. Greer S, Matarasso A, Wallach SG, Simon G, Longaker MT
C.V. Mosby Co, St Louis
(2001) Importance of the nasal-to-cervical relationship to
17. Williams EF 3rd, Lam SM (2002) A systematic, graduated
the profile in rhinoplasty surgery. Plast Reconstr Surg
approach to rhinoplasty. Facial Plast Surg 18(4):215222
108(2):522531
8. Guyuron B (1988) Precision rhinoplasty. Part I: the role of
life size photographs and soft tissue cephalometric analysis.
Plast Reconstr Surg 81(4):489499
 Otoplasty
Cristina Isac, Aurelia Isac, Tiberiu I. Bratu,
and Nicolae Antohi
18.1 Introduction
Prominent ears are a relatively common congenital
deformity with an incidence in Caucasians of 5%. Two
thirds of the patients have a positive family history,
inherited as an autosomal dominant trait. In most of
the cases, they are diagnosed at birth and there is no
sex predilection [1]. Prominent ears represent a source
of great distress psychologically and emotionally and
may induce serious behavioral problems in children. A
well-performed otoplasty results in a truly gratifying
patient.
C. Isac (*)
Department of Plastic Surgery, University Hospital for Plastic
Surgery and Burns, University of Medicine and Pharmacy
Carol Davila, Bucharest, Romania
e-mail: ina@drisac.ro
A. Isac
Department of Plastic Surgery, University Hospital for Plastic
Surgery and Burns, Bucharest, Romania
e-mail: ireliflorin@yahoo.com
T.I. Bratu
Brol Medical Center Private Clinic, Timisoara, Romania
Department of Plastic and Reconstructive Surgery, University
of Medicine and Pharmacy Victor Babes, Timisoara, Romania
e-mail: office@brol.ro
N. Antohi
University Hospital for Plastic Surgery and Burns,
Bucharest, Romania
University of Medicine and Pharmacy Carol Davila,
Bucharest, Romania
e-mail: nantohi@yahoo.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_18, Springer-Verlag Berlin Heidelberg 2013
18
18.2 History
Dieffenbach (1845) [2] was the first who excised the
postauricular skin and used a conchomastoidal fixation.
In 1881, Ely [3] added a conchal strip excision. Luckett
(1910) [4] introduced the concept of antihelical fold
restoration; his technique consisted in skin and cartilage
excision along the antihelical fold followed by horizontal
mattress sutures [14]. Attempts of softening the contour
of the antihelix were made afterwards by Becker (1952)
[5] and Converse et al. (1955) [6]. Mustard (1963)
[7] introduced the concept of conchoscaphal perma-
nent mattress sutures for creation of a smooth, natural-
looking antihelical fold.
Gibson and Davis [8] showed in 1958 that the carti-
lage has a very important ability it warps away from
the injured surface. This led to different techniques of
creating the antihelical fold by scoring sharply with the
scalpel its anterior surface (Chongchets technique, 1963
[9]) or with a rasp (Stenstroems technique, 1963 [10]).
Conchal reduction has been performed by excision or
using conchomastoidal sutures, a technique introduced
by Furnas (1968) [11] and modified by Spira [12] by
using a posterior flap of cartilage, based laterally adja-
cent to the antihelix, that is elevated and sutured to the
mastoid process. The maneuver serves to bring the con-
cha closer to the scalp and thus reduces the protrusion.
Approximately 200 techniques have been described
over the years, which include bending, suturing, excis-
ing, scoring, and repositioning the auricular cartilage
through posterior or even anterior approaches [13]. This
demonstrates that no one technique is ideally used single
for correction of the prominent ear. Most of the favorable
results are achieved using a combination of techniques.
267
268
a b
fossa triangularis
cymba conchae
radix helicis
cavum conchae
tragus
incisura intertragica
lobule
Fig. 18.1 (a) Anatomy of a normal ear (anterior surface). (b) Anatomy of a normal ear (posterior surface)
18.3 Anatomy of the Normal Ear
In order to obtain maximal aesthetic outcomes, it is
absolutely imperative for the surgeon to thoroughly
understand the unique anatomical features of such a
complex and varied structure, such as the ear.
The ear is composed of cartilage and skin with its
subcutaneous tissue. The cartilage has many convolu-
tions and folds, and it is more malleable and soft in the
younger person.
By 3 years of age, the ear reaches approximately
85% of its maximal dimensions. Ear width reaches its
mature size at around 7 years, and ear length matures
at around 13 years [14]. In all, it is appreciated that the
ear is fully developed by 7 years, so that by this time,
it is the appropriate timing for correction.
Figure 18.1 shows the normal surface anatomy of
the ear. The arterial supply of the ear comes from the
posterior auricular, superficial temporal, and occipital
arteries (Fig. 18.2).
C. Isac et al.
superior crus
scaphoid fossa
helix
inferior crus
antihelix
antitragus
helical tail
The veins drain into the posterior auricular, superfi-
cial temporal, and retromandibular veins. The innerva-
tion of the external ear is provided by the greater
auricular nerve (C2C3), the auriculotemporal nerve
(V3), the lesser occipital nerve, and the auricular branch
of the vagus (Fig. 18.3) [16].
The superior margin of the ear corresponds to the
level of the brows, and the inferior margin corre-
sponds to the columella. The length of a normal adult
ear is 5.56.5 cm, and the width measures 5060%
of its length (3.5 cm) [17]. The auriculo-cephalic
angle reaches 2530 in men and 21 in women [17].
The scapho-conchal angle usually measures 90 or
less.
The helix projects laterally from the scalp
1012 mm at the superior pole, 1618 mm at the
midpoint, and 2022 mm at the lobule. This corre-
sponds to a conchal bowl depth of 15 mm. The helix
should project 25 mm beyond the antihelix on frontal
view [14].
18 Otoplasty 269

Fig. 18.2 Arterial supply of the ear

Superficial temporal artery

Posterior auricular artery

Auriculotemporal n.

Lesser
occipital n.

Vagus n.

Great auricular n.
Fig. 18.3 Nerve supply of the ear
270
a b
Fig. 18.4 (a) Absence of antihelical fold. (b) Deep concha
18.4 Anatomy of the Prominent Ear
The anatomical features describing prominent ears
may be summarized as follows:
1. Absence of an adequate entire antihelix or a part of
it root, superior, or inferior crus; as a result, the
conchoscaphal angle is greater than 90 up to as
much as 150 or more; as a consequence, the scapha
is flattened, the cephalo-auricular angle is widened,
and the upper pole is rotated externally.
2. A large and deep concha.
3. Inadequate helical rim (insufficient helical curling)
with or without anterolateral displacement of the
tail of the helix or protrusion of the helical root.
4. Excessive antitragal protrusion.
5. Abnormal, overprojected lobule.
The prominent ear features are usually combined,
although there may be cases in which only one of the
deformities is present. They may also coexist with
macrotia. Usually, both ears are affected but not always
both of them have the same underlying abnormalities.
Any surgical procedure should address the underlying
anatomical defect and attempt to correct it. A single
one approach or technique is obviously not appropriate
for all clinical cases.
Figure 18.4 shows an example of prominent ear that
result from two typical features: underdevelopment of
C. Isac et al.
antihelical fold with obtuse scapho-conchal angle and
increased depth of conchal bowl and auriculo-cephalic
angle.
18.5 Goals of Otoplasty
The main goal of otoplasty is to achieve a permanent
correction with natural-looking ears that do not appear
to have been operated on [1]. The goals can be sum-
marized as follows:
1. Creation of a smooth, rounded, well-defined antihe-
lix, with the helix seen beyond the antihelix on the
front view
2. Conchal reduction
3. Conchomastoidal angle of 25 or less
4. Conchoscaphal angle of 90 or less
5. Symmetrical ears within 3 mm of variation from the
contralateral ear
Nonsurgical intervention is successful only if
applied within the first 3 days of birth with surgical
tape [18]. An appropriate timing for the operation
would be around 5 years old, before the child goes to
school but when he is old enough to cooperate with the
postoperative regimen, although intervention at
younger ages doesnt affect in any way the growth of
the ear [19].
18 Otoplasty
Fig. 18.5 Skin incision made for both Mustard and Furnas
sutures placement
18.6 Surgical Procedures
Most of the techniques used focus on the creation of a
natural antihelix, conchal setback, or a combination of
them. The authors describe in the following section
their most often used technique and continue by dis-
cussing other techniques published in literature. The
preferred authors technique has been originally
described by Chongchet [9], modified by Tolhurst [20]
and others (Colpaert-[21], Fatih Peker-[22]).
The incisions made on the posterior surface of
the ear vary, depending on the goals of the procedure.
If Mustard sutures are planned, the skin incision is
placed in the center of the posterior surface; if Furnas
sutures are taken into consideration, the skin incision
is designed closer to the mastoid area (Fig. 18.5).
Hemostasis is achieved with bipolar cautery always
(monopolar cautery damages the cartilage at the slight-
est contact [23]).
18.6.1 Authors Preferred Technique
The operation is generally performed under general
anesthesia in patients younger than 810 years of age
or local anesthesia in adults. Appropriate full facial
and hair preparation is carried out, and moist cotton
pledgets are inserted in the ear canals.
The anterior and posterior subcutaneous surfaces are
infiltrated with 1% Xylocaine and epinephrine 1:100,000
with a 30-gauge needle. Bilateral great auricular nerve
blocks with 0.25% bupivacaine may be performed for
postoperative analgesia.
271
The desired antihelical fold is determined by gentle
digital pressure on the helix and marked accordingly
(Fig. 18.6).
A row of ink marks is made on the anterior skin with
a 25-gauge needle (with or without methylene blue); the
marks run superiorly to the supposed superior crus site,
then along the length of the helix till its tail (Fig. 18.7).
The posterior row of marks is thus made simultaneously,
corresponding exactly to the anterior ones (Fig. 18.8).
The goal is to maintain intact the helical shape.
A posterior cutaneous incision is made, extending
from the upper corner of the fossa triangularis to the
antitragus. The lateral extent of the skin excision is
made 12 mm medial to the posterior row of marks.
An ellipse of skin of about 1-cm width is excised
(Fig. 18.9) depending on how much the ear needs to be
reduced in width.
The skin is undermined for a distance of about
3 mm toward the helical rim as well as on the poste-
rior surface of the concha for about 2 cm with small,
curved, blunt-tipped scissors. The medial dissection
can reach the postauricular sulcus, even the mastoid
periosteum if Furnas sutures are planned. The dis-
section is performed in the supraperichondrial plane.
Preserving the perichondrium intact on the surface
of the cartilage avoids sutures pulling through it. The
cartilage is incised immediately beyond the upper
part of the incision, leaving a strip of helix intact
(Fig. 18.10).
The incision in the cartilage extends parallel to the heli-
cal rim from beyond the superior crus to the tail of the
helix, following the contour of the helical fold. The helical
tail is left in place if not displaced. If it is rotated, we make
a full-thickness cut which through the helical tail , which
allows a better folding back of the cartilage; if the helical
tail is enlarged, we excise part of it. The anterior surface of
the cartilage and perichondrium is then dissected free from
the skin on a sufficient surface (Fig. 18.11).
The dissected cartilage is then folded posteriorly so
that an antihelical fold is created with the superior crus
(Fig. 18.12).
The shape of the new antihelix is checked, and, if
appropriate, the anterior surface may be scored or be
abraded (using for example a Brown-Adson forceps).
The scoring is accomplished using a no. 15 blade,
taking care to make only partial-thickness cartilage
incisions on the anterior surface of the scapha and
concha.
Scoring the anterior surface of the cartilage will
allow the upper portion to fold back. In this manner,
272 C. Isac et al.

a b

Fig. 18.6 (a) Gentle digital pressure on the upper pole of the ear determines the formation of the antihelical fold. (b) Superior crus
of the antihelical fold marked

Fig. 18.7 Anterior row of marks corresponding to the supposed Fig. 18.9 Posterior skin excision
superior crus site

Fig. 18.8 Posterior row of marks Fig. 18.10 Cartilage incision

18 Otoplasty
a a
b
Fig. 18.11 (a) Anterior cartilage dissection. (b) The anterior
and posterior surface of the conchal and scaphal cartilage are
dissected free
the antihelical fold is formed and simultaneously the
concha is diminished. The folded cartilage, forming a
tube, is sutured on itself with three 4-0 clear nylon
mattress sutures (Fig. 18.13).
A similar technique for creating the antihelical fold
is used by Laberge [24] (who does not suture the folded
cartilage) and Nordzell [25] (who abrades the anterior
surface and sutures the medial edge of the incised car-
tilage to the lateral one, overlapping them). Davis [15]
folds the cartilage in a similar manner but through an
anterior approach; he scores the anterior surface with-
out using any sutures. We believe that suturing the car-
tilage prevents a recurrence of the deformity. If the
concha is still large, a wedge resection of the concha
may be performed.
The posterior incision is sutured with 5-0 running
suture after careful hemostasis. A dressing consisting
of strips of cotton moistened in mineral oil or alcohol
is used for packing the various depressions of the ear
273
b
Fig. 18.12 (a) Partial-thickness cartilage scoring on the ante-
rior surface. (b) Cartilage folded on itself
(Fig. 18.14). Fluff dressings are placed in front of the
ear, and some gauzes are also placed behind the ear.
A moderately compressive dressing and an elastic
strap are applied.
18.6.2 Creation of the Antihelix
The antihelical fold can be created using horizontal
scapho-conchal Mustard sutures [7] three to four 4-0
clear braided nylon sutures on a half-circle, round, non-
cutting needle, including the anterior perichondrium,
taking care not to include the anterior auricular skin (a
method to avoid this complication is hydrodissection,
proposed by Brent [26] infiltration of the anterior
auricular skin with saline solution prior to placement of
the suture). To mark the location of the Mustard
sutures, many surgeons use a hypodermic needle
charged with methylene blue drawn back from the ante-
rior to the posterior surface of the auricle. Pearl [27]
274 C. Isac et al.

Fig. 18.14 Dressing the postoperative ear strips of cotton

packing various depressions of the ear

Fig. 18.13 (a) The folded cartilage is sutured on itself with 4-0
clear, nonabsorbable mattress sutures. (b) Final view of the car-
tilage folded, sutured, and scored

proposed another method of marking the placement of

Mustard sutures: he uses 5-0 black nylon sutures
placed in full thickness through the cartilage so that
they are easily visible on the posterior surface at the
desired location of the antihelical fold.
The most upper suture is placed between upper
scapha and fossa triangularis to create the superior
crus. The suture is not tightened, but is put on a hemo-
stat (Fig. 18.15).
The next horizontal mattress suture is placed Fig. 18.15 Mustard scapho-conchal sutures
between scapha and lateral concha. All of the 3-4
sutures are left long and then lightly tightened to see if
the desired shape of the antihelical fold is achieved. In addition to placement of the Mustard sutures, it
The lowermost Mustard suture is often placed from is frequently necessary to score the anterior surface of
the cauda helicis to the concha [23]. The bowstringing the cartilage in order to increase its pliability. The scor-
resulting from tying the knots will be subsequently ing can be done by various methods with the blade,
filled with fibrous tissue [28]. with an Adson-Brown forceps, with an otobrader. The
18 Otoplasty
a b
Mastoid
fascia
Conchal
cartilage
Origin of
sternocleidomastoid
muscle
Fig. 18.16 (a) Furnas sutures (concha-mastoid sutures) (From Furnas [23]). (b) Sutures Mustard and Furnas in place
scoring should be done deep enough to determine carti-
lage folding away from the cuts but, in the same time,
not as a full-thickness penetration which results in a
sharp, undesirable antihelical edge which would be a
telltale sign of the operation. Stenstroem introduced the
technique using the otobrader that nowadays has his
name [10]. The scoring is performed by inserting the
instrument via a small tunnel which begins from a
slot found on the edge of the cartilage next to the tail
of the helix. The device reaches the anterior surface of
the cartilage, and the scoring is performed on this sur-
face exactly at the level where the antihelical fold is
desired to be formed. Gibson and Davis [15] demon-
strated that the cartilage warps away from the surface
being scored.
For upper pole overprojection, the helical root can
be attached to the temporalis fascia through a longitudi-
nal 5-mm incision at the base of the helix. A horizontal
mattress suture is used to decrease the helical-temporal
angle and decrease the upper pole projection. Webster
indicates a slight overcorrection of the upper pole to
allow for postoperative changes.
18.6.3 Conchal Correction
The conchal deformity should be addressed first, so as
to minimize the need for excessive Mustard sutures
tightening [17].
275
The conchal hypertrophy can be treated using one
of the following procedures:
1. Placing the antihelical fold more medially on the
concha (either by cartilage folding or by sutures)
will reduce the height of the concha.
2. Concha-mastoid sutures (Furnas sutures) [11] placed
medial to Mustard sutures; the technique is adwe-
quate for conchal depth less than 2.5 cm and should
be tried before conchal resection techniques. The
posterior surface of the concha is adequately exposed
through a posterior skin incision over the concha.
The anterior and posterior skin flaps are elevated.
The posterior auricular muscle and ligament are
excised, and the mastoid fascia is exposed over
2 cm. The concha setback is achieved through four
4-0 clear nylon mattress sutures placed in an ante-
rior-to-posterior direction in order to avoid external
auditory canal stenosis. The bites should hold the
fascia strong enough and should contain the carti-
lage together with anterior and posterior perichon-
drium. Care should be taken to avoid taking in the
bites on the anterior auricular skin. Tension is
adjusted to hold the conchal bowl back. Tying of the
sutures will bring the concha closer to the mastoid,
reducing the overall projection of the ear
(Fig. 18.16).
Spira and Stal use a laterally based conchal car-
tilage flap sutured to the mastoid periosteum which
brings the concha closer to the scalp. The flap offers
276
a robust anchorage to the periosteum with a
decreased tendency to obstruct the external audi-
tory canal [12].
In case of a too deep a concha, using only Furnas
sutures could make the tragus too proeminent. In
this case conchal excision is also indicated.
3. Wedge excision of the concha (technique appro-
priate for conchal depth more than 2.5 cm); the
excessive conchal cartilage is excised as an ellipse
through a posterior approach, and the remaining
Fig. 18.17 (a) Elliptical conchal excision. (b) Concha excised. (c) Anterior aspect of the ear immediately after conchal excision
C. Isac et al.
cartilaginous parts are approximated; the concha
may be excised with skin through an anterior
approach, as, in some authors opinion, the excess
skin left after cartilage excision may not shrink
down enough. There has been no proven advantage
of an anterior versus a posterior approach [14]. If
the antitragus is prominent, the resection comprises
the lower conchal bowel and the ponticulus may
also be thinned [14]. Bauer underlined the impor-
tance of conchal resection in the prominent ear
18 Otoplasty
Fig. 18.17 (continued)
correction where more cartilage than skin is excised
[29]. The author states that hypertrophy of the con-
cha is a common denominator of prominent ears,
and it is most frequently underappreciated and
under-addressed. With even limited resection and
resuturing of the cut concha, the antihelix yields to
the posterior placement of sutures. The scar on the
anterior surface is hardly visible if done correctly,
just inside the antihelical rim. The shape of the
cartilage resected is crescent, and the edges are
approximated with 5-0 clear nylon sutures. Conchal
resection is a very versatile method and provides a
proven, reproducible, and effective way for correct-
ing virtually all prominent ears [29, 30]. Even a
limited amount of conchal resection results in less-
ened spring and increased ease of shaping the anti-
helix (Fig. 18.17) [31].
4. Scoring the anterior surface of the concha to deter-
mine it to warp posteriorly (according to Gibsons
principle). Scoring of the entire anterior surface of
the concha reduces the tension on the subsequently
placed mattress sutures [32].
277
Fig. 18.18 Fishtail excision of the skin on the posterior side of
lobule
18.6.4 Correction of the Protruding Lobule
Some consider lobule protrusion to be due to an excess
of skin; others consider the cause as being a prominent
tail of the helix. A prominent lobule is a frequent fea-
ture encountered with prominent ears. Placement of
Mustard sutures often exacerbates this finding.
There are several techniques for setback of the pro-
truding lobule that usually utilize a combination of skin
resection and plicating sutures [16]. A wedge of carti-
lage may be excised in the inferior part of the concha,
which will allow both the lobule and the antitragus to
rotate toward the mastoid. If the lobule is still promi-
nent, a plicating suture is applied between the helical tail
and the concha cavum (ponticulus). Having the helical
tail moved in several positions allows the surgeon to
observe the effect it has on the lobule. The appropriate
position can be found and the helical tail anchored to the
concha. A vertical excision (ellipse or fishtail/dumbbell)
of the skin on the posterior side of the lobule positioned
with its maximal width at the point of maximal lobule
prominence (Fig. 18.18) will complete the procedure.
A procedure described by Gosain [18] is to make an
incision on the posterior part of the lobule, extending
278
Fig. 18.19 Immediate postoperative appearance
perpendicularly from the postauricular one. A suture
is passed from the endpoint of the incision to the
mastoid fascia and mastoid skin. Tightening the knot
will set back the lobule. Spira [28] uses a wedge exci-
sion followed by a deep dermis-to-scalp periosteum
suture.
18.7 Postoperative
Most of the patients develop significant ecchymosis
after this procedure (Fig. 18.19).
Patients are asked to take an oral antibiotic (usually
a first-generation cephalosporin) for 5 days. Dressing
gauzes may be impregnated with heparin gel 1000 IU
on the anterior surface [32] (reduces the risk of postop-
erative hematoma) and Betadine cream on the poste-
rior surface of the ear. The patient is usually discharged
on the day of surgery and is seen after 24 h to check for
hematomas or excessively tight dressing. Sutures are
removed at 10 days postoperative. Hair may be washed
after 67 days.
C. Isac et al.
The patient is asked to wear a light elastic headband
for at least 3 weeks; the patient is also told not to par-
ticipate in contact sports for 1 month.
18.8 Results
A few of the patients treated with various methods are
shown in the Figs. 18.2018.25.
18.9 Complications
18.9.1 Early Complications
Hematoma is secondary to incomplete hemostasis dur-
ing surgery. If encountered, sutures should be removed
and the blood collection drained as soon as possible to
prevent subsequent infection or even skin necrosis.
Infection occurs in case of improper sterile surgical
technique, as a consequence of a late hematoma, or
in case of dehiscence secondary to excessive tension
during closure [14]. Infections are rare, as blood sup-
ply to the ear is rich; however, when they are encoun-
tered especially when periosteum is disrupted during
abrasion, they should be promptly treated with intrave-
nous antibiotics. Chondritis, a consequence of infec-
tion, is a surgical emergency and can lead to serious
deformities of the ear if left untreated with immediate
debridement of devitalized tissues.
Skin loss (necrosis) appears as a consequence of an
untreated hematoma or of dressings applied exceed-
ingly tight, obstructing the venous circulation. How-
ever, the skin of the ear can be widely undermined
due to the rich blood supply, especially the subdermal
circulation.
18.9.2 Late Complications
Abnormal scar formation, either hypertrophic or
keloid, is controlled with serial intralesional steroid
injections.
Recurrence of the deformity is caused by failure of
the suture (either break or fatigue the knot loosens
and unties), insufficient breaking of the cartilage
sprung by scoring, or insufficient number of sutures. It
requires reoperation with replacement of the sutures to
correct it not earlier than 6 months.
18 Otoplasty 279

Fig. 18.20 (a) Preoperative eleven-year-old boy with a lack of protruding lobule, a plicating suture together with excision of the
antihelical fold definition, conchal bowl hypertrophy, and promi- helical tail and dumbbell skin excision was applied (photos: b1, b2)
nent lobules. (photos: a1, a2) (b) One month postoperative after (c) Pre- and post-operative lateral view with antehelix reconstruction
cartilage folding was used for the antihelix and concha. For the (photos: a3, b3)
280
Fig. 18.20 (continued)
Residual deformity may consist in any one of the
following aspects: irregular contour of the antihelix
with sharply ridged appearance (corrected by curet-
tage, camouflage with temporalis fascia, or an anteri-
orly based conchal cartilage flap swiss-rolled into the
posterior surface of the released antihelical fold, as
described by Widgerow [33]), lack of the normal curve
of the superior crus, residual large scapha or concha,
narrow external auditory canal.
Telephone ear deformity is caused by excessive
setback of the middle third of the helical rim and
aggressive resection of the concha combined with
undercorrection of the antihelical rim in the upper-
most pole of the helix and incomplete correction of
the lobule position. Correction requires reoperation
and appropriate antihelical fold and lobule
positioning.
Postsurgical appearance consists of a too verti-
cally oriented antihelical fold instead of a gentle ante-
rior curve due to incorrect placement of Mustard
sutures [34]. Irregularities of helical contour exces-
sively set back (overcorrection) may also lead to a
postsurgical appearance.
Reverse telephone ear deformity occurs when the
upper and lower thirds of the ear are set back correctly,
but the antihelix and especially the concha protrude.
The cause is failure to recognize and address the
enlarged concha during the procedure.
C. Isac et al.
Narrowing of the external auditory canal [34] occurs
when the concha is set back too far posteriorly due to
incorrect placement of concha-mastoid sutures.
Complications with Mustard sutures: kinking within
the antihelix, sutures cutting out, suture extrusion, sinus
formation [14], and projection of the lobule. Suture
extrusion may be prevented by a postauricular fascial
flap as described by Horlock [35].
Obliterated postauricular sulcus due to excessive
skin resection can be corrected with a zigzag incision,
approximation of the skin triangles points, and filling
the remaining points with skin grafts [14].
18.10 Conclusions
Prominent ears are relatively frequent with high aes-
thetic and psychological impact on the patient.
One of the most important steps in otoplasty is
the correct analysis of each ear deformity. Generally,
techniques that employ cartilage scoring or abrasion
should be used cautiously and only superficial, as they
all run the risk of cartilage weakening and visible
irregularities. Another important caveat is to preserve
the perichondrium on both the anterior and posterior
surfaces, as it lessens the risk of sutures pulling
through the cartilage and a subsequent recurrence of
the deformity.
18 Otoplasty 281

Fig. 18.21 (a) Preoperative 13-year-old boy with a lack of anti- nique (photos: b1, b2) (c) Pre- and post-operative lateral view
helical fold and large, deep concha. (photos: a1, a2) (b) Six with antehelix reconstruction (photos: a3, b3)
months postoperative after the antihelix was created and the con-
cha reduced with cartilage folding, scoring, and suturing tech-
282 C. Isac et al.

Fig. 18.21 (continued)

Fig. 18.22 (a) Preoperative 6-year-old boy with unilateral pro- the concha reduced with cartilage folding, scoring, and suturing
eminent ear and lack of antehelical fold and deep concha. technique (c) Pre- and post-operative lateral view
(b) Two weeks postoperative after the antihelix was created and
18 Otoplasty 283

Fig. 18.22 (continued)

284 C. Isac et al.

Fig. 18.23 (a) Preoperative 28-year-old girl with unilateral proeminent ear and lack of antehelical fold. (b) One month postoperative
after the antihelix was created using Mustard and Furnas sutures. (c) Pre- and post-operative lateral view
18 Otoplasty 285

Fig. 18.23 (continued)

Fig. 18.24 (a) Preoperative 28-year-old man with prominent ears. (b) One month following Mustard and Furnas sutures and
conchal excision
286 C. Isac et al.

Fig. 18.24 (continued)

Fig. 18.25 (a) Pa. Preoperative six-year-old boy with proeminent ears and lack of antehelical fold and deep concha. (b) Two
weeks post-operative after the antihelix was created and the concha reduced with cartilage folding, scoring, and suturing technique
18 Otoplasty
Fig. 18.25 (continued)
With the technique presented, the authors have seen
no changes in the position of the ear in the long-term
follow-up. The procedure allows the creation of the anti-
helix and simultaneously reduction of the concha with
immediate evaluation: The method has a short learning
curve, is quick and safe, offering good long-lasting
results and a low recurrence rate. Various techniques
described in the literature are also presented. Most often,
a combination of all these needs to be used.
Patients are generally happy and satisfied if the ears
are symmetrically set back to within 11.5 cm of the
scalp [28]. The operation can be very successful but
can also be a source of distress if not carried out with
close attention to all details. Accurate preoperative
diagnosis and planning and careful execution of the
technique are critical to obtaining a good, long-lasting,
satisfying result.
References
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Brockhaus, Liepzig
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3. Ely ET (1881) An operation for prominence of the auricles.
Arch Otolaryngol 10:9799
4. Luckett WH (1910) A new operation for prominent ears
based on the anatomy of the deformity. Surg Gynecol Obst
10:635637
5. Becker OJ (1952) Correction of the protruding deformed
ear. Br J Plast Surg 5(3):187196
6. Converse JM, Nigro A, Wilson FA, Johnson N (1955)
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Surg 15(5):411418
7. Mustard JC (1963) The correction of prominent ears using
simple mattress sutures. Br J Plast Surg 16:170178
8. Gibson T, Davis WB (1958) The distortion of autogenous
cartilage grafts: its cause and prevention. Br J Plast Surg
10:257274
9. Chongchet V (1963) A method of antihelix reconstruction.
Br J Plast Surg 16:268272
10. Stenstroem SJ (1963) A natural technique for correction
of congenitally prominent ears. Plast Reconstr Surg 32:
509518
11. Furnas DW (1968) Correction of prominent ears by conchal
mastoid sutures. Plast Reconstr Surg 42(3):189193
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plasty. Ann Plast Surg 11(4):291298
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Reconstr Surg 115(4):60e172e
15. Davis J (1987) Aesthetic and reconstructive otoplasty. New
York, Springer
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(2000) Otoplasty- anterior scoring technique and results in
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108(6):14871490
 Brow Lift
19
Shoib Allan Myint

19.1 Introduction

In the past 20 years, brow lifting has taken an evolu-

tionary course from the original coronal procedure to
the newly endoscopic approach. There have been many
debates as to which type is the best procedure. One
thing for certain is there is no foolproof method for
brow lifting. Each surgeon must determine what pro-
cedure works in their hands with predictable and con-
sistent results depending on the patient and their
expectations. The positioning of the eyebrow is crucial
for maintaining periorbital symmetry that is aestheti-
cally pleasing to the human eye. There have been for-
mulas described for positioning the ideal brow based
on bony and soft tissue anatomy. This position varies
from patient to patient depending on their unique facial
feature. The positioning is affected by many factors
such as brow elevator and depressor muscles, genetics,
gravity, skin laxity, surgery, trauma, and the patients
expressivity. All or some of these factors result in brow
ptosis. Although each eyebrow has its own shape, posi-
tion, and contour, in general, the female eyebrow Fig. 19.1 Female eyebrow position
should lie approximately at or above the superior orbital
rim with the tail higher than the head (Fig. 19.1).
The male eyebrow should be at the level of the supe- 19.2 Anatomy
rior orbital rim with a less curved configuration
(Fig. 19.2). This chapter will discuss the three most When planning brow surgery, the imbalance between
common brow lifting techniques: endoscopic, direct, the elevators (frontalis muscle) and the depressors
and trichophytic. (orbicularis oculi, depressor supercilii, corrugators,
procerus) must be addressed (Fig. 19.3). The frontalis
muscle originates at the skin and superficial fascia of
S.A. Myint the orbicularis muscle. It inserts into the galea aponeu-
Department of Ophthalmic Plastic and Reconstructive Surgery,
rotica. The main function of the frontalis muscle is to
Valley Hospital, University Medical Center,
Las Vegas, NV, USA elevate the eyebrows, and it is responsible for the trans-
e-mail: shoibmyint@gmail.com verse rhytids in the forehead. The corrugator muscle

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 289

DOI 10.1007/978-3-642-21837-8_19, Springer-Verlag Berlin Heidelberg 2013
290
Fig. 19.2 Male eyebrow position
Fig. 19.3 (1) Frontalis. (2) Orbicularis. (3) Depressor super-
cilii. (4) Procerus. (5) Corrugator
originates at the medial orbital rim and inserts into the
frontalis muscle and the skin of the eyebrow. It primar-
ily elevates the head of the brow, with descent of the
tail. It is responsible for the glabellar frown lines. The
orbicularis oculi muscles originate at the medial orbital
rim and the medial canthal tendon and inserts at the
medial aspect of the bony orbit. It depresses the total
brow and is responsible for vertical rhytids. The
depressor supercilii muscle also originates at the
medial orbital rim and medial canthal tendon and it
inserts on the medial aspect of the bony orbit. It is
responsible for depressing the head of the brow. The
procerus muscle originates at the nasal bone fascia
and upper cartilages. It inserts onto the skin at the
S.A. Myint
Fig. 19.4 (a) Preoperative. (b) Following endoscopic brow lift
medial lower forehead. Like the depressor supercilii,
the procerus depresses the head of the brow. It is
responsible for the horizontal rhytids at the radix of
the nose. These muscles are critical in understanding
eyebrow anatomy and its function. If the depressor
muscles are not addressed in an appropriate fashion,
results may be suboptimal in procedures such as the
endoscopic approach. Botox can also be administered
to these depressor muscles 2 weeks prior to surgery.
19.3 Endoscopic Brow Lift
The goal of endoscopic brow surgery is to elevate the
eyebrow, decrease forehead rhytids, decrease vertical
glabellar rhytids, improve lateral canthal hooding, and
decrease infrabrow skin (Fig. 19.4). Every surgeon will
need to accomplish some or all of these goals depend-
ing on the patient. Give the patient a mirror and discuss
realistic expectations. Remember that skin hanging
over the eyelid margin in the lateral periorbital area
(Connells sign) is a hallmark of forehead ptosis and
will need a brow lift, not blepharoplasty. Also take into
account the fact that women tend to pluck and shape
their brow area to give the illusion that it is higher.
Do not let this fool you. Two useful preoperative quan-
titative measurements are the glide test and the frame
height. The glide test measures brow excursion in
the medial, central, and lateral portions of the eyebrow.
19 Brow Lift 291

Fig. 19.5 Planes Deep subgaleal release

of dissection Subperiosteal release

Deep galeal fat

Arcus marginalis

Orbital fat

Orbital septum

Fig. 19.6 Temporal crescent

and extent of dissection

Central
Pocket

Temporal
Line

Temporal
Pocket

Temporal
Port

Extent of
Dissection

The frame height measures the distance from mid pupil
to the top of the brow. The best results of an endo-
scopic brow lift typically occur with frame heights of
1.52.0 cm and glide test of 2.03.0 cm. Most surgeons
will lift the eyebrow approximately 1.02.0 cm. There
are two planes of dissection, subperiosteal and subgal-
eal (Fig. 19.5). The subperiosteal approach results in
less blood loss, doesnt move the hair line down, and is
the preferred choice for most surgeons.
19.3.1 Marking
Marking is critical when planning for this surgery.
There is a temporal crescent (temporal line, conjoint
tendon), which separates the temporal pocket from the
frontal pocket (Fig. 19.6). This crescent is the fusion
of the galea aponeurotica. It can be palpated along
the lateral portion of the superior orbital rim and it
extends superolaterally. It is more pronounced when
292
Fig. 19.7 Incision: two paramedian, two lateral, and two
temporal
2.0 2.0 2.0
Fig. 19.8 Facial nerve
the patient clenches the jaw. This temporal line must
be released to connect the frontal and temporal pock-
ets. The temporal branch of the facial nerve runs along
the temporal pocket which makes this the most critical
area of dissection. The incision areas are marked as
follows: either one central, two paramedian, and two
temporal, or two paracentral, two lateral, and two
S.A. Myint
temporal (Fig. 19.7). The amount and placement of
these incisions will depend on the surgeons learning
curve in using the endoscope. For a beginning sur-
geon, the two paracentral, two lateral, and two tempo-
ral incisions might be an easier approach. The central
incisions are marked at or 1 cm behind the hairline
extending 1.01.5 cm in length. The paramedian
incisions are marked approximately 4 cm lateral to
prevent injury to the superficial branches of the
supraorbital nerve, which supply sensation in that
region. This incision is parallel to the tail of the brow
in women (typically at the lateral limbus). It can be
moved slightly medially in men to prevent a high arch.
The temporal markings are done 2.5 cm posterior to
the hairline extending 23 cm in length. The midline
of this incision is perpendicular to a line drawn from
the nasal ala to the lateral canthal angle. In the pres-
ence of male pattern baldness, these incisions can be
made behind the fringe line. The trajectory course of
the temporal branch of the facial nerve is outlined to
avoid contact (Fig.19.8). This nerve courses from the
lower portion of the tragus to 1.5 cm above the tempo-
ral brow. It originates deep near the parotid gland and
crosses over the periosteum of the zygoma. The nerve
then becomes more superficial and runs on the deep
surface of the temporal parietal fascia before entering
the undersurface of the frontalis muscle (Fig. 19.9).
The supraorbital nerve is marked approximately
2.4 cm from midline and the supratrochlear nerves
about 1.6 cm from midline (Fig. 19.10). An arch
extending 23 cm above the orbital rim is marked to
prevent injury to the superficial branches of the
supraorbital nerve. The supraorbital nerve can emerge
1 cm above the orbital rim in 40% of patients. This is
the safety zone for blunt dissection.
19.3.2 Anesthesia
Local infiltration of a mixture of 2% lidocaine
with 1:100,000 epinephrine and 0.5% Marcaine with
1:200,000 epinephrine is used for the forehead
and temporal areas. Generally, monitored intrave-
nous (IV) sedation is given. Local blocks can also be
performed in the region of the supraorbital, supra-
trochlear, lacrimal branch of the trigeminal nerve,
zygomaticotemporal and zygomaticofacial nerve
branches if desired. The arcus marginalis along the
19 Brow Lift 293

Fig. 19.9 Facial nerve (fn). Temporal branch (tb). Superficial temporal fat pad (stfp). Deep temporal fascia (dtf). Superficial tem-
poral fascia (stf). Superficial temporal artery (sta). Zygomatic arch (za)

superior orbital rim across the entire eyebrow is also

infiltrated.

19.3.3 Incisions

The central and paramedian incisions are made down to

Fig. 19.10 Supraorbital and supratrochlear nerves bundles
the periosteum. The temporal incisions are made down
to the superficial layer of the deep temporal fascia. This
is a shiny white layer, which does not move. The tem-
poral branch of the facial nerve runs superficial to this
layer under the superficial temporal fascia. It is very
important to stay along the superficial layer of the deep
temporalis fascia to avoid damage to this nerve.
294 S.A. Myint

19.3.4 Dissection

The temporal and frontal pockets are then connected

through the temporal crescent by detaching the crescent,
which is the fusion of the galea aponeurotica (Fig. 19.11).
Blunt dissection in the frontal pocket is continued to
2 cm above the supraorbital rim (Fig. 19.12). Endoscopic
dissection can then be continued towards the arcus mar-
ginalis from lateral canthus to lateral canthus. The
periosteum should be completely released here for ade-
quate elevation. The success of this procedure is depends
on complete release of the periosteum at the arcus mar-
ginalis along the entire brow. If needed, the corrugators,
depressor supercilii, and orbicularis muscles can be
addressed to prevent regeneration and possible descent
of the brow postoperatively. These myotomies are done
with caution not to injure the supratrochlear vessels.
Some surgeons will myotomize the orbicularis muscle
lateral to the supraorbital nerve. When dissecting
endoscopically through the temporal incision, the zygo-
maticotemporal vein (sentinel vein) will be seen about
Fig. 19.11 Frontal and temporal pockets
2.5 cm above zygomaticotemporal arch (Fig. 19.13).
This is a landmark for the temporal branch of the facial
nerve, which lies superior to it.

19.3.5 Fixation

After the release is completed, fixation becomes

the choice of the surgeon. There have been many
fixation methods from K wire, external screws, bone
tunnels, and LactoSorb screws. I prefer using Endotine
from Coapt (Fig. 19.14). It is consistent and predict-
able. A 4-mm drill bit is used to drill a hole at the
anterior edge of the paramedian or lateral incisions
on both sides. The Endotine is placed and the brow
lifted with the patient sitting up to a desired height and
secured. The vectors will depend on the individual
patient. The Endotine will dissolve in approximately
68 months.

19.3.6 Closure

Surgical staples are used to close the incisions. In the

temporal region, a 4-0 PDS suture can be used to
reapproximate the superficial temporal fascia to the
deep fascia to pull the crows feet and elevate the tail
laterally if needed. Fig. 19.12 Blunt dissection
19 Brow Lift 295

19.3.7 Postoperative Care

A Kerlex pressure dressing (The Kendall Company,

Mansfield, MA) is placed around the forehead for 48 h.
Oral antibiotics can be given along with a Medrol dose
pack (Pharmacia and Upjohn, Kalamazoo MI). Patient
is seen 1 day postoperatively. Scalp numbness can per-
sist for 3 months, and hair shock can result in some
alopecia, which will grow back.

19.3.8 Complications

The most serious complication is injury to the temporal

Fig. 19.13 Sentinel vein branch of the facial nerve. Hematomas and infec-
tions are rare with meticulous dissection and hemosta-
sis. A surgical drain can be placed if there is any
doubt of postoperative hemorrhage. The drain is typi-
a
cally removed in 12 days. Postoperative neuropraxia
is usually temporary if it occurs.

19.4 Direct Brow Lift

The direct brow lift is a simple procedure mostly

reserved for those patients not too concerned with
visible scarring. The closer a surgery is performed to
the eyebrow, the more effective it is. The incision can
be placed at the brow hair or an existing forehead
b crease. This chapter will discuss the ciliary incision.
Vertical brow

Canthal
19.4.1 Preoperative Evaluation
Malar
The evaluation is preferred with the patient sitting
upright with relaxed frontalis muscle action. A 1:1
ratio is used in determining the amount of skin to be
excised and the amount to be lifted. The eyebrow is
elevated to the appropriate position and marked in
relationship to a reference point, typically the corneal
light reflex. The lateral central and medial points are
marked. An elliptical skin incision is marked with the
inferior marking at the cilia and the superior at the
desired height (Fig. 19.15). This extends from the head
of the brow to the tail, being careful not to extend too
Fig. 19.14 (a) Endotine. (b) Vectors of pulling far laterally to minimize a visible scar. If there is exces-
sive lateral hooding of the eyebrow, either a temporal
lift or endoscopic lift should be entertained. The
supraorbital notch is marked to avoid injury.
296
Fig. 19.15 Direct brow markings
Fig. 19.16 Beveled incision 45
19.4.2 Anesthesia
Local infiltration of 2% Lidocaine with 1:100,000 epi-
nephrine mixed with 0.5% Marcaine with 1:200,000
epinephrine is the anesthesia of choice infiltrated along
the entire eyebrow length. IV sedation can also be con-
sidered if needed.
19.4.3 Procedure
The incision is made with an extreme bevel of 45
parallel to the follicles to prevent any hair loss
(Fig. 19.16). The incision on the superior marking
follows with the blade angled in the same direction
to provide adequate apposition and eversion of the
wound edges. Care should be taken at all times to
stay superficial near the supraorbital neurovascular
bundle. Only skin and subcutaneous tissue are excised.
Meticulous hemostasis is highly recommended to pre-
vent postoperative hematoma.
Wound closure is accomplished with buried subcu-
taneous 5-0 Vicryl suture. Each suture must be per-
fectly aligned in the plane horizontal to the wound
edges. This layer must be done with great precision to
avoid a significant scar. The skin closure is done with
S.A. Myint
a 6-0 nonabsorbable suture in a vertical or horizontal
mattress fashion to allow some degree of skin ever-
sion. This will flatten as scarification takes effect.
19.4.4 Postoperative Care
Ophthalmic antibiotic ointment and oral antibiotic
of choice is given postoperatively. Bandaging is not
necessary. Ice packs 15 min every hour while awake is
recommended for the first 2448 h. Sutures are typi-
cally removed in 1014 days. Patient is to avoid any
sun exposure to that area during the healing process.
19.4.5 Complications
Most commonly, hematomas can occur if intraopera-
tive hemostasis is not achieved properly. This can be
avoided with meticulous surgical technique. Damage
to the temporal branch of the facial nerve is usually
not encountered here. Although infections are rare,
they can be avoided with oral antibiotics. Brow hair
loss can occur if the incision is not beveled or placed
incorrectly.
19.5 Trichophytic Brow Lift
For patients who have a high hairline or a long fore-
head, a trichophytic or subcutaneous brow lift is an
excellent approach. This will bring the hairline down
and lift the brow, making it more aesthetically appeal-
ing for the patient (Fig. 19.17). Because of the plane of
dissection, the forehead creases will be less visible
with this procedure.
19.5.1 Anesthesia
Local infiltration with a mixture of lidocaine and
Marcaine with epinephrine or tumescent infiltration
can be used below the dermis and above the frontalis
muscle. This procedure can be either done with straight
local or localized monitored anesthesia.
19.5.2 Marking and Incision
Again, the incision in this type of brow lift is critical to
prevent hair loss and significant unacceptable scarring.
19 Brow Lift
a the neurovascular bundles of the supratrochlear and
b depending on the patient. Removing the excess skin is
Fig. 19.17 (a) Preoperative. (b) Following trichophytic
brow lift
One should never make a horizontal pretrichial inci-
sion as it will routinely cause an unacceptable scar.
The markings should be positioned approximately
5 mm posterior to the hairline in an irregular and ran-
dom fashion. This is the area where the follicular den-
sity changes. The eyebrow should mostly elevate at its
peak at the lateral two thirds (lateral limbus) in women.
In younger patients, this is the lateral extent of the inci-
sion. In patients with lateral hooding, this incision can
extend out to the lateral tail of the brow. It is very
important that the incision is extremely beveled at
1020 with an 11 blade. This extreme bevel is for the
hair shaft to regrow through the skin flap. When cau-
terizing, it is important to be very careful not to destroy
the hair follicles.
19.5.3 Procedure
Pretunneling can sometimes make the dissection easier.
Facelift scissors can also be used in the subcutaneous
plane (below dermis and above frontalis muscle). This
dissection is carried down to just above the supraor-
bital rim. With lighted retractors and good exposure,
297
supraorbital nerves are visualized. The undersurface
of the flap should have subcutaneous fat. Dissection
of the neurovascular bundle in a vertical fashion
will release adhesions and allow access to the eyelid.
The procerus and corrugator muscles can be addressed
here with gentle release.
19.5.4 Closure
Cutbacks are usually made approximately 20 mm
done in a bevel fashion following the geometric inci-
sion to prevent a step off. Retention sutures with 4-0
gut or surgical staples are placed at the cutbacks cen-
tral, medial, and lateral. Subcutaneous closure and skin
closure are done with 5-0 gut suture. The scar is impec-
cable if the geometric incision is done meticulously.
19.5.5 Postoperative Care
Typically no bandage is required. Antibiotic ointment
to the wound, oral antibiotics, and a Medrol dose pack
is given for 1 week. If desired, a Kerlex dressing may
be placed for 24 h. Patient is seen the next day, then in
1 week. Ice is given for 2448 h. No drain is required.
19.5.6 Complications
Hair loss and scarring are the two most common prob-
lems seen with the trichophytic lift. Therefore, it is
very important to pay attention to details. As in the
other brow procedures, hematoma and infection can
also be encountered. One must be prepared to handle
these issues if they arise. They can be prevented with
good hemostasis and postoperative care.
Suggested Reading
Holcomb JD, McCollugh EG (2001) Trichophytic incisional
approaches to upper facial rejuvenation. Arch Facial Plast
Surg 3(1):4853
Isse NG (1997) Endoscopic facial rejuvenation. Clin Plast Surg
24(2):213231
Nesi FA, Gladstone GJ, Myint S, Brazzo BG, Black EH
(2001) Ophthalmic and facial plastic surgery: a compen-
dium of reconstructive and aesthetic techniques. Slack Inc.,
Thorofare
 Mid-Forehead Buttonhole
Eyebrow Elevation
Harry Mittelman, Gregory J. Vipond,
and Joshua D. Rosenberg
20.1 Introduction
The upper third of the face encompasses the region
from the trichion superiorly to the nasion inferiorly
and from temporal line to temporal line laterally.
Within this zone, the glabellar, brow, upper lid, and
forehead regions are further subdivisions. Some sur-
geons would also include the entire periorbital com-
plex. While not always receiving the same emphasis as
the lower two-thirds of the face, failure to address the
upper third can lead to an uneven facial rejuvenation
and an unnatural, operated look.
A youthful upper facial third consists of a smooth
forehead without transverse furrows, a smooth glabel-
lar region without the horizontal procerus and diagonal
corrugator supercilii furrows, and an eyebrow in its
gender-specific ideal position without evidence of
lateral hooding or crows feet. Additionally, the upper
eyelid has a well-defined supratarsal crease without
significant dermatochalasis or fat pseudoherniation.
With advancing age, certain characteristic changes
occur. With repeated contraction of the frontalis mus-
cle and deformation of the forehead skin, horizontal
H. Mittelman (*)
Mittelman Plastic Surgery, Los Altos, CA, USA
Associate Clinical Professor, Department of Otolaryngology,
Stanford University Medical Center, Palo Alto, CA, USA
e-mail: hmittelman@yahoo.com
G.J. Vipond
VIP Facial Artistry, Arcadia, CA, USA
e-mail: gvipondmd@yahoo.com
J.D. Rosenberg
Mittelman Plastic Surgery, Los Altos, CA, USA
e-mail: jrosenberg@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_20, Springer-Verlag Berlin Heidelberg 2013
20
forehead furrows develop. Similarly, with repeated
contraction of the glabellar muscles, the procerus, cor-
rugator supercilii, and depressor supercilii, the hori-
zontal and diagonal glabellar furrows develop along
with muscular hypertrophy. In the upper lid, derma-
tochalasis leads to hooding of the eyelid skin while fat
pseudoherniation and orbicularis oculi hypertrophy
can lead to lid fullness.
With regard to the brow, it is classically taught that
with advancing age, the brow descends, especially in
its temporal aspect. This is due to a combination of
forehead dermatochalasis, facial laxity, and hypertro-
phy of the brow depressor muscles. The accepted ideal
brow configuration [1] varies with patient gender. In
both men and women, the medial edge of the brow
begins at the intersection of a vertical line drawn from
the lateral edge of the nasal ala with the medial can-
thus. It is described as club-shaped. In women, it arches
over the supraorbital rim with its peak at the lateral
limbus or lateral canthus. The lateral edge of the brow
is at the same vertical height as the medial edge and
ends at the intersection of a line drawn through the lat-
eral aspect of the nasal ala intersecting with the lateral
canthus. The thickness of the eyebrow may vary by
person, but generally tapers from the thick medial edge
to a thin lateral edge. In men, the length of the eyebrow
is similar, but the shape varies. The position is rela-
tively flat and lies along the supraorbital rim. The
thickness also remains relatively constant without any
discernable taper. However, it is important to realize
that this configuration needs to be individualized. To
maintain a natural appearance, the patients eyebrow
position must be restored to its former youthful one,
not to a new position or shape.
299
300
While it is generally accepted that the lateral por-
tion of the brow descends due to limited support by the
frontalis muscle and relative strengthening of the
orbicularis oculi with its concomitant brow depression
action, the change of the medial brow is more contro-
versial. Freund and Nolan showed that brow lifts
depicted in the medical literature often elevated the
medial brow to a position above the supraorbital rim
and created a medial brow shape that was flat and not
arched like the accepted ideal [2]. Matros et al. [3] per-
formed an objective photographic study which com-
pared eyebrow position between two cohorts: a 20- to
30-year-old group and a 50- to 60-year-old group.
Comparing positions at the medial canthus, pupil, and
lateral canthus, they found that the eyebrow position
was significantly higher at the pupil and medial can-
thus. They concluded that given the paradoxical eleva-
tion of the mid and medial brow with aging, further
surgical elevation would lead to a result that is neither
youthful nor aesthetically pleasing [3].
There are numerous means used in rejuvenation of
the brow area. Nonsurgical means include botulinum
toxin A and the use of skin fillers. Ahn et al. [4] dem-
onstrated that botulinum toxin led to lateral brow ele-
vation through paralysis of the eyebrow depressors,
and that the amount of temporal eyebrow elevation
achieved with proper injection is approximately equiv-
alent to the temporal eyebrow elevation achieved at 1
year after endoscopic forehead elevation. Other non-
surgical techniques include filler placement to improve
lateral hooding and skin resurfacing techniques such
as fractional carbon dioxide (CO2) laser resurfacing for
skin texture and tightening [5]. The biggest disadvan-
tage to these nonsurgical techniques is their lack of
permanence and need for repeat treatment.
While the longevity of surgical techniques may
be debatable, it is generally agreed that it outlasts
nonsurgical methods. There are a number of different
techniques including open, encompassing coronal, pre-
trichial, trichophytic, direct, bilateral temporal, trans-
blepharoplasty, and mid-forehead, and minimal incision
techniques, such as endoscopic and featherlift/barbed
suture methods. Open techniques are generally viewed
as more traditional, although many consider the coro-
nal lift as the gold standard in forehead rejuvenation.
With the advent of endoscopic technology, many
were quick to embrace endoscopic brow lifts as they
involved minimal incisions, did not change the hairline,
were popular with patients, and offered potentially
H. Mittelman et al.
less morbidity than the coronal lift. An older survey
conducted by Elkwood et al. [6] did conclude that while
both open and endoscopic techniques were considered
efficacious, the younger surgeons were more likely to
use the endoscopic techniques while senior surgeons
were more likely to use open methods. However, with
more experience with the endoscopic approach, many
surgeons have returned to open techniques due to
unpredictability of results both in the amount and dura-
tion of brow elevation [7]. Additionally, it was found
that the endoscopic approach was more technically dif-
ficult, could in fact elevate the hairline, and could lead
to late-onset development of subcutaneous venous dila-
tation in the temporal and forehead areas. Another
study by Cilento and Johnson [8] found that, in the
review of 1,004 procedures, open procedures had a
complication rate equal to or lower than published rates
in endoscopic brow lift series. They also found that
patient acceptance of surgical approach depended in
a large part by the way in which it was presented to
the patient. They concluded that the selection of the
appropriate technique should be based on a balance
between patient characteristics and desires and physi-
cians abilities.
Regarding open techniques, there are a number of
advantages and disadvantages to each approach. Con-
siderations include gender of patient, hairline, presence
of forehead rhytids, need for forehead rejuvenation ver-
sus change in eyebrow position. It is important to note
that forehead rejuvenation and eyebrow elevation are
not synonymous, and it is possible to elevate the eye-
brow without elevating the forehead or hairline. The
objectives of an eyebrow lift should be superior reposi-
tioning of the eyebrow with precise contouring; long-
lasting, dependable, and reproducible results; minimal
neurovascular morbidity; acceptable incisions; and
minimal complications. Unfortunately, there is not a
consensus on one such surgical approach.
The Mid-Forehead Buttonhole Eyebrow lift is the
authors preferred method of eyebrow elevation due to
a very cosmetically acceptable incision, easy access to
the brow in the subcutaneous plane, and very precise
control of eyebrow elevation, with a high margin of
safety and low morbidity. The incision is made in a
forehead rhytid with or without skin excision. It does
not address glabellar musculature and may eliminate
the need for upper blepharoplasty in a small minor-
ity of patients. Although the senior author (H.M.)
has been using this technique for almost 10 years, the
20 Mid-Forehead Buttonhole Eyebrow Elevation
longevity of the eyebrow elevation is still uncertain.
Nonetheless, the Mid-Forehead Buttonhole Eyebrow
lift remains an easily learned, effective means of
accurately restoring a youthful eyebrow position and
contour.
20.2 Technique
In general, preoperative assessment of the brow lift
patient involves assessment of the need for eyebrow
lift alone or eyebrow lift with concurrent upper bleph-
aroplasty. The hairline must also be analyzed: male
pattern baldness both current and future, hair density,
and high temporal hairline in women. The skin thick-
ness and oil content should be examined along with
the laxity of the forehead skin-muscle complex. Bony
contour is also important and it is essential to evaluate
eyebrow symmetry and to demonstrate any preopera-
tive asymmetry to the patient. Preoperative photo-
graphs include the anterior-posterior (AP) view both
with neutral expression and with eyebrow elevation
and lateral and oblique views, which help demon-
strate lateral hooding. As with any procedure, informed
patient consent is essential, with attention given to the
possibility of a visible scar and the unpredictable lon-
gevity of result with possible return of brow ptosis.
The incision is designed within a natural forehead
rhytid (Fig. 20.1). It is centered over the lateral two-
thirds of the brow, and a rhytid close to the brow is
ideally chosen. If both the medial and the lateral brow
are to be addressed, separate incisions should be
planned. On occasion, the junior author (G.V.) tries to
use a different level of rhytid on each side so as to
avoid symmetrical incisions and better camouflage the
scar. If a well-defined skin rhytid is not present at rest,
the patient is asked to elevate his or her eyebrows and
the incision is drawn along a dynamic rhytid. A pro-
posed skin ellipse is then drawn centered about the
incision line. The senior author (H.M.) prefers to esti-
mate the vertical dimensions of the ellipse. However,
the junior author (G.V.) has changed his technique to
include a measurement of the skin ellipse. The incision
is drawn along the rhytid, and then the eyebrow is ele-
vated to its ideal position. Using a ruler, the amount of
elevation needed for the correct position is noted and
then overcompensated by 1 mm. This measurement is
then divided in half and represents the vertical dimen-
sion of the ellipse above and below the incision line.
301
Fig. 20.1 The Mid-Forehead Buttonhole incision is designed
within a natural forehead rhytid. Ideally, a static rhytid is chosen,
but if not present, the incision may be made within a dynamic
furrow
This measurement is performed at the apex of brow
contour and is tapered to form an ellipse encompass-
ing the entire region of brow to be elevated. Any con-
current surgical incisions are marked, and the face is
then sterilely prepped and draped. Local anesthetic
is infiltrated in the subcutaneous plane in the area of
the ellipse and skin inferior to the ellipse all the way to
just below the superior orbital rim. While the senior
author (H.M.) generally performs these procedures
under general anesthesia, the junior author (G.V.) pri-
marily performs them under local anesthetic with oral
sedation.
The skin incision is made with a scalpel, and under-
mining of the ellipse is performed in a plane just super-
ficial to the frontalis muscle (Fig. 20.2). The skin and
subcutaneous tissue are removed, exposing the fascia
of the frontalis. Undermining is performed in the
subcutaneous plane inferiorly, medially, and laterally
until the orbicularis oculi muscle is in view (Fig. 20.3).
The inferior extent is the muscle overlying the superior
orbital rim. Meticulous hemostasis is ensured through-
out the procedure using bipolar cautery to minimize
thermal damage to the tissues and neurovascular struc-
tures. The orbicularis is then palpated to ensure mobil-
ity to the desired eyebrow position (Fig. 20.4).
Once the ideal position is determined, the muscle is
secured using a modified purse-string suture (Fig. 20.5).
The junior author prefers to use 5-0 Polypropylene
suture. Beginning at the medial edge of the incision, the
first bite is horizontal through the frontalis muscle and
302 H. Mittelman et al.

Fig. 20.2 The skin incision is made with a scalpel, and Fig. 20.4 The orbicularis oculi is palpated to ensure adequate
undermining is performed in the subcutaneous tissue superficial mobility to the desired brow position
to the frontalis muscle. The ellipse of skin is excised with the
underlying subcutaneous tissue, avoiding the fascia of the fron-
talis muscle
a

Fig. 20.3 Subcutaneous undermining is done medially, later-

ally, and inferiorly until the orbicularis oculi is in view

grasps the periosteum of the frontal bone. The second

bite is through the orbicularis oculi using three consec-
utive throws (Fig. 20.6). The suture is then tightened
until the brow is elevated to the desired position and
then tied down in a buried fashion. The assistant sup-
ports the brow inferiorly while the suture is being tied
Fig. 20.5 (a) The orbicularis oculi is suspended using a modi-
to avoid any change in the brow position. Depending
fied purse-string suture of either 5-0 or 6-0 Polypropylene.
on the length of the elliptical incision, this modified The first bite is through the periosteum of the supraorbital fron-
purse-string suture is repeated as needed to ensure tal bone. (b) Intraoperative
20 Mid-Forehead Buttonhole Eyebrow Elevation
Fig. 20.6 The second bite is through the orbicularis oculi using
three consecutive throws. The brow is elevated to the desired
position and then tied with square knots
Fig. 20.7 The modified purse-string suture is repeated as nec-
essary along the length of the brow for optimal elevation and
contour of the brow
even elevation of the brow (Fig. 20.7). In the junior
authors (G.V.) experience, this typically involves a
total of three sutures. One advantage of multiple sutures
is that the brow can be elevated by different amounts at
each suture, thereby allowing more precise control of
brow contour which is especially useful for the female
eyebrow.
Once the orbicularis suturing has been completed,
thorough hemostasis is ensured. The incision is then
closed. This is generally the most time-consuming
303
Fig. 20.8 The dermis is reapproximated using 5-0 or 6-0
Monocryl suture to ensure no tension on the skin edges
portion of the procedure as meticulous closure is essen-
tial to ensure a minimally visible incision. The dermis
is closed using either 5-0 or 6-0 monofilament long-
term absorbable suture, such as Monocryl (Ethicon,
Inc.), so that there is minimal tension on the epidermal
closure (Fig. 20.8). The epidermis is then closed using
6-0 Polypropylene in a simple and vertical mattress
fashion. The junior author (G.V.) prefers to place inter-
rupted vertical mattress sutures along the length of the
incision for optimal skin eversion and then use a sim-
ple continuous suture to complete the epidermal
approximation. Petroleum jelly or antibiotic ointment
may be applied to the incision and a nonadhesive dress-
ing, such as Telfa (The Kendall Company, Ltd.), may
be used to apply light pressure. Sutures are removed in
two stages: The continuous suture is removed on post-
operative day 4 or 5, and SteriStrips (3 M,
St. Paul, MN) are placed in between the remaining ver-
tical mattress sutures. All sutures are removed by post-
operative day 7, and the incision is again reinforced
with SteriStrips which are allowed to fall off on
their own. Patients are encouraged to call with any
concerns and follow-up photos are generally taken at 3
and 12 months postoperatively.
20.3 Discussion
Ideal eyebrow configuration and position is an essential
component of a youthful, refreshed face. While many
techniques exist to reposition the eyebrow and address
the aging in the upper one-third of the face, there is an
304
Fig. 20.9 (a, b) Preoperative (left) patient with congenital right
brow ptosis. Postoperative (right) after right Mid-Forehead
Buttonhole eyebrow lift. There is significant improvement of
absence of any one optimal technique. There is much
debate on the merits of various procedures with regard
to technical difficulty, precision, complications, proce-
dure length, recovery time, and longevity of result. The
ideal procedure would accurately restore a youthful
eyebrow position and configuration, have minimal
morbidity, and would be long lasting in its result. The
Mid-Forehead Buttonhole Technique was developed
to address concerns with both the invasiveness and
sequelae of the coronal brow approach as well as
the unpredictability of the endoscopic approach. It is
H. Mittelman et al.
brow symmetry and in lateral hooding even though no concomi-
tant upper blepharoplasty was performed
important to note that the Mid-Forehead Buttonhole
Technique elevates and configures the eyebrow but
does not address the forehead complex in terms of skin
excess, rhytides, and forehead or glabellar muscula-
ture. The approach does, however, involve an ellipti-
cal excision of lateral brow skin. Both authors prefer
to address the muscular component of brow aging,
namely the horizontal forehead creases and glabellar
furrows, with neurotoxin administration of botulinum
toxin A. It is their opinion that appropriate chemi-
cal treatment allows a natural look which, although
20 Mid-Forehead Buttonhole Eyebrow Elevation
Fig. 20.10 (Left) Preoperative male patient with concerns of lateral brow position. (Right) Postoperative following Mid-Forehead
Buttonhole eyebrow lift
temporary, is completely reversible with time and may
be reproduced with minimal risk and discomfort.
There are numerous advantages of the Mid-Forehead
Buttonhole Technique. The surgical approach involves a
minimal dissection in the subcutaneous plane, allowing
excellent visualization of the involved anatomy. The
dissection is technically easier than either the coronal or
endoscopic approached, but the skin closure must be
meticulous and may take longer. Due to the proximity of
the dissection to the target area, the orbicularis oculi
may be elevated directly at the level of the eyebrow,
thereby allowing a very accurate elevation and the ability
to differentially elevate different components of the
brow, creating a youthful contour to the brow, rather
than elevating it as a unit. There is less risk of morbidity
compared to the endoscopic of coronal approaches with
regard to ecchymosis, edema, pain, and recovery time.
There is no risk of trauma to either the supraorbital or
supratrochlear neurovascular bundles. Additionally, this
procedure may be done in the office under local anes-
thesia and requires inexpensive surgical instrumenta-
tion. As each brow is addressed on an individual basis,
they may be elevated independently, thereby improving
on preoperative asymmetry. In fact, the junior author
(G.V.) has performed surgery on a patient with long-
standing right unilateral brow ptosis with good position
of the left brow. Figure 20.9 demonstrates the improve-
ment in symmetry obtained with performing a unilateral
brow lift. In contrast to the coronal or trichophytic
approaches, the Mid-Forehead Buttonhole Technique
does not elevate the hairline and is not limited to patients
with a receding hairline.
305
While there are many benefits of the Mid-Forehead
Buttonhole Technique, there are also some limitations.
The incision is made in a forehead rhytid (static if
possible, otherwise in a dynamic crease), and patients
must be informed of the resultant scar. In order to min-
imize any visible scar, the skin closure must be meticu-
lous and may be time-consuming compared to the
endoscopic approach. Additionally, the Mid-Forehead
Buttonhole Technique does not address glabellar or
frontalis musculature. If treatment is needed in these
areas, the authors prefer to use botulinum toxin type A.
Both authors find that the results of this procedure are
not as predictable as rhytidoplasty or blepharoplasty,
but are equivalent or more predictable than the endo-
scopic approach, although less predictable than the
coronal approach.
Potential complications involved with the Mid-
Forehead Buttonhole Technique include the need for
scar revision, although neither author has experienced
this to date. There is also the potential for hematoma or
seroma formation. A mild pressure dressing over the
incision and area of undermining may be used for the
first 24 h, but is rarely needed beyond that point. Pain
or headache may be seen postoperatively, especially
with forced eye closure. This phenomenon is explained
to patients preoperatively and resolves with time. The
senior author (H.M.) has also experienced two cases of
paresthesia over the V1 (supraorbital/trochlear) nerve
distribution which have been transient in nature.
Figures 20.1020.18 demonstrate some of the
typical pre and postoperative results from the Mid-
Forehead Buttonhole Technique.
306 H. Mittelman et al.

Fig. 20.11 (Left) Preoperative male patient with concerns of lateral brow position. (Right) Postoperative following Mid-Forehead
Buttonhole eyebrow lift

Fig. 20.12 (Left) Preoperative female who had concerns of brow position and lateral hooding. (Right).Postoperative after undergo-
ing Mid-Forehead Buttonhole eyebrow lift. No concomitant blepharoplasty was performed

Fig. 20.13 Preoperative (left) and postoperative (right) AP views of a female patient who wanted a more dramatic eyebrow lift who
also underwent concomitant upper blepharoplasty
20 Mid-Forehead Buttonhole Eyebrow Elevation 307

Fig. 20.14 (Left) Preoperative photograph of a female with concerns of lateral hooding and eyebrow position after a previous upper
lid blepharoplasty. (Right) Postoperative photograph after bilateral Mid-Forehead Buttonhole eyebrow lift

Fig. 20.15 Preoperative (Left) and two month postoperative degree of frontalis hyperfunction needed to keep her brow in an
(Right) AP views of a female patient who underwent the Mid- elevated position which is significantly improved post-opera-
Forehead Buttonhole eyebrow lift with both medial and lateral tively without the use of Botulinum toxin
incisions. The preoperative photograph demonstrates the significant

Fig. 20.16 (Left) Preoperative female with significant brow ptosis, upper and lower lid dermatochalasis, and fat pseudoherniation.
(Right) Early postoperative following Mid-Forehead Buttonhole eyebrow lift with concomitant upper and lower lid blepharoplasty
308 H. Mittelman et al.

Fig. 20.17 (Left) Preoperative female patient. (Right) Postoperative after undergoing Mid-Forehead Buttonhole eyebrow lift with
concomitant upper blepharoplasty

Fig. 20.18 (Left) Preoperative female patient with significant lateral hooding. (Right) Postoperative after Mid-Forehead
Buttonhole eyebrow lift with excellent improvement in both brow position and lateral hooding

20.4 Conclusions In the experience of the authors, the Mid-Forehead

There are several important surgical concepts when
considering approaches to the eyebrow. The closer
the incision is to the target structure, namely the eye-
brow, the more effective and accurate the lift. The mid-
forehead location for small incisions maximizes the
surgical result with minimal risks, including scar visi-
bility. The ability to fixate the orbicularis oculi to the
supraorbital periosteum improves eyebrow elevation
and contour in combination with the elliptical skin
excision of the mid-forehead procedure. Finally,
despite all of the various surgical approaches to the
eyebrow, no perfect, consistent, long-lasting, and pre-
dictable eyebrow lift procedure exists.
Buttonhole Technique for eyebrow elevation pro-
vides comparable or better results than other sur-
gical approaches with less risk and morbidity in
exchange for small, well-camouflaged, mid-forehead
scars.
References
1. Ellenbogen R (1983) Transcoronal eyebrow lift with con-
comitant upper blepharoplasty. Plast Reconstr Surg 71(4):
490499
2. Freund RM, Nolan WB III (1996) Correlation between brow
lift outcomes and aesthetic ideals for eyebrow height and
shape in females. Plast Reconstr Surg 97:13431348
20 Mid-Forehead Buttonhole Eyebrow Elevation
3. Matros E, Garcia JA, Yaremchuk MJ (2009) Changes in
eyebrow position and shape with aging. Plast Reconstr Surg
124:12961301
4. Ahn MS, Catten M, Maas CS (2000) Temporal brow lift using
botulinum toxin A. Plast Reconstr Surg 105(3):11291135
5. Punthakee X, Kelle GS, Vose JG, Stout W (2010) New tech-
nologies in aesthetic blepharoplasty and brow-lift surgery.
Facial Plast Surg 26(3):260265
309
6. Elkwood A, Matarasso A, Rankin M, Elkowitz M, Godek CP
(2001) National plastic surgery survey: brow lifting techniques
and complications. Plast Reconstr Surg 108(7):21432150
7. Chiu ES, Baker DC (2003) Endoscopic brow lift: a retro-
spective review of 628 consecutive cases over 5 years. Plast
Reconstr Surg 112(2):628633
8. Cilento BW, Johnson CM (2009) The case for open forehead
rejuvenation. Arch Facial Plast Surg 11(1):1317
 Facelift
Phillip R. Langsdon and Courtney Shires
21.1 Introduction
The facelift procedure has undergone several modifi-
cations over the last century since first explained by
Hollnder in 1901 [1]. The various techniques differ in
the length and placement of the incision, the extent
of undermining and dissection, and the handling of
the SMAS. Methods include simple skin dissection,
superficial musculoaponeurotic system (SMAS) sus-
pension, SMAS undermining, deep plane, extensive
skin undermining, and other variations. The subcuta-
neous facelift with imbrication of the SMAS is still
the most commonly used technique [2]. This chapter
focuses on our method of a skin-SMAS lift.
21.2 Indications
Although there are many variations of the facelift
procedure, the goals remain the same. These include
removing excess fat and repositioning tissue to achieve
a more youthful, yet natural lift. The authors tech-
nique involves the removal of any excess cervical
fat, repositioning the SMAS and platysma, and remov-
ing excess cervical and facial skin. Ideal candidates
are those in good health with good vascularity who
P.R. Langsdon ()
The Langsdon Clinic, Germantown, TN, USA
Division Facial Plastic Surgery, University of Tennessee Health
Science Center, Memphis, TN, USA
e-mail: langsdon@bellsouth.net
C. Shires
Department of Otolaryngology-Head and
Neck Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_21, Springer-Verlag Berlin Heidelberg 2013
21
exhibit a loss of skin elasticity, sagging of the cheek
tissues and cervical platysma, and who may also have
excess neck fat. Patients who enjoy average weight, an
aesthetic facial bony contour and a high posteriorly
positioned hyoid bone are usually better candidates
than those who have thin tissues, are overweight, or
who have a low-anteriorly placed hyoid.
Patients should be psychologically stable, possess
realistic expectations, and demonstrate a comprehen-
sion of the limitations of the facelift procedure. In my
practice, the details are usually discussed on three
occasions prior to surgery. Patients must also under-
stand that no surgical rejuvenation procedure can
remove facial asymmetries, improve the general facial
deflation that occurs with aging, halt aging, remove
wrinkles or facial expression lines, or restore the
deteriorated condition of skin. Other techniques, not
included with the facelift procedure, might be consid-
ered or needed to address facial atrophy, wrinkles, skin
deterioration, asymmetries, and/or future aging.
21.3 High Points
1. The incisions are placed in reference to the hairline,
lobule, tragus, and postauricular crease. The authors
attempt to preserve the temporal sideburn at the level
of the superior portion of the ear. In female patients, a
post-tragal incision is used, and in male patients, the
incision carried in front of the tragus. Postauricularly,
the incisional mark is carried into the postauricular
sulcus and then along the posterior hairline.
2. The SMAS layer is deep to the subcutaneous fat
and superficial to the parotid fascia and invests the
mimetic musculature of the face and neck. It is
311
312
generally thought to be continuous from the tem-
poroparietal fascia to the platysma. The SMAS is
also inclusive of the orbicularis oculi and orbicularis
oris muscles [35]. This connection and investment
system allows for plication and/or imbrication of the
SMAS to support the sagging system and add lon-
gevity and efficacy to a facelift. The SMAS is directly
connected to the skin in the central portion of the
face, contributing to support in this area when the
system is suspended lateral and/or superiorly. It is
the opinion of the senior author that skin suspension
alone does not provide as good longevity of results.
3. Great attention is paid to elevation and placement
of the tragus and earlobe. Tragal skin is elevated
in a very superficial, almost dermal plain, thereby
leaving as much deep tissue as possible to prevent
postoperative contracture. When closing the skin,
the neotragal skin is left redundant to avoid for-
ward displacement of the tragus by skin contrac-
ture. The earlobe is placed in a position that is about
cm superior to the position where it naturally
lies in the unrepaired state. This overcorrection pre-
vents the lobe from being pulled too far inferiorly
during the natural healing process.
4. Two important securing sutures are placed when
redraping the elevated flap, one at the most superior
postauricular point and one at the junction of the
horizontal temporal incision and the superior extent
of the preauricular incision. These sutures anchor
the skin for trimming.
5. The author has found that preserving the mandibular
ligament area vessels results in better flap vascular-
ity. Therefore, minimal undermining should be per-
formed in this area unless enough vasculature is
preserved in other regions of the face lift to sustain
adequate capillary flow.
6. Significant submental tissue and platysmal banding
will not be improved unless submental muscular pli-
cation and skin redraping is performed along with
elevation and support of facial tissues. Other proce-
dures might be needed and/or recommended such as
blepharoplasty, forehead lift, chin augmentation, etc.
The patient should also understand that a rhytidec-
tomy will only help reposition tissues. It will not
replace volume loss or improve wrinkled skin.
Ancillary procedures, the injection of facial fillers and
chemical peel, are often recommended as necessary.
7. Anesthetic technique for this procedure varies from
surgeon to surgeon.
P.R. Langsdon and C. Shires
21.4 Surgical Technique
Sedation should only be undertaken in a state approved
and yearly inspected setting that is restricted by safety
guidelines (or by a similar legitimate governing orga-
nization) (Figs. 21.121.38). All emergency equip-
ment, proper personnel, and appropriate emergency
medications should be present. In our facility, the
patient is administered diazepam 20 mg orally, dimen-
hydrinate 200 mg orally, and prednisone 40 mg orally
1 h prior to surgery. The patient is also administered an
oral antibiotic. It may take an hour or slightly longer
for the diazepam to have full effect.
Local anesthesia is undertaken with 1% xylocaine
containing 1:100,000 epinephrine to include the inci-
sion lines and the circumferential periphery of the flap
margins. The area to be undermined is injected with
% xylocaine containing 1:200,000 epinephrine.
Intravenous sedation is optional, but can be very help-
ful during the injection of local anesthesia. Intravenous
sedation may be offered and must be monitored in an
appropriate setting. It is usually delayed until the oral
diazepam has been fully absorbed. We accomplish
intravenous sedation with diazepam in 2.5 mg doses
and/or hydromorphone in 0.25 or 0.5 mg doses admin-
istered in 5 min intervals until the patient is relaxed.
The 5 min interval allows for complete circulation and
time for the physician to adequately observe the respi-
ratory impact of the dose, before additional sedation is
administered.
Fig. 21.1 Preoperative marking in a female, including a post-
tragal mark
21 Facelift 313

Fig. 21.2 Preservation of the temporal sideburns and incisional Fig. 21.4 Submental marking
marking in a male, which travels in front of the tragus in a preau-
ricular crease. The extent of skin undermining is marked approx-
imately 5 cm from the incision site

Fig. 21.5 Incision used for platysmal plication and submental

lipectomy

Fig. 21.3 Incisional mark carried into the postauricular sulcus

extending onto the posterior hairline forming a short gentle
curve along the hairline

The senior author believes in preserving the tem-

poral sideburn at the level of the superior portion of
the ear. Therefore, a horizontal mark is usually placed
in this location to prevent the migration of hair to a
point superior to the cephalic portion of the ear. The
resulting incision may then be reused in future facial
rejuvenation procedures without elevation of the
sideburn area and loss of temporal hair. Instead of
shaving the patients hair, parted segments on either Fig. 21.6 Elevation of the anterior neck skin flap
314 P.R. Langsdon and C. Shires

Fig. 21.7 Elevation of the anterior neck skin flap Fig. 21.9 Liposuction of the anterior neck

Fig. 21.10 Submental lipectomy showing excised fat strip

Fig. 21.8 Liposuction of the anterior neck

side of the incision are twisted and wrapped with

paper tape.
The mark is continued in the preauricular groove
found just in front of the curvature of the auricle. In
female patients, a post-tragal mark (12 mm behind
the tragus) is incorporated to hide the scar. In male
patients, the incisional mark is usually carried in front
of the tragus in a preauricular crease. The author usually Fig. 21.11 Submental lipectomy showing excised fat strip
21 Facelift 315

Fig. 21.12 Plication of medial borders of platysma muscle Fig. 21.15 Beveling of the blade during the incision behind the
tragus and along the temporal hairline

Fig. 21.13 After placement of platysmal plication sutures Fig. 21.16 Undermining of the skin beginning at the tragus,
preserving subdermal tissue attachments to the deep tissue

Fig. 21.14 Beveling of the blade during the incision behind the Fig. 21.17 Undermining of the skin beginning at the tragus,
tragus and along the temporal hairline preserving subdermal tissue attachments to the deep tissue
316 P.R. Langsdon and C. Shires

Fig. 21.18 Undermining the remainder of the facial skin from Fig. 21.20 Asterisks showing areas of the mandibular ligament
laterally to medially, in a supraSMAS (subdermal) layer to a point vessels
averaging 5 cm from the incision, following the preoperative
marking plan. The assistant is shown providing counter-traction

Fig. 21.21 SMAS-ectomy showing removal of 3 1 cm strip of

SMAS down to the parotid fascia
Fig. 21.19 Elevated flap

leaves an area of non-hair-bearing skin between the

tragus and sideburn in male patients. The mark then
curves around the earlobe.
Postauricularly, the incisional mark is carried into
the postauricular sulcus. Some surgeons stop the inci-
sion low in the postauricular sulcus. However, we have
found the resulting bunching of skin unsatisfactory to
the patient in the early postoperative period. Therefore,
we extend the mark up the postauricular sulcus and
onto the posterior hairline forming a short gentle curve
along the hairline. This extension of the postauricular
incision allows for removal of excess skin and the pre-
vention of bunching. The extent of skin undermining is Fig. 21.22 Beginning suture through the periosteum of the
marked approximately 5 cm from the incision site. zygomatic arch
21 Facelift
Fig. 21.23 Suture directed inferiorly
Fig. 21.24 Suture directed inferiorly
The submental area is addressed first. A 1.52 cm
horizontal incision is placed in the submental crease or
a few millimeters posterior to the crease. This place-
ment will ensure that the incision remains well hidden
in the submental region with superior and posterior
movement of the adjacent skin during the facelift. A
2.5 cm incision may be necessary for visualization
during platysmal plication. Subcutaneous elevation of
the anterior neck skin flap is performed with facelift
scissors, maintaining a 2-mm cuff of fat on the deep
surface of the skin. Submental lipectomy may be per-
formed with a 4-mm liposuction cannula connected to
wall suction. The medial borders of the platysma are
plicated with 3-0 Vicryl buried mattress sutures. In
patients with a poorly defined cervicomental angle and
317
Fig. 21.25 Suture directed anteriorly
Fig. 21.26 Suture directed superiorly
excessive subplatysmal fat, facelift scissors are used to
remove fat between the medial borders of the plat-
ysma. The platysma muscles are then medialized to
each other and suspended to tissue deep to the medial
subplatysmal fat removal with interrupted buried
sutures of 3-0 Vicryl. Three to four interrupted sutures
are placed, beginning from the deepest point of the
new cervical angle, and continued to the area of the
submental incision.
A #15 blade is used to make the incisions in the
preoperative periauricular markings. The incision is
carried through the dermis and is beveled across the
direction of the hair follicles in hair bearing temporal
and posterior hairline skin. This maneuver allows the
hair to grow through the incision line.
318
Fig. 21.27 Suture directed again through the periosteum of the
zygomatic arch
Fig. 21.28 Suture plicating the depression created by the lifting
suture
The skin is then undermined using facelift scissors
beginning at the tragus, leaving as much subdermal tis-
sue as possible attached to the deep tissue. A thin tra-
gal flap minimizes tragal contracture during the
postoperative healing phase. The remainder of the
facial skin is then fully undermined in a supraSMAS
(subdermal) layer to a point averaging 5 cm from the
incision, following the preoperative marking plan.
P.R. Langsdon and C. Shires
Fig. 21.29 First securing stitch at the highest postauricular
point with a surgical staple once the skin is draped in a posterior-
superior vector
Fig. 21.30 Second securing staple at the junction of the
horizontal temporal incision and the superior extent of the preau-
ricular incision
Countertraction is provided by the assistant. Hemostasis
is achieved with bipolar cautery under direct visualiza-
tion. The dissection continues forward until the dissec-
tion of the previously raised neck flap is reached.
Minimal dissection should be performed in the area of
the mandibular ligament vessels in order to prevent
flap necrosis unless other regions of the face or neck
are spared of extensive undermining.
With the skin flap adequately elevated, SMAS-
ectomy is performed. A 1 3 cm strip of SMAS is
excised in the preauricular area down to the parotid fas-
cia. The SMAS is then plicated in a posterior-superior
21 Facelift
Fig. 21.31 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus
Fig. 21.32 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus
vector using a 2-0 Ethibond or 2-0 Vicryl suture. The
suture is secured at the zygomatic periosteum and
placed through the SMAS creating a purse string
loop. The suture is first continued inferiorly, then
directed anteriorly, and then posterior-superiorly to
return back to the zygomatic periosteum, creating a
teardrop loop. The SMAS suspension will elevate the
jowl, neck, and nasolabial fold. This SMAS suture
often leaves a trough deformity that is closed with
interrupted plication sutures across the depression.
319
Fig. 21.33 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus
Fig. 21.34 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus
Free fat grafts are placed as necessary to fill suture
depressions.
The skin is draped in a posterior-superior vector
and secured at the highest postauricular point with
an interrupted 2-0 nylon suture or surgical staple.
This is followed by a second securing suture or sta-
ple at the junction of the horizontal temporal incision
and the superior extent of the preauricular incision.
The redundant skin is then resected in a manner
creating minimal skin tension. If any dimpling or
320
Fig. 21.35 Removal of excess occipital skin
Fig. 21.36 Removal of excess occipital skin
bunching of skin is noted, further undermining can
be performed. The neotragal skin is left redundant to
avoid forward displacement of the tragus by skin
contracture. The earlobe is placed in a position that
is about cm superior to the position where it the level of the hairline, is performed in a manner
naturally lies in the unrepaired state. This overcor-
rection prevents the lobe from being pulled too far
inferiorly during the natural healing process, thus
preventing the pixie earlobe deformity. The skin
along the postauricular occipital hair is reapproxi-
mated with surgical staples. The skin edges in the
non-hair-bearing postauricular areas are approxi-
P.R. Langsdon and C. Shires
Fig. 21.37 Removal of excess occipital skin
Fig. 21.38 Skin repaired and patient ready for dressing
mated with a 5-0 plain gut suture in a running inter-
locking fashion, using a 4-0 Vicryl for additional
support as necessary. The postauricular closure,
above the posterior portion of the earlobe and below
that leaves 1 cm gaps between sutures. This helps
prevent the accumulation of blood beneath the flaps.
A penrose drain is brought out through the postau-
ricular incision at the midlevel of the incision. A
separate incision is not made for the drain. The
preauricular and tragal skin is closed using 5-0 plain
gut in a running interlocking fashion. The hair
21 Facelift
bearing temporal scalp incision is closed with sta-
ples. The submental incision may be closed with 5-0
plain gut suture in a running interlocking fashion.
Any collected blood is expressed from under the
flaps via the postauricular closure gaps. Xeroform
gauze is placed over the incisions. Then, a second layer
of light dressing is applied with 4 4 gauze pads and a
cotton wrap, applying only very gentle pressure over
the periauricular area, lower face, and neck. Lastly, a
light elastic wrap is placed over the dressing. The elas-
tic wrap is removed 4 h after placement.
The patient is evaluated the following day. The
remaining dressing is removed, and the incisions are
cleaned with hydrogen peroxide and dressed with
Vaseline. The Penrose drain is removed. The patient
is instructed to keep the head of the bed elevated 30,
avoid strenuous activities, not bend over, and not turn
his or her head.
21.5 Complications
Complications occur in any surgical procedure and the
facelift is no exception. Hematoma formation is pos-
sible but can be minimized with meticulous surgical
hemostasis, proper patient selection, and the cessation
of all medications, herbs, vitamins, and red wine that
may cause bleeding. All patients should be counseled
to discontinue medications, herbs, vitamins, etc., that
may cause bleeding 2 weeks prior to surgery. Large
hematomas should be treated to avoid skin flap necro-
sis and can usually be easily expressed through the
postauricular skin closure gaps.
Flap necrosis might occur at the distal ends of
flaps where blood supply is most tenuous. Most com-
monly necrosis occurs in the mastoid region because
the flap is the thinnest at this site, and this area is
farthest away from the blood supply [6]. This would
most commonly be an issue in heavy smokers, who
are not consciously accepted as patients. Caution
should be exercised in smokers or patients with dia-
betes, collagen vascular disease, or Raynauds dis-
ease. However, the senior author does not consider
these situations or conditions necessarily contraindi-
cations to facelifting. Smokers should be counseled
to reduce or discontinue smoking at least 2 weeks
prior to surgery. We do not accept candidates who
smoke over one half pack per day. Undermining is
limited in these patients.
321
Nerve injury may be sensory or motor. Sensory
reduction is common and not considered a complica-
tion; rather a normal consequence of surgery. Care
must be taken when dissecting deep to the fascia over-
lying the sternocleidomastoid muscle to avoid injuring
the greater auricular nerve [6]. Branches of the facial
nerve become very superficial as they continue anteri-
orly from the parotid masseteric fascia. The marginal
mandibular branch is at risk as it crosses the mandibu-
lar margin, deep to the platysma muscle and the super-
ficial layer of the deep cervical fascia. The most
commonly injured branch of the facial nerve during
facelift surgery is the frontal branch. This branch
becomes superficial at the zygomatic arch and travels
just beneath the subcutaneous tissues underlying the
SMAS layer. The nerve travels 1.52 cm in front of the
auricle and halfway between the lateral orbital rim and
the temporal tuft of hair [7]. The author has never
experienced a major motor or sensory nerve injury.
Masterful knowledge of facial nerve and greater auric-
ular nerve anatomy will prevent most major nerve
injuries. The majority of facial nerve paralysis that
appears immediately after surgery is due to the local
anesthetic, stretch, or compression. These nerve inju-
ries usually resolve with time [6].
Deep infection is rare, as is cellulitis. Antibiotic
prophylaxis is used routinely. Treatment of cellulitis
should cover Staphylococcus and Streptococcus. These
infections can usually be treated without permanent
sequela.
21.6 Conclusions
Over time, many approaches to the facelift procedure
have been developed. However, the goals of facelifting
still remain to remove excess cervical fat, tighten the
SMAS and platysma, and remove excess cervical and
facial skin. Facelifting can result in a younger yet natu-
ral appearance in the hands of experienced surgeons
(Fig. 21.39). In order for both the patient and surgeon
to have the best possible results, it is essential for the
physician to obtain a comprehensive medical history
and to understand the patients expectations from the
surgery and for the patient to understand the limita-
tions of the facelift procedure. Certain pearls regarding
the location of incisions, undermining technique, and
placement of closure sutures can help in achieving an
optimal outcome.
322
Fig. 21.39 (a) Preoperative a b
patient. (b) Postoperative
facelift with upper and lower
blepharoplasty
References
1. Hollander E (1932) Plastiche (kosmetische) operation:
kristiche darstellung ihres gegenwartigen standes. In:
Klemperer G, Klemperer F (eds) Neue Deutsche Klinik.
Urban and Schwarzenberg, Berlin
2. Baker SR (2005) Rhytidectomy. In: Cummings CW (ed)
Otolaryngology: head & neck surgery. Mosby, Philadelphia,
pp 714748
3. Gossain AK, Yousif NJ, Madiedo G, Larson DL, Matloub
HS, Sanger JR (1993) Surgical anatomy of the SMAS: a rein-
vestigation. Plast Reconstr Surg 92(7):12541263
4. Ghassemi A, Prescher A, Riediger D, Axer H (2003) Anatomy
of the SMAS revisited. Aesthetic Plast Surg 27
(4):248264
5. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C
(2003) The fascial planes of the temple and face: an en-bloc
anatomical study and a plea for consistency. Br J Plast Surg
56(7):623629
6. Gillman GS et al (2008) Face lift (rhytidectomy). In: Myers
EN (ed) Operative otolaryngology: head and neck surgery.
Saunders, Philadelphia, pp 845855
7. Perkins S, Dayan S (2002) Rhytidectomy. In: Papel ID (ed)
Facial plastic and reconstructive surgery. Thieme, New York,
pp 153170
P.R. Langsdon and C. Shires
General References
Baker TJ, Gordon HL (1971) The temporal face lift (mini-lift).
Plast Reconstr Surg 47(4):313315
Duminy F, Hudson DA (1997) The mini rhytidectomy. Aesthetic
Plast Surg 21(4):280284
Fulton JE, Saylan Z, Helton P, Rahimi AD, Golshani M (2001)
The S-lift facelift featuring the U-suture and O-suture com-
bined with skin resurfacing. Dermatol Surg 27(1):1822
Joseph J (1928) Verbesserung meiner Hangewangenplastik
(Melomioplastik). Dtsch Med Wochenschr 54:567
Onizuka T, Hosaka Y, Miyata M, Ichinose M (1995) Our mini-
facelift for orientals. Aesthetic Plast Surg 19(1):4958
Saylan Z (1999) The S-lift: less is more. Aesthetic Surg J
19:406
Stephenson KL (1970) The mini-lift, an old wrinkle in face
lifting. Plast Reconstr Surg 46(3):226235
Tonnard PL, Verpaele A, Gaia S (2005) Optimising results from
minimal access cranial suspension lifting (MACS-lift).
Aesthetic Plast Surg 29(4):213220
Yarborough JM, Beeson WH (1986) Aesthetic surgery of the
aging face. Mosby, St. Louis, p 142
 Short-Scar Purse-String Facelift
Amir M. Karam, L. Mike Nayak, and Samuel M. Lam
22.1 Introduction
Despite the expanse of novel facial rejuvenation tech-
nologies available today, the gold standard for correction
of the senescent jaw line and neck remains rhytidectomy.
Facelift surgery has continued to evolve since the first
cases described nearly a century ago [16]. In many
ways, we have come full circle. In the early 1900s
through the 1970s, the original skin-only rhytidectomy
remained the predominate method. Following the identi-
fication of SMAS in the late 1970s, the surgical tech-
niques became increasingly more sophisticated and
complex. This continued through most of the 1990s and
peaked with the description of the composite facelift
technique described by Hamra [5].
These operations required a longer and slower learn-
ing curve and carried a considerably higher morbidity
and postoperative healing time. The question came up
by several surgeons: Do the results justify these more
involved procedures? The paradigm began to slowly
shift as surgeons began to realize that perhaps bigger
A.M. Karam
Carmel Valley Facial Plastic Surgery, San Diego, CA, USA
e-mail: md@drkaram.com
L.M. Nayak
Department of Otolaryngology-Head and Neck Surgery,
Nayak Plastic Surgery and Skin Enhancement Center,
St. Louis University, St. Louis, MO, USA
e-mail: mikenayak@gmail.com
S.M. Lam (*)
Willow Bend Wellness Center, Lam Facial Plastics Surgery
Center & Hair Restoration Institute, Plano, TX, USA
e-mail: drlam@lamfacialplastics.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_22, Springer-Verlag Berlin Heidelberg 2013
22
operations do not necessarily result in bigger or better
results. Innovative surgeons, such as Baker [7] and
Saylan [8], who developed the Lateral SMASectomy
and the S-Lift, respectively, began to popularize proce-
dures that focused on shorter incisions, supra-SMAS
dissection, and a vertically oriented lifting vector.
These concepts were in direct opposition to conven-
tional dictums. The rationale was simple; however,
these novel techniques illustrated the potential for
excellent naturally enhancing results, decreased poten-
tial morbidity, and surgical expediency. This became
the bases for their continued popularity.
22.2 The Evolution of the Short-Scar
Purse-String Facelift
In 1999, Saylan [8] reported on the S-Lift. Saylans
S-Lift was the first purse-string facelift and involved a
SMAS plication technique that was intended to provide
an even less invasive facelift procedure. It featured a
short, preauricular-only incision, short flap, and double
purse-string sutures that were anchored to the perios-
teum of the posterolateral zygomatic arch. The proce-
dure was intended to be performed under local anesthesia,
which was very appealing to many patients. Though the
technique was considerably more conservative, it deliv-
ered efficacious results for both men and women
between the ages of 40 and 50 years. The most obvious
shortcoming was the inability to significantly improve
the cervicomental angle and overall neck laxity.
Tonnard et al. (2002) [9] described the MACS
(minimal access cranial suspension) lift, which was a
significant advance in purse-string facelift. By per-
forming additional undermining onto the lateral face
323
324
a b
Fig. 22.1 (a) Before surgery. (b) One year following short scar purse-string facelift with a limited submentoplasty (Photo courtesy
of L. Mike Nayak)
and jowl region, adding judicious submental liposuction,
and using larger purse-string sutures to more effec-
tively capture the cranial border of the platysma, over-
all results were improved, especially in heavier faces
or those with more cervicomental laxity than the S-Lift
could correct.
In 2004, Brandy [10, 11] introduced a modification
of the S-Lift of Saylan. Since then, the operation has
continued to become more refined. Compared to the
original S-Lift, Brandys modified purse-string facelift
involves postauricular undermining, and undermining
of a larger region in the lateral neck, which more aggres-
sively corrects the platysma-SMAS complex. The lift is
more vertically oriented compared to the S-Lift, which
further corrects the cervical laxity. The ability to cor-
rect greater degrees of neck and jowl laxity broadens
the indications to include individuals of all ages.
This chapter is largely based on this modification and
A.M. Karam et al.
we owe credit to him for the advances he has made to the
purse-string facelift (Figs. 22.1 and 22.2).
22.3 Surgical Technique
22.3.1 Surgical Markings
Figure 22.3 illustrates the typical incision marking
used, beginning as a short, intensively beveled preau-
ricular trichophytic incision that continues into a
preauricular, posttragal incision. This incision then
continues for a variable degree into a postauricular
incision. In patients with mild laxity or excellent skin
tone, the incision may terminate at the base of the con-
chal bowl. In a very lax, photodamaged skin, the inci-
sion will likely need to be carried up to the helix-hair
touch-point, then back down the hairline as a beveled,
22 Short-Scar Purse-String Facelift 325

a b

Fig. 22.2 (a) Before surgery. (b) One year following short-scar purse-string facelift. This patient underwent simultaneous neck
liposuction and limited submentoplasty as well (Photo courtesy of L. Mike Nayak)

trichophytic occipital hair edge incision. Average
undermining distances are then drawn 5 cm anterior to
the tragus incision line, 5.5 cm anterior to the earlobe
along the angle of the mandible, and 6 cm inferior to
the earlobe (Fig. 22.4). In general, the less elastic the
skin, the more prone it is to postoperative sweeping
from a strictly vertical lift, and the more aggressive the
skin undermining will need to be to prevent this.
22.4 Anesthesia
When performed under local anesthesia, diazepam
10 mg is then administered orally, and a combination
of 2.5 mg of midazolam and 50 mg of meperidine
hydrochloride is given intramuscularly prior to the
initiation of the procedure.
The patient is then brought into the operating room
at which time the face is prepped with povidone-iodine
solution. The area to be undermined is infiltrated
with 0.25% lidocaine hydrochloride with 1:400,000
epinephrine using a 21 gauge spinal needle and making
certain to remain in the subcutaneous space.
In patients who have the presence of superficial
submental fat, a standard submental liposuction is
performed. In patients with a moderate degree of
submental platysmal banding, a medial platysmaplasty
is preformed to the level of the hyoid following the
elevation of a submental skin flap. Back cuts are made
in the platysma to enhance the cervicomental angle.
Next, an incision is initiated at the temporal hairline.
Subcutaneous undermining is begun with a Bard-Parker
No.15 blade and then completed using the facelift
scissors. The most critical aspect of the skin undermin-
ing is to make certain that the flap is not excessively
thin at the predicted site where the V-shaped advanced
flap opposes the scalp (at the superior attachment of
the pinna). This region is most susceptible to necrosis
and should be as thick as possible, without capturing the
superficial temporoparietal fascia. Upon completion of
326
Fig. 22.3 Surgical markings. The markings are begun on the
tragus and extend along the front of the ear and 3 mm behind the
temporal hairline. Notice how the line meanders along the anat-
omy of the ear. This creates a much less detectable scar. The line
is extended 2 mm above the posterior earlobe crease and is 4 cm
all of the aforementioned undermining, thorough
hemostasis is accomplished.
At this point in the procedure, the encircling double
purse-string submuscular aponeurotic system (SMAS)
plication is performed. First, 1/4% lidocaine hydro-
chloride with 1:400,000 epinephrine is injected into
the site of the anchor sutures. These injections are per-
formed with a 1-in. 30-gauge needle and are extended
all the way down to the zygomatic arch 1.5 cm away
from the skin edge of the tragus, which should be
safely behind the expected course of the frontal branch
of the facial nerve. The choice of suture is dependent
on the surgeons performance and ranges from 2 to 0
green braided nylon (Ethibond) to 0 or 1 purple poly-
dioxanone (PDS). The anchoring suture is placed
1.5 cm away from the skin edge, directly over the
posterior zygomatic arch. The suture needle should
scrape bone and should grasp the periosteum before
surfacing. The postero-superior position of the first
A.M. Karam et al.
in length. The hockey stick is usually 1.53.5 cm in length but
will vary in size depending upon the amount of excessive poste-
rior neck skin available for Burrows triangle excision during the
procedure (Photo courtesy of Dominic Brandy)
purse string is the anchor suture. The diameter of this
purse string is about 45 cm and extends down to the
cranial portion of the platysma just below the angle of
the mandible (Fig. 22.4). Each bite is roughly 1.5 cm
long, taking bites deep enough to engage the fibrous
SMAS (not just subcutaneous fat) but not so deep as to
jeopardize the facial nerve.
The second anchoring stitch is now performed
eccentric to the first. The needle enters 3 mm above
and 3 mm medial to the knot of the first purse string.
This anchor suture is placed in the periosteum of the
zygomatic arch similar to the first suture. Four to five
1.5-cm-long grasps through the SMAS are taken in a
directly inferior direction (Fig. 22.4), taking care to
continue well beyond the angle of the mandible before
turning anteriorly to ensure the capture of several
solid bites of the cranial border of the platysma in the
submandibular region. The remainder of the 1.5-cm-
long grasps follows the outer edge of the undermined
22 Short-Scar Purse-String Facelift
5 cm
1 cm
5.5 cm 4 cm
6 cm
a b
Fig. 22.4 (a) The undermining should be 1 cm below the
inferior border of the brow, 5 cm anterior to the tragus parallel to
the floor, 5.5 cm anterior to the earlobe along the mandible, 6 cm
directly inferior to the earlobe, and 2.54.0 cm away from the
earlobe crease. (b) Purse-string pattern. Following placement of
the first anchor suture, a series of 11.5 cm bites of fibrous
SMAS starting (posteriorly) and extending down toward the
angle of the mandible and then extending back up toward the
anchor point. The diameter of this first purse string is 45 cm. (c)
The second 1.5 cm anchor suture (indicated by grey) starts 3 mm
superior and 3 mm lateral to the first anchor sutures knot. Four
zone toward the periorbital region. The first four grasps
along the line of undermining will tighten platysma
with the remaining grasps tightening the SMAS. Note
the overlapping of the grasps in the lower neck and
midface areas (Fig. 22.4). These overlaps prevent
rip-through in an area where the tissues can sometimes
be frail.
When the second purse string arrives at the same
height as its origin anchor suture, 1.5-cm grasps of
SMAS are made toward this higher anchor suture
(3 mm above the first anchor suture). The last grasp,
before meeting the second anchor suture, should be a
third anchor suture creating a V-shaped double anchor-
ing point for the larger second purse-string suture. This
third anchor suture is not as deep as the first two but
should at least be 3 mm deep. Once again, five throws
of the suture are made and a 2-mm suture end is left.
As soon as the encircling double purse string is
completed, thorough hemostasis is accomplished and
the redundant skin is excised. The skin drape vector
can vary from patient to patient. While the vector usu-
ally has a predominantly vertical direction, in patients
with extensive photoaging, a more posterior skin drape
may be required to prevent upward striae in the healing
skin flap. The flap is inset using a combination of deep
327
c
to five 1.5-cm-long grasps of SMAS are made in a directly
inferior direction. The next four 1.5-cm-long grasps will be of
platysma and should follow directly behind the edge of skin
undermining. Once the surgeon has reached the same height as
the superior aspect of the second anchor suture, superficial
grasps are made directly toward the second anchor suture. The
last grasp of tissue before hitting the second anchor suture will
be the third anchor suture and should be 3 mm deep. The second
and third anchor sutures will thus create a V-shaped anchoring
point for the platysma, jowl, and midface (Figure courtesy of
Dominic Brandy)
5-0 polydioxanone (PDS) sutures. The deep sutures
from the temporal hairline to the superior attachment
of the ear are tacked down to the temporalis fascia.
These tacking sutures are critical for stabilization and
anchoring of the flap. Once these are completed, the
5-0 polydioxanone (PDS) sutures are placed through-
out the length of the remaining incision. After all deep
sutures are placed, the skin is sutured with a running
6-0 fast-absorbing gut suture.
Patients are asked to wash the incisions 3 times per
day with a mild soap. Antibiotic ointment is applied
to all incisions for 45 days. Antibiotics are typically
prescribed. A cold compress is placed under the chin
strap for the first 23 days. At 1 week, the patient can
apply water-based makeup to all incision sites. Patients
are seen in 1 week, 6 weeks, 3 months, and 1 year
postoperatively.
22.5 Complications
Complications were found to be rare with this approach.
The authors experienced a 1% incidence of flap skin
necrosis (>1 cm2) at the level of the superior helix.
Conservative wound care was used with spontaneous
328
resolution. Hematomas requiring evacuation occurred
at a rate of 1%. These were managed by simple aspira-
tion in the office on postoperative day 1 without the
need for re-exploration. Hypertrophic scarring of the
postauricular incision occurred in 1% of the cases.
This was managed with steroid injection without com-
plication or need for scar revision. There were no cases
of permanent or temporary facial nerve weakness. All
patients had temporary anesthesia over the undermined
area that resolved in approximately 3 months.
To date, the results have been extremely gratifying
with patient satisfaction being very high. Naturally, the
durability of the results must always be questioned
when evaluating a novel technique. Though the 1-year
photos shown in Figs. 22.122.3 illustrate anatomic
stability of the surgical outcomes, several studies have
evaluated this concept in comparative studies. In 1996,
Aston et al. [12] performed a prospective comparison
of limited incision and limited dissection techniques
(Lateral SMASectomy and standard SMAS) to more
extensive techniques (composite and extended SMAS
facelifts). The results did not illustrate a detectable dif-
ference in outcomes between these techniques. Their
conclusion was that the increased morbidity, surgical
risks, and convalescence associated with these more
extensive approaches may not be warranted in the aver-
age facelift patient. Later, Prada et al. [13] published a
split-face study comparing the Lateral SMASectomy
with the MACS lift (purse-string facelift). In this study,
at 2 years, there was no detectable difference in result
durability between the SMASectomy and the purse-
string facelift side. The overall conclusion of these
studies is that as long as something is done to funda-
mentally reposition and stabilize the SMAS and plat-
ysma, the results will be meaningful and enduring. As
an extension of this concept, the choice of technique
should be based on achieving the best results with the
least risk, morbidity, and convalescence.
22.6 Conclusions
A variety of surgical approaches exist to rejuvenate the
lower face and neck. When comparing these approaches,
it is tempting to focus primarily on the potential results
each of these procedures can achieve. However, it is
equally, if not more, important to remember that these
procedures are elective and cosmetic. Keeping this in
A.M. Karam et al.
mind, it is essential to balance the risk-benefit ratio
when comparing operative techniques. Patients today
are less accepting of long downtimes and relatively
high-risk exposure. They want meaningful results in
the safest way possible. In our experience, many
patients prefer improvement over perceived perfection
if it means less downtime, less risk, and lower potential
of having an unnatural or over-operated appearance. As
a result of its vertical advancement, the vertical purse-
string facelift combines the simplicity and safety of a
superficial rhytidectomy technique while providing
substantial rejuvenating outcomes to the lower face,
neck, and midface. Patient recovery ranges from 1 to
2 weeks. The potential for serious long-term complica-
tion (i.e., motor nerve damage or distorted facial soft-
tissue contour) is limited. To date, consistency and
patient satisfaction have been extremely high.
References
1. Lexer E (1910) Zur Gesichtplastik. Arch Klin Chir 92:749
2. Joseph J (1921) Plastic operation on the protruding cheek.
Dtch Med Wochenschr 47:287
3. Ramirez OM, Pozner JM (1996) Subperiosteal minimally
invasive laser endoscopic rhytidectomy: the SMILE facelift.
Aesthetic Plast Surg 20(6):463470
4. Toledo LS (1994) Video-endoscopic facelift. Aesthetic Plast
Surg 18(2):149152
5. Hamra ST (1992) Composite rhytidectomy. Plast Reconstr
Surg 90(1):113
6. Ullmann Y, Levy Y (2004) Superextended facelift: our
experience with 3,580 patients. Ann Plast Surg 52(1):814
7. Baker DC (1997) Lateral SMASectomy. Plast Reconstr Surg
100(2):509512
8. Saylan Z (1999) The S-lift for facial rejuvenation. Int J
Cosmetic Surg 7(1):1823
9. Tonnard P, Verpaele A, Monstrey S, Van Landuyt K,
Blondeel P, Hamdi M, Matton G (2002) Minimal access cra-
nial suspension lift: a modified S-lift. Plast Reconstr Surg
109(6):20742086
10. Brandy DA (2004) The QuickLift: a modification of the
S-lift. Cosmetic Dermatol 17:251360
11. Brandy DA (2005) The Quicklift: featuring an encircling
double purse-string plication technique with blunt neck/jowl
undermining for tightening of the sagging SMAS, platysma
and skin. Am J Cosmetic Surg 22(4):223232
12. Ivy EJ, Lorenc ZP, Aston SJ (1996) Is there a difference?
A prospective study comparing lateral and standard SMAS
face lifts with extended SMAS and composite rhytidecto-
mies. Plast Reconstr Surg 98(7):11351143
13. Prado A, Andrades P, Danilla S, Castillo P, Leniz P (2006)
A clinical retrospective study comparing two short-scar
face lifts: minimal access cranial suspension versus lateral
SMASectomy. Plast Reconstr Surg 117(5):14131425
 Modied Facelift
Phillip R. Langsdon and Courtney Shires
23.1 Introduction
Humans, by nature, have always sought to maintain
the appearance of youth. In ancient times, various skin
treatments, derived from wine and fruit were used in
an attempt to improve aging skin [1]. As the art and
science of medicine and surgery evolved over the last
century, the quest moved from the application of
creams and potions, into the operating room.
Hollnder [2] published an account of a surgical lift
performed in 1901 for the removal of excess facial skin
or wrinkles. Joseph [3] was the first to emphasize the
effect of aging skin on women trying to gain employ-
ment and the benefits of cosmetic surgery
The techniques for the facelift have continued to
evolve since those early reports. Techniques include
simple skin dissection, superficial musculoaponeurotic
system (SMAS) suspension, SMAS undermining, deep
plane, and extensive skin undermining; or various
combinations of the above. Additional treatments of the
forehead and eyelids may or may not be included with a
surgical facial rejuvenation procedure. This chapter
focuses on the mini facelift technique that treats the
lower cheeks and jowls. Depending on several factors,
the mini lift may or may not improve the neck. If the
neck tissues require significant improvement, then these
P.R. Langsdon ()
Division Facial Plastic Surgery, University of Tennessee
Health Science Center, Memphis, TN, USA
The Langsdon Clinic, Germantown, TN, USA
e-mail: langsdon@bellsouth.net
C. Shires
Department of Otolaryngology-Head and Neck Surgery,
University of Tennessee Health Science Center,
Memphis, TN, USA
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_23, Springer-Verlag Berlin Heidelberg 2013
23
tissues may require specific cervical surgical maneuvers
in addition to the upper mini lift procedure.
The mini lift is simply a more minor version of facial
suspension. There are variations of the mini facelifting
technique among surgeons, but the basic principle is the
same. The procedure is designed to resuspend the sag-
ging tissues. The theoretical difference between a mini
facelift and a facelift is that the mini facelift is less exten-
sive and causes less swelling and bruising. Therefore,
theoretically, the patients require less recovery time.
23.2 Indications
The ideal candidate is a patient with early facial sag-
ging who demonstrates a comprehension of the limita-
tions of the mini lift procedure. In my practice, the
details of the differences are usually discussed on three
occasions prior to surgery. Additionally, the patient must
understand that no surgical rejuvenation procedure can
remove facial asymmetries, improve the general facial
deflation that occurs with aging, halt aging, remove
wrinkles or facial expression lines, or restore the dete-
riorated condition of skin. Other techniques, not included
with the mini lift procedure, might be considered or
needed to address facial atrophic deflation, wrinkles,
skin deterioration, asymmetries, and/or future aging.
23.3 High Points
1. The SMAS (superficial musculoaponeurotic system)
layer is found deep to the subcutaneous fat and super-
ficial to the parotid fascia. The SMAS invests the
mimetic musculature of the face and neck. It is
329
330 P.R. Langsdon and C. Shires

generally thought to be continuous from the tem-

poroparietal fascia to the platysma [46]. The SMAS
is also inclusive of the orbicularis oculi and orbicu-
laris oris muscles [46]. This connection and invest-
ment system allows for plication and/or imbrication
of the SMAS to support the sagging system and add
longevity and efficacy to a facelift. The SMAS is
directly connected to the skin in the central portion of
the face, contributing to support in this area when the
system is suspended laterally and superiorly. It is the
opinion of the senior author that skin suspension
alone does not provide the longevity of results that
can be obtained by also suspending the SMAS.
2. The mini facelift involves limited skin undermin-
ing; this is an advantage in patients who smoke and
desire some facial rejuvenation. Hematoma forma-
tion is also less likely with a short skin flap. Fig. 23.1 Patient preoperative marking
3. A mini lift targets early to moderate jowling and will
not improve any condition or region of the face not
included in the procedure. For instance, significant
submental tissue and platysmal banding, will not be
improved as it would with a lower facelift performed
in conjunction with submental muscular plication
and extensive skin redraping. Other procedures might
be needed and/or recommended and the patient
should understand that volume replacement and skin
wrinkle improvement will not occur with a mini lift.
Ancillary procedures such as neck liposuction with
or without platysmal plication, chin augmentation,
forehead procedures, and upper and lower blepharo-
plasty may be performed along with the mini lift.
Volume replacement or skin resurfacing may also be
needed in some patients. It should be fully explained
what reasonable results are possible with differing
techniques and patients should understand and accept
the limitations of this procedure.
4. Anesthetic technique for this procedure varies from
surgeon to surgeon, and from patient to patient. The Fig. 23.2 Patient preoperative marking
author attempts to use oral or intravenous (IV) seda-
tion. The medication selected depends on the emergency medications should be present. In our
patients health and expected response to several facility, the patient is administered diazepam 20 mg
different medications. orally, dramamine 200 mg orally, and prednisone
40 mg orally 1 h prior to surgery. An oral antibiotic
is also administered. It may take an hour or slightly
23.4 Surgical Technique longer for the diazepam to have full effect. Patient
(Figs. 23.123.11) tolerances vary.
Local anesthesia includes 1% xylocaine containing
Sedation should best be undertaken in a facility with 1:100,000 epinephrine buffered with NaHCO3 to
strict guidelines and regulatory oversight. All emer- anesthetize the incision lines and the circumferen-
gency equipment, proper personnel, and appropriate tial periphery of the flap margins. The area to be
23 Modified Facelift 331

Fig. 23.6 Suture directed inferiorly

Fig. 23.3 Elevated flap

Fig. 23.4 Beginning suture through the periosteum of the zygo-

matic arch Fig. 23.7 Suture directed anteriorly

Fig. 23.5 Suture directed inferiorly Fig. 23.8 Suture directed superiorly
332
Fig. 23.9 Suture directed again through the periosteum of the
zygomatic arch
Fig. 23.10 Suture plicating the depression created by the lifting
suture
undermined is injected with 1/2% xylocaine contain-
ing 1:200,000 epinephrine. Intravenous sedation is
optional, but can be very helpful during the injection of
local anesthesia. If offered, the patient should be moni-
tored in an appropriate setting. Intravenous sedation
is usually delayed until the oral diazepam has been
fully absorbed (11.5 h). We accomplish intravenous
sedation with diazepam in 2.5 mg doses and/or
P.R. Langsdon and C. Shires
Fig. 23.11 Skin repaired and patient ready for dressing. The
nylon suture was not used in this patient
hydromorphone in 0.25 mg or 0.5 mg doses adminis-
tered in 5 min intervals until the patient is relaxed. The
5 min interval allows for complete circulation and time
for the physician to adequately observe the impact of
the dose upon respiration, before additional sedation is
administered.
The author believes in preserving the temporal side-
burn at the level of the superior portion of the ear.
Therefore a horizontal mark is usually placed in this
location to prevent the migration of hair to a point
superior to the cephalic portion of the ear. The result-
ing incision may then be reused in future facial rejuve-
nation procedures without elevation of the sideburn
area and loss of temporal hair.
The marking is continued in the preauricular groove
found just in front of the curvature of the auricle. In
female patients, a post-tragal mark (12 mm behind
the tragus) is incorporated to hide the scar. In male
patients, the incisional mark is usually carried in front
of the tragus in a preauricular crease. Usually, an area
of non-hair-bearing skin between the tragus and side-
burn is preserved in male patients. The mark then
curves around the earlobe.
Postauricularly, the incisional mark is carried into the
postauricular sulcus. Some surgeons stop the incision
low in the postauricular sulcus. However, some patients
find the resulting bunching of skin, however temporary,
to be unsatisfactory in the early postoperative period.
23 Modified Facelift
Therefore, the mark is extended up the postauricular
sulcus and on to the posterior hairline, forming a short
gentle curve along the hairline. This extension of the
postauricular incision allows for removal of excess skin
and the prevention of bunching.
The extent of skin undermining is marked approxi-
mately 4 cm from the incision site.
A #15 blade is used to make the incisions in the
preoperative periauricular markings. The incision is
carried through the dermis and is beveled across the
direction of the hair follicles in hair-bearing temporal
and posterior hairline skin. This maneuver allows the
hair to grow through the incision line.
The skin is then undermined beginning at the tra-
gus, leaving as much subdermal tissue as possible
attached to the deep tissue. A thin tragal flap mini-
mizes tragal contracture during the postoperative
healing phase. The remainder of the facial skin is then
fully undermined in a supra-SMAS (subdermal) layer
to a point averaging 4 cm from the incision, following
the preoperative marking plan. Hemostasis is achieved
with bipolar cautery under direct visualization.
With the skin flap adequately elevated, the SMAS
is then plicated in a posterior-superior vector using
2-0 Vicryl suture. The suture is secured at the zygo-
matic periosteum and placed through the SMAS, creat-
ing a purse string loop. The suture is first continued
inferiorly, then directed anteriorly, and then posterior-
superiorly to return back to the zygomatic periosteum,
creating a teardrop loop. This SMAS suture often leaves
a trough deformity that is closed with interrupted plica-
tion sutures across the depression. Free fat grafts are
placed as necessary to fill suture depressions.
The skin is draped in a posterior-superior vector
and secured at the highest postauricular point with
an interrupted 2-0 nylon suture. This is followed by a
second securing suture at the junction of the horizontal
temporal incision and the superior extent of the preau-
ricular incision. The redundant skin is then resected in
a manner creating minimal skin tension. The neotragal
skin is left redundant to avoid displacement of the
tragus by skin contracture. The earlobe is placed in a
position that is about 1/23/4 cm superior to the posi-
tion where it naturally lies in the unrepaired state. This
overcorrection prevents the lobe from being pulled too
far inferiorly during the natural tissue relaxation pro-
cess that occurs over the first postoperative year, thus
preventing the pixie ear lobe deformity. Skin edges are
333
approximated with a 5-0 plain gut suture. Deeper 4-0
Vicryl may be placed prior to skin repair if additional
support is necessary. The postauricular crease closure,
above the posterior portion of the ear lobe and below
the level of the hairline is performed in a manner that
leaves 1-cm gaps between sutures. This loose closure
allows any excess tissue fluids or blood to escape.
Just prior to applying the dressing, any collected
blood is expressed from under the flaps via the postau-
ricular closure gaps. A light dressing is applied with 4 4
gauze pads and a cotton wrap, applying only very gentle
pressure. A light elastic wrap is placed over the dressing.
The elastic wrap is removed 4 h after placement. Excess
dressing pressure could prevent natural subdermal blood
flow and is avoided as much as possible.
The patient is evaluated the following day. The
remaining dressing is removed and the incisions are
cleaned with hydrogen peroxide and dressed with
Vaseline.
23.5 Complications
Complications occur with any surgical procedure and
the mini lift is no exception. However, mini lift sur-
gery should have less opportunity for complications
than a full facelift since there is less tissue undermin-
ing. Hematoma formation is possible but can be mini-
mized with meticulous surgical hemostasis, proper
patient selection, and cessation of all medications,
herbs, vitamins, and red wine that may cause bleed-
ing. All patients should be counseled to discontinue
medications, herbs, vitamins, etc. that may cause
bleeding 2 weeks prior to surgery. Large hematomas
should be treated to avoid skin flap necrosis, but the
senior author has not seen large hematomas associ-
ated with this limited flap procedure. If a small accu-
mulation of blood is seen the following morning it is
usually easily expressed through the post-auricular
skin closure gaps.
Flap necrosis might occur at the distal ends of flaps
where blood supply is most tenuous. This is a very infre-
quent occurrence with limited flap elevation and would
most commonly be an issue in heavy smokers, who are
not consciously accepted as patients. Caution should be
exercised in smokers or patients with diabetes, collagen
vascular disease, or Raynauds disease. However, the
senior author does not consider these situations or
334 P.R. Langsdon and C. Shires

a b

Fig. 23.12 (a) Preoperative patient. (b) Postoperative following minilift with forehead lift

conditions necessarily as contraindications to mini lift- 23.6 Conclusions

ing. Smokers should be counseled to reduce or discon-
tinue smoking at least 2 weeks prior to surgery.
Sensory or motor nerve injuries are possibilities.
Sensory reduction is common and not considered a
complication; rather a normal consequence of surgery.
The senior author has never experienced a major motor
or sensory nerve injury. Masterful knowledge of facial
nerve and greater auricular nerve anatomy will prevent
most major nerve injuries. Compression nerve injuries
usually resolve with time.
Deep infection should be rare, as should cellulitis.
Antibiotic prophylaxis is used routinely.
The mini lift is not a replacement for a classic face-
lift, but it provides an option for patients who do not
present with advanced facial aging or those who are
unwilling to undergo a more extensive procedure
(Fig. 23.12). There is relatively less risk, less morbid-
ity, less surgical time, and less down time for the mini
lift patient. Patients also enjoy the reduced postopera-
tive restrictions. The mini lift has proven to provide a
high degree of patient satisfaction for those who
understand the limitations, are realistic, and are emo-
tionally stable.
23 Modified Facelift
References
1. Yarborough JM, Beeson WH (1986) Aesthetic surgery of the
aging face. Mosby, St. Louis, p 142
2. Hollander E (1932) Plastische (kosmetische) Operation:
Kritische Darstellung ihres gegenwartigen Standes. In:
Klemperer G, Klemperer F (eds) Neue Deutsche Klinik.
Urban and Schwartzenberg, Berlin
3. Joseph J (1928) Verbesserung meiner Hangewangenplastik
(Melomioplastik). Dtsch Med Wochenschr 54:567
4. Gossain AK, Yousif NJ, Madiedo G, Larson DL, Matloub
HS, Sanger JR (1993) Surgical anatomy of the SMAS: a rein-
vestigation. Plast Reconstr Surg 92(7):12541263
5. Ghassemi A, Prescher A, Riediger D, Axer H (2003) Anatomy
of the SMAS revisited. Aesthetic Plast Surg 27(4):248264
6. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C
(2003) The fascial planes of the temple and face: an en-bloc
anatomical study and a plea for consistency. Br J Plast Surg
56(7):623629
335
General References
Baker TJ, Gordon HL (1971) The temporal face lift (mini-lift).
Plast Reconstr Surg 4(4):313315
Duminy F, Hudson DA (1997) The mini rhytidectomy. Aesthetic
Plast Surg 21(4):280284
Fulton JE, Saylan Z, Helton P, Rahimi AD, Golshani M (2001)
The S-lift facelift featuring the U-suture and O-suture com-
bined with skin resurfacing. Dermatol Surg 27(1):1822
Onizuka T, Hsaka Y, Miyata M, Ichinose M (1995) Our mini-
facelift for orientals. Aesthetic Plast Surg 19(1):4958
Saylan Z (1999) The S-lift: less is more. Aesthet Surg J 19:406
Stephenson KL (1970) The mini-lift, and old wrinkle face
lifting. Plast Reconstr Surg 46(3):226233
Tonnard PL, Verpaele A, Gaia S (2005) Optimising results from
minimal access cranial suspension lifting (MACS-lift).
Aesthetic Plast Surg 29(4):213220
 Subperiosteal Face-Lift
Lucas G. Patrocinio, Tomas G. Patrocinio,
Jose A. Patrocinio, and Marcell M. Naves
24.1 Introduction
Fullness of the cheek represents youthfulness. It is
important to understand the anatomic changes associated
with aging and have a clear vision of what needs to be
accomplished for correction. Aging process initiates
during the third decade, affecting the lower lid and
midface together, and in response to gravitational
forces, the fat and soft tissues of the cheek drift down-
ward in relation to the underlying bony skeleton. In
this process of aging, a constant hollowness of the
midface develops. As a result, a patient may display an
appearance that is tired, old, or sad [1].
Weakening of the malar and orbital ligaments is a
major component of the aging process. The result is a
downward and medial displacement of the malar fat pad
and other soft tissues over the fixed ligaments of the
nasolabial fold. The fat over the malar eminence is left
standing, accentuating the malar bag. Another anatom-
ical change that occurs is the weakening of the orbital
ligaments, which contributes to hollowness under the
orbit. The malar fat pad, which in youth was at the
level of the orbital rim, falls downward and medially,
producing this hollowness. This concavity, which is
below the convexity of the ocular globe and orbital fat,
L.G. Patrocinio (*) T.G. Patrocinio J.A. Patrocinio
M.M. Naves
Division of Facial Plastic, Department of Otolaryngology,
Medical School, Federal University of Uberlandia, Uberlandia,
MG, Brazil
e-mail: lucaspatrocinio@clinicaotoface.com.br
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_24, Springer-Verlag Berlin Heidelberg 2013
24
accentuates and no longer covers the bulge of herni-
ated orbital fat. This produces the double contour
deformity characteristic of the aging orbital/midface
complex. The vertical aperture of the eye elongates,
creating a more round shape with increasing scleral
show. As tarsoligamentous laxity increases, the lateral
commissure often descends, creating a more inferior
slant from medial to lateral commissure. Eyelid tone
decreases, exhibited by skin and muscle laxity. A volume
loss of the midface also contributes to the aging pro-
cess. Finally, the collapse of the zygomaticus major
and minor muscles, which suspend the ligamentous
and muscular connections of the midface, results in a
droop of the corner of the mouth and deepens the
labiomental fold (Fig. 24.1) [2].
The purpose of the face-lift procedure is to reverse
the aging process that has occurred. This can be
achieved through various techniques that have been
developed to date. The evolution of face rejuvenation
consists in deciding which facial plane is going to be
accessed [3].
On the beginning of the twentieth century, the prior
technique consisted of interrupted incisions placed both
in front of and behind the ears in natural wrinkles and
were combined with limited strips of excised skin [4, 5].
Then, there were the first descriptions of extensive skin
undermining and lipectomy. More recently, the discov-
ery of the SMAS (superficial musculoaponeurotic sys-
tem) improved the technique (plication, suture, partial
sectioning, etc.), aiming long-lasting results. Trying to
address the nasolabial fold, which so far has not been
modified by other techniques, the deep plane and com-
posite face-lift were describe. They consisted in a
deep SMAS dissection, accessing the nasolabial fold;
337
338 L.G. Patrocinio et al.

Fig. 24.1 (Left) Youthful

contours. (Right) Aged Aging face Youthful face
anatomical findings

Increased
Short vertical
vertical eyelid
eyelid lenght
length

Periorbital
Inferior orbital
hollowing
rim

Tear trough
deformity High malar fat
pad
Low malar
fat pad
Soft nasolabial fold
Proeminent
nasolabial fold

Platysmal ptosis

Jowling

however, its use has been increasingly questioned
because of the risk of facial nerve injury [6]. Moreover,
Barton, in 1992, showed with histologic sections as well
as cadaver and clinical dissections that the SMAS
became the investing fascia of the zygomaticus major
and minor muscles in the medial cheek, providing sup-
port for the clinical finding that the nasolabial crease
was minimally improved by traction on the SMAS [7].
Recent studies emphasize the central third of the
face, often referred as midface, the most difficult region
of the face to effectively address. In 1979, Paul Tessier
[8, 9] revolutionized the treatment of the aging face
reducing signs of aging in young and middle-aged patients.
He applied his innovative and extensive experience
in craniofacial surgery to aesthetic plastic surgery by
utilizing the subperiosteal approach in the upper and
middle thirds of the face with an extensive coronal inci-
sion. Following the studies of Tessier, Psillakis [1012],
Santana [13], and others have improved the application
of subperiosteal dissection in face rejuvenation. Isse
[14] and Ramirez [1517] led to the popularization of
this technique in United States with the introduction
of the endoscope. Others described correction of mid-
facial aging using the transblepharoplasty approach
[1820]. To address the atrophy of soft tissues, particu-
larly the subcutaneous fatty layer, other techniques
were described [2125].
The authors describe their preferred technique for
subperiosteal face-lift and discuss its indications, com-
plications, advantages, and limitations.
24 Subperiosteal Face-Lift 339

Table 24.1 Patient classification with lower-lid and/or midfacial changes

Group Characteristics Surgical technique
1 Postseptal fat herniation with taut skin; no lower-lid skin laxity Transconjunctival blepharoplasty
or excess and no midfacial changes (young patients)
2 Laxity and/or excess of lower-lid skin, with or without postseptal Transblepharoplasty fat reposition
fat herniation; minimal midfacial changes or vertical descent of
the malar soft tissue
3 Lower-lid aging with descent of lid/cheek junction; skeletalization Subperiosteal transblepharoplasty midface-lift
of the orbital rim and deepening of the nasolabial fold; no lower-
lid malposition or deformities of the lateral canthus
4 Lower-lid aging with descent of lid/cheek junction; skeletalization Transtemporal midface-lift
of the orbital rim and deepening of the nasolabial fold; lower-lid
malposition (scleral show)

24.2 Preoperative Evaluation In this chapter, the transtemporal endoscopic sub-

A complete medical history has to be obtained before
any aesthetic surgery of the face, including allergies,
medications, medical problems, previous surgery, drink-
ing, and smoking habits. Smoking cessation is advocated
before and after surgery; however, patient disagreement
may not affect final results due to the thickness of the
flap created during the subperiosteal face-lift. As well,
emotional and psychological evaluation is important for
elective aesthetic surgery. Preoperative photographs are
essential, helping on preoperative planning, intraopera-
tive decisions, patient communication, and medicolegal
documentation. At the time of the preoperative consulta-
tion, the patients are oriented about the planned procedure
with written and verbal information provided. Written
informed consent is also requested [3].
Subperiosteal face-lift is especially advantageous to
patients who had undergone other face-lift procedures,
need skin resurfacing and/or soft tissue augmentation (fat
graft or alloplastic implants). The association to forehead-
lift is common and produces excellent results [26, 27].
Ramirez [1517] and Psillakis [1012] demonstrated that
subperiosteal face-lift could be applied across the full
spectrum of facial aging.
24.3 Patient Classication
and Approach Selection
A preoperative classification of patients is essential for
both diagnosis and approach planning. Each one of the
following categories represents patients with specific
lower-lid and/or midfacial changes (Table 24.1).
periosteal face-lift (Group 4) is described, which is the
technique the authors use most often.
24.4 Surgical Technique
The surgery is usually performed with the patient
under sedation, and local anesthesia (2% lidocaine
with 1:100.000 epinephrine) is infiltrated in all areas of
planned surgery for anesthesia and vasoconstriction.
The surgeon is positioned upwind to the patients head
and the video on the left.
Important anatomic structures to consider are the
frontal branch of the 7th nerve and the infraorbital neu-
rovascular bundle. The important dissection planes
include the dissection deep to the temporoparietal fas-
cia along the deep layer of the deep temporalis fascia
and the subperiosteal midface dissection. The surgical
technique is divided into 3 major steps: (1) the endo-
scopic creation of a temporal pocket, (2) mobilization
of the midface by subperiosteal dissection, and (3) ele-
vation and suspension of the mobilized midface to the
deep temporalis fascia.
On the temporal region, a 35 cm incision, perpen-
dicular to the temporal line, is placed 3 cm behind the
hairline. The dissection is performed to identify the
deep layer of the deep temporalis fascia (Fig. 24.2). As
the pocket is enlarged, the endoscope is introduced for
visualization. The frontal branch of the 7th nerve is
contained in the overlying temporoparietal fascia,
which is analogous to the SMAS found in the lower
face, facilitating the mobilization of the entire zygo-
matic arch periosteum and protecting the frontal branch
340
Fig. 24.2 Cadaver dissection showing the temporoparietal fascia
(forceps) and the underlying deep temporalis fascia
of the facial nerve from injury. Identification of the
superficial temporal fat pad is an important landmark
that assures the surgeon that the frontal branch of the
facial nerve is lateral to the endoscope.
The dissection continues medially and inferiorly
exposing the medial third of the zygomatic arch and
orbital rim. An incision is made on the zygoma perios-
teum, and lower subperiosteal elevation is performed
to malar imminence, gingival buccal sulcus, and naso-
labial fold. It is important to respect the arcus margin-
alis, the confluence of the periosteum of the orbital rim
and the periorbital tissues, in order to minimize the
risk of edema and lid eversion in the final result. Care
is taken to avoid damage to the infraorbital nerve.
The dissection is extended to the pyriform aperture
medially, the oral vestibular mucosa inferiorly, and the
superior/anterior border of the masseter muscle later-
ally. All the dissection detach the eyelids, external can-
thi and Lockwood ligaments, parotid fascia inferiorly
and temporalis fascia superiorly, zygomatic muscles
and levator labii superioris, and other muscles from
their superior origins (Fig. 24.3). The periosteum is
very thin medially and a careful dissection avoids mus-
cle injury. Complete periosteum release and division
must be accomplished to avoid incomplete suspension.
The final step involves suspension of the mobilized
midface to the deep temporal fascia by using three 3-0
polyester sutures (Ethibond, Ethicon, Inc., Somerville,
NJ) to secure the cheek. The sutures are crossed
and secured to the deep temporalis fascia, creating
appropriate superior and lateral vectors of force.
Systematization of the midface-lifting is made by three
L.G. Patrocinio et al.
Fig. 24.3 Extent of undermining for the transtemporal subpe-
riosteal face-lift
main points: Bichats fat pad, malar fat pad, and subor-
bicularis oculi fat (SOOF) (Fig. 24.4). The first point is
the B point (Bichats fat pad). It is located in a point
of intersection of a vertical line from the lateral canthus
and a horizontal line from the nasal base. Suspension
of this point promotes volumetric augmentation of the
midface, elevation of the corner of the mouth, and res-
toration of a triangular face. The second point is the
M point (malar fat pad), and it is located in a point of
intersection of the same previous vertical line and a
horizontal line from the superior margin of the nasal
ala. The third point is the S point (SOOF). This point
is located in a point of intersection of a vertical line
form the most lateral portion of the brow and a hori-
zontal line from the inferior orbital rim.
These three previously marked points are lifted
using Casagrande needle [28] (similar to Reverdin nee-
dle, but smaller) for passing the 3-0 polyester suture
(Fig. 24.4). The needle is introduced transcutaneously
through the B point and, with endoscopic view, is
driven through the temporal incision. Then, the polyes-
ter suture is passed through the needles guide-hole and
is returned to the Bichats fat pad area. Keeping the
24 Subperiosteal Face-Lift
Fig. 24.4 The systematization of the three main points for mid-
face-lifting: Bichats fat pad (B point), malar fat pad (M point),
and suborbicularis oculi fat (S point)
needle inside the soft tissues, a change of direction is
performed to grasp more tissue, and the needle is driven
to the temporal incision again. There, the suture is
removed from the needle and it sutured to the deep tem-
poralis fascia. The same procedure is performed at the
M point and the S point, bilaterally (Fig. 24.5).
At the deep temporalis fascia, the Bichats fat pad is
suspended and sutured medially, the malar fat pad cen-
trally, and the SOOF laterally. Such fixation lengthens
the zygomatic muscles and the soft tissue of the cheeks,
correcting tear-trough deformity, softening the nasolabial
fold. The zygomatic area is also well modeled because
the zygomatic muscle insertions are reinserted in a
higher position. Both sides must be suspended and fix-
ated concomitantly (interchanging one suture of each
side) to avoid asymmetries (Fig. 24.6).
The temporal scalp incision is closed by securing the
temporoparietal fascia from the anterior edge of the
incision to the deep temporalis fascia posteriorly. The skin
341
is sutured with uninterrupted 4-0 nylon (Ethilon,
Ethicon, Inc., Somerville, NJ).
24.5 Postoperative Care
Compressive bandage is kept during the first 610 h
postoperatively.
Supportive taping is placed for 7 days.
Another bandage is used for 7 days more after tap-
ing is removed.
Lid incision skin stitches are removed in the 7th
postoperative day.
Temporal incision skin stitches are removed in the
10th postoperative day.
Antibiotics are started prior to surgery and contin-
ued for 7 days after surgery.
24.6 Pitfalls and Complications
In spite of all care during the surgery, complications can
occur. Prevention of complications is the best approach
to managing them. Well-recognized complications of
face-lift surgery include hematoma, hair loss, skin slough,
hypertrophic scarring, infection, and motor nerve or sen-
sory nerve injury. Major complications including cardio-
pulmonary emergency, anesthetic disaster, or death are
fortunately extremely rare [29, 30].
Hematoma and seroma are the commonest complica-
tions after face-lift. Major hematomas occur in the first
1012 h postoperatively, due to hypertension, medica-
tion use, bleeding abnormality, intraoperative technique,
cough, retching, and agitation. Expanding hematoma is a
feared complication requiring prompt return to operative
room for inspection, hemostasis, supportive taping, and
compressive dressing. Due to the bloodless plane of dis-
section, hematomas are extremely rare. Small hemato-
mas and seromas can be either observed, needle aspirated,
or rolled through openings in the incision.
Long-lasting edema, sometimes more than 3 months,
may occur and is due to the extensive undermining,
especially at the zygomatic arch. It is advocated to avoid
dissection over the whole zygomatic arch. Massage is
recommended after 7 days of surgery.
Nerve injury is one of the frightening complications
by patients. Nerve damage is frequently transient as a
result of anesthetic infiltration, direct injection into the
nerve, blunt dissection injury, edema of the nerve
342 L.G. Patrocinio et al.

Fig. 24.5 Midface suspension by sutures

anchored to the deep temporalis fascia

Fig. 24.6 (Left) Preoperative iatrogenic ectropion caused by superiosteal face-lift, in which lid skin excision was performed after
midface suspension. (Right) Postoperative outcome of the correction with canthoplasty and skin graft
24 Subperiosteal Face-Lift
Fig. 24.7 (Left) Preoperative. (Right) Immediate postoperative outcome of the midface-lift when the surgeon pulls the sutures
sheath, traction, or cautery trauma. Injury of branches
of the facial nerve can be prevented with a careful dis-
section under the superficial layer of the deep temporal
fascia, as the temporal branch of the facial nerve is
located superficially within the temporoparietal fascia.
Temporary numbness is caused by interruption of
small sensory branches. Sensibility always recovers,
although it may take months to do so.
Hypertrophic scarring is frequently attributable to
excessive tension on the incision closure. Nevertheless,
some patients develop hypertrophic scars despite the
best efforts of the surgeon. Diluted triamcinolone can
be injected into the scars, and usually improves the
appearance of the scar considerably.
Asymmetries are rare. They are usually due to the
learning curve of the procedure. Careful bilateral suture
of the three points of suspension using the lateral can-
thus as a parameter is an important rule to follow. An
augmentation of the face width may be noted, due to fat
pads repositioning in a superior and lateral position.
When using the transblepharoplasty lower-lid app-
roach, there are other concerns. We should be careful
to avoid complications as lateral orbital skin excess, can-
thal deformity, and lower-lid malposition.
343
The lateral orbital skin excess can be avoided by:
maximizing the lateral skin excision via temporal-brow
incisions; and by a wider preperiosteal lateral and supe-
rior undermining via the lateral extensions of the lower-
lid incisions, allowing the lateral orbital tissues to more
effectively redrape with elevation of the brow.
Lateral canthal anchoring procedures are used to
provide excellent lid support and avoid canthal defor-
mity. A simple canthopexy is used in most of the cases.
Canthotomy with horizontal lower-lid shortening is
used only in older patients who exhibit more severe
degrees of laxity.
The lower-lid malposition can be avoided by a
suture fixation of the musculoligamentous cheek flap
to the periosteum of the lateral orbital rim and deep
temporal fascia, providing secure elevation of the mid-
face and minimizing postoperative midfacial descent.
By performing the skin excision as usual for an iso-
lated lower-lid blepharoplasty, and before the subpe-
riosteal cheek lift is performed, the amount of skin
excision is reduced compared with performing the skin
excision after the cheek lift has been performed and
stabilized to the lateral orbital rim, avoiding lower-lid
skin overresection (Fig. 24.7).
344
Patient satisfaction is imperative for face-lift sur-
gery. Although physicians try to help patients under-
stand why complications occur, patients do not fully
expect that complications will happen to them. Indeed,
any complication detracts from the quality of the out-
come. As such, it is difficult for both surgeons and
patients to accept complications.
24.7 Discussion
The earliest recorded contributions to the field of facial
plastic surgery came from ancient Egypt and India
over 2,500 years ago. In 1901, surgeons in Germany
performed the first modern face-lift [4]. In these proce-
dures, they excised ellipses of facial skin without any
tissue undermining. In 1920 and 1921, Bettman [31]
and Bourguet [32] were independently credited with
the first subcutaneous rhytidectomy. Unlike previous
procedures, this one consisted of extensive undermining
and lipectomy. This subcutaneous face-lift was the face-
lift most commonly performed prior to the 1970s.
Subcutaneous dissection of a variably sized skin flap in
the face and neck is performed, followed by redraping
of the skin flap, excising the excess skin, and closing
the incisions, mostly indicated on young, thin individ-
uals with minimal ptosis of deep structures and no sub-
mental fullness. Advantages of this technique include
ease of operation, limited postoperative edema due to
limited dissection, no risk of facial nerve injury, and a
smooth contour of the face immediately following the
procedure. The major disadvantage of the subcutane-
ous lift is the fact that the deeper tissues of the neck
have not been lifted.
More recently, technique modifications have occurred
to address the dissatisfaction with the lack of long term
correction that occurred with the classic skin under-
mining from the procedures described in the early
1900s. In 1974, Skoog [33] described a technique in
which the fascia and platysma muscle were under-
mined to the level of the nasolabial fold and jowl in an
attempt to address the lower third of the face. In 1976,
the discovery of the superficial musculoaponeurotic
system (SMAS) by Mitz and Peyronie [34] confirmed
the existence of a fascial layer investing the facial
mimetic musculature. It is also important to note that
this was the first approach that advocated the effective-
ness of imbrication as a rhytidectomy technique. The
SMAS may be incorporated into the face-lift operation
L.G. Patrocinio et al.
in several ways. Making an effort for a long-lasting
procedure, the SMAS dissection and plication, or par-
tial sectioning can be done; however, this procedure
has a longer learning period.
During the past 30 years, various modifications and
changes to these traditional face-lift techniques have
been developed. These have varied in scope, incisions,
and level of tissue dissection.
In 1979, Tessier [9] applied his innovative and
extensive experience in craniofacial surgery to aes-
thetic plastic surgery by utilizing the subperiosteal
approach in the upper and middle thirds of the face.
His extensive use of the coronal incision allowed him
to effect increased lifting of the temporal region and
the lateral canthus by a subperiosteal dissection of the
zygoma down to the maxilla, thereby reversing the
changes in midfacial aging.
In the 1980s, the emphasis turned to improving the
midface, traditionally the most difficult region of the
face to effectively address. This was accomplished
through the introduction of the deep plane and com-
posite rhytidectomy, which was pioneered by Hamra
[35]. He realized that by undermining the orbicularis
oculi muscle through a lower blepharoplasty approach
and joining this with the face-lift dissection, he could
create a composite flap that was composed of the orbic-
ularis oculi, cheek fat, and platysma muscle. Reposi-
tioning the composite flap corrected these three ptotic
areas while maintaining their relationship with each
other and the skin. The SMAS and skin are dissected
together as a single flap, rather than independently.
The advantage of this procedure is that theoretically
the flap is better vascularized and less likely to
slough. The disadvantage of the technique is the mag-
nitude of the procedure and the prolonged recovery
period, and a higher risk of nerve damage.
Barton, in 1992, [7] showed with histologic sections
as well as cadaver and clinical dissections that the
SMAS became the investing fascia of the zygomaticus
major and minor muscles in the medial cheek, provid-
ing support for the clinical finding that the nasolabial
crease was minimally improved by traction on the
SMAS.
Psillakis et al. [1012] described the subperiosteal
midface-lift as an open, nonendoscopic procedure.
Their technique involved subperiosteal dissection of
the midface through a coronal incision in combination
with an eyebrow lift. They thought that since the
SMAS was firmly attached to the periosteum through
24 Subperiosteal Face-Lift
the facial muscles, subperiosteal undermining was
necessary for adequate mobilization of the cheek.
Isse [14] and Ramirez [1517] were pioneers in devel-
oping the endoscopic approach to the midface. Ramirez
noted that the midface dissection had several compo-
nents, which required careful elevation of the suborbicu-
laris oculi fat pad with the underlying periosteum along
the inferior orbital rim and malar areas. By starting his
dissection in the temporal area and creating a tunnel
between the malar-zygomatic arch and the temporal
pocket, he was able to suspend the midface suborbicu-
laris oculi fat pad to the temporal fascia. He approached
the zygoma from the superior direction along the deep
temporalis fascia as Psillakis did. However, at 23 cm
above the arch, he incised both the superficial and deep
layers of the deep temporalis fascia to gain access to the
zygomatic arch to separate the periosteum and overlying
soft tissue, as the frontal branch of the 7th nerve remained
superficial to their dissection. He suspended the midface
by placing sutures through the periosteum and the SOOF
and the periosteum just superior to the zygomaticus
major origin. Each suture was then secured to the deep
temporalis fascia.
Several authors have advocated the nonendoscopic
elevation of the midface through lower-eyelid blepharo-
plasty incisions. In 1996, Hester, Codner, and McCord
[18] published The Centrofacial Approach for Corr-
ection of Facial Aging Using the Transblepharoplasty
Subperiosteal Cheek Lift. This technique was designed
to correct midfacial aging by a central, direct approach,
avoiding extensive peripheral to centra11.6 ptl dissec-
tion in the subcutaneous, subSMAS, deep plane, or sub-
periosteal plane. In 1996, Cardim [19] described a
subperiosteal blepharoplasty to correct midface aging.
Similar to this technique, in 1997, Paul [20] published
the periosteal hinge flap as a method of correcting mid-
face aging. This technique produced vertical elevation
of the midface by suspending the subperiosteal cheek
flap to a dissected orbital rim periosteal flap. Canthopexy
was not routinely performed.
Moelleken [36] described a superficial subciliary
cheek lift with the use of a single subciliary incision
with suborbicularis dissection of the malar fat pad
(superficial to the zygomaticus major and minor mus-
cles) and fixation to the intermediate temporalis fas-
cia located just lateral to the lateral orbital rim. Gunter
and Hackney [37] presented a technique in which the
cheek is undermined in the subperiosteal plane
with fixation of the ptotic malar fat pad to the thick
345
periosteum over the lateral orbital rim. They determine
the amount of skin excision before the subperiosteal
dissection was performed, avoiding lower-lid malposi-
tion or having to perform a lateral canthoplasty.
Subperiosteal face-lift fascinated many authors
since it raises the eyebrows, eyelid lateral corners,
forehead, glabella, cheeks, and nasolabial fold, reach-
ing the middle third of the face. This technique includes
less incision, use of endoscope, better fixation (espe-
cially of the cheeks), allows for more ancillary proce-
dures, repositioning of the Bichats fat pad, and jowl
treatment.
Subperiosteal face-lift is indicated for patients with
significant aging and ptosis of the oval center of the
face, tear-trough deformity, scleral show in severe
malar pockets, in cases of past facial fractures, when
there is the need for simultaneous resurfacing, in cases
of facial implants that need to be changed, when there
is a need for soft tissue augmentation with fat transfer,
and even in smokers.
As a result of the procedure, the cheek advances
upward and backward, and a tremendous amount of
vertical lift is produced. The fat pad is repositioned,
reducing the orbital hollow and the double contour
deformity. A volume augmentation is enhanced by
meloplication that fills in both the orbital hollow and
the cheek hollow. The nasolabial fold is diminished.
The oral frown is diminished, to a degree. Malar
bags are diminished, to a degree.
The advantages of the subperiosteal face-lift include:
easier correction of prominent midface wrinkles, lateral
orbital bulging caused by brow ptosis, and ptosis of
deep soft tissue and orbital festoons; not compromis-
ing the blood supply to overlying tissue, especially for
cigarette smokers and those who have thinner tissue;
and reduced possibility of facial nerve injury when
compared with any other intermediate plane.
The subperiosteal face-lift technique, as originally
described by Tessier, has benefited from significant
technologic advances in medicine. The endoscope
now allows extensive subperiosteal undermining of
facial soft tissue through minimal access incisions.
Improved understanding of facial anatomy and the
facial aging process now allows surgeons to reposition
and remodel the soft tissue envelope with excellent
aesthetic results. Restoration of facial volume can
be achieved with the subperiosteal techniques descri-
bed and can be applied to the full spectrum of patients
with long-lasting results.
346
Correct diagnosis of the aging changes in the mid-
face, therefore, dictates the most appropriate choice of
surgical approach. If the findings are confined predom-
inantly to the periorbital area, with only mild descent
of the cheek structures evident, blepharoplasty utilizing
a variety of techniques may be all that is required to
restore a youthful appearance to the midface. Classical
transconjunctival or skinmuscle blepharoplasty is
effective when the problem is confined to fat pseudoh-
erniation and skin excess, without deepening of the
nasolabial fold. When mild cheek descent is present
with resultant thinning of the soft tissues over the
infraorbital rim and/or deep nasolabial folds are pres-
ent, blepharoplasty with fat repositioning is more
appropriate (Fig. 24.8). Fat repositioning is especially
indicated when a negative vector is present and the
bony orbital rim lies posterior to the plane of the cor-
nea. These patients often have scleral show preopera-
tively, which will often be exacerbated with fat removal
as in the traditional blepharoplasty.
Fig. 24.8 (Left) Preoperative female patient. (Right) Ten months postoperative after undergoing blepharoplasty with fat repositioning
L.G. Patrocinio et al.
As the distance from the infraorbital rim to the
malar fat pad increases, the nasolabial folds deepen
and the aging perioral changes are evident; midface-
lifting should be considered along with blepharoplasty.
The subperiosteal face-lift is ideal because all areas of
midface aging, from the lower eyelid to the perioral
area, can be addressed with a single exposure, and the
effects of gravity can be directly opposed by a 180-degree
vertical vector. The transtemporal approach offers a
good possible reversion of the aging effects on the
midface, especially when associated to forehead-lift
(Figs. 24.924.11). On the other hand, the subpe-
riosteal midface-lift through lower-lid incision, com-
bined with lateral canthal anchoring procedures, should
be used when the patients present lower-lid malposi-
tion (scleral show) and/or deformities of lateral
canthus.
Subperiosteal midface-lift can be enhanced with
injection of fat graft (lipotransfer) [38]. Coleman, in
1994, [21] published his philosophy and technique of
24 Subperiosteal Face-Lift 347

Fig. 24.8 (continued)

348 L.G. Patrocinio et al.

Fig. 24.9 (Left) Preoperative male patient. (Right) Eighteen months postoperative after undergoing subperiosteal midface-lift
24 Subperiosteal Face-Lift 349

Fig. 24.10 (Left) Preoperative female patient. (Right) Two years postoperative after subperiosteal midface-lift
350 L.G. Patrocinio et al.

Fig. 24.11 (Left) Preoperative female

patient. (Right) One year postoperative after
subperiosteal midface-lift and endoscopic
forehead-lift
24 Subperiosteal Face-Lift 351

Fig. 24.12 (Left) Preoperative female. (Right) Eighteen months postoperative following subperiosteal midface-lift and injection of
fat graft to the nasolabial folds
352
soft tissue augmentation and lifting with fat grafting.
He advocated that the technique of lipoinfiltration
allows the surgeon to support and fill the periorbital
region. The graft helps to restore the youthful appear-
ance in more cases with more severe loss of midface
volume (Fig. 24.12). Ramirez also described his
technique to address the atrophy of soft tissues, particu-
larly the subcutaneous fatty layer. Three-dimensional
endoscopic midface enhancement was achieved by
adding volume to the midface while avoiding potential
lower-lid complications with temporal and intraoral
access incisions [24, 25].
The demand for face-lift surgery has increased dra-
matically in recent years as people from all socioeco-
nomic levels become interested in facial rejuvenation.
The evolution through surgical correction of the aging
midface began with peripheral approaches and, as we
began to understand the dynamics of midface aging,
moved to a vector-based attempt to reposition ptotic
soft tissues. Only later did the volumetric component
of midface aging become a recognized essential clini-
cal finding. The pathways developed to correct this
component were repositioning of soft tissues when the
displaced volume was adequate and additive when
more volume was required to recapture the soft tissue
fullness of youth.
Anatomic knowledge combined with a thorough
understanding of the variety of techniques available
will permit to continue serving patients with the best
care possible. An important point to understand is that
all techniques are simple to those familiar with it, and
regardless of the procedure, the results will be better
for those who adhere to the fine details and the art of
the objective.
24.8 Conclusions
The subperiosteal face-lift by temporal approach is a
procedure designed to rejuvenate the upper and middle
thirds of the face. After subperiosteal detachment, the
soft tissues of the cheek, forehead, jowls, lateral can-
thus, and eyebrows can be lifted to re-establish their
youthful relationship with the underlying skeleton. It
is a technique that produces satisfactory cosmetic
results in most of the cases, causing malar augmenta-
tion, nasolabial fold improvement, and mild jowl
improvement.
L.G. Patrocinio et al.
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 Suture Facelift Techniques
Peter M. Prendergast
25.1 Introduction
In recent years, minimally invasive facial rejuvenation
procedures have become more popular. From 1997
to 2008, surgical cosmetic procedures in the USA
increased by 180% whereas non-surgical cosmetic
procedures in the same period increased by more than
750% [1]. Patients seek minimally invasive treatments
that do not require prolonged recovery periods, are low
risk, inexpensive, and provide results that look natural.
These include chemodenervation with botulinum tox-
ins, soft tissue augmentation using injectable implants,
laser skin resurfacing, and skin tightening using a
variety of light and radiofrequency-based technologies
[2]. Non-surgical procedures improve hyperdynamic
and static wrinkles, volume loss, and skin surface
imperfections but do not address ptosis of deeper tis-
sues including the malar fat pad and the superficial
musculoaponeurotic system (SMAS). Although an
open facelift remains the gold standard for sagging
skin, fat, and the SMAS in older patients, less invasive
measures using various suture systems and designs
provide a novel alternative for younger patients with
early signs of aging. Suture facelift techniques are used
as adjunctive measures during traditional open proce-
dures [3], as a complement to less invasive open tech-
niques [4], or as closed procedures without dissection
through minimal incisions or punctures [5]. This chap-
ter will focus on closed suture lifting techniques, com-
monly referred to as thread lifts, for the face and
P.M. Prendergast
Venus Medical, Dundrum, Dublin 14, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_25, Springer-Verlag Berlin Heidelberg 2013
25
neck using various suture materials and designs. These
include barbed and non-barbed sutures, coned sutures,
and slings using materials such as polypropylene,
polytetrafluoroethylene, and polycaproamide sutures.
Although still in its infancy, the practice of suture
lifting to improve facial contours, restore appropriate
tissue projection, and redefine bony landmarks has
been widely adopted. Despite this, published data on
safety, efficacy, and long-term results remains scant
[6]. Unfortunately, the furor and media-driven hype
over suture lifts, touted as lunchtime facelifts or
1-hour mini-lifts, often generate unrealistic expecta-
tions amongst potentially suitable patients, or sway
patients who would best be treated with a conventional
rhytidectomy into believing they can achieve similar
results with a suture facelift [7]. Nevertheless, these
innovative techniques should be embraced rather than
discarded so that they can be further studied, improved
and refined, and eventually find their rightful place in
aesthetic surgery and medicine. In the authors view,
suture facelift techniques currently provide a better
alternative to non-surgical tissue tightening devices
such as radiofrequency and infrared light for patients
who would benefit from lifting mild to moderate ptosis,
but they do not replace open facelift procedures for
those with more severe ptosis or excessive skin laxity
(Table 25.1).
25.2 Concept
The goal of any facial rejuvenation procedure is to
restore the youthful appearance of the skin and facial
features and create contours, proportions and shapes
that are generally perceived as being attractive. These
355
356
Table 25.1 Advantages of suture lifting techniques
Advantages for the patient Advantages for the surgeon
Performed under local Short learning
anesthesia curve
Short downtime Performed in office setting
Minimal or hidden scars High patient demand
Provide subtle, natural- Useful adjunct to other
looking rejuvenation surgical and non-surgical
Relatively inexpensive procedures
Can be repeated over time
include a gently arching brow in females, high, defined
cheekbones, full cheek anteriorly with smooth lid-
cheek junction, and a clearly defined jawline. Several
classifications for facial aging have been proposed that
describe senescent changes in the upper, middle, and
lower thirds of the face as well as the neck [8]. Gravity
facilitates the aging process by providing a vertically
inferior vector for tissue that has lost elasticity, under-
lying structural support, or both [9]. Volume changes
are usually involutional and are now known to occur
both in the underlying bony skeleton [10, 11] as well
as the soft tissues. In the forehead and temples, thin-
ning of subcutaneous fat reduces the buffer between
skin and the underlying hyperdynamic muscles of
facial expression, resulting in horizontal and vertical
forehead lines. As periorbital bony support decreases
and tissues become lax, the brow drops to a horizontal
position below the level of the supraorbital ridge,
resulting in dermatochalasis. In the midface, the malar
fat pad descends gradually from its normal position
over the zygoma. This descent leads to several aging
traits. As the fat falls away from the lid-cheek junction,
the lower lid appears to lengthen and the infraorbital
area above the cheek develops a crescent-shaped hol-
low or tear trough deformity. The nasolabial fold deep-
ens as the malar fat pad superolateral to it drops.
Further inferolateral descent of the malar fat pad
accentuates the jowls and flattens the cheek superiorly.
In the jowls, fat deposition rather than involution is
typical and this reduces jawline definition characteris-
tic of a youthful appearance. Aging in the neck begins
with mild skin laxity and hypertrophy of the platysma
muscle, which appears as vertical bands. This pro-
gresses to prominent sagging platysmal bands and
horizontal folds, with varying degrees of submental fat
accumulation and submandibular gland ptosis.
P.M. Prendergast
The rationale for treatment using suture facelift
techniques is to reverse early signs of aging by lifting
and suspending tissues that have begun to drop. By
repositioning soft tissue in this way, not only are the
sagging tissues lifted, but volume is also restored in
important areas, such as the midface. Even a lift of
510 mm in the midface area restores the beauty tri-
angle by changing the shape of the face from one that
is rectangular to a heart-shaped one that is more pleas-
ing and youthful. Suture techniques are not intended to
correct more advanced signs of aging where signifi-
cant skin laxity is present. Similarly, excessive fatty
deposits in the face, submental area, and neck are not
improved with suture facelift techniques alone, partic-
ularly when the overlying skin is tight. These problems
require more aggressive measures such as rhytidec-
tomy and lipoplasty.
Closed suture lifting techniques employ sutures of
various types and designs to either loop around or
spear subcutaneous fat or fascia and lift or suspend it
in a predetermined vector. The author performs suture
lifts under regional and infiltrative local anesthesia
only without sedation. These minimally invasive pro-
cedures can be performed in an office-based setting,
through minimal incisions or punctures, and allow a
quick return to normal activities. They offer appropri-
ately selected patients a natural-looking rejuvenation.
For the physician, the learning curve is short and sev-
eral hands-on workshops and preceptor courses are
available throughout the world [12].
25.3 Patient Selection
The ideal patient for a suture facelift has mild ptosis of
one or more of the following areas: brow, lateral can-
thus, malar fat pad, jowls, and neck. Even mild ptosis of
these areas can produce a sad or sullen look and lifting
by a few millimeters will change the overall counte-
nance to a more pleasing one (Fig. 25.1). Visible tear
troughs, flattened anterior cheeks, and deepened naso-
labial folds are evidence of descent of the malar fat
pads and all improve with suture elevation of the fat
pads alone. Suture lifting of the face and neck are
appropriate when there is interruption in the definition
of the jawline and an increase in the cervicomental
angle. Most suitable candidates are 3045 years old,
although the author has successfully treated patients
25 Suture Facelift Techniques
a b
Fig. 25.1 (a) Preoperative. (b) After suture facelift showing subtle rejuvenation
ranging from 27 to 66 years. Skin laxity should not be
excessive and facial volume should be normal or
slightly reduced. Expectations should be realistic in
terms of both the extent of lifting and the longevity of
the results. One maneuver used by the author to deter-
mine suitability and likely results achievable from a
suture lift is shown in Fig. 25.2. The surgeons index
fingers are placed at the points where the sutures pur-
chase on the subcutaneous tissues and lifted about
10 mm. This degree of lifting is realistic and achievable
in most selected cases. Instructions are provided to the
patient prior to the procedure (Table 25.2). Following a
detailed discussion including all potential risks and
complications, a consent form is signed (Table 25.3).
25.4 Suture Types and Materials
There are several sutures in use today to lift the face
and neck. The wide variation in both suture type and
operative technique reflects the origins of suture
357
lifting. There was no one procedure from which all
others evolved. Rather, separate inventors and pio-
neers independently developed their own techniques
using different concepts and materials, from coun-
tries as disparate as Russia and the USA [13]. Some
sutures have tiny projections called barbs or cogs
along their length to grasp tissue; another has tiny
cones for the same purpose; and others are non-
barbed and designed to simply pass around tissue
like a sling. Newer sutures and techniques are emerg-
ing as the demand for minimally invasive procedures
continues [14]. A classification for suture lifting
techniques is presented in Table 25.4. There is a lack
of evidence that one technique or system is superior
to the others. As such, personal experience, training,
and perhaps even marketing influence the decision
to adopt one method over another. The author uses
absorbable non-barbed sutures for the upper and
lower thirds of the face, coned sutures for the mid-
face, and either non-absorbable or coned sutures for
the neck.
358 P.M. Prendergast

25.4.1 Barbed Sutures

a
Although the concept of barbed sutures began in 1956
[15], their use for facial rejuvenation was first reported
in the 1990s [16]. Barbed sutures are designed with tiny
hook-like projections cut into their long axes. The func-
tion of the barbs is to grasp tissue, distribute forces
along the length of the barbed portion of the suture, and
elevate or compress tissue in the direction of the barbs.
Over the last decade, several barbed sutures have been
brought to market that vary in length, number of barbs,
orientation, and arrangement along the suture, as well
as insertion and deployment characteristics.

25.4.2 Non-anchored Bidirectional

b
c effect of bunching up subcutaneous fat along the length
Fig. 25.2 Assessing a patient for a suture lift. The surgeons
finger lifts the tissues 10 mm. (a) Temporal lift. (b) Lower face-
lift. (c) Neck lift
Barbed Sutures
In 1998, Sulamanidze invented a non-absorbable
polypropylene suture with barbs on both halves of the
suture converging toward the central portion (Fig. 25.3).
Sulamanidze called these sutures Aptos threads
(APTOS, Moscow, Russia), referring to the anti-ptosis
procedure they perform. Aptos threads are available in
2-0 and 3-0 sizes and in various lengths. They are
inserted into the subcutaneous tissues of the face in pre-
determined paths by threading them through an 18 G
spinal needle. Once the needle is removed, the suture
remains in place with either end protruding from the
skin. The soft tissue is then fashioned around the barbs,
as slight traction is applied to each end. This has the
of the suture and lifting the tissues in a vector perpen-
dicular to the long axes of the sutures (Fig. 25.4). In this
way, the malar fat pad can be made to lift superolaterally
and project anteriorly, and the jawline can be made to
straighten by lifting the jowls [17, 18]. After manipulat-
ing the tissue to create the desired effect, the ends of the
suture are trimmed and pushed under the skin.
The Happy Lift Double Needle (Promoitalia
International Srl, Rome, Italy) is a newer polypropyl-
ene suture with bidirectional barbs arranged conver-
gently. Unlike Aptos threads, there is a straight needle
swaged to either end of the suture, obviating the need
for a spinal needle for placement (Fig. 25.5). The barbs
on Happy Lift threads are forked, presumably to
improve purchase on the tissues (Fig. 25.6). The
concept of these threads is the same as Aptos, and the
placement is similar, although more acute angles are
25 Suture Facelift Techniques 359

Table 25.2 Pre-operative instructions: suture lift

1. DO NOT SMOKE for 2 weeks prior to and 2 weeks after surgery. Smoking reduces blood circulation, slows down healing
and may increase complications.
2. DO NOT TAKE ASPIRIN or products containing aspirin for 2 weeks prior to or following your scheduled surgery. Aspirin
affects your bloods ability to clot and could increase your tendency to bleed during surgery or during the post-operative period.
3. DO NOT TAKE DIETARY SUPPLEMENTS for 2 weeks before and after surgery. These include vitamins, ginger, Ginkgo
biloba, garlic, ginseng, and fish oils. They may increase your risk of bleeding and bruising during and following surgery.
4. DO NOT DRINK ALCOHOL for 5 days prior to surgery. Alcohol may increase your risk of complications such as bruising.
5. IF YOU DEVELOP A COLD, COLD SORE, FEVER, OR ANY OTHER ILLNESS PRIOR TO SURGERY PLEASE
NOTIFY US.
6. WASH HAIR ON THE DAY PRIOR TO SURGERY.
7. LEAVE JEWELRY AND VALUABLES AT HOME. Do not wear wigs, hairpins, or hairpieces.
8. AVOID WEARING MAKEUP OR FACIAL MOISTURIZERS.
9. SURGERY TIMES ARE ESTIMATES ONLY. You could be at the clinic longer than indicated.
10. HAVE A LIGHT BREAKFAST on the morning of surgery. Your suture lift procedure will be performed under local
anesthesia without sedation.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE ITEMS 110.

Table 25.3 Consent for suture lift procedure

What is a suture lift?
A suture lift is a thread lift procedure in which a special thread (e.g. polycaproamide or polypropylene) is passed under the skin,
looped around, or inserted through fat or other tissue such as the superficial musculoaponeurotic system (SMAS) and retracted
back to lift areas of the face or neck. It is minimally invasive, requiring a small incision or puncture, often placed behind the
hairline. The procedure is performed under local anesthesia.
Suitability for a suture lift
You will be assessed thoroughly beforehand to determine if you are suitable or not. Typically, patients who are suitable have
mild drooping or sagging of cheeks, jowls, neck, or brow, and are otherwise in good physical and mental health. If you have
more severe sagging, a suture lift might not be appropriate, and you will be advised on alternatives.
Procedure
A number of markings are made on the treatment area. Then a small incision is placed, usually behind the hairline where it is out
of sight, and a stitch is passed under the skin in the fat or under muscle or fascia (layer above muscle). Sometimes a small patch
is placed in the incision to secure the sutures. The tissues are gently retracted and the suture is tied, securing the lift. Finally, if
present, the skin incision is closed.
Special precautions
You should not proceed with this procedure if you are pregnant or breast feeding, or if you are allergic to local anesthetic agents.
If you have medical conditions or are on certain medications, such as aspirin, steroids, or warfarin, treatment may be deferred, so
you need to give your doctor your complete medical history. You should avoid taking vitamins and herbal supplements such as
Ginkgo biloba and St Johns Wort for 2 weeks before treatment.
Potential risks and complications of a suture lift procedure
A small cannula (like a needle) is passed under your skin. As such, there is always a small risk of damage to structures under the
skin, including the facial nerve, other nerves, and blood vessels, causing facial weakness, numbness, or bleeding. Weakness,
although extremely rare, may be permanent. Numbness usually resolves or improves over time You may experience some
swelling, bruising, and pain following the procedure. As with any injectable or invasive procedure, you may develop an
infection, though the chance is low. You will receive a course of prophylactic antibiotics for 1 week following your treatment.
Benefits and outcomes of treatment
It is usual to notice immediate lifting of the treatment area. You may see some bunching of skin near the hairline. This is
normal and resolves after about 34 weeks. There is a small possibility that the procedure will fail if the suture cuts through the
fat and tissue under the skin. Adhering to aftercare instructions will lessen this risk. Benefits of a suture lift will last a variable
period of time, depending on the individual, and no guarantee of results or longevity of results is given. It is usually possible to
reverse or repeat the procedure if required.
Alternatives to a suture lift procedure
Alternatives to a suture lift procedure include non-invasive skin tightening using infrared light or radiofrequency, other suture lift
procedures, a surgical face lift procedure, or indeed no treatment at all.
Initial:___________
(continued)
360 P.M. Prendergast

Table 25.3 (continued)

CONSENT FOR SUTURE LIFT PROCEDURE
Please answer the following questions by ticking the appropriate box
Have you previously undergone a suture lift or facelift procedure? Yes No
If yes, specify: ________________________________________
Do you have any known allergies? Yes No
If yes, specify: ________________________________________
Are you currently taking any of the following medications: warfarin, Yes No
aspirin, plavix, steroids?
Are you pregnant or breast feeding? Yes No
Have you previously completed a New Patient Data Form at Venus Yes No
Medical Beauty?
Please state if you have any other medical conditions, allergies, or are taking any medications not previously outlined in the New
Patient Data Form:

I have read the information on the suture lift procedure outlined on this form and fully understand the nature of treatment, all
clinical implications and potential risks involved. I have had the opportunity to ask questions to my satisfaction. I understand that
it is my right to withdraw consent to treatment at any time. I consent to being photographed prior to treatment and understand
that this photograph will remain the property of Venus Medical Beauty and may be used for educational or academic purposes.
I willingly accept and consent to treatment with the suture lift procedure.
Patient signature _____________________________________________ Date ______________________
PRINT _____________________________________________

OFFICIAL USE ONLY

I have explained to the patient the suture lift procedure. I have outlined the expected benefits of treatment, as well
as any potential risks, complications, and side-effects of treatment. I have given the patient the opportunity to read
the literature pertaining to this treatment and clarified any further questions and queries where they existed. I have
explained alternatives to treatment, including no treatment.

Doctor signature _____________________________________________ Date ______________________

PRINT _____________________________________________

possible due to the ease of insertion using the attached
needles. There is little information in the literature on
the use of these threads.
25.4.3 Anchored Bidirectional
Barbed Sutures
In 2002, Wu devised a bidirectional barbed polypro-
pylene suture to elevate soft tissue and anchor it to
stable temporalis or mastoid fascia [19]. This 60-cm
long thread has a 4-cm smooth central portion, a 20-cm
section on either side of this with convergent barbs,
and a smooth portion measuring 8 cm at either end.
This so-called Woffles thread is passed subcutaneously
along the chosen vector through an 18 G spinal needle
via two stab incisions. The needle passes from the
inferior incision, through the subcutaneous fat, and
bites the deep temporalis or mastoid fascia superiorly.
One arm of the thread passes from the inferior to
25 Suture Facelift Techniques 361

Table 25.4 Classification for closed suture lifts

Type Subtype Suture
Barbed suture Bidirectional barbed Non-anchored 1. Aptos suture (APTOS, Moscow, Russia)
lifts 2. Happy Lift Double Needle (Promoitalia Int Srl, Rome, Italy)
Anchored 1. Woffles sutures (Singapore)
2. Articulus (previously Surgical Specialties Corp., Reading, PA)
3. Happy Lift Revitalizing threads (Promoitalia Int Srl, Rome,
Italy)
4. I-Lift Tensor Threads (Argentina)
Unidirectional barbed 1. Isse Endo Progressive Facelift suture (KMI Inc, Anaheim, CA)
2. Contour Threads (previously Surgical Specialties Corp.,
Reading, PA)
3. Happy Lift Ancorage (Promoitalia Int Srl, Rome, Italy)
Non-barbed Subcutaneous lift 1. Curl lift using polypropylene
suture lifts 2. Malar fat pad sling using ePTFEa (Gore-Tex Inc, Flagstaff,
Ariz)
SMAS lift 1. Serdev technique using polycaproamide
Coned suture 1. Silhouette suture (Silhouette Lift, Kolster Methods Inc.,
lifts Corona, CA)
a
Expanded polytetrafluoroethylene

Fig. 25.3 Aptos

polypropylene suture with
bidirectional barbs

superior incision via the spinal needle as far as the
smooth central portion of the thread. The needle is
then removed and reinserted through the superior inci-
sion to the lower one so the other arm of the thread can
be passed in the same way. The needle is removed, and
the two ends emerging from the superior incision are
lifted. This traction lifts the tissues at the smooth end
of the thread and fastens the thread ends in the deep
fascia via the downward facing barbs (Fig. 25.7). Both
ends of the sutures are either cut flush with the fascia
or tied to each other above it. Wu has developed sec-
ond and third versions of this technique by inverting
the V so that both free ends are in the face (Fig. 25.8),
and interlocking two sutures to reduce the likelihood
of cheese-wiring through the soft tissues at the point
of maximal tension.
A second version of the Aptos thread by Sulamanidze
employs the same bidirectional barbed suture as the
original Aptos thread but to either end a straight needle
is attached. The two needles are lightly fused, enabling
a single entry point. After the two needles puncture the
skin as one whole, they are broken apart and take two
different courses. The point of anchorage using this
technique is the point of entry: zygomatico-cutaneous
ligaments for a midface lift or temporalis fascia for an
eyebrow lift.
Ruff, an American plastic surgeon, did extensive
work and research on the use of barbed sutures for tis-
sue approximation as well as facial rejuvenation [20].
In 2001, he obtained a patent for his barbed sutures
and insertion devices and formed Quill Medical.
Working with Surgical Specialties Corporation, Ruff
developed and marketed his barbed sutures for face-
lifting under the name Contour Threads. Although
Angiotech has since acquired Quill Medical, and
Contour Threads are no longer in distribution, they
362 P.M. Prendergast

Fig. 25.4 Free-floating Aptos sutures with lifting vectors in the

brow, malar fat pad and jawline

were used widely [2123]. One version of Contour

Threads, called Articulus, is an anchored bidirectional
barbed suture. It consists of a 55-cm clear polypropyl-
ene suture with two 17-cm straight needles swaged to
the ends. The central 5 cm of the suture is smooth and
adjacent to this there are two 15-cm barbed sections.
The barbs are convergent toward the central portion.
Each needle is attached to a 10-cm non-barbed section
(Fig. 25.9). Placement of the Articulus is via a small
incision in the temporal hairline. One of the needles
is passed distally through the temporal incision, taking
a bite of deep temporal fascia, and exiting in the
midface, lateral to the nasolabial fold. The second
needle follows along a similar vector but exits more
inferiorly. The thread ends are then held as the skin and
fat pad are walked up the barbed suture until their
elevated position provides a satisfactory enhancement
(Fig. 25.10). The barbs prevent slippage of the elevated
tissues whilst the non-barbed central portion of the
thread is anchored superiorly to the temporalis fascia.
To prevent cheese-wiring, this portion can be rein-
forced with a non-absorbable Gore-Tex pledget.
I-Lift Tensor Threads, a company based in Argentina
and Spain, produce other anchored bidirectional barbed
sutures called I-Lift sutures. These non-absorbable,
Fig. 25.5 Double Needle Happy Lift suture with bidirectional
barbs
clear polypropylene sutures vary in size for face, neck
and brow lifting (Fig. 25.11).
25.4.4 Unidirectional Barbed Sutures
The early bidirectional free-floating Aptos sutures,
marketed in the USA as FeatherLift, were modified by
Isse who designed a unidirectional barbed suture. The
Isse Endo Progressive Facelift suture (KMI Inc,
Anaheim, CA) is a polypropylene thread measuring
25 cm with the distal 15 cm bearing 50 unidirectional
barbs. Isse describes his technique of closed melopli-
cation using six threads for each malar fat pad [24].
Through a temporal incision, a small area of dissection
is carried toward the zygomatic arch between the
25 Suture Facelift Techniques
Fig. 25.6 Happy Lift suture
with bifid barb morphology
superficial and deep temporal fascia. A 20 G 16-cm
spinal needle is used to thread each barbed suture
through the malar fat pad. Once the needle is removed,
the sutures are lifted, trimmed and secured to the
deep temporal fascia by tying the smooth ends to a
neighboring suture. The upward-facing barbs engage
the fibrofatty tissue of the malar fat pad and elevate it
to a more youthful position. This also reduces the
appearance of the tear trough, nasojugal fold, and soft-
ens the nasolabial fold.
Contour Threads (Surgical Specialties Corp.,
Reading, PA) were pioneered by Ruff and patented in
2004. The original and most widely used design was
the 25-cm, 2-0 polypropylene suture which contains
helicoidally arranged unidirectional barbs along its
middle 10 cm. On one end there is a half-circle needle
for anchoring to fascia and on the other a 7-in. taper-
point straight needle for thread placement (Fig. 25.12).
The straight needle is passed, in a serpentine course,
through small stab incisions in the scalp or behind the
ear, and exits at the brow, lateral to the nasolabial fold
or near the midline of the neck. The straight needle is
then removed and the superior end of the thread is
secured by suturing it to the fascia. With the patient in
the sitting position, the distal end of the suture is held
and the tissues are pushed up along the cogs to lift and
contour the brow, midface, or neck. Finally, the distal
ends of the sutures are cut flush with the skin. Despite
being the most widely used barbed suture suspension
technique in the USA, there is limited data on their
efficacy and longevity [21].
363
Fig. 25.7 Woffles bidirectional suture in situ
The Happy Lift Anchorage sutures (Promoitalia
International Srl, Rome, Italy) provide a similar
method of suspension to Contour Threads, although
differences exist. These include a greater barb den-
sity on Anchorage sutures (10 barbs per 1.6 cm)
compared to Contour Threads (7 barbs per 1.6 cm),
and a different barb-morphology (Fig. 25.13). Happy
Lift sutures are now also available in both non-
absorbable polypropylene and slowly absorbable
polydioxanone.
25.4.5 Non-barbed Sutures
Bukkewitz described the first suture suspension lift for
cosmetic enhancement in 1956 [25]. He used a strip of
nylon, inserted subcutaneously, to retract and improve
a ptotic buccolabial fold. Starting in 1966, Guillemain,
working with Galland and Clavier, started lifting all
areas of the face by passing tendons or nylon into the
tissues with a Reverdin needle and in their 1970 publi-
cation gave the technique the term curl lift [26].
Since then, other materials used to sling and suspend
drooping tissues include polypropylene (Prolene),
expanded polytetrafluoroethylene (Gore-Tex), and
polycaproamide (Polycon).
364
Fig. 25.8 Woffles inverted suture in situ
Fig. 25.9 Articulus suture. This is a clear polypropylene suture
with two 17-cm straight needles, a smooth 5-cm central portion,
two 15-cm barbed sections and a 10-cm non-barbed portion
adjacent to each needle. The barbs converge toward the central
portion
25.4.6 Non-absorbable Non-barbed
Sutures
Mendez Florez revisited Guillemains curl lift tech-
nique and designed a straight double-bevel needle
to pass the polypropylene suture into the tissues
(Fig. 25.14) [26]. A small puncture is made in the
cheek or brow and another one behind the hairline.
The straight needle passes through the lower incision
and exits via the one in the scalp to receive one end of
the thread. Then the thread is retracted back into the
wound to a point just cephalad to the inferior puncture.
Here, the needle is rotated 180 and tunneled once
P.M. Prendergast
Fig. 25.10 Contouring following the insertion of the Articulus
suture. The end of the suture is held as the tissues are pushed
up along the barbs. The ends of the suture are then cut flush with
the skin
again toward the scalp incision just parallel to the first
passage. The other end of the thread exits, and the two
ends are lifted and tied. This is a simple, quick tech-
nique to lift subcutaneous fat but the smooth inelastic
polypropylene suture tends to cut through the soft
tissue at the point of lifting and results are short-lived.
Erol and Hernandez-Perez described simplified
suture suspension techniques to elevate the brow using
nylon and polypropylene, respectively [27, 28]. Small
punctures are made at the hairline and at the level of
the brow to allow passage of the sutures in the subcu-
taneous plane using a needle (Fig. 25.15). In Erols
technique, the brow is suspended in the elevated posi-
tion it assumes when the patient lies supine. Following
infiltration of lidocaine 2% with 1:200,000 adrena-
line, four stab incisions are made using a #11 blade,
two directly above the lateral brow and two at the
temporal hairline. A 4/0 nylon suture is passed from
the medial to lateral brow incisions and the needle is
then cut from the suture. Then an angiocatheter is
passed subcutaneously from the lateral hairline inci-
sion to lateral brow incision and the end of the suture
is passed through the eye of the catheter. The angio-
catheter is withdrawn, bringing the suture out through
the lateral hairline incision. The same maneuver is
25 Suture Facelift Techniques
Fig. 25.11 Bidirectional
barbed polypropylene sutures
with swaged needles from
I-Lift Tensor Threads
Fig. 25.12 The Contour Thread. A 25 cm, 2-0 polypropylene
suture with helicoidally arranged unidirectional barbs along its
middle 10 cm. On one end there is a half-circle needle for
anchoring to fascia and on the other a 7-in. taper-point straight
needle for thread placement
Fig. 25.13 The Happy Lift sutures have ten regularly spaced
barbs per 1.6 cm of barbed portion
performed for the medial end so that both ends are
exiting from the hairline incisions. Finally, the
angiocatheter is passed from the medial to lateral inci-
365
sions to bring the suture to the medial incision. A knot
is made to hold the eyebrow in position so that it does
not drop inferiorly when the patient stands upright.
Hernandez-Perez uses 3-0 polypropylene and a Keith
needle to lift the brow in a similar manner and pro-
poses that the loose tissues of the lateral brow, the
undermining effect of the Keith needle, and the
postoperative fibrosis that occurs along the sutures is
enough to hold the brow in place without cheese-
wiring. These brow-lift procedures require superficial
passage of needles, just under the skin, to avoid injur-
ing the temporal division of the facial nerve where it
passes about 2 cm above the lateral brow.
For midface rejuvenation, permanent sutures or
slings elevate the malar fat pad without the need for
long incisions, undermining or dissection [3]. Sasaki
describes his technique using either permanent CV-3
expanded polytetrafluoroethylene (Gore-Tex Inc,
Flagstaff, Ariz) or 4-0 clear Prolene sutures. The suture
system used consists of a CV-3 Gore-Tex suture, a
3-0 braided Vicryl suture, a 3 8 mm Gore-Tex anchor
graft, a second 4 4 mm anchor graft, two 10-cm
Keith needles and a 4-0 dyed Prolene guide suture
(Fig. 25.16). Two stab incisions using a #11 blade are
made along the nasolabial fold and a 1.5-cm incision is
made in the temple 1 cm above the hairline. The first
Keith needle with suture slings attached passes through
the upper incision near the nasolabial fold and travels
subcutaneously, through the malar fat pad, and exits
from the temporal incision. The second needle passes
through the same incision at the nasolabial fold, but in
a course parallel to the first needle, and also exits
through the incision behind the hairline. Then the
braided Vicryl suture is used like a gigli saw to cut
366 P.M. Prendergast

Fig. 25.14 Double-bevel

needle used for curl lift

a b

c
d

Fig. 25.15 Brow suspension using a simple suture. (a) Two
stab incisions are made at the lateral brow and two at the tempo-
ral hairline. (b) A suture is passed from the medial brow incision
to the lateral one and the needle is cut from the suture. (c) An
angiocatheter is passed subcutaneously to bring the suture end to
the lateral temporal incision. (d) The same maneuver is repeated
so that a loop is created and both suture ends exit at the medial
hairline incisions. The suture is tied to suspend the brow in an
elevated position
25 Suture Facelift Techniques 367

Keith Needle 3-0 Vicryl Braided 4-0 Blue Prolene

4-0 Clear Prolene
Suture Guide Suture
Suspension Suture

Gore - Tex Anchor

Graft (3x8mm)

Temporal Gore-Tex
Anchor Graft
(4x4mm)

Fig. 25.16 Sasakis suture suspension system for elevation of the malar fat pad

through any dermal attachments at the nasolabial

puncture site before the Gore-Tex sling and anchor
graft are pulled under the skin through the puncture.
The dyed Prolene suture is used to guide the anchor
graft into place, or to retrieve the graft if it does not lie
correctly. Once the Gore-Tex sling is in place and the
malar fat pad is suspended adequately, the Vicryl and
guide sutures are removed and the Gore-Tex ends are
secured by passing them through the second 4 4 mm
anchor graft and suturing them to the deep temporal
fascia using a French-eye needle (Fig. 25.17). This
technique can also be performed during open proce-
dures, or with some dissection along the deep temporal
fascia to create a pocket anteriorly past the brow [29].
Yousif describes his technique using expanded polytet-
rafluoroethylene (Gore-Tex MycroMesh, W.L. Gore
and Associates, Flagstaff, Ariz.) to lift the malar fat pad
in a vertical vector, although this is a true sling and not
a suture and is performed as an open procedure [30].
The Aptos Needle, invented by Sulamanidze, con- Fig. 25.17 Elevation of the malar fat pad using polypropylene
sists of a smooth non-barbed polypropylene suture slings with Gore-Tex anchor grafts
attached to the middle of a double-pointed needle
(Fig. 25.18) [16]. Midface elevation is achieved using rejuvenate the neck. For this, an incision is made in the
the suture to loop around the tissues to lift them in retroauricular area and a 2-0 Prolene suture is placed in
different superior vectors. The double-point allows the mastoid fascia as a holding suture. By passing the
passage of the needle in a loop without the need to long Aptos Needle from one retroauricular incision to
completely exit the skin so that the suture remains in the contralateral side, without completely exiting the
the same plane throughout its course. A single incision skin as above, the suture is brought from one side to
need only be made and the sutures are anchored to the the other subcutaneously, and functions as a sling.
periosteum of the lateral or inferior orbital rim Each end of the suture is tied to the holding sutures,
(Fig. 25.19). A similar longer Aptos Needle is used to securing them to the mastoid fascia. More than one
368
Fig. 25.18 Aptos needles are designed to pass through tissues
without the need to exit completely. This keeps the suture in the
same plane throughout its course
Fig. 25.19 Suture suspension using Aptos needles. The sutures
are passed like slings around the tissues of the midface and
anchored to periosteum on the infraorbital rim
P.M. Prendergast
suture can be placed in this way until the tissues are
lifted and the cervicomental angle is restored.
Giampapa described a similar suture suspension tech-
nique to improve the cervicomental angle using Prolene
in combination with liposuction and partial platysma-
plasty through a submental incision [31].
25.4.7 Absorbable Non-barbed Sutures
Serdev, a Bulgarian cosmetic surgeon, improved upon
Guillemains original and Mendez-Florezs revised
curl lift techniques by using slowly absorbable non-
barbed semi-elastic polycaproamide sutures to lift
moveable tissues and secure them to stable structures
such as deep fascia or periosteum [3234]. Using
curved suture-passing needles (Fig. 25.20), the braided,
antimicrobial sutures are passed through the platysma
of the neck, the superficial musculoaponeurotic system
(SMAS) of the mid and lower face, the malar fat pad,
and the superficial temporal fascia of the upper face.
These tissues are gently lifted and suspended by pass-
ing the suture ends under the mastoid fascia, perios-
teum, or deep temporal fascia. These suspension
techniques improve the cervicomental angle and defi-
nition of the jawline, reduce the appearance of jowls,
elevate the malar fat pad, and lift the corner of the eyes
and tail of the brow (Fig. 25.21). There are certain
advantages of Serdevs techniques. The propensity of
the sutures to cheese-wire through the tissues is less
because the SMAS, and not just subcutaneous fat, is
lifted. The braided sutures also yield somewhat to
movement due to their elasticity. Using special needles,
the sutures are anchored to deep fascia or periosteum
through tiny punctures only, obviating the need for
incisions or skin closure. The polycaproamide sutures
absorb over 23 years, an obvious advantage for suture
lifting where subsequent procedures are likely as the
aging process continues. These simple but effective
suture suspension techniques will now be described
for the upper, mid, lower face, and neck.
25.4.7.1 Upper Face (Fig. 25.22)
The suture facelift technique in the temporal area pro-
vides a subtle but important rejuvenation of the upper
face by lifting the tail of the eyebrow, the lateral can-
thus, and the upper cheek. In the periorbital area, ele-
vation of soft tissues by 13 mm provides noticeable
rejuvenation (Figs. 25.23 and 25.24). Markings are
made at the proposed incision points. The first is along
25 Suture Facelift Techniques
a and above the deep temporal fascia between each upper
b
Fig. 25.20 (a) Curved suture passing needles for percutaneous
SMAS lifting techniques. (b) Braided anti-microbial slowly
absorbable polycaproamide sutures are used to lift and anchor
moveable tissues to stable ones
a line drawn perpendicular to the tail of the eyebrow,
just behind the temporal hairline. A second point is
made just behind the hairline 45 cm inferior to the
first point. Two further points are made superior to the
first points, along the desired vector lines of lift. One
of these points should be along the superior temporal
crest line where the deep temporal fascia attaches to
periosteum. The hair is tied or retracted to expose the
skin at the marked points. After skin preparation and
sterile draping, local anesthesia using lidocaine 12%
with 1:200,000 adrenaline is injected along the pro-
posed path of the suture: subcutaneously between the
lower two points, on the periosteum between the upper
two points, and under the superficial temporal fascia
369
and lower point. The superficial temporal fascia is a
continuation of the galea over the frontalis muscle and
the SMAS of the middle and lower thirds of the face.
Stab incisions using a #11 blade are made at the marked
points. The curved needle is passed from the upper
medial incision to the lower medial incision, under the
superficial temporal fascia but above the deep tempo-
ral fascia. To find this plane, lift a tuft of hair above the
path of the needle and pass the needle deeply. There
should be a thick layer of tissue covering the needle
following passage, but it should not be so deep that the
patients head rocks when the needle is moved. This
indicates that the needle has passed under the deep
temporal fascia. Once the needle tip exits the inferior
point, a USP #2 polycaproamide sutures is passed
through the eye of the needle and the needle is with-
drawn. Next, the needle is passed in the superficial
subcutaneous plane from the lower lateral incision to
the lower medial incision and the suture end is threaded
through the needles eye and brought to the lower lat-
eral incision. The suture is above the superficial tem-
poral fascia along this line. Then the suture is brought
from the lower lateral to the upper lateral incision
under the superficial temporal fascia as before. Finally
the needle is passed into the upper medial incision,
taking a bite of periosteum and deep temporal fascia
along the superior temporal fusion line, and exits
from the upper lateral incision. The suture is brought
from this incision to the upper medial one so that both
ends exit from the same incision. The suture ends are
lifted gently to elevate the superficial temporal fascia
(temporal SMAS) along the hairline, and elevate the
tail of the brow and upper face. The suture is tied and
the incision points, if inverted or tethered down, are
released using the tip of a mosquito. The incisions heal
quickly by secondary intention. A small amount of
bunching of skin is usual along the hairline but this
contracts and disappears in 12 weeks. This technique
provides an instant rejuvenation, particularly around
the eyes (Fig. 25.25).
25.4.7.2 Midface (Fig. 25.26)
Traditional rhytidectomy procedures that include
resection, retraction, or plication of the SMAS often
do not achieve optimal elevation of the malar fat pad
and midface. The triangular malar fat pad is oriented
with its base along the nasolabial fold and apex over
the zygoma. It is superficial to the medial part of the
SMAS and adherent to the overlying skin. Retracting
370
Fig. 25.21 Suture lift of
SMAS (moveable) to deep B
fascia or periosteum
(non-moveable) through
minimal incision (red dots). D Hairline
The red area shows area of
zygomatic arch over which
the facial nerve passes
(0.83.5 cm from external C A >> B: Under STF
acoustic meatus). STF G F
superficial temporal fascia,
DTF deep temporal fascia
H arch
E J >> H: Subcutaneous,
the SMAS in this region does not elevate the malar fat
pad, and may deepen the nasolabial fold. Repositioning
the malar fat pad using the suture suspension tech-
nique restores the beauty triangle of the face, softens
the nasolabial fold, and reduces the lower lid length.
The vector of lift to achieve this is superolateral.
Three punctures are made: two in the temporal hair-
line over the temporal fascia and one just lateral to
the nasolabial fold. An artery forceps is inserted into
Fig. 25.22 Upper face (temporal) SMAS lift using slowly
absorbable polycaproamide sutures. The SMAS is called the
superficial temporal fascia (STF) in the temporal area and the
galea aponeurotica medial to this over the forehead. (a) Four
points are marked as shown and stab incisions using a #11 blade
are made. One of the superior incisions (B) is made along the
superior temporal crest line (red dots). (b) The curved needle is
passed under the STF (above the deep temporal fascia) from
point B to A. (c) A USP#2 or #4 polycaproamide suture is passed
through the eye of the needle and the suture is brought back from
point A to B. (d) The needle is passed from point C to A in the
P.M. Prendergast
Superior temporal fusion line
A
Suture plane
A >> C: Above STF
(subcutaneous)
C >> D: Under STF
D >> B: Under TM
E >> F: subcutaneous,
Catching SMAS atzygomatic
E >> G: Subcutaneous
F >> G: Under TM
Catching SMAS (platysma)
at J and mastoid fascia at H
Zygomatic extension of SMAS
the incision at the nasolabial fold to make sure the
incision has passed thoroughly through the dermis.
Using the curved needles, a USP#2 or USP#4 poly-
caproamide suture is passed from the nasolabial fold
incision to the temporal incisions, forming a sling
around the malar fat pad. A braided suture such as
Vicryl can be passed together with the polycaproam-
ide suture. This second suture is used to cut through
the dermis or other connections to the skin that might
superficial subcutaneous plane (above STF) and the suture end is
threaded through. (e) The suture is brought to point D under STF
as before. (f) Now both ends of the suture are exiting at the upper
incisions. (g) The needle is passed deep into point B until it
reaches periosteum. (h) A deep bite is taken, underneath the
deep temporal fascia, and the needle receives the suture end at
point D. (i) The needle is retracted so that both ends exit at point
B. The sutures are gently lifted and tied. This lifts the STF, tail
of the brow and upper face. The suture is cut and buried by
applying traction to the puncture site with the tip of an artery
forceps
25 Suture Facelift Techniques 371

a b

c
372 P.M. Prendergast

e f

g h

Fig. 25.22 (continued)

25 Suture Facelift Techniques
i curved needles. As well as lifting the malar fat pad
Fig. 25.22 (continued)
a SMAS. It is important to stay within 8 mm from the
b needle is withdrawn and a similar maneuver is made in
Fig. 25.23 (a) Preoperative. (b) After temporal SMAS lift
using absorbable sutures. Even a 12-mm lift makes the eyes
look less tired
cause a depression or dimple at the nasolabial fold
incision. Once the skin is smooth at the site of lifting,
the Vicryl suture is removed and the remaining sus-
pension suture sits in place. The suture is then
anchored beneath the deep temporal fascia using the
373
superiorly, it projects anteriorly and improves infraor-
bital volume loss (Fig. 25.27).
25.4.7.3 Lower Face (Fig. 25.28)
Descent of the lower face and jowls obscures jawline
definition and changes the shape of the face from a
desirable inverted triangle or heart-shape to an unde-
sirable rectangular one. To lift the jowls, the zygomatic
extension of the SMAS is lifted using an absorbable
non-barbed suture and anchored to temporalis fascia
above the ear. Three points are marked: two above the
ear in the hairline and one just below the zygomatic
arch in front of the lobule of the ear. Lidocaine with
adrenaline is infiltrated in the subcutaneous plane
between the three points, and deeper on the periosteum
between the upper two points. Stab incisions using a
#11 blade are made at the three points. The tip of an
artery forceps is used to puncture through the entirety
of the dermis at the lower point to reduce the likeli-
hood of dimpling. A curved needle is passed subcuta-
neously from the upper anterior incision downwards
toward the lower incision. At the level of the zygo-
matic arch, a slightly deeper bite is taken to catch the
external acoustic meatus at this level to avoid injury to
the facial nerve. The nerve always passes over the
zygomatic arch between 8 mm and 3.5 cm from the
external acoustic meatus, and usually about 2.5 cm
from it [35]. After biting SMAS, the needle comes
superficially and exits through the lower incision and
the suture is passed through the eye of the needle. The
order to pass the suture from the lower incision to the
upper lateral incision. The needle is then passed deeply
into the upper lateral incision to catch the periosteum
under the temporal fascia and exits from the upper
medial incision to receive the suture end. In the correct
position under this deep fascia, any movement of the
needle should rock the patients head. The suture end
is brought through to the upper lateral incision where
the two ends can be lifted gently and tied. The lifting
of the zygomatic extension of the SMAS as well as the
attached overlying skin should smooth the jawline and
even lift part of the neck (Fig. 25.29). Any dimpling or
inversion of skin at the puncture sites is released using
the tip of an artery forceps. Some bunching in front
of the ear is normal and resolves spontaneously in
12 weeks.
374 P.M. Prendergast

a b

Fig. 25.24 (a) Preoperative. (b) After temporal SMAS lift to lift the tail of the brow in a younger patient

a b

Fig. 25.25 (a) Preoperative. (b) Immediately after temporal SMAS lift

Fig. 25.26 Closed suture suspension of the malar fat pad. (a) A
point is marked just lateral to the nasolabial fold and two points
in the temporal hairline. The markings represent the proposed
course of the suture to lift the malar fat pad in a superolateral
vector. (b) Lidocaine with epinephrine is infiltrated subcutane-
ously along the marked lines. (c) Using a #11 blade, stab inci-
sions are made at the three points. (d) The dermis is fully
penetrated at the inferior incision to minimize dimpling of the
skin. (e) The curved needle is passed along the lower line from
the posterior temporal incision and exits at the incision lateral to
the nasolabial fold. (f) A USP#4 polycaproamide suture, together
with a 3-0 Vicryl suture, are passed through the eye of the needle
and withdrawn to the temporal incision. (g) The needle is passed
from the anterior temporal incision along the other line and
receives the ends of the sutures. (h) The needle and sutures are
withdrawn, creating a loop around the malar fat pad. (i) The
Vicryl suture is grasped and a sawing motion is used to cut
through any dermal attachments at the inferior puncture until the
skin is smooth. The Vicryl suture is then removed. (j) The needle
is passed between the temporal incisions, below the deep tempo-
ral fascia, and the polycaproamide sutures are brought through
one incision. (k) The sutures are lifted gently to elevate the malar
fat pad, and tied. The punctures are allowed to heal by secondary
intention. A steristrip or 6-0 suture is used to seal the puncture at
the nasolabial fold
25 Suture Facelift Techniques 375

a b

c e
376 P.M. Prendergast

f G

Fig. 25.26 (continued)

25 Suture Facelift Techniques 377

j
25.4.7.4 Neck (Fig. 25.30)
Mild to moderate ptosis of the neck can be treated using
suture lifting alone, or in combination with lipoplasty
to remove fat under the chin, along the jawline and
in the jowls. The suture suspension technique using
absorbable sutures is simple and quick. After infiltra-
tive local anesthesia, two skin punctures are made: one
behind the ear over the mastoid and one in the upper
neck over the anterior border of the sternocleidomas-
toid muscle. The needle is passed through the upper
point, deeply at first to include the mastoid fascia or
periosteum, and advanced in a sinusoidal path superfi-
k cially under the skin toward the lower point. Before
exiting from the lower incision, a deeper bite is taken to
catch the platysma. A USP# 2 polycaproamide suture is
threaded through the needle and brought back to the
retroauricular incision. Another pass is made, taking a
parallel course to the first pass, and the end of the suture
is passed from the lower to upper incision so that both
ends of the suture exit behind the ear. The sutures
are retracted enough to lift the platysma and improve
the contour of the neck, and tied. If there is dimpling of
the skin at the lower puncture, an artery forceps tip is
passed into the incision and gently lifted until the
dimple is softened. Bunching of skin along the length
of the suture improves without intervention.
Fig. 25.26 (continued)

a b

Fig. 25.27 (a) Preoperative.

(b) After suture lift of the
malar fat pad. Note the
anterior projection of the
cheek and improvement in
tear trough hollows. A
temporal SMAS lift has also
improved dermatochalasis of
the lateral brow
378 P.M. Prendergast

a b

c d

g
25 Suture Facelift Techniques
h i
j
Fig. 25.28 (continued)
Fig. 25.28 Lower SMAS suture facelift. (a) Local anesthesia is
infiltrated subcutaneously in front of the ear and under the tempo-
ral fascia above the ear. (b) Three stab incisions are made at points
E, F, and G. (c) An artery forceps is used to penetrate the full
thickness of the dermis at point E. (d) The curved needle is passed
in the subcutaneous plane from point F toward point E. At the
lower border of the zygomatic arch a deeper bite is taken to catch
the zygomatic extension of SMAS. (e) The needle is advanced
superficially and exits at point E. A USP#2 or USP#4 polycapro-
amide suture is threaded through the eye of the needle. (f) The
needle is withdrawn. (g) The needle is passed subcutaneously
379
k
from incision G to point E and receives the distal end of the suture.
(h) The needle is withdrawn so that a sling around the SMAS is
created. (i) To anchor the suture superiorly, the needle is passed
under the deep temporal fascia above the ear from point G to point
F. Moving the needle in this plane should move the patients
whole head. (j) The suture end is passed through the tip of the
needle and the needle is withdrawn. (k) Both ends exit from the
incision G. Lifting the sutures lifts the patients jowls and even
neck as the SMAS is suspended. The suture is tied. (l) The inci-
sions are lifted to bury the knot
380 P.M. Prendergast

a b

Fig. 25.29 (a) Preoperative. (b) After lower suture facelift. There is an improvement in the jawline as well as the platysmal bands
of the neck

a b

c d

e f
25 Suture Facelift Techniques
g h
Fig. 25.30 (continued)
25.4.8 Coned Sutures
Isse designed a polypropylene suture with regularly
spaced knots along its length and small floating cones
made of poly-L-lactic acid. He modified his earlier
barbed polypropylene suture for several reasons.
Firstly, he felt a suture with knots would be stronger
than a suture designed with cuts to create barbs, since
the tensions applied to the barbs are prone to linear
shredding where the barbs meet the body of the suture.
Secondly, the cones are made of a material that incites
an inflammatory response and stimulates collagen to
secure the sutures over time. Finally, Isse believed the
biomechanics of the cone design would be inherently
stronger than most barbed sutures. Isses suture is cur-
rently marketed as the Silhouette Suture (Silhouette
Lift, Kolster Methods Inc., Corona, CA). This is pre-
sented as a clear 3-0 polypropylene suture with 11
cones and multiple knots to prevent slippage of the
cones and to hold them equidistant from each other
within the tissues. The cones are made of poly-L-lactic
acid and absorb over 810 months. There is a 20.3-cm
20 G straight needle swaged to the distal end of the
suture and a 26-mm half-circle needle to the proximal
Fig. 25.30 Neck lift using suture suspension technique. (a)
Local anesthetic is infiltrated superficially along lines h to j. An
incision using a #11 blade is made behind the ear (h) and over
the anterior border of the sternocleidomastoid muscle (j). (b) A
curved needle is passed from incision h toward incision j. Just
before exiting at j, the needle takes a deeper bite to catch the
platysma muscle (SMAS). (c) The needle exits and a USP#2
polycaproamide absorbable suture is passed through the tip. (d)
The needle is retracted through point h. (e) The needle is
381
end (Fig. 25.31). Included with Silhouette Sutures are
2 0.5 cm polypropylene mesh patches for anchorage
to deep fascia. These coned sutures are particularly
useful for midface and neck rejuvenation and can be
performed under local anesthesia through minimal
incisions [36]. There is evidence that coned sutures
offer a more secure and stable lifting than most popu-
lar barbed sutures and are more resistant to struc-
tural damage in human tissues [37]. The author uses
Silhouette Sutures alone or in combination with non-
barbed absorbable sutures for midface, lower face, and
neck lifting. The technique of midface and neck lifting
using Silhouette Sutures is described below.
25.4.8.1 Midface (Fig. 25.32)
The patient is marked in the sitting position. A line is
drawn from the lobule of the ear to the modiolus.
Sutures should not cross this line as animation and
movement at the mandible may lead to disruption. The
proposed path for the sutures is marked along the sides
of the face. These markings reflect the appropriate lift-
ing vectors, which are superior and superolateral. The
inferior points mark the exit sites for the needles and
start about 1 cm lateral to the nasolabial fold with
advanced again through the same puncture, taking a serpentine
course through the superficial tissues, and exits at the distal inci-
sion to receive the end of the suture. (f) The needle is retracted
again so that both suture ends exit at the retroauricular incision.
(g) Retracting the sutures lifts the neck and improves the cervi-
comental angle. If there is a dimple at the inferior incision, this
is released with an artery forceps. (h) The sutures are tied and
cut. Slight bunching along the length of the suture is normal and
resolves spontaneously in 23 weeks
382
Fig. 25.31 (a) Silhouette
suture. A straight needle
a
is swaged to one end of
the polypropylene suture
and a half-circle needle
to the other. There are knots
and cones along its length.
(b) Absorbable poly-l-lactic
acid cones
1.5 cm between each point. The vector lines converge
in the temporal area, behind the hairline, where a 3-cm
mark is made for the incision site. After skin prepara-
tion and sterile draping, the marked areas are infiltrated
with 2% lidocaine with 1:200,000 epinephrine. A 3-cm
incision is made in the temporal area and diathermy is
used for hemostasis. The superficial temporal fascia is
exposed, grasped, and opened, exposing the shiny,
white deep temporal fascia. A small 1.5 cm 0.5 cm
patch of polypropylene mesh is placed on the deep
temporal fascia and sutured in place. The first Silhouette
suture is measured externally over the cheek to deter-
Fig. 25.32 Silhouette suture midface lift. (a) The patient is
marked in the sitting position. The inferior points start about
1 cm lateral to the nasolabial fold. Subsequent points are spaced
1.5 cm apart. (b) A 23-cm incision is made in the temporal area
behind the hairline where the vector lines converge. (c) The
superficial temporal fascia is grasped and opened. (d) The shiny
white deep temporal fascia is exposed. (e) A 1 1.5 cm piece
of polypropylene mesh is cut and placed in the wound on the
deep temporal fascia. (f) The mesh is sutured to the deep tempo-
ral fascia using a 4-0 non-absorbable suture. (g) The Silhouette
suture is placed over the face to measure how many cones will
span the malar fat pad and midface without extending into
the upper face. This determines how many cones, if any,
should be cut from the distal end of the suture after placement.
P.M. Prendergast
mine how many cones are needed to run the length of
the malar area. If all of the cones are left on the suture,
some of the proximal ones may be visible under the
thin skin of the temple area, or they may catch on the
superficial temporal fascia when the suture is retracted.
The author usually cuts three to four cones from the
distal end of the suture after they exit at the inferior
points. The suture is passed in the deep subcutaneous
plane from the temporal incision, along the marked
path, to the exit points. To do this, the straight needle
enters the tissues just above the superficial temporal
fascia under direct vision at the upper incision. The
(h) The straight needle is passed just superficial to the superficial
temporal fascia (STF) at the temporal incision, and through the
substance of the cheek to exit at the first of the marked points.
The STF splits into two leaves just inferior to the hairline and the
temporal branch of the facial nerve travels through its layers.
Staying superficial to the STF avoids inadvertent injury to
the nerve. (i) The Silhouette suture is slowly pulled through the
midface until the cones emerge from the inferior puncture. A
number of cones (usually two to four) can be cut from the suture
at this time. (j) The suture is then cut distal to one of the knots
and retracted to lift the malar fat pad. Each suture is tied to a
neighboring one, and anchored to the deep temporal fascia and
mesh, before closure in two layers
25 Suture Facelift Techniques 383

a b

c e

g
384
h effect on the tissues can be seen. The proximal half-
i tly lifted and tied to its neighboring suture. The tempo-
j appropriate [34]. The author commonly uses ultra-
Fig. 25.32 (continued)
non-dominant hand gently grasps the tissues over the
needle as it passes through the temple and then malar
fat pad, maintaining the same depth throughout. If the
suture passes too superficially it may catch the dermis
and result in irregularities. If it passes too deeply it
risks injury to facial nerve branches, particularly the
frontal branch as it passes between the layers of the
superficial temporal fascia lateral to the eye. The nee-
dle should exit the skin at the inferiorly marked points
perpendicularly to avoid catching the dermis. The
straight needle is pulled through until the cones begin
to emerge from the skin. At this point, one or more
cones can be cut from the suture as outlined above,
making sure not to pull through any cones that are to
remain on the suture. The suture is cut just distal to one
of the knots and retracted proximally so that the lifting
P.M. Prendergast
circle needle is passed through the superficial temporal
fascia at the incision and then the needle is passed
through both the deep temporal fascia and the anchored
polypropylene mesh. The suture is not tied until all
other sutures have been passed. Usually a total of four
sutures are placed on each side of the midface. Once
all of the sutures are in place, the half-circle needles
are cut from the proximal ends and each suture is gen-
ral incision is closed in two layers. A gentle lift is
sufficient to elevate the malar fat pad and even jowls
and provide pleasing results (Fig. 25.33).
25.4.8.2 Neck (Fig. 25.34)
The coned Silhouette sutures are also used to lift mild
to moderate ptosis of the neck. If ptosis is coupled with
significant submental and submandibular fatty depos-
its, lipoplasty combined with the Silhouette lift is more
sound-assisted lipoplasty (VASER) combined with
Silhouette sutures for this purpose. For the Silhouette
suture lift, markings are made from behind the ear,
along the neck under the line of the mandible to a point
just proximal to the midline. Alternatively, this line
can continue across the midline to a point just distal to
it. A 1-cm retroauricular incision is made and the first
suture is passed in the subcutaneous fat along the line
of marking, and exits at the distal point. The author
prefers to continue across the midline, so that the
suture acts as a sling to support and lift the midline and
improve the cervicomental angle. To bring the suture
across the midline, the needle should first exit from a
point just proximal to the midline. Before the needle
exits completely from the skin, with the proximal end
of the needle still under the skin, the needle is turned
around so that the proximal end of the needle with the
suture attached is now advancing toward the midline.
It is advanced to a point just distal to the midline where
a stab incision with a #11 blade is made to allow the
blunt end of the straight needle to emerge. Once the
suture is seen, it is cut from the needle and the needle
is removed from the site. The suture end is pulled until
the most distal knot on the suture is just visible. The
suture is cut just distal to the knot and the proximal end
of the suture at the retroauricular incision is gently
retracted. The coned portion of the suture passes across
the midline and provides a lifting along its length as
well as a suspension of the submental area. Usually
25 Suture Facelift Techniques
two sutures are passed on either side of the neck. The
proximal ends of the sutures are secured to the mastoid
fascia using the half-circle needles and tied to one
another. The incision is then closed.
25.5 Postoperative Care
Although suture facelift techniques are minimally
invasive and performed through small incisions or
punctures, postoperative care is important. The closed
Fig. 25.33 (a) Preoperative. (b) After midface and lower face lift using Silhouette and polycaproamide sutures respectively
385
techniques described in this chapter do not involve
dissection or undermining. The relatively atraumatic
insertion of sutures, although advantageous in terms of
downtime, means there is less inflammation and fibro-
sis around the sutures, which can dislodge or migrate
or potentially become disrupted in the tissues. Careless
handling of the face or neck following a suture lift can
disrupt the sutures or result in cheese-wiring of the
tissues through the sutures. Ideally, the treatment area
should be taped and a head garment should be worn
for 34 days to immobilize the tissues (Fig. 25.35).
386
Fig. 25.33 (continued)
Fig. 25.34 Coned (Silhouette) suture lift of the neck. (a)
Markings are made behind the ear and along the neck under the
mandible to a point about 2 cm proximal to the midline. A second
point is marked 2 cm distal to the midline. (b) After local infiltra-
tion of lidocaine with epinephrine along the marked points, a
1 cm retroauricular incision is made and the Silhouette needle is
passed subcutaneously toward the midline. (c) The needle exits at
the first point proximal to the midline. (d) The needle is redi-
rected so the blunt end advances across the midline toward the
P.M. Prendergast
point on the contralateral side. (e) A stab incision is made to
allow the blunt end to emerge with suture attached. The suture is
cut. (f) The end of the suture is grasped and pulled through until
the first knot is visible. The suture is cut again just distal to the
knot. (g) The half-circle needle is used to pass the proximal end
through the mastoid fascia for anchorage. (h) A second suture is
passed in the same way parallel to the first one. Both sutures are
retracted to lift the neck, and tied to one another. The retroauricu-
lar incision is closed with interrupted sutures
25 Suture Facelift Techniques 387

a b

c d

f
388
Fig. 25.34 (continued)
Patients should be instructed to avoid excessive facial
animation, chewing gum, and laughing for a week
and to be gentle when handling the face or neck for
46 weeks following the procedure. This includes
cleansing or applying make-up upwards along the
vector of lifting rather than downwards against the
sutures. Following the procedure, the author adminis-
ters cephalexin for 5 days and tramadol for 3 days as
needed if simple analgesia is insufficient to control
discomfort. Normal sequelae following suture lifts
include edema, ecchymosis, and point tenderness over
the suture-ends. To reduce swelling, the patient is
advised to use cold packs and sleep with the head
elevated for a few days. A clear instruction leaflet
should be provided, including a contact telephone
number in case the patient has any concerns following
the procedure (Table 25.5). A follow-up appointment
is arranged in 1 week, at which time sutures, if present,
are removed.
P.M. Prendergast
Fig. 25.35 Tape and head garment are used to immobilize the
tissues for 34 days following a suture lift
25.6 Complications
Patients tolerate suture lift procedures well under infil-
trative local anesthesia with complementary regional
nerve blocks if required. These methods are preferred
as they eliminate unnecessary risk associated with
intravenous sedation or general anesthesia. Mild
edema, ecchymosis, tenderness, and transient bunch-
ing of overlying skin are common following suture
lifts. Complications include infection, bleeding, palpa-
bility, visibility, skin irregularities, migration, extru-
sion, prolonged pain, nerve injury, and asymmetries
(Figs. 25.36 and 25.37) [3840]. These complications
should be prevented by proper placement of appropri-
ate sutures using sterile techniques. If they do occur,
they often resolve spontaneously or can easily be
treated (Table 25.6).
25 Suture Facelift Techniques 389

Table 25.5 Postoperative instructions: suture lift

IF YOU EXPERIENCE EXCESSIVE PAIN OR BLEEDING, FULLNESS, OR SPREADING REDNESS IN TREATMENT
AREAS, OR FEVER, PLEASE CALL US IMMEDIATELY.
1. Do not massage or rub vigorously the treatment area for at least 4 weeks; this could disrupt the sutures under the skin.
2. Wear the head garment 24 h/day for 3 days and then in bed at night for a further 1 week.
3. Continue to refrain from smoking for at least 2 weeks during the healing process. Smoking affects blood supply and
nourishment to skin and soft tissues.
4. Complete the prescribed course of antibiotics.
5. Be gentle when brushing your hair until your stitches are removed.
6. There may be some bunching of skin near the hairline following the lift. This will soften out over 14 weeks, depending on
skin quality.
7. You may experience a tighter sensation over your face where skin has been retracted. Some of this tightness will lessen over
12 weeks as the skin relaxes into its new position.
8. You may experience some swelling, bruising, or tenderness over the first week but this will subside and fade over time. If you
notice increasing redness, swelling, and tenderness a few days after the procedure that was not there before, call our clinic.
This may be a sign of infection, which is uncommon.
9. If you received skin stitches you will need to return to the clinic after 57 days for removal.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE ITEMS 19.
___________________________ ___________________
Patient Signature Date

a b

Fig. 25.36 (a) Dimpling of skin at the right nasolabial fold incision following a suture suspension lift. (b) After subcision using an
18 gauge needle to release dermal attachments

25.7 Conclusions
There has been a dramatic increase in patient demand
for non-surgical cosmetic procedures in the last
decade. Suture facelift techniques offer a quick, safe,
and effective rejuvenation by elevating soft tissues
and restoring the youthful contours of the face and
neck. The aim is to lift tissues that have dropped,
restore the beauty triangle by creating a heart-shaped
face, and improve definition of the jawline and neck.
Patients who benefit from suture facelift techniques
have mild tissue laxity or ptosis and realistic expecta-
tions. The results are usually subtle and natural and
often make the patient appear a few years younger.
The author combines suture facelift techniques
with other non-surgical procedures such as botuli-
num toxins, fillers, and cheek and lip enhancement
(Fig. 25.38). Combined approaches using different
sutures and methods in the same patient are also
appropriate and may provide superior results than one
method alone. Longevity of results following a suture
facelift is variable and depends on several factors,
390 P.M. Prendergast

a b

Fig. 25.37 (a) Palpable and visible cones in the temple following a Silhouette suture lift. (b) Spontaneous improvement after
2 months without intervention. Cutting a few cones from the distal end of the suture after placement will prevent this problem

Table 25.6 Complications of suture facelift techniques

Complication Prevention Management
Skin irregularities 1. Avoid superficial placement of suture in dermis 1. Conservative, massage
and dimpling 2. Release dermis with artery forceps during procedure 2. Subcision
3. Remove suture and redo procedure
Palpability 1. Avoid patients with thin, translucent skin 1. Conservative, massage if absorbable
or visibility 2. Place sutures in deep subcutaneous plane, or deeper 2. Remove if barbed, non-absorbable
Migration 1. Use anchored sutures 1. Trim sutures
or extrusion 2. Bury sutures when appropriate 2. Remove sutures completely
Prolonged pain 1. Use absorbable sutures 1. Remove sutures
or nerve injury 2. Avoid path of facial nerve 2. Analgesia
Asymmetries 1. Proper marking 1. Add or remove sutures to restore symmetry
2. Equal tension bilaterally
Infection 1. Ensure sterile technique 1. Antibiotics
2. Prophylactic antibiotics 2. Remove sutures
3. Keep hair out of punctures and incisions
Bleeding or 1. Use lidocaine with epinephrine for infiltrative local anesthesia 1. Pressure hemostasis
hematoma 2. Use diathermy for temporal incisions 2. Conservative for ecchymosis and hematoma
3. Discontinue antiplatelets, vitamins, and herbal 3. Drainage for large hematoma (rare)
supplements before procedure

including the sutures used, the lifting technique, the
patients tissues, and the aftercare. For a stable lift,
the author prefers to employ techniques that lift the
SMAS rather than just the subcutaneous fat, and to
use coned sutures to elevate the fibrofatty malar fat
pad. To improve healing, patients must stop smoking
for at least 2 weeks before and after the procedure,
wear a head garment for 3 days, and handle the face
and neck carefully for 6 weeks. Once the patient
understands what can be achieved with suture facelift
techniques, the limitations, and the value of combina-
tion procedures for optimum results, the likelihood of
success and satisfaction for both patient and surgeon
is high.
25 Suture Facelift Techniques 391

a b

Fig. 25.38 (a) Preoperative. (b) After suture facelift combined with cheekbone and lip enhancement using temporary fillers

References 8. Shiffman MA (2008) Facial aging: a clinical classification.

In: Shiffman MA, Mirrafati SJ, Lam SM (eds) Simplified
facial rejuvenation. Springer, New York, pp 6567
1. The American Society for Aesthetic Plastic Surgery (2008)
9. Vleggaar D, Fitzgerald R (2008) Dermatological implications
Cosmetic surgery national databank statistics. ASAPS web-
of skeletal aging: a focus on supraperiosteal volumization for
site www.surgery.org
perioral rejuvenation. J Drugs Dermatol 7(3):209220
2. Hodgkinson DJ (2009) Clinical applications of radiofre-
10. Mendelson BC, Hartley W, Scott M, McNab A, Granzow
quency: nonsurgical skin tightening (Thermage). Clin Plast
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and the implications for facial rejuvenation. Aesthetic Plast
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4. Paul MD (2008) Barbed sutures for aesthetic facial plastic
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5. Hochman M (2007) Midface barbed suture lift. Facial Plast
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14. Bisaccia E, Kadry R, Rogachefsky A, Saap L, Scarborough DA
7. Teitelbaum S (2006) Enthusiasm versus data: how does an
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 Facial Implants
Bruce B. Chisholm
26.1 Introduction
Facial rejuvenation requires volume retention, replace-
ment, and soft tissue support. The procedure can be
surgical, nonsurgical, temporary, or permanent. The
temporary, nonsurgical options include injection with
hyaluronic acid, autologous fat, calcium hydroxylapa-
tite, poly-l-lactic, and others. Permanent nonsurgical
options include injection with polymethylmethacry-
late. Most surgical procedures are temporary unless an
alloplastic implant is placed.
A facial implant is the most effective surgical tech-
nique to permanently restore facial volume, support,
and esthetic balance. The implant reliably restores lost
volume and soft tissue support to create a natural,
youthful appearance. The procedure is permanent but
can be reversed.
Coleman [1, 2] demonstrated the importance of
restoring facial volume with autologous fat. Coleman
demonstrated that moving atrophic structures to new
locations was not as effective as the additional volume
and support obtained from fat grafting [3]. Fat is an
excellent material for volume restoration and to pro-
vide support, but lacks reliable long-term results and
requires numerous surgical procedures [4]. The mid-
face and chin regions are more effectively treated with
an alloplastic implant. The augmentation is permanent
and requires one procedure. With experience, alloplas-
tic implant placement is fast, reliable, predictable, and
postoperative complications are minimal.
B.B. Chisholm
Department of Surgery, Eisenhower Medical Center,
Rancho Mirage, CA, USA
e-mail: bchish9127@aol.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_26, Springer-Verlag Berlin Heidelberg 2013
26
The goal of alloplastic implant placement in the
treatment of the aging face is restoration of esthetic
facial balance through replacement of lost volume and
support. Loss of soft tissue volume and support are the
leading causes of facial aging and the subsequent loss
of the esthetic balance of the face. The aging face is a
changed look for the patient. The primary goal of a
facial implant is not to change a patients appearance
but to restore the youthful volume, support, and facial
balance.
In addition, a patient may request to change their
appearance or augment a congenitally atrophic chin,
midface, or zygoma.
While the midface and chin are best restored with
an alloplastic implant, the remainder of the face is
more difficult to augment with an implant. The angle
and body of the mandible can be augmented with an
alloplastic implant or fat. The clinical results achieved
with fat will be temporary, and implant placement can
be technically challenging. The best option for the
periorbital region remains a series of fat injections
or one of the nonpermanent synthetic fillers such as
hyaluronic acid.
The aged, skeletonized appearance of the thinning,
atrophic face results from loss of volume and soft tis-
sue support more than from additional or excess skin
(Fig. 26.1). Procedures to replace, maintain, and sup-
port soft tissue are the most important procedures per-
formed in facial rejuvenation. Restoration of skin and
soft tissue tension through surgical lifting augments a
well-supported face that has had the youthful balance,
support, and volume restored [5].
The region of the midface most affected by volume
loss is the central region located below the midpupil-
lary line (Fig. 26.2). The zone below the midpupillary
393
394
Fig. 26.1 Midface atrophy with facial collapse
Fig. 26.2 Maximum midface atrophy located vertically at
midpupillary line and horizontally at the nasal ala
B.B. Chisholm
Fig. 26.3 Small silastic midface implant
line has generous soft tissue volume and support during
youth but severely atrophies, becomes skeletonized,
and descends with age. Subsequently, the youthful bal-
ance is lost.
The zygoma and zygomatic arch have less soft
tissue volume during youth, and the atrophic changes
of aging are less dramatic. Primary alloplastic implant
restoration is rarely utilized in these zones as it will
change the patients appearance by widening the face.
A wider-appearing face and a changed appearance is
not the goal for most patients.
Patients at or near ideal weight will benefit from
midface alloplastic augmentation after 40 years of age.
Patients with significant additional body weight may
maintain volume and support in the midface region.
The soft tissue chin envelope atrophies less than the
midface. The chin does not usually require alloplastic
support until the sixth or seventh decade unless the
patient has microgenia.
The midface is a broad region and the soft tissue of
the entire region atrophies with advancing age. The
maximum point of surgical augmentation corresponds
to the maximum height of the implant. The original
submalar implant [6] provided support but failed to
adequately address the surrounding midface atrophy.
In addition, the submalar implant will not continue to
support the entire midface with advancing age. The
submalar implant also requires screw fixation to remain
stable. Therefore, a midface shell (Fig. 26.3) is used on
every patient to augment, support, and maintain the
midface. It is individually trimmed to provide custom-
ized augmentation for each patient. The broad base
provides permanent augmentation and support of the
entire midface, restores the natural youthful appear-
ance without changing the youthful appearance, and
does not require screw fixation to remain stable. The
m4-1 midface shell by Hanson (Hanson Medical, Inc.,
26 Facial Implants
Fig. 26.4 Point of maximum atrophy of midface marked with
an X
Paso Robles, CA, USA) and the CSM1 shell by
Implatech (Implatech, Inc., Ventura, CA, USA) are
used on 99% of the patients. A larger implant may be
used if atrophy or underlying lack of skeletal support is
moderate to severe. In addition, the patient may request
a fuller face.
26.2 Technique
The patient is marked preoperatively. An X is placed at
the point of maximum midface atrophy (Fig. 26.4) and
is generally located below the midpupillary line verti-
cally and approximately at the nasal ala horizontally.
The area of maximum atrophy is easily identified
visually.
The surgical procedure is performed under light
sedation. The head and neck is prepped and draped in
the usual sterile fashion Antibiotics are started 1 day
preoperatively and continued 5 days postoperatively.
The patient is instructed to rinse with Peridex twice a
day beginning the day before surgery and continue for
5 days after surgery.
395
Fig. 26.5 Midface implant used to guide outline of planned
surgical pocket
Fig. 26.6 Outline of midface implant with maximum projec-
tion marked with an X
An outline of the ideal implant location is made on
the cheek with the maximum projection of the implant
centered over the area of maximum atrophy (Figs. 26.5
and 26.6). Care is taken to not allow the implant to
touch the skin. A small incision is made in the canine
fossa with iris scissors (Fig. 26.7). Care is taken to
keep the incision anterior, conservative, and close to
the buccal reflection. A periosteal elevator is used
to create an exact subperiosteal pocket corresponding
to the ideal location drawn on the cheek (Fig. 26.8).
The dissection extends over the superior fibers of the
masseter muscle at the zygomatic arch (Fig. 26.9). The
implant is scored with a no. 15 blade on the external
surface to allow better adaptation to the underlying
malar and midface contour (Figs. 26.10 and 26.11).
The implants are soaked in a solution containing cefa-
zolin, vancomycin, and gentamicin. The antibiotic
solution is also used to irrigate the subperiosteal pocket
(Fig. 26.12).
396 B.B. Chisholm

Fig. 26.9 Release of soft tissue over anterior zygomatic arch

Fig. 26.7 Mucosal incision made with iris scissors in anterior,

superior buccal reflection

Fig. 26.10 Scoring of midface implant with surgical blade

Fig. 26.8 Creation of subperiosteal pocket with periosteal

elevator

The implant is custom trimmed and placed in the

surgical pocket (Figs. 26.13 and 26.14). Fixation is
not required. The implant should not move anterior/
posterior or inferior/superior. If the surgical pocket is
over-dissected and there is implant movement, the
implant must be secured with sutures. Screws are not
required.
Fig. 26.11 Scored midface implant
The incision is closed with a double-layer 4-0
chromic gut. The left side is completed and symmetry
verified. Total surgical time is 1020 min.
26 Facial Implants 397

Fig. 26.12 Irrigation of surgical pocket with antibiotic solution Fig. 26.15 Extended anatomic silastic chin implant

Fig. 26.13 Placement of small silastic midface shell implant Fig. 26.16 Small submental incision in submental crease

Fig. 26.14 Placement of small silastic midface shell implant Fig. 26.17 Periosteal elevator used to make subperiosteal
pocket
398
Fig. 26.18 Irrigation of surgical pocket with antibiotic solution
26.3 Postoperative
Minimal bruising with moderate edema is expected.
Normal physical activity can be resumed in several
days.
26.4 Discussion
The chin implant is an extended silastic anatomic
implant (Fig. 26.15). The small (size 1) is used for
the majority of female patients, and small to medium
(size 2) is used for the majority of male patients. An
incision is made in the submental crease (Fig. 26.16).
Dissection is completed to the periosteum. An exact
subperiosteal pocket is made on the anterior, inferior
mandibular border (Fig. 26.17). The mental nerve is
protected at all times. The implant is soaked in antibi-
otic solution and the pocket is irrigated with the antibi-
otic solution (Fig. 26.18). The implant is placed in the
pocket (Fig. 26.19) and secured with three 4-0 polyg-
lycolic sutures. Closure is completed with 5.0 polygly-
colic and 6.0 plain gut sutures.
B.B. Chisholm
Fig. 26.19 Silastic chin implant partially placed in pocket
26.5 Complications
Two thousand two hundred and fifty-six implants were
placed over the last 6 years. There were four infec-
tions. There have not been any infections since the
initiation of antibiotic irrigation of the surgical pocket
4 years ago. There were no facial nerve injuries.
Dysesthesia of the upper lip was reported in three
patients that resolved over time.
No hematomas or seromas were reported. Irrigation
of the surgical pocket was required in one patient after
autologous fat used for facial augmentation was found
in the surgical pocket.
26.6 Conclusions
Alloplastic augmentation of the aging, atrophic face is
invaluable to a natural, long-term result. The proce-
dure is fast and predictable (Figs. 26.2026.26).
Augmentation of the midface during a facelift proce-
dure restores esthetic balance and produces a perma-
nent result.
26 Facial Implants 399

Fig. 26.20 (a) Preoperative. (b) Six months postoperative after facelift, small midface implants, upper and lower blepharoplasty,
and laser skin resurfacing
400 B.B. Chisholm

Fig. 26.21 (a) Preoperative.

a b
(b) Seven months
postoperative after facelift,
small midface implants, and
laser skin resurfacing
26 Facial Implants 401

Fig. 26.22 (a) Preoperative.

a
(b) Six months postoperative
following facelift, small
midface implants, upper
blepharoplasty, and laser skin
resurfacing

b
402 B.B. Chisholm

Fig. 26.23 (a) Preoperative.

(b) Six months postoperative
a b
after rhinoplasty, small
anatomic chin implant, and
small midface implants

a b

Fig. 26.24 (a) Preoperative. (b) Six months postoperative following facelift, small midface implants, blepharoplasty, and laser skin
resurfacing
26 Facial Implants 403

a b

Fig. 26.25 (a) Preoperative. (b) Six months postoperative after facelift, small midface implants, and laser skin resurfacing

a b

Fig. 26.26 (a) Preoperative.

(b) Six months postoperative
facelift, small midface and
chin implants, blepharoplasty,
and laser skin resurfacing
404 B.B. Chisholm

References 4. Shiffman MA, Kaminski MV (2001) Fat transfer to the face:

technique and new concepts. Facial Plast Surg Clin N Am
9(2):229237
1. Coleman SR (1997) Facial recontouring with lipostructure.
5. Little JW (2000) Three dimensional rejuvenation of the
Clin Plast Surg 24(2):347367
midface: volumetric resculpture by malar imbrication. Plast
2. Coleman SR (2006) Facial augmentation with structural fat
Reconstr Surg 105(1):267285
grafting. Clin Plast Surg 33(4):567577
6. Binder WJ, Schoenrock LD, Terino EO (1994) Augmentation
3. Hamra ST (2002) A study of the long-term effects of malar
of the malar-submalar/midface. Facial Plast Surg Clin N Am
fat repositioning in facelift surgery; short-term success but
2:265283
long term failure. Plast Reconstr Surg 110(3):940951
 Fat Transfer to the Face
Melvin A. Shiffman
27.1 Introduction
The minimally invasive technique using autologous fat
transplantation has become a standard procedure in
facial rejuvenation. It is simple, inexpensive, permanent,
and effective. Injectable fillers, such as collagen and
hyaluronic acid, are only temporary and, therefore,
have minimal indication. Gore-Tex, which is a permanent
material, may extrude or be palpable. Since 1994,
when Adatasil (silicone) was approved by the Federal
Drug Administration (FDA) for use in ophthalmic
problems, the use of silicone injected into other areas
of the body is called an off-label use and is considered
legal if it is used for a specific patient with a specific
product and there is no advertising.
Autologous fat can be used to augment facial struc-
tures, rejuvenate rhytids, or fill depressed scars or defects
of the face. Since the introduction of liposuction in
1975 [1] for body contouring, there has been an easy
way to obtain fat for transplantation through very small
incisions. The use of the tumescent technique for
retrieving large amounts of fat for transfer has reduced
the amount of blood loss and made the technique safer
[2]. Although some reports have shown that fat trans-
fer had disappointing results in some cases, the success
of fat transfer is operator dependent and can be quite
successful if attention is paid to the details of the tech-
niques of the procedure. The transfer of fat to the face,
M.A. Shiffman
Chair, Section of Surgery, Newport Specialty Hospital,
Tustin, CA, USA
e-mail: shiffmanmdjd@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_27, Springer-Verlag Berlin Heidelberg 2013
27
where vascularity is excellent, has an excellent chance
for fat survival.
The only relative drawback has been the resorption
of some of the fat graft. With proper technique, approx-
imately 3070% of the fat is retained. Low-speed, short-
time centrifugation of the fat decreases the fluid in the
transplant and reduces the apparent loss of graft by
compacting the fat and separating out the excess liquid.
Since some of the apparent graft loss is the resorption
of fluid from the transplanted fat, there is less fluid in
centrifuged fat and, therefore, more mass retained.
A newer concept to facilitate graft retention is the
use of albumin during the harvesting and transfer
phases. Albumin reduces the colloid osmotic pressure
disparity between the low colloid osmotic pressure of
the fat graft with saline, epinephrine, lidocaine, and
sodium bicarbonate and the interior of the fat cells.
The higher the difference in colloid osmotic pressure
between the cells and the surrounding fluids, the more
fluid that will enter the cells and the more the likeli-
hood of cell destruction. If the colloid osmotic pres-
sures between the fat cells and the surrounding fluid
with albumin are almost equal, the more likely there
will be improved fat survival and retention.
27.2 History of Fat Transfer
Since Neuber [3], in 1893, reported that transplanted fat
can be used to fill in a depressed area of the face, there
have been many reports [414] that have shown that fat,
in pieces, can be transplanted and survive in various
areas of the body. Since, liposuction was conceived by
Fischer and Fischer in 1974 [15] and put into practice in
1975 [1]. The aspirate has been used to fill defects
405
406 M.A. Shiffman

and for contouring [1622]. Aspirated fat should be a

atraumatically washed in physiologic solution to remove
blood, which would allow better fat survival [23].
Certain principles of fat transfer have evolved [20,
2468] over the years, which include aspiration at lower
vacuum rather than at atmospheric pressure (Fig. 27.1).
It is essential to avoid desiccation of the fat during
transfer. Fat that is present for over 60 days after trans-
fer will survive and grow, and fat grafts survive when
there is vascular ingrowth. The survival of free fat used
as an autograft is operator dependent and requires deli-
cate handling of the graft tissue, careful washing of the
fat to minimize extraneous blood cells, and installation
into a site with adequate vascularity. There is evidence b
that fat cells will survive and that filling of defects is not
from the residual collagen following cell destruction.
There is some loss of fat after transplant, and most sur-
geons will overfill the recipient site.

27.2.1 Insulin

Some physicians have added insulin to the fat in prepa-

ration for transplantation [19, 69, 70]. The theory is
that insulin inhibits lipolysis. Sidman [71] found that
insulin decreases lipolysis. Hiragun et al. [72] stated
that theoretically insulin may induce fibroblasts to pick
up the lipid lost and become adipocytes. Chajchir et al.
[73] found that the use of insulin did not show any
positive effect on adipocyte survival during transplan- Fig. 27.1 Hematoxylin eosin stain 200. (a) Central core of fat
with 95100% intact fat cells that was harvested with a 3-mm
tation compared to fat not prepared with insulin. cannula at 500 mm mercury vacuum. (b) Periphery of core
with >10% fat cell disruption (arrow) when harvested with a
3-mm cannula at 700 mm mercury vacuum
27.2.2 Centrifugation

Some physicians centrifuge the adipose tissue to
remove blood products and free lipids to improve the
quality of the fat to be injected [6971]. Asken [42]
stated that his method of reducing the material to be
injected to practically pure fat is to place the fat-filled
syringe with a rubber cap (the plunger having been
previously removed and kept in a sterile environment)
into a centrifuge. The syringe is then spun for a few
seconds at the desired rpm and the serum, blood, and
liquefied fat collect in the dependent part of the
syringe Toledo [70] reported that for facial injec-
tion we spin the full syringes for 1 minute in a man-
ual centrifuge (about 2000 rpm), eject the unwanted
solution, and transfer the fat
Chajchir et al. [72] centrifuged 1 mL of bladder fat
pad from mice (both at 1000 rpm for 5 min and
5000 rpm for 5 min) and injected this into the subder-
mis of the malar area. Microscopically, after 12
months, there were macrophages filled with lipid drop-
lets, giant cells, focal necrosis of adipocytes, and cyst-
like cavities of irregular sizes and shapes. After 12 months
following injection, no recognized adipocytes
could be found. Total cellular damage was present in
both groups.
27 Fat Transfer to the Face
Fig. 27.2 Hematoxylin eosin stain 200. Centrifugation at
3600 rpm for 1 min showing cell compaction
Brandow and Newman [73] found that centrifuga-
tion of harvested fat did not after the microscopic
structured integrity of cells. Spun and unspun samples
were examined and were similar. Fulton et al. [68]
noted that centrifuged fat, 3 minutes at 3400 rpm,
works well for small volume transfers, but not for large
volume transfers into breasts, biceps, or buttocks. Low
rpm centrifugation for a short time will compact the fat
cells and not destroy them (Fig. 27.2).
27.2.3 Ratchet Gun for Injection
Newman and Levin [23] designed a lipo-injector with
gear-driven plunger to inject fat tissue evenly into
desired sites. Fat injected with excessive pressure in
the barrel of a syringe can cause sudden injections of
undesired quantities of fat, which will pour into recipi-
ent sites. Agris [44] stated that a ratchet-type gun
allows controlled accurate deposition of autologous
407
fat. Each time the trigger is pulled, 0.1 mL is deposited.
Asaadi and Haramis [55] described the use of a gun
with a disposable 10-mL syringe for fat injection.
Niechajev and Sevcuk [60] utilized a special pistol and
a blunt-type cannula, with 2.3-mm internal diameter,
to inject the fat. Berdeguer [74] used a lipo-transplant
gun to inject fat into areas to be enhanced. Fulton et al.
[68] stated that it is beneficial for a beginning surgeon
to use a ratcheted pistol for injection as this gives a
more uniform injection volume.
27.3 Albumin in Improving
Fat Cell Survival
27.3.1 Oncotic Pressure
When a molecule is greater than 10,000 D (dalton
arbitrary unit of mass equal to the mass of the nuclide of
carbon-12 or 1.657 1024 g), it is called a colloid and is
capable of generating an oncotic pressure if it is restricted
to one side of a semipermeable membrane. Colloid
restricted to one side of a semipermeable membrane cre-
ates an osmotic gradient measured in millimeters of
mercury. Very small molecules and ions such as sodium,
potassium, glucose, and urea easily cross a capillary mem-
brane and can increase osmolarity toward isotonicity to
prevent red blood cells from taking up water and bursting.
Osmolarity is measured by freezing point depression, and
the greater the number of particles in solution, the colder
the solution must be before it will freeze.
27.3.2 Colloid Osmotic Pressure
In determining the colloid osmotic pressure (COP), the
LandisPappenheimer equation [75] takes into account
that soluble proteins, whether albumin, globulin, or
fibrinogen, are highly negatively charged:
COP = 2.1(TP) + (0.16 TP 2) + 0.009 TP3
COP = Colloid Osmotic Pressure
TP = Total Protein
Positively charged sodium ions surrounding the core
protein attract and hold water, thus accumulating more fluid
408
on one side of the semipermeable membrane. The combina-
tion of the oncotic pressure of the protein and the osmotic
pressure of the sodium ions resulting in an increased
pressure gradient is called the colloid osmotic pressure.
Albumin is 69,000 D, whereas globulin is 150,000
D and fibrinogen 400,000 D. Since it is the number of
molecules that are held on one side of the semiperme-
able membrane that creates COP, albumin will create
the most pressure because 1 g of albumin has twice as
many molecules as globulin and five times the number
of molecules as fibrinogen. Starch molecules, found in
Hetastarch and Dextran, should not be used for fat
transfer since such molecules are too large to be evacu-
ated through the lymphatics and will cause localized
edema in the interstitial space.
27.3.3 Avoiding Hypo-oncotic
Trauma in Fat Transfer
When Kleins solution or any modification is used in har-
vesting fat, the infranatant of the harvested fat contains
1.11.2 g% protein. The normal level is 2.04.0 g%. When
one ampule of concentrated human albumin (12.5 g in
50 mL) is added to 1 L of tumescent solution or 8.3 mL
added to a 60-mL harvesting syringe, the harvested fat
contains 2.6 g% protein. Three washes of harvested fat
also increase the difference in colloid osmotic pressure
and, therefore, it is necessary to add 18.75 g of albumin to
each liter of washing solution. Adequate time must be
allowed between each wash to allow the fat cells to pack
above the infranatant layer. The process can be acceler-
ated by centrifugation. The supranatant oil must be
removed before insertion of the fat into the recipient site.
27.4 Indications for Fat Transfer
There are a variety of indications for fat transfer, which
can be distilled down to the following:
1. Fill defects
a. Congenital
b. Traumatic
c. Disease (acne)
d. Iatrogenic
2. Cosmetic
a. Furrows (rhytids, wrinkles)
b. Refill of lost supportive tissue (aging)
c. Enhancement
M.A. Shiffman
27.5 Preoperative Consultation
The patient is carefully examined in relation to the
specific complaint for which the patient has come in
for consultation. A description of the physical problem
needs to be recorded with appropriate measurements.
Pictures should be taken before any procedure is under-
taken, and postoperative photos taken at an appropriate
interval of time when healing is completed.
If there are other problems detected by the physi-
cian, other than that of which the patient complains,
this must be recorded and possible treatment explained
to the patient so that steps may be taken to correct other
deficits not previously identified by the patient or so
that the patient understands that adequate correction
may require other procedures. At the same time, the
patient must not be talked into procedures that are not
really wanted by the patient. An interval of time may
be needed for the patient to think about what surgery
may be necessary and to seek other consultations.
The patient must understand the need for using
autologous fat as a filler substance in comparison to
other fillers presently available. To conform to the
standard of care for informed consent, the patient must
have sufficient information to be knowledgeable about
the procedure, the possible material risks and compli-
cations, and the alternatives and their possible material
risks. Someone in the office must take time to explain
this information, and the physician must at least make
sure the patient understands the procedure, risks, and
alternatives, and answer any questions about the pro-
cedure. It is suggested that the physician include in the
record the statement that the surgical procedure was
discussed as well as viable alternatives and all material
risks and complications.
27.6 Technique
Fat survival depends upon the careful handling of fat
during harvesting, cleansing, and injecting. Harvesting
is performed by liposuction in areas of fat with
alpha-2 receptors where the fat responds poorly to
diet such as the abdominal or lateral thigh areas (genetic
fat) [42]. The fat can be retrieved with liposuction
using a 2.03.0-mm cannula or needle (1416 gauge)
with syringe (1050 mL).
The fat should be cleansed with a physiologic
solution of normal saline or lactated Ringers by gen-
27 Fat Transfer to the Face
Fig. 27.3 (a) Fat retrieval
a b
with supranatant fat and
infranatant fluid of blood and
local tumescent fluid. (b) Fat
following washing with
sterile saline
tly mixing and decanting the infranatant liquid con-
sisting of tumescent fluid, serum, and blood
(Fig. 27.3). Fat can be concentrated with the use of
centrifugation at 3600 rpm for 2 min. This allows less
need for as much overfilling (3050%) as is usually
used. Kaminski [76] has proposed the addition of
12.5 g of concentrated human albumin for each
1000 mL of Kleins solution used for harvesting and
18.5 g for each 1000 mL of washing fluid in order to
maintain the normal extracellular oncotic pressure
necessary to prevent the influx of solution into the
cells with possible rupture. Alternatively, 8.3 mL of
human serum albumin can be added to a 60-mL har-
vesting syringe.
409
Injection of the fat is with a needle (18 gauge) or
cannula (1.52.0 mm) uniformly distributed into tun-
nels in multiple layers to fill the defect (Figs. 27.4 and
27.5). With depressed scars, the attachments to the
skin should be subcised before fat injection. The use of
the ratchet gun for injection does not damage fat cells
[77].
The areas of the face that can be enhanced include
the cheeks (malar, submalar), lips, and chin (mentum)
(Fig. 27.6). The brows may be lifted with fat transfer to
the forehead, and indentations can be improved in
almost any area of the face. Rhytids in the glabella,
nasolabial fold, and marionette lines can be improved.
If the glabella is to be injected, the patient should be
410 M.A. Shiffman

a b

Fig. 27.4 (a) Fat transferred to 1-mL syringe with small cannula attached. (b) Injecting fat into face with palm of hand pressing on
the plunger

a b

Fig. 27.5 (a) Ratchet gun with 1-mL syringe and cannula. (b) Fat being injected with ratchet gun

informed of the rare possibility of blindness. Any area
of the face can have a depressed scar elevated by subci-
sion and fat transfer.
27.7 Complications
There are very few serious complications of autolo-
gous fat transfer. Since it is the patients own tissue,
there is no rejection phenomenon or allergic reac-
tion. The harvesting of large amounts of fat using
liposuction is prone to the complications of lipo-
suction in the donor area but facial fat transfer is
usually with small amounts of fat. If small amounts
of fat (under 50 mL) are retrieved, then one may
expect the possibility of bruising or infection in the
donor site.
The injection of autologous fat may be associated
with the following risks:
1. Loss of fat volume (the most frequent problem)
2. Possible need for repeat injection(s) of fat
3. Bruising, hematoma
4. Swelling (especially with over injection)
5. Asymmetry
6. Prolonged erythema (usually temporary over a short
period of time)
27 Fat Transfer to the Face 411

a1 a2 a3

b1 b2

c1 c2 c3

Fig. 27.6 A 60-year-old female with atrophy of facial fat. (a) Preoperative. (b) Fat transfer markings in submalar area. (c) Four
years postoperatively
412
7. Scar that is depressed or thickened (rare except in
the area of liposuction)
8. Tenderness, pain
9. Fibrous capsule around fat accumulation (from
too much fat injected into one area)
10. Fat cyst (mass)
11. Infection (rare)
12. Microcalcifications (has not been reported in the face)
13. Central nervous system damage or loss of sight
from retinal artery occlusion (can occur with injec-
tion in the glabellar area)
14. Plus all of the problems following liposuction if a
large amount of fat is removed
27.8 Conclusions
Autologous fat transfer has been a very successful
filler in the facial area. If care is taken in the transfer
process and postoperatively, there will be 4060% fat
survival on the first transfer. At times a second or even
third fat transfer (using the patients frozen fat) may be
necessary to reach the volume best for the patient.
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 Facial Fillers
Peter M. Prendergast
28.1 Introduction
The development of biocompatible, temporary, and
long-lasting fillers for soft tissue augmentation has
had a significant impact on the practice of cosmetic
surgery. Injectable fillers reduce and soften wrinkles,
enhance features, and provide facial volume and con-
touring in procedures that are performed either under
local anesthesia or under general anesthesia concur-
rently with open surgical procedures. In recent years,
there has been a paradigm shift in cosmetic surgery
from a focus on lifting and excisional techniques to
one on procedures that add and restore volume to the
face. This change in practice reflects our better under-
standing of facial aging and the significance of volume
loss, both as a result of fat atrophy and bony resorption
[1, 2]. The asynchronous volume loss in the different
superficial and deep fat compartments of the face leads
to contour irregularities and folds that define the signs
of aging [3]. The midface flattens, tear trough hollows
under the eyes appear, nasolabial folds deepen, and
oral commissures give the mouth a downturned appear-
ance (Fig. 28.1). With appropriate use of fillers, either
in the skin, subcutaneous, or supraperiosteal plane,
all of the effects of aging due to volume loss are
improved or corrected, often without the need for inva-
sive surgery. When surgical procedures such as rhyti-
dectomy are appropriate, the complementary use of
fillers provides a third dimension to facial rejuvena-
tion with superior, more natural-looking results than
lifting alone [4].
P.M. Prendergast
Venus Medical, Dublin, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_28, Springer-Verlag Berlin Heidelberg 2013
28
Most fillers are presented in pre-filled syringes for
injection at various depths in the skin and subcutaneous
tissues depending on the filler used and specific indica-
tion (Fig. 28.2). Lines and wrinkles require dermal
injections, whereas facial volumizing and contouring
require deeper injections, either in the subcutaneous
tissues or supraperiosteal plane. Temporary and perma-
nent fillers can be further classified depending on their
origin or source: xenogenic, allogenic, bacterial, syn-
thetic, or combination fillers (Table 28.1). This chapter
provides a summary of these fillers, and describes the
techniques for facial rejuvenation using temporary
hyaluronic acid fillers and long-lasting calcium hydrox-
ylapatite. It is the authors view that permanent syn-
thetic fillers may be useful in selected individuals who
request long-lasting results and understand the poten-
tial sequelae following complications with permanent
fillers, but should not be used as first-line treatments
for aesthetic purposes.
28.2 History
The use of facial fillers began at the end of the nine-
teenth century when Neuber harvested blocks of free
fat from the upper arms and transferred them to con-
cave defects in the face [5]. At the turn of the century,
Gersvny used paraffin as an injectable filler for cos-
metic enhancement [1]. Paraffin was initially embraced
as a safe, inexpensive, and effective way to rejuvenate
the face. As experience increased, significant complica-
tions such as paraffinomas and product migration
occurred and the popularity of paraffin as a filler dwin-
dled quickly [6]. In 1911, Bruning first reported the use
of autologous fat injections to fill a post-rhinoplasty
415
416
Fig. 28.1 Signs of facial
aging
Tear trough
Nasojugal groove
Nasolabial fold
Oral commisure
Fig. 28.2 Injectable facial fillers
deformity [7]. With the introduction of liposuction in
1975, several authors reported their experience using
aspirated fat as a facial filler with promising results [8].
The early development of a bovine collagen gel in the
1960s by Gross and Kirk led, in 1981, to the Food and
Drug Administration (FDA) approval of Zyderm I
(INAMED Aesthetics, CA), an injectable bovine col-
lagen filler. Zyderm II, a similar product with a higher
concentration of collagen, was introduced in 1983 and
Zyplast, a bovine collagen cross-linked with glutaral-
dehyde to increase longevity, received FDA approval in
1985. About 20 years following the approval of bovine
collagen in the USA, a bioengineered human collagen
was developed to obviate the need for skin testing
and reduce the incidence of hypersensitivity reactions.
P.M. Prendergast
Orbitopalpebral sulcus
Bony resorption
Flattened cheek
Perioral lines
Lip atrophy
Cosmoderm and Cosmoplast received FDA approval in
2003. In 1989, Balazs identified hyaluronic acid as an
appropriate facial filler because of its biocompatibility
and lack of immunogenicity [9]. In 1998, the first
efficacy studies of non-animal-stabilized hyaluronic
acid (Restylane, Q-Med, Uppsala, Sweden) were per-
formed. In 1999, the product was purified further to
reduce immunogenicity and hypersensitivity reactions.
In 2003, after 4 years of use in Europe, Restylane was
approved in the USA by the FDA and has maintained a
large share of the hyaluronic acid filler market since.
Other FDA-approved hyaluronic acid fillers include
Restylane, Perlane, Juvederm, Elevess, and Prevelle
Silk. In Europe, many more hyaluronic acid and other
fillers are available for soft tissue augmentation [10].
Although testing of fillers by the FDA delays approval
in the USA, it is likely that many of the fillers currently
available in Europe will become available for use in the
USA in the near future [11].
28.3 Types of Fillers
28.3.1 Collagens
The first FDA-approved dermal fillers were a group of
collagen products derived from the hides of a closed
herd of cattle in the USA. The three products within
28 Facial Fillers 417

Table 28.1 Classification of temporary and permanent facial fillers

Xenogenic
Bovine collagen (temporary) Zyderm I, Zyderm II, Zyplast (Allergan, Irvine, CA, USA)
Hyaluronic acid derived from cockerel combs Hylaform, Hylaform Fineline, Hylaform Plus (no longer marketed
(avian) (temporary) in the USA)
Allogenic
Bioengineered human collagen (temporary) Cosmoderm, Cosmoplast (Allergan, Irvine, CA, USA)
Bacterial
Hyaluronic acid derived from streptococcus Restylane, Restylane Fine Lines, Restylane Lipp, Perlane, Sub-Q (Q-Med,
equi (temporary) Uppsala, Sweden); Teosyal Fine Lines, Teosyal Global Action, Teosyal
Deep Lines, Teosyal Ultra, Teosyal Ultimate (Teoxane, Geneva,
Switzerland); Juvederm Ultra, Juvederm Ultra Plus, Juvederm Voluma,
Juvederm Smile (Allergan, Irvine, CA, USA); Elevess (Anika
Therapeutics, MA, USA); Prevelle Silk, Puragen (Mentor Corp., Santa
Barbara, CA, USA); Belotero (Merz, Germany)
Synthetic
Calcium hydroxylapatite (long-lasting) Radiesse (Bioform Medical, San Mateo, CA, USA)
Polyacrylamide (permanent) Aquamid (Contura Int., Soeborg, Denmark)
Polyalkylimide (permanent) Bio-Alcamid (Polymekon, Italy)
Purified polydimethylsiloxane (permanent) Silikon-1000 (Alcon Laboratories, Fort Worth TX, USA)
Combination
Polymethylmethacrylate + bovine collagen Artefill (Artes, San Diego,
(long-lasting) CA, USA)
Hyaluronic acid + dextranomeres (long-lasting) crm-DEX, crm-DX (Biopolymer GmbH & Co. KG, Montabaur, Germany)

the group, Zyderm I, Zyderm II, and Zyplast, were
used extensively for over two decades for treating
facial wrinkles and folds, until hyaluronic acid fillers
received FDA approval in 2003 and became more
popular. The bovine collagens consist of 9598% type
I collagen and up to 5% type III collagen presented in
0.52.5-mL syringes and suspended in phosphate
buffered saline with 0.3% lidocaine. Zyderm I con-
tains 35 mg/mL of bovine collagen for superficial
injection in the papillary dermis to correct fine lines.
Since saline absorbs soon after injection, overcorrec-
tion by up to 200% is required to achieve satisfactory
results that last up to 3 months. Zyderm II contains
65 mg/mL of collagen for deeper injection in the
papillary dermis to correct deeper lines. Some over-
correction is required with Zyderm II to achieve satis-
factory final results. Zyplast, the most robust in this
family of bovine collagens, contains 35 mg/mL of
collagen cross-linked with glutaraldehyde. Zyplast is
suitable for nasolabial folds, marionette lines, and to
define the vermilion border of the lip. No overcorrec-
tion is required, and results last 34 months. About
3% of the population is allergic to bovine collagen. As
such, double skin testing is required prior to treatment
with these products. About 0.1 mL of Zyderm I is
injected into the dermis of the forearm and inspected
for erythema, swelling, pain, and pruritus. Up to 12%
of those with negative initial skin tests prove to be
allergic to bovine collagen. Therefore, a second test
2 weeks after the initial one should be performed. The
inconvenience and delay in treatment with skin testing
prompted the search for a collagen-based filler that is
non-immunogenic. A bioengineered collagen, derived
from human tissue, received FDA approval for soft
tissue augmentation in 2003. Cosmoderm I contains
35 mg/mL of collagen that is purified and screened
for viral and bacterial pathogens. Like Zyderm I, Cos-
moderm I is injected in the superficial dermis for fine
lines. Cosmoplast, like Zyplast, is cross-linked with
glutaraldehyde and injected in the deep dermis and
lips for deep wrinkles and lip enhancement. Despite
the evolution in collagen products in terms of immu-
nogenicity, shortcomings include the need to overcor-
rect, the relatively short residence times in tissues, and
the potential for serious adverse effects such as vascu-
lar occlusion or compression [12].
28.3.2 Hyaluronic Acid Fillers
Hyaluronic acid (HA) is a naturally occurring polysac-
charide that is ubiquitous in the extracellular matrix of
all animal tissues and consists of regularly repeating
units of d-glucuronic acid and N-acetyl-d-glucosamine
418
Table 28.2 Comparison of hyaluronic acid fillers
HA
concentration
Source (mg/mL)
Restylane Streptococcus equi 20
Juvederm Ultra Streptococcus equi 24
Prevelle Silk Streptococcus equi 5.5
Hylaform Plusa Cockerel combs 5.5
BDDE 1,4-butanediol diglycidyl ether, DVS divinyl sulfone
a
Hylaform is no longer promoted in the USA
Fig. 28.3 Particulate hyaluronic acid filler
[13]. It provides structural support to tissues by attract-
ing up to 1000 times its weight in water. The HA bio-
polymer shows no tissue or species specificity, a feature
that has led to the development of hyaluronic acid fill-
ers for human injection from both avian and bacterial
sources. In its natural state, non-cross-linked hyaluronic
acid has a half-life of approximately 24 h before it is
broken down in the skin by hyaluronidase and free
radicals into carbon dioxide and water [14]. The impor-
tant differences between currently available HA fillers
include the source of HA, concentration of HA in each
syringe, agent used for cross-linking HA polymers,
degree of modification and cross-linking, amount of
free unmodified HA present, and whether the product
is monophasic (cohesive gel) or biphasic (particulate).
In addition, the elastic modulus (G) of a gel is a mea-
sure of its firmness and resistance to deformation when
a force is applied [15]. A comparison of two groups
of HA fillers is shown in Table 28.2. Most currently
marketed HA fillers are derived from the biofermenta-
tion of Streptococcus equi bacteria and are presented
in pre-filled syringes with volumes ranging from 0.5 to
3.0 mL. Monophasic products such as the Juvederm
P.M. Prendergast
Particle Cross- Degree of Elastic
size linking cross- modulus
(mm) agent linking (%) (G) (Pa)
300 BDDE 1.2 660
300 BDDE 2 105
350 DVS 12 230260
700 DVS 12 140220
and Teosyal range are viscoelastic gels that are not
sliced or sized into particles during the manufacturing
process. Biphasic particulate gels, such as the Restylane
group of products, are passed through screens during
the manufacturing process, so that Restylane Fine Lines
has 200,000 particles per milliliter of product, Resty-
lane has 100,000 particles, Perlane has 10,000, and
Restylane Sub-Q is thicker with just 1000 particles per
milliliter (Fig. 28.3). Products with a higher concentra-
tion of cross-linked HA or larger particle sizes are gen-
erally indicated for deeper injection in the dermis and
subcutaneous tissues to correct deep folds or for facial
contouring and may have higher tissue residence times
compared to products with lower concentrations of
cross-linked HA or smaller particle sizes.
28.3.3 Calcium Hydroxylapatite
Radiesse (Bioform Medical, San Mateo, CA, USA) is
a long-lasting temporary filler consisting of calcium
hydroxylapatite microspheres of 2545-mm diameter
suspended in a carboxymethylcellulose gel carrier. The
calcium hydroxylapatite found in Radiesse is identical
to that found in the matrix of bone. Radiesse is biocom-
patible and provides long-lasting correction of deep
wrinkles and folds and contouring of facial features
such as cheekbones and the nasal dorsum. Following
injection, the microspheres undergo fibrous encapsula-
tion and provide a network of scaffolding for collagen
ingrowth from surrounding tissue. Although the gel
carrier absorbs over about 2 months, tissue ingrowth
provides long-lasting results until the calcium hydrox-
ylapatite microspheres degrade over several months to
years [16]. Radiesse is an opaque, white, viscous prod-
uct presented in 0.3-, 0.8-, and 1.5-mL syringes
for injection in the dermalsubcutaneous junction or
28 Facial Fillers 419

Table 28.3 Summary of permanent fillers

Product Composition
Artefill (Antes, San Polymethylmethacrylate
Mateo, CA, USA) microspheres (2040 mm) in
3.5% bovine collagen + 0.3%
lidocaine
Aquamid (Contura A/S, 2.5% hydrophilic polyacryl-
Soeborg, Denmark) amide gel in 97.5% water
Bio-Alcamid (Polymekon, 97% hydrophilic
Italy) polyalkylimide gel
Silikon-1000 (Alcon Int., Polydimethylsiloxane oil
Fort Worth, TX, USA) (1000 cSt)
Evolution (ProCytech, Polyvinyl microspheres
France) (40 mm) suspended in
polyacrylamide gel
Indications
Deep wrinkles and folds
Facial contouring
Facial contouring, treatment
of lipoatrophy
Wrinkles, lipoatrophy, acne
scarring (microdroplet
technique)
Moderate to deep wrinkles
and folds
Complications
Granulomas, palpable nodules
Migration, granuloma, infection,
delayed inflammatory reactions
Palpable nodules, implant
migration, infection, delayed
inflammatory reactions
Granulomas, migration, palpable
nodules
Inflammatory reactions

subcutaneous plane through 27- or 28-gauge needles.
Compared to hyaluronic acid fillers, Radiesse feels
firm following injection, although this softens some-
what over a few days. Superficial injections, injections
in the mucosa, and lip injections with Radiesse should
be avoided to prevent lumps, nodules, and granulomas.
Typically, the results following soft tissue augmenta-
tion with Radiesse last about 1218 months [17].
28.3.4 Permanent Fillers
The concept of permanently correcting an imperfec-
tion with an injectable filler or providing aesthetic
enhancement with permanent results is attractive.
However, it must be remembered that facial aging is a
dynamic process. A filler implant that corrects volume
loss or improves facial contours in a 35-year old patient
may look out of place 10 years later when overlying
skin and surrounding tissues have become thin, invo-
luted, or ptotic. More importantly, complications asso-
ciated with permanent injectable fillers are generally
more difficult to treat than the transient side-effects
typical of temporary fillers such as hyaluronic acid
[18]. Nevertheless, several permanent fillers are avail-
able, most of which are synthetic polymers or combi-
nation materials. Table 28.3 provides a summary of the
most common permanent fillers available today.
Artefill (Artes Medical, San Diego, CA, USA) is cur-
rently the only FDA-approved permanent filler, indi-
cated to treat nasolabial folds.
28.4 Choosing the Right Filler
The decision to choose one facial filler over another
depends on a number of factors, including the particular
indication, injector experience, patient expectations,
and local restrictions and availability. Hyaluronic acid
fillers have become the gold standard for temporary soft
tissue augmentation in most countries, and now super-
sede bovine and human collagen in the USA as the
most popular choice. In general, finer, less viscous
products are indicated for superficial wrinkles and lines,
such as those above the lip, in the skin of the cheeks,
and around the eyes. Thicker hyaluronic acid fillers
with larger gel particle sizes, higher elastic moduli, and
a greater degree of modification and cross-linking are
appropriate for deep, subcutaneous or supraperiosteal
placement during facial contouring. Thicker gels placed
superficially may create unsightly ridges or palpable
lumpiness, whereas finer gels placed deeply below the
dermis provide insufficient projection of tissues and
absorb quickly. Manufacturers endeavor to cater for all
indications by providing a selection of products with
varying viscosity, particle size, and HA concentration
(Table 28.4). Some fillers, such as Radiesse, are too vis-
cous and firm for superficial placement and should only
be placed at the dermis-subcutaneous junction or sub-
dermal plane. The firmness of Radiesse provides excel-
lent structural support, making it ideal for deep
nasolabial folds, cheekbone enhancement, and non-
surgical nose reshaping [19, 20]. Injections of Radiesse
in the superficial dermis or lips have a propensity for
420 P.M. Prendergast

Table 28.4 Authors choice of filler for facial rejuvenation

Indication Filler Needle/cannula choice
Nasolabial folds (superficial) Teosyal Global Action, Restylane 30 G " needle
Nasolabial folds (deep) Teosyal Deep Lines, Perlane, Radiesse 27 G " needle
Oral commissures Teosyal Deep Lines, Perlane 27 G " needle
Lip enhancement Teosyal Kiss, Restylane Lipp 27 G " or 28 G " needle
Perioral (smokers) lines Restylane, Teosyal Global Action 30 G " needle
Tear trough hollows Restylane, Perlane 30 G " or 27 G " needle
Upper eyelids Restylane 30 G " needle
Anterior cheek Teosyal Ultimate, Restylane Sub-Q 21 G 2" or 18 G 3" cannula
Cheekbones Radiesse 27 G 1 " needle
Nasal dorsum Radiesse 27 G " needle
Glabellar linesa Restylane, Teosyal Global Action 30 G " needle
a
First-line treatment for the glabella is botulinum toxin type A

nodule formation [21]. Soft fillers should be used to

augment naturally soft facial compartments, such as the
buccal and malar fat pads. As such, large volume
hyaluronic acid fillers such as Restylane SubQ,
Juvederm Voluma, and Teosyal Ultimate are ideally
suited to provide smooth anterior projection of the
cheeks lateral to the nasolabial folds. For tear trough
hollows in the medial infraorbital area, conservative
volumes of a small particle hyaluronic acid filler should
be placed deep to the orbicularis oculi muscle on the
periosteum to avoid visible and palpable lumpiness.
Several HA fillers designed for lip enhancement have
been introduced that are soft enough to provide natural
results but robust enough to optimize longevity in this
dynamic area. These include Teosyal Kiss, Restylane
Lipp, and Juvederm Ultra Smile. Although collagens
such as Zyplast and Cosmoplast do not provide lasting
results, they provide crisp definition rather than just
volume to the vermillion border of the lip. When start-
ing the practice of injectable fillers, the author recom-
mends using hyaluronic acid products only as they tend
to be more forgiving than long-lasting fillers and,
although rarely necessary, can be reversed using
hyaluronidase [22]. Fig. 28.4 Indications for facial fillers. Blue: basic techniques;
green: Advanced techniques

28.5 Pretreatment Considerations
28.5.1 Patient Selection
There are several basic and advanced indications for
injectable fillers in facial rejuvenation. These are
shown in Fig. 28.4 and listed in Table 28.5. Basic indi-
cations are commonly performed and technically sim-
ple. Advanced techniques require more precision, are
less forgiving, or involve contouring of features rather
than just filling lines. With all filler treatments, patients
should have realistic expectations and understand that
the aim is to soften folds and lines or improve features
and proportions, rather than eliminate lines altogether
28 Facial Fillers 421

Table 28.5 Areas amenable to treatment with injectable facial

a
fillers
Common Less common
Nasolabial folds Tear trough
Lip border Upper eyelid
Lip body Nasal dorsum
Oral commissures Columella of nose
Vertical lip lines Philtrum of lip
Fine lines Jawline
Zygomatic arch Brow
Malar fat pad Chin
Acne scars Glabella, crows feet, and
forehead linesa
a
First line treatment is botulinum toxin type A b

or create perfection. The value of combining soft tissue

augmentation with other aesthetic medical procedures
such as botulinum toxins and skin resurfacing should
be emphasized, particularly if the patient seeks more
dramatic results. Facial assessment begins during the
consultation while the patient is speaking by observing
the activity of the muscles acting on the mouth. Often,
there is a discrepancy in the activity of the right and left
levator labii muscles during animation, resulting in
asymmetry of nasolabial fold depth that is resistant to
correction using fillers alone. Any asymmetry should
be brought to the attention of the patient before treat-
ment and documented with photography. The face is
inspected from the front and side profiles to determine
the presence and extent of tear trough hollows, nasoju-
gal grooves, malar flattening, nasolabial folds, mario-
nette lines, lip height and projection, chin projection,
nose shape, and perioral and cheek lines. Effacing the
nasolabial fold with gentle lateral traction on the skin of
the cheek indicates that fillers are likely to soften the
fold satisfactorily (Fig. 28.5). Similarly, if skin traction
above the lip softens vertical rhytids, fillers in this area
are likely to be of benefit. Minimal or no improvement
in the lines with this maneuver is common with etched
in lines that require more aggressive measures such as
CO2 laser skin resurfacing.
Rejuvenation of the infraorbital area with fillers
alone can be challenging, particularly when there is
skin laxity or prominent infraorbital fat pads. Never-
theless, appropriate use of fillers in the right candidate
can produce dramatic results, sometimes obviating the
need for surgery. The value of soft tissue augmenta-
tion in this area is appreciated when one studies the
Fig. 28.5 (a) Assessing the nasolabial fold. (b) Folds that soften
with gentle lateral traction are treated successfully with fillers
lid-cheek complex [23]. The aim of injectable fillers
under the eye is to create a smooth lid-cheek junction,
so that the lid blends seamlessly with the cheek, with-
out a groove or depression between them (Fig. 28.6).
Atrophy of midface volume results in a cheek that
falls away from the lid, giving the appearance of
a longer lower eyelid and bags under the eyes.
Restoring a smooth lid-cheek junction is achieved by
placing filler along the tear trough groove, and often
complementing this with volume in the malar area
anteriorly, to lift the cheek and efface the nasojugal
groove that runs further laterally from the tear trough
(Fig. 28.7).
Botulinum toxin type A is the treatment of choice
for hyperdynamic lines in the upper third of the face:
glabellar lines, horizontal forehead lines, and perior-
bital lines. For etched-in lines or deep glabellar lines
that remain despite chemodenervation, dermal fillers
should be considered. Fillers injected in very dynamic
areas such as the glabella without chemodenervation
422 P.M. Prendergast

a b

Fig. 28.6 (a) Before. (b) After hyaluronic acid fillers. The nasojugal groove has been effaced, improving the smooth convexity of
the lid-cheek complex

a b

Fig. 28.7 (a) Before. (b) After 1-mL hyaluronic acid filler placed at the preperiosteal level in each tear trough and 2 mL in each
malar area to improve volume and smooth contour irregularities

first may lead to migration and premature absorption. 28.5.2 Contraindications

Adverse effects associated with fillers in the upper face
include vascular compromise in the glabellar area and Contraindications to treatment with fillers include a
palpable lumps in the thin skin around the eye [24]. known allergy to any ingredient within the product,
28 Facial Fillers 423

Table 28.6 Guidelines for anesthesia in facial soft tissue augmentation

Area Anesthesia Volume per side (mL)a
Nasolabial folds Infraorbital n. blocks 12
Top lip, vertical rhytids above lip Infraorbital n. blocks + midline frenulum 12
Bottom lip, chin Mental n. blocks + midline frenulum 12
Oral commissures Mental n. blocks 1
Anterior malar area Infraorbital n. block + infiltrative anesthesia (with epinephrine) 23
Tear trough, infraorbital Infraorbital n. (percutaneous approach) 0.5
Cheekbones, zygomatic arch Infraorbital n. + zygomaticofacial n. blocks topical cold 23
a
Total maximum lidocaine dose should not exceed 4 m/kg (plain) or 7 mg/kg (lidocaine with epinephrine)

active inflammation or infection in the treatment area,
anticoagulation, and unrealistic expectations. For med-
icolegal reasons, the author also defers treatment for
anyone who is pregnant or breastfeeding. Patients on
antiplatelet therapy such as aspirin should be advised
that bruising is likely if they wish to proceed.
28.5.3 Preparation
In order to minimize posttreatment ecchymosis, patients
are advised to stop aspirin, anti-inflammatory medica-
tion, and nutritional and herbal supplements such as
fish oils, vitamin E, ginger, garlic, Ginkgo biloba, and
St. Johns Wort at least 7 days before the treatment.
Patients should be warned that swelling, transient ery-
thema, and bruising are possible, and should plan their
social activities accordingly. Herpes simplex prophy-
laxis with an antiviral such as valaciclovir (500 mg per
day) can be commenced 2 days prior to treatment in
patients susceptible to cold sores, particularly for lip
enhancement. A consent form describing the procedure
in detail, after-effects, risks, benefits, potential compli-
cations, and alternatives to treatment should be pro-
vided and signed by the patient before treatment.
Finally, good quality photographs should be taken from
frontal, oblique, and side views using a digital camera.
efficacy and endpoint of augmentation. Regional nerve
blocks provide excellent anesthesia for soft tissue aug-
mentation procedures and allow large areas to be anes-
thetized, often at sites distant to the proposed treatment
area. The author uses plain 2% lidocaine for most
regional blocks, providing a rapid-onset anesthesia that
lasts less than 1 h. For augmentation of the malar area
using a blunt cannula, infiltrative local anesthesia using
lidocaine with 1:200,000 epinephrine is useful for two
reasons. Firstly, the vasoconstrictive effects of epineph-
rine serve to limit ecchymosis from blunt trauma in the
cheek. Secondly, the volume of filler required for opti-
mum enhancement is loosely determined by analyzing
the effect the local anesthetic alone has on the tissues.
If 3 mL of anesthetic produces sufficient augmentation,
then the same volume of hyaluronic acid can be placed
immediately afterward.
The supplementary use of topical ice or cold packs
is often helpful, particularly for areas where nerve
blocks are less accurate or produce incomplete anesthe-
sia, such as the lateral cheeks, or when superficial vaso-
constriction is desirable. For lip enhancement, small
volumes of infiltrative anesthesia into the labial frenula
in the midline supplement infraorbital and mental nerve
blocks. Table 28.6 provides a list of guidelines for anes-
thesia in soft tissue augmentation of the face.

28.6 Anesthesia
Adequate pain relief should be provided to patients
prior to injectable filler treatments. Topical anesthesia
alone using creams containing lidocaine, benzocaine,
tetracaine, prilocaine, or mixtures often do not provide
adequate anesthesia, particularly for sensitive areas
such as the lips. Infiltrating the treatment area with
local anesthesia is simple and effective, but may distort
the tissues and interfere with the ability to assess the
28.7 Materials
Fillers are available in different volumes in pre-filled
syringes. Although needles of appropriate gauge are
often included within the product packaging, this does
not preclude the use of other needles. However, whilst
it is acceptable to use a larger bore needle, longer nee-
dle, or blunt cannula in place of the needle provided,
needles of smaller internal diameter than the one pro-
vided should not be used. The rheological (flow) prop-
erties of the filler as well as gel particle size may not
424
Fig. 28.8 Blunt cannulas for subcutaneous placement of fillers
for facial contouring
allow adequate expression through needles of smaller
internal diameter. Longer needles (11") are useful
for lip and cheek enhancement where single long passes
facilitate the procedure with less needle punctures.
Blunt cannulas are ideal for facial contouring and cheek
enhancement where 34 mL of hyaluronic acid is
placed in the deep subcutaneous tissues and over the
periosteum through a single skin puncture. For hyaluro-
nic acid, the author employs blunt cannulas ranging in
size from 22-gauge to 18-gauge of various lengths
(Fig. 28.8). Before injections, the skin is prepared using
70% isopropyl alcohol wipes. Other materials required
for augmentation using injectable fillers include local
anesthetic, sterile gauze, 3 mL syringes, needles, cold
packs, and gloves.
28.8 Indications and Technique
28.8.1 General Technique
The following general techniques are used to inject
fillers superficially for lines and folds and deeply for
facial contouring or volume enhancement (Fig. 28.9):
1. Superficial droplet
The tip of the needle (usually 30-gauge) is barely
injected into the skin at approximately a 30 angle,
as superficially as possible, and tiny droplets (0.005
0.01 mL) are placed. A small wheal-like appearance
or localized blanching is acceptable because the drop-
lets are so small and settle quickly (Fig. 28.10). This
P.M. Prendergast
technique is indicated for superficial wrinkles and
lines, such as those along the cheeks, lateral to the
oral commissures, or in the glabellar area. A series
of extremely superficial, quick injections are made at
34-mm intervals so that one droplet fuses into the next
along the wrinkle. Only less viscous hyaluronic acid
fillers should be injected using this technique. The nee-
dle should be changed once or twice during the treat-
ment to ensure it remains as sharp as possible.
2. Linear retrograde threading
To place filler along a fold or groove, the needle is
inserted to the desired depth, advanced, and withdrawn
slowly as product is expressed into the cavity created by
the needle in front of it. For nasolabial folds, the depth
is usually the deep dermis. For vertical lip rhytids, the
needle is placed perpendicular to the lines in the super-
ficial dermis. This technique is also used to define the
vermilion border or enhance the body of the lips.
Although it is difficult to be sure of the precise depth of
the needle in the skin, steady resistance is felt when the
needle is advanced through the dermis, whereas the
subdermal plane offers little resistance to the needle. If
the color of the needle is visible through the skin, the
needle is too superficial and should be withdrawn and
reinserted before placing any product (Fig. 28.11).
Hyaluronic acid filler that is injected too superficially
using this technique may result in an unsightly bluish
tinge or visible thread of filler that may take over a
year to degrade. To reduce the likelihood of intravascu-
lar injection in the periorbital area, the syringe should be
aspirated gently before injection, followed by slow ret-
rograde movement of the syringe as the filler is placed.
3. Perpendicular buttress
This technique is indicated for deep nasolabial folds
that tend to overhang the crease despite placement of
filler along its length using the linear retrograde thread-
ing technique. After a column of filler is placed into
and medial to the crease in the usual way, multiple short
threads are placed intradermally perpendicular to the
crease to add support and reduce ptosis (Fig. 28.12). A
robust filler such as calcium hydroxylapatite (Radiesse)
works well using this buttress technique.
4. Fanning
The needle is inserted, often to the hilt, and filler is
injected during withdrawal as in linear retrograde
threading. However, before the needle tip exits the skin,
it is redirected so that further product is placed next to
the first thread. The maneuver is repeated, through the
same needle puncture, until a fan or triangular-shaped
28 Facial Fillers 425

Fig. 28.9 Techniques for filler injections. (a) Superficial droplet. (b) Linear retrograde threading. (c) Perpendicular buttress.
(d) Fanning (e) Cross-hatching. (f) Depot. (g) Push technique
426
Fig. 28.10 Superficial droplet technique. Small wheals appear
as small droplets of hyaluronic acid filler are placed in the super-
ficial dermis
a ture lateral to the modiolus.
b 28.8.2 Nasolabial Folds
Fig. 28.11 Linear retrograde threading. (a) Needle placed too
superficially with color of needle visible. (b) Correct placement
in the dermis
layer of filler is laid down. The fanning technique is
usually employed at the superior part of the nasolabial
fold beside the nasal alae, at the oral commissures, and
in the cheeks.
P.M. Prendergast
5. Cross-hatching
A grid-like pattern of filler is placed through mul-
tiple injection points so that the first series of threads
lie parallel to one another. A second series of threads is
then placed perpendicular to the first threads. This
technique provides structural support to an anatomic
area and builds up volume over features, such as the
cheeks. It is particularly appropriate for firm, collagen-
stimulating fillers such as calcium hydroxylapatite
(Radiesse), where a scaffolding of filler is laid down to
allow tissue ingrowth over time.
6. Depot
A bolus or depot injection of filler is placed deeply
to provide volume and project tissues anteriorly. The
depot technique should only be performed using blunt
cannulas to avoid intravascular injection. For malar
enhancement, the author uses a combination of the
depot and fanning techniques through a single punc-
7. Push
This novel technique has been described for filling
the tear trough [25]. Using a fine blunt cannula, a small
depot of filler is placed supraperiosteally in the infraor-
bital groove. Then this small pool of filler is pushed
or massaged gently using the thumb along the tear
trough deformity medially. The technique avoids mul-
tiple punctures with a needle, and could be applied to
other facial areas.
(Figs. 28.13 and 28.14)
The folds are assessed in the upright position to deter-
mine the depth and predict the volume of filler required
for correction. Deeper folds generally require larger
volumes and more viscous fillers such as Radiesse,
Perlane, or Teosyal Deep Lines. Fine lines along the
fold should be treated with the superficial droplet
technique. Fillers are injected at different depths dur-
ing the same treatment to address both deep folds and
superficial rhytids. With the patient reclined at a 45
angle, an infraorbital nerve block is performed. The
extent of the fold is determined by gently pushing
the tissue toward the nasolabial crease. The needle is
measured over the skin to determine a puncture site
that will allow the needle tip advance to the most
cephalad part of the crease. Filler is placed in the
deep dermis using both linear retrograde threading
28 Facial Fillers 427

and fanning techniques. At first, a sufficient volume of
filler should be placed in the triangle beside the ala of
the nose. Then, as filler is placed inferiorly along the
crease, it is important to stay slightly medial to the
fold to create a smooth transition between the skin of
the upper lip and the nasolabial fat. At the inferior part
of the nasolabial fold, a dimple or tethered area is
often encountered where the zygomatici have dermal
attachments. Softening the fold here requires superfi-
cial placement of small volumes of filler, using the tip
of the needle to gently subcise or cut the dermal
attachments where possible.

a b

c d

e f

Fig. 28.12 Perpendicular buttress technique. (ad) The needle threads are placed in the deep dermis perpendicular to the fold.
shows the direction and placement of filler along the nasolabial (g) Before. (h) After 1.3-mL Radiesse in each nasolabial fold
fold and perpendicular to it. (e) Long threads of filler are placed using perpendicular buttress technique
in the deep dermis along and just medial to the fold. (f) Short
428
g h
Fig. 28.12 (continued)
28.8.3 Oral Commissures (Fig. 28.15)
Fillers placed in the oral commissures lifts the mouth
corners and creates a pleasant countenance. Placing a
small amount of filler in this area is almost always
indicated during lip enhancement. To treat the oral
commissures, the extent of the groove can be assessed
by gently pushing the jowl toward the chin. The index
finger of the non-injecting hand lifts the mouth corner
into the desired position. Then the thumb stabilizes
the lower-lip skin to allow the needle pass easily into
the dermis at the correct depth. The needle is mea-
sured over the commissure such that the tip reaches
into the upper lip when advanced to its hilt. To achieve
a successful lift, the needle must be in the superficial
dermis with the distal third of the needle immediately
adjacent to the vermilion border. Two or three passes
may be necessary to place adequate threads using the
linear retrograde technique. Injections in this area
that are too deep may worsen the oral commissure
rather than improve it. Once the lip edge has been
P.M. Prendergast
lifted, the fanning technique is used to support the
mouth corners and fill along the commissure toward
the chin.
28.8.4 Lips (Figs. 28.1628.18)
Both the vermilion border of the lip and the body of
the lip can be augmented using fillers. Although
hyaluronic acid is the most commonly used filler,
collagen may also be used for the border to provide
crisp definition. Fillers with long-lasting microspheres
such as calcium hydroxylapatite and permanent fillers
should not be used for lip enhancement. For aestheti-
cally pleasing proportions, the bottom lip to top lip
height should be approximately 1:0.6, although this
sometimes varies according to personal preference.
For anesthesia, infraorbital and mental nerve blocks
are performed, supplemented with 0.5 mL of anesthe-
sia in the mucosa at the midline around the upper and
lower frenula.
28 Facial Fillers
a midline. Shorter needles may be used near the philtrum
b
c that the product is distributed evenly. Equal volumes
Fig. 28.13 Filling the nasolabial fold. (a) Filler is injected in
the deep dermis starting at the superior aspect of the fold. (b)
The area adjacent to the nasal ala should be filled to soften the
fold superiorly. (c) The fold is effaced using the linear retrograde
threading technique inferiorly toward the mouth
To enhance the vermilion border, the needle is
placed at or just above the vermilion border, in the
white roll, a tube-like structure that gives the lip
border its definition. Using the linear retrograde
threading technique, small volumes are injected along
the length of the border, from the commissure to the
429
for accurate placement along the lip border without
distorting the angles of Cupids bow. Gentle moulding
in this area is used to maintain sharp definition. For
experienced physicians, a thin thread of filler can also
be placed along the philtrum ridges from the vermil-
ion to the columella, using the non-injecting hand
to feel the needle and hold the thread of filler in place
as the needle is withdrawn (Fig. 28.17). Augmenta-
tion of the vermilion border improves definition and
also reduces vertical lip rhytids in older patients and
smokers who experience bleeding of lipstick above
the lip.
To improve overall lip volume and provide some lip
eversion, filler is injected into the body of the lip
(Fig. 28.18). The lip is everted slightly with the non-
injecting finger and a suitable hyaluronic acid is
injected deeply into the lip at the point where the wet
mucosa meets the dry epidermis. A continuous sau-
sage-like tube of filler should be placed along the
length of the body of the lip, except for the lateral
34 mm, where filler may distort the shape of the lip
and make the mouth look wider. When the needle is
withdrawn each time, the lip should be grasped gently
with sterile gauze to prevent bruising and moulded so
should be placed on either side, unless an asymmetry
exists before the procedure. Usually, 1 mL is sufficient
to provide subtle lip enhancement, or even less if the
border only is being treated. Mild swelling is usual and
subsides within a few hours.
28.8.5 Perioral Lines (Fig. 28.19)
One of the most commonly requested treatment areas
is the skin above the lip, where vertical lines radiate
from the vermilion border. These perioral lines are par-
ticularly common in smokers with hyperdynamic
orbicularis oris muscles and poor skin quality. Sun
exposure and normal senescent changes due to loss of
fat, collagen, and elastin in the skin are also responsi-
ble. To reduce perioral lines, a thin sheet of hyaluronic
acid filler is placed in parallel threads into the superfi-
cial dermis. The threads act as scaffolding that lifts the
tissues and softens the rhytids. Very superficial place-
ment in the upper papillary dermis should be avoided
to prevent lumpiness. Complementary use of botulinum
430
a b
Fig. 28.14 (a) Before. (b) Immediately after 1-mL Teosyal Deep Lines in each nasolabial fold
toxin to partially denervate orbicularis oris will enhance
the results and may prolong the tissue residence of
the filler. For lines that do not respond to either of these
modalities, deep complete or fractional CO2 laser
resurfacing usually works well.
28.8.6 Tear Trough (Fig. 28.20)
Filling the tear trough hollow in the medial infraorbital
area with even small volumes of hyaluronic acid can
result in significant rejuvenation. Unfortunately, it is
Fig. 28.15 Lifting the mouth corners with fillers. (a) The oral
commissure is assessed in the resting position. (b) The index
finger of the non-injecting hand lifts the mouth corner to the
desired position. (c) The thumb stabilizes the lower lip skin.
(d) The needle is measured externally to determine the point
of entry. The needle tip should reach the upper lip. (e) A thread
P.M. Prendergast
also a less forgiving area prone to swelling, puffiness,
and lumpiness with improper technique or poor patient
selection. Patients with very lax skin or excessive pro-
trusion of orbital fat should not be treated. An under-
standing of the complex anatomy in this area is
essential before addressing it with fillers (Fig. 28.21).
When the orbital and zygomatic retaining ligaments
attenuate, fat protrudes below the eye, bags begin to
form, and the tear trough and nasojugal folds become
prominent. Small volumes (<0.5 mL) of lidocaine with
epinephrine are injected transcutaneously over the
periosteum around the infraorbital nerve. After waiting
of filler is placed in the superficial dermis just lateral to the
vermilion border. Further threads should be placed as required
until the lip edge remains elevated. (f) The needle is measured
over the skin medial to the fold. (g) Filler is placed medial to the
oral commisure to support the lift and soften the fold here (h)
After 0.5-mL hyaluronic acid, the mouth corner appears elevated
28 Facial Fillers 431

a b

c d

e f

g h
432 P.M. Prendergast

a b

c d

e f

g h
28 Facial Fillers
a During the procedure, the patient is asked to gaze
b
Fig. 28.17 (a) Before. (b) After lip border enhancement and
enhancement of the philtrum
10 min, the needle is placed perpendicularly first to
reach periosteum, then withdrawn 1 mm and tunneled
slowly medially under orbicularis oculi to reach the
medial extent of the tear trough. After aspiration, small
aliquots of filler are placed under orbicularis oculi and
the orbital retaining ligament as the needle is with-
drawn. Gentle massage after each injection ensures the
filler is in the correct position behind the muscle.
Fig. 28.16 Defining the lip borders. (a) A " or 1" needle is
ideal for placing fillers along the border of the lip. (b) A thread of
filler is placed all the way to the cupids bow, at or just above the
vermilion border in the white roll of the lip. (c, d) Using
the linear retrograde threading technique, filler is placed from the
cupids bow to a point just short of the lip edge laterally. (e) Filler
433
upward intermittently to delineate the tear trough,
which becomes more pronounced as the orbital fat
bulges outward. It is imperative to protect the globe by
placing the fingers of the non-injecting hand along the
orbital rim. This technique can also be performed using
fine bore blunt cannulas through one or two skin punc-
tures [26]. The skin in the tear trough area is extremely
thin, making it important to place the filler deeply
under the muscle, either in the prezygomatic space or
in the preperiosteal fat. Subdermal injections in this
area can only be performed if microdroplets are used
[27]. To efface the tear trough hollow, the author usu-
ally injects 0.40.5-mL hyaluronic acid per side during
an initial treatment, with further filler placed 23 weeks
later at a follow-up visit if required.
28.8.7 Malar Fat Pads (Fig. 28.22)
A youthful midface is characterized by smooth con-
vex curves from the lower lid with full anterior malar
fat pads (Fig. 28.23). The anterior cheek should blend
seamlessly with the lower lid, nasolabial fat pad, lat-
eral cheek, and tissue over the lateral orbital rim so
light is reflected from the smooth contours. The apex
or most anteriorly projecting part of the cheek is usu-
ally over the zygoma, just below the lateral canthus.
First, an infraorbital nerve block is performed using
the intraoral approach. Then a small bleb of anesthe-
sia is raised using a 30-gauge needle in the dermis just
lateral to the modiolus. To make an entry site for an
18-gauge cannula, a 16-gauge needle is used to punc-
ture the skin. Further infiltrative local anesthesia using
lidocaine and epinephrine is performed with deep
injections into the site of augmentation with a long
27-gauge needle. After waiting 10 min for adequate
vasoconstriction, the blunt cannula is used to deposit
hyaluronic acid using the depot and fanning tech-
nique. In order to create seamless transitions between
the contours, filler must be placed close to the orbital
rim, deeply in the buccal fat pad, into the sublevator
should be placed all the way to the midline to enhance the
Cupids bow. (f) A small bolus can be placed just prior to the
needle exiting the skin where the philtrum line meet the lip. (g)
Gentle moulding enhances the philtrum. (h) To define the lower
lip, a thin thread is placed at or just below the vermilion border
along the entire length of the lip
434
a b
c d
Fig. 28.18 Lip volume enhancement. (a) Slight eversion of the
lip with the non-injecting hand exposes the mucocutaneous
(wet-dry) junction. (b) Filler should be placed from the midline
space deep to levator labii near the nose, along the
medial part of the zygomatic arch, and feathered from
the most prominent part over the zygoma toward the
lower third of the face. The index finger feels for the
tip of the cannula at the infraorbital rim where it
advances below the orbicularis oculi muscle. The
author typically places 1.54 mL of Teosyal Ultimate
or Restylane Sub-Q on each side to achieve satisfac-
tory results.
28.8.8 Cheekbones (Fig. 28.24)
Soft tissue augmentation over the zygomatic arch and
zygoma provide an attractive youthful appearance
characterized by high, defined cheekbones. This tech-
P.M. Prendergast
to a point just medial to the lateral border of the lip. (c) The
needle is placed deeply into the body of the lip. (d) A thin sau-
sage of filler is placed as the needle is withdrawn
nique is usually indicated for patients who are
2550 years old who have reasonable soft tissue cov-
erage. Filler implants injected in patients who have
very thin faces may look excessively prominent and
unnatural. The aim is to create subtle definition so
that a shadow is cast along the zygomatic area
(Fig. 28.25). Firm, robust fillers such as Radiesse are
particularly well suited for enhancing and defining
bony features such as the cheekbones. The area is
marked bilaterally to ensure symmetry. Infraorbital,
zygomaticofacial, and zygomaticotemporal nerve
blocks can be used for anesthesia, supplemented with
topical cooling where necessary. Most of the filler is
placed over the zygomatic arch and below the lateral
canthus over the zygoma, with feathering into the
malar and buccal areas. Threads of filler are placed at
28 Facial Fillers
a b
c d
Fig. 28.19 Perioral rejuvenation using fillers. (a) The depth
and distribution of perioral rhytids is determined by gently
compressing the skin above the lip. (b) The skin is stabilized.
the dermal-subcutaneous junction using the fanning
and cross-hatching techniques. A long needle facili-
tates placement with fewer puncture sites. With cal-
cium hydroxylapatite, approximately 1.32-mL filler
on each side achieves satisfactory enhancement. Once
placed, firm moulding into place with the fingertips
flattens the subcutaneous threads of filler and helps
blend the augmented soft tissue with the surrounding
area.
28.8.9 Nose (Fig. 28.26)
Even minor alterations to the shape of the nose with
temporary fillers can produce immense patient satis-
faction. The most common indication is filling the tis-
sue between the nasion and rhinion (Fig. 28.27). The
nasion lies at the root of the nose in the midline and the
rhinion is the junction of the bony and cartilaginous
dorsum of the nose in the midline. A small amount of
plain lidocaine is placed around the infratrochlear
435
(c) Thin threads are placed perpendicular to the lines across the
upper lip in the superficial dermis. (d) Further compression
produces fewer lines once sufficient filler has been placed
nerve to anesthetize this area. Then a filler such as
Radiesse is injected along the periosteum, moulding
gently until the nasal dorsum appears straight. Asian
patients often request a more prominent nasal bridge.
To achieve this, filler is placed more proximally, start-
ing at the glabella and blending with the nasal dorsum.
Filler should be placed in small volumes deeply on the
periosteum to reduce the likelihood of intravascular
injection that could lead to skin necrosis in this area.
To lift the tip of the nose, a small depot injection of
hyaluronic acid is placed in the subnasale at the junc-
tion of the columella and the upper cutaneous lip. An
injection of botulinum toxin in the depressor septi
muscle complements this by alleviating the downward
pull on the tip of the nose.
28.8.10 Chin
To enhance the chin, a depot injection is placed on the
anterior aspect of the mentum in the midline. About
436 P.M. Prendergast

a b

c d

Fig. 28.20 Augmenting the infraorbital hollows. (a) The nee-
dle is placed along the periosteum just below the infraorbital
margin. (b) Markings can be made to define the extent of infraor-
bital volume loss. (c) The needle is measured over the skin first
so that the needle tip reaches the medial extent of the hollow,
short of the angular vessels. (d) The needle passes deeply first
until the tip touches the periosteum. (e) Then the needle is
withdrawn a fraction, redirected toward the medial canthus,
and glides deep to the orbicularis oculi above the periosteum.
After gently aspirating on the syringe, small aliquots are placed
using linear retrograde threading, releasing pressure on the
plunger before the needle is withdrawn superficial to the muscle.
(f) These steps are repeated along the extent of the tear trough
hollow until adequate correction is achieved
28 Facial Fillers
e f
Fig. 28.20 (continued)
2 mL of hyaluronic acid placed on the periosteum is
usually sufficient.
28.8.11 Supraorbital (Fig. 28.28)
Elevation and anterior projection of the lateral third of
the eyebrow is achieved by injecting approximately
0.5 mL of filler along the periosteum under the brow.
Placing the filler a fraction inferior to the level of the
brow has the effect of pushing the hair of the brow
superiorly.
28.8.12 Eyelids (Fig. 28.29)
Periorbital volume loss results in deepening of the
superior orbitopalpebral sulcus with a visible bony
orbital rim. Improving this sunken eye appearance
with fillers requires carefully placed injections in
the retroorbicularis oculi fat (ROOF) pad behind the
eyelid (Fig. 28.21). This is a particularly unforgiving
area and should only be performed by those with
extensive experience using fillers. If too much filler is
placed, or if the filler is injected in the skin, the eyelid
may appear swollen with visible bumps and uneven-
ness. Successful augmentation in this area softens
the appearance and provides a more youthful look
(Fig. 28.30). The author uses Restylane for periorbital
437
augmentation, injected through a 29- or 30-gauge
needle. Even without anesthesia, injections in the eye-
lid are well tolerated. Topical anesthesia may be used,
but infiltrative anesthesia should not be used because
of its propensity to cause tissue distortion. After mark-
ing the hollows, tiny threads of filler are placed under
the dermis and orbicularis oculi and gently mas-
saged against the supraorbital ridge to ensure an even
distribution. The orbital septum lies deep to the ROOF.
The septum is very thin, and covers the subseptal fat
medially and the lacrimal gland laterally. Injections
should remain superficial to avoid penetrating the
orbital septum. The needle will enter the correct
plane by gently pinching up the skin and placing the
needle into the tented area. Tiny aliquots of filler are
placed during the initial treatment to avoid complica-
tions, with additional augmentation at a second visit
if required. Results using hyaluronic acid fillers last
about 68 months. A similar technique using fat has
also been described [28].
28.8.13 Combination Approaches
Volume loss is only one facet of the aging process.
Other aging features, such as hyperdynamic lines,
ptosis, and various skin pigmentation and textural
irregularities are addressed using injectable, laser, and
minimally invasive procedures in combination with
438 P.M. Prendergast

Fig. 28.21 Components

of periorbital volume loss and
correction using hyaluronic
acid filler Orbitopalpebral sucus

Tear trough

Nasojugal fold

Orbicularis oculi

Retroorbicularis oculi
fat (ROOF)

Hyaluronic acid filler

Orbital retaining ligament

Suborbicularis oculifat
(SCOF)

Hyaluronic acid filler

Preperiosteal fat
Prezygomatic space
Zygomatic retaining
ligament

Fig. 28.22 Soft tissue augmentation of the midface. (ac)
Filler is placed medially and laterally along the orbital rim and
inferior to it, protecting the globe with the finger resting on the
orbital rim. (d) The skin is anesthetized by raising a dermal
bleb. (e) A puncture is made using a 16-gauge needle. (f, g)
With the finger on the orbital rim, the cannula is inserted to the
periosteum and filler is placed deep to the muscles and in the
subcutaneous tissue using the fanning technique. (h) Smooth
anterior projection of the cheek following 3-mL hyaluronic acid
filler
28 Facial Fillers 439

a b

c d
440 P.M. Prendergast

e f

Fig. 28.22 (continued)

the techniques described above. The combination of In the upper face, botulinum toxin type A is the
multiple procedures provides synergy, enhancing over- most appropriate first-line treatment for hyperdynamic
all results without creating an unnatural appearance lines in the lateral periorbital area, glabella, and fore-
(Fig. 28.31). head. One injection of botulinum toxin in the lower
28 Facial Fillers
Fig. 28.23 (a) Flattening of
the midface. (b) Improvement a b
after soft tissue augmentation
with 3-mL Teosyal Ultimate
using an 18-gauge cannula
eyelid below the eyelash partially denervates pretarsal
orbicularis oculi and softens the appearance of the lid-
cheek junction, particularly when fillers have also been
placed in the tear trough (Fig. 28.30). Carbon dioxide
laser skin resurfacing is the gold standard for treating
photoaged skin and etched-in lines lateral to the
orbit and around the mouth. For glabellar frown lines,
botulinum toxin is the first-line treatment unless con-
traindicated, followed 2 weeks later by dermal fillers
when chemodenervation has been achieved but deep
lines remain.
In the midface, suture lifting techniques complement
soft tissue augmentation with fillers by elevating the
malar fat pad. Superior and superolateral lifting vectors
soften the nasolabial fold and improve volume defi-
ciency in the tear trough. Radiofrequency and infrared
light devices for tissue tightening may also improve
laxity, but the lifting effect of these external technolo-
gies is subtle. Fine perioral lines above the lip respond
to a combination of ablative resurfacing, dermal fillers,
and conservative doses of botulinum toxin.
Combined suture lifting of the lower face and filling
of the oral commissures provides better results than
441
each procedure can achieve individually. To improve
the definition of the jawline, suture lifting of the lower
face and soft tissue augmentation of the prejowl sulcus
with fillers can be performed together. Softening the
chin with botulinum toxin also compliments the use of
fillers in the mental crease.
28.8.14 Aftercare
Patients should receive verbal and written instructions
following injectable filler treatments. Although patients
are advised to massage the face after treatments with
stimulating agents such as Sculptra, gentle handling is
more appropriate for most other fillers. Manipulating
soft, pliable fillers such as hyaluronic acid following a
treatment may lead to displacement or lumpiness.
Excessive animation, such as laughing or chewing
gum, should also be avoided, particularly following
filler injections in dynamic areas such as the nasola-
bial folds. Some swelling, erythema, and bruising are
normal after most injectable treatments. The patient
should be reassured, and cold packs can be applied as
442 P.M. Prendergast

a b

c d

e f

Fig. 28.24 Cheekbone enhancement using calcium hydroxy-
lapatite. (a) The area to be enhanced is marked carefully. This
should be quite high over the zygomatic arch and taper toward
the zygoma. (b, c) The fanning technique is used to place filler in
the superficial subcutaneous plane. (d) Augmentation continues
through further injections medially over the prominent zygoma.
(e, f) Further injections are made from the medial aspect of the
zygomatic arch to blend with the previously placed filler and
feather over the infrazygomatic area
28 Facial Fillers
a b
Fig. 28.25 (a) Before. (b) After cheekbone enhancement with 1.5-mL Radiesse on each side
desired for the first few hours. Mineral make-up can be
used to camouflage ecchymosis. Prophylaxis with
valaciclovir may be considered in patients who have
frequent herpes simplex outbreaks, particularly before
injections in or around the lips.
28.9 Complications
With the greatly increased use of injectable temporary
and permanent facial fillers in recent years, there has
been an increase in reported complications [29]. Proper
training in basic and advanced techniques, a thorough
knowledge of soft tissue and facial anatomy, and an
understanding of the indications, limitations, and
potential side effects with each of the currently used
fillers are required to reduce the incidence of unneces-
sary complications [18]. Using only temporary fillers
with high safety profiles such as hyaluronic acid also
serves to reduce serious complications [12].
443
Normal after-effects associated with the use of
injectable fillers include transient swelling, erythema,
and ecchymosis. The incidence and nature of more
serious complications depend on the type of filler used
and area injected. Minor complications due to superfi-
cial injections include visible or palpable lumpiness.
Allergic or inflammatory reactions associated with
hyaluronic acid fillers have been documented, but are
rare [30]. Granulomatous reactions are more likely with
collagen stimulating synthetic products such as pol-
ymethylmethacrylate and poly-l-lactic acid. These
may be treated with intralesional steroid injections.
Several treatments with small volumes of triamcino-
lone acetonide injected directly into the granuloma may
be required [31]. Some of the most serious complica-
tions associated with fillers occur due to inadvertent
intravascular injection. In the glabellar tissue, this
may lead to skin necrosis. Reports of iatrogenic visual
loss due to intravascular injection of collagen and fat
in the periorbital area exist [32]. Other significant
444 P.M. Prendergast

a b

Fig. 28.26 Nose reshaping using fillers. (a) The soft tissue is be placed from a point just proximal to the rhinion. (c) The filler
lifted upward and the needle is placed deeply on the periosteum. is moulded gently to create the desired degree of augmentation
After aspiration, small volumes are injected. (b) Filler can also or straightening

a b

Fig. 28.27 (a) Before. (b) After 0.3-mL Radiesse in the proximal nasal dorsum
28 Facial Fillers 445

a b

c d

Fig. 28.28 Filler enhancement of the lateral brow. (a) An intra- linear retrograde threading technique. (c) Before. (d) After
dermal injection of local anesthetic is made. No other anesthesia enhancement with 0.4-mL Perlane per side
is required. (b) Filler is injected along the periosteum using the

complications, such as implant migration, infection,
and delayed inflammatory reactions, are more likely
with permanent fillers [3336].
Immediate posttreatment swelling and erythema do
not require treatment, although topical ice packs may
accelerate resolution. In order to minimize bruising,
lidocaine with epinephrine can be used for infiltrative
local anesthesia, except when treating areas with end-
arteries, such as the nose. Although slight lumpiness
usually resolves spontaneously, gentle massage is
advised to improve a discrete lump that bothers the
patient. Although rarely necessary, hyaluronic acid
fillers may be dissolved quickly using hyaluronidase
[37]. The author routinely performs skin testing with
hyaluronidase before treatment as hypersensitivity
reactions and angioedema can occur [38]. Hyaluronidase
(e.g., Hyalase 1500 IU/amp) is reconstituted with
saline and small volumes are injected directly into the
lump or area that has been overfilled. Reconstituting
1500 IU with 10 mL saline produces a 150 IU/mL
solution. The volume of this reconstituted hyaluroni-
dase solution injected should equate to the volume of
HA that requires removal. Breakdown of the filler can
be expected within hours.
446 P.M. Prendergast

a b

c d

e f

Fig. 28.29 Treating the superior orbitopalpebral sulcus (sunken
eyelid) with hyaluronic acid. (a) Mark the groove under the
brow where there is volume loss. (b) Gently pinch up the eyelid
and insert a 30-gauge needle. (c) The needle should be under the
dermis or orbicularis oculi in the retroorbicularis oculi fat
(ROOF). (d) Lifting the needle reveals the depth. (e) After each
thread of filler is placed, the lid is gently massaged against the
supraorbital rim. (fh) Injections of tiny aliquots of filler con-
tinue medially along the orbitopalpebral sulcus until the groove
has been corrected. (i, j) The filler is gently moulded against the
underlying periosteum to ensure evenness
28 Facial Fillers 447

g h

i j

Fig. 28.29 (continued)

a b

Fig. 28.30 (a) Before. (b) After periorbital rejuvenation with hyaluronic acid and botulinum toxin: 0.2-mL Restylane in each orbi-
topalpebral sulcus, 0.5-mL Restylane in each tear trough, and 4U Dysport in each inferior pretarsal orbicularis oculi
448 P.M. Prendergast

a b

Fig. 28.31 (a) Before. (b) After botulinum toxin for upper face hyperdynamic lines, hyaluronic acid fillers in the nasolabial folds
and oral commissures, and a lower face suture suspension lift

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 Ultrasound-Assisted Lipoplasty:
Basic Physics, Tissue Interactions,
and Related Results/Complications
William W. Cimino
29.1 Introduction
Safe and effective use of ultrasonic instrumentation for
lipoplasty requires an understanding of both the tech-
nology and associated surgical methods that differ sig-
nificantly in many ways from the basic tools and
methods of suction-assisted lipoplasty. This chapter
presents the basic physics and tissue interactions for
ultrasound-assisted lipoplasty, the benefits of proper
use of this technology, and complications associated
with improper use of this technology.
29.2 Basic Physics
Over the past decade and a half, there have been three
distinct generations of ultrasonic instrumentation for
lipoplasty introduced to the market. In each subsequent
generation, there have been design changes that
improve the safety, efficacy, and usability of the equip-
ment. In the following section, the basic physics of
ultrasonic instrumentation is explained and used to
describe the differences in each of the three genera-
tions of ultrasonic instrumentation for lipoplasty. First-
generation ultrasonic instrumentation is represented
by the SMEI Sculpture technology; second-generation
ultrasonic instrumentation is represented by the Mentor
Contour Genesis and Lysonix 2000/3000 technologies;
and third-generation ultrasonic instrumentation is rep-
resented by the Sound Surgical VASER technology.
W.W. Cimino
Louisville, CO, USA
e-mail: williamcimino@comcast.net
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_29, Springer-Verlag Berlin Heidelberg 2013
29
Ultrasonic surgery is the use of metal probes
vibrating at low ultrasonic frequencies (2060 kHz) to
achieve a desired surgical effect in tissues. The probe
design, the frequency of vibration, and the surgical
technique all play a role. To be clear, it is the vibrating
metal tip of the probe interacting with the tissue that is
of concern; it is not sonic radiation or some other mys-
terious phenomenon. It is complex, but understand-
able. Ultrasonic surgical instruments are in common
use as dental descalers (from the 1950s and 1960s), for
phacoemulsification (from the 1960s and 1970s), for
neurosurgery (from the mid-1970s), for laparoscopic
surgery (from the 1980s and 1990s), and for lipoplasty.
First-generation ultrasonic lipoplasty devices arrived
in the late 1980s and early 1990s, second-generation
devices arrived in the mid-1990s, and the third-
generation device arrived in the early 2000s.
The basic ultrasonic surgery system has an elec-
tronic generator that interacts with an ultrasonic hand-
piece. The ultrasonic handpiece has an ultrasonic
motor, most often composed of PZT crystals that con-
vert electrical energy to vibratory motion. The vibra-
tory motion is passed to a probe that vibrates in
resonance with the handpiece. The electronic circuits
in the generator maintain vibration at the selected reso-
nant frequency and adjust the amplitude of vibration
based on controls on the generator. Vibration frequen-
cies for ultrasonic systems for lipoplasty range from
22 to 36 kHz. There is no significant difference in tis-
sue effect across this frequency range; it simply alters
the lengths of the resonant pieces by changing the
wavelength of the vibration. Because the devices must
resonate, the lengths are multiples of wavelength.
The ultrasonic probe and handpiece vibrate longitu-
dinally at the designed resonant frequency. This means
451
452
that standing waves are established in the probe and
handpiece such that the tip of the probe experiences
maximum longitudinal motion, on the order of a peak-
to-peak displacement of a few thousandths of an inch,
barely visible to the naked eye. The amplitude is a
function of the vibration frequency and the amplitude
setting. It is important to understand that the vibration
is not lateral, i.e., transverse to the long axis of the
probe. When transverse vibration occurs, as it some-
times can with smaller diameter or longer probes, it
has a very strong audible zing. Such a vibration can
easily fracture the ultrasonic probe because the probe
was not designed to accommodate bending stresses. It
is also important to visualize standing waves in the
probe as opposed to a single back and forth motion of
the entire probe. A reciprocating powered cannula
device moves the cannula back and forth as a solid
unit. Ultrasonic probes vibrate with standing waves
and thus achieve the ability to concentrate energy
at the tip of the probe. The peak-to-peak vibration
amplitudes and probe dimensions for the various first-,
second-, and third-generation ultrasonic devices for
lipoplasty have been summarized [1]. The available
vibration amplitudes for the various devices are of
actual little consequence. What matters is the available
power at the tip of the device, which does scale with
amplitude, but is also a function of frequency. Thus,
lower amplitudes and higher frequencies can achieve
the same level of power as higher amplitudes and lower
frequencies.
Electrical power into the generator or amplitude
of vibration is a not useful indicator of actual power for
effecting tissues. Power deposited in tissues is a func-
tion of the generator setting, but also a strong function
of the coupling between the tip of the probe and the
tissues. A vibrating tip that is pressed strongly into
tissue will couple significantly more energy to the tissue
than the same tip that is gently touching the same tis-
sue. Furthermore, the design and shape of the vibrating
tip will strongly influence how much power is coupled
to the tissue and where on the tip the energy will be
concentrated. Thus, what was needed was a measure of
the maximum acoustic power that could be coupled
from a probe with a specific design and a selected
amplitude of vibration. This information has been mea-
sured and reported [1]. In short, a water bath was used
as a repeatable and reliable way to assess the power
available from ultrasonic devices. Water is a very effec-
tive medium in which to assess power because it is a
W.W. Cimino
consistent and strong coupling agent. The data show
that first- and second-generation ultrasonic devices,
when run in the range of clinically effective amplitudes,
deliver between 20 and 30 W of power to the water
bath. The third-generation devices typically delivery
1015 W of power to the water bath, generally 50% of
the power of the earlier generation devices. However,
the third-generation devices deliver the reduced overall
power with much greater efficiency [1]. The measure
of efficiency developed was the energy per unit active
volume at the tip where the active volume of the tip can
be determined by measurements of the tip geometry.
This measured data showed that the design of the tip
greatly influences the efficiency of the coupling. First-
and second-generation devices possess efficiencies in
the range of 100175 mJ/mm3 in the clinically usable
amplitude range, whereas the third-generation technol-
ogy has efficiencies in the range of 175250 mJ/mm3 in
the clinically usable range. In summary, third-generation
technology was able to roughly double the efficiency
while cutting the power applied in half.
The various probe designs shown in Fig. 29.1 can
be used to explain this result. The probe on the left is a
5-mm probe with two aspiration holes and a relatively
flat front surface. The majority of the frontal surface is
active on this probe. Thus, when the probe is pressed
into tissues strongly, there is strong coupling of the
ultrasonic energy from the face of the probe. The sec-
ond probe from the left is a golf-tee design, having a
concave surface at the front of the tip. The active area
for this probe is inside the concave recess and will not
contact tissue unless the tissue is pulled into the recess
with suction or unless the probe is pressed strongly
into a tissue area. Thus, the useful active area for this
probe design is actually quite small. The outside ring
around the outside diameter of the probe will act as an
ultrasonic knife when vibrating, which will be dis-
cussed later. The energy density along the outside ring
is very high, resulting in the cutting action.
The fourth probe from the left (Fig. 29.1) is a
smooth hemispherical tip. This style is from the first-
generation UAL technology. This active area for this
probe is actually only a small portion in the center of
the hemispherical dome. The efficiency of such a
design is very low, and the energy intensity is very
high at the active area.
All of the ringed or grooved probes shown in
Fig. 29.1 are from third-generation technology. The
grooves act to increase the active area for each probe,
29 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications
Fig. 29.1 Different
lipoplasty probe designs.
From left: second-generation
5-mm hollow, second-
generation 5-mm golf-tee
hollow, third-generation
4.5-mm 3-ring solid,
first-generation 4-mm solid,
third-generation 3.7-mm
3-ring solid, third-generation
2.9-mm 3-ring solid, and
third-generation 2.2-mm
2-ring solid
Fig. 29.2 Four identical probes except for number of rings
and the small flat disk at the center of the hemispherical
end increases the useful active area of the tip portion.
This probe design has significantly decreased energy
density due to the distribution of the total energy deliv-
ered by the probe across a much greater area. The effi-
ciency of this style of probe is much greater than
first- or second-generation designs.
The impact of the grooves can be examined and
quantified. Figure 29.2 shows four identical probes
except for the number of rings at the tip. The efficiency
of each probe can be measured as well as the distribu-
tion of the energy around the vibrating tip. The grooves
have surfaces that are perpendicular to the vibratory
motion. More grooves have more surfaces and hence
more coupling. Table 29.1 shows the relative partition-
ing of the energy for the four probes. Note that as the
number of grooves increases, more and more energy,
453
Table 29.1 Relative partitioning of energy based on number
of rings
Probe % Front % Side Tissue
3.7-0 100 0 Extreme fiber
3.7-1 65 35 Fibrous
3.7-2 55 45 Moderate
3.7-3 42 58 Soft
on a percentage basis, is coupled from the sides of the
probe tip and less is coupled from the front surface of
the tip. Thus, a probe with more grooves will not glide
as well in fibrous tissue and is more suited to softer
tissues. A probe with fewer grooves will have more
energy at the front of the tip and will thus penetrate
fibrous tissues better.
The extent or reach of the energy from the surface
of the probe is a common question and concern. While
some energy does radiate away from the tip, such
energy is excessively weak and not capable of tissue
disruption. The very long wavelength (on the order of
5 cm) means that the energy quickly passes through
any tissues and does not concentrate or focus at distal
locations. The active energy is associated with the zone
very near to the metal vibrating tip. Experiments with
tissues, tissue phantoms, fingers, and other mediums
can be used to show that the effective zone around
a vibrating tip is limited to approximately 0.5 mm
from the surface of the tip. If tissue is outside of this
distance then generally it will not be impacted in any
way. Therefore, effective use of an ultrasonically
vibrating probe requires that the probe tip be placed in
contact with all targeted tissues. It is not analogous to
an air brush or some other device that has effect at a
distance.
454
Pulsed delivery of energy further reduces the
average energy but maintains peak energy densities.
This is analogous to the techniques used to calm the
thermal delivery in continuous wave lasers. Short
bursts of intense (peak) energy achieve the desired
effect but limit the overall thermal energy deposition.
The duration of the pulse must be short enough and the
number of pulses per second must be large enough to
achieve the desired effect. Less than about ten pulses
per second results in non-significant differences rela-
tive to continuous wave.
29.3 Tissue Interactions
The interaction between the tip of the ultrasonic
probe and the tissue is a complex function of three
different phenomena and is further strongly influ-
enced by the technique of the surgeon. The three
basic tissue interactions are (1) cavitation, (2) ther-
mal, and (3) mechanical.
The cavitation theory was the original theory that
was advanced for the interaction between the ultra-
sonic device and the fatty tissue. The theory holds that
the ultrasonic energy at the tip of the probe induces an
acoustic field that causes gases dissolved in the tissue
and fluids to accumulate in bubbles which are then
acoustically driven to grow in size until they become
unstable, at which time they implode. The implosion is
a violent process that releases energy in the form of
shock waves and heat. The implosion actually only
releases a very small amount of energy per bubble
because the bubbles are very small. The net energy
is the sum of the many bubbles that are being gener-
ated by the ultrasonic energy at the tip of the probe.
The cavitation bubbles exist as a beard around the tip
of the ultrasonic probe, seemingly attached to the
probe surface and extending no more than a millimeter
therefrom. The bubbles exist at profile changes in the
tip, not along smooth surfaces parallel to the axis of
vibration.
There is significant energy present in these zones of
cavitation bubbles, no doubt it is enough to damage or
lyse adipose cells. However, the question remains as to
whether or not this is the primary interaction with tis-
sue. For example, one can examine the interaction
between the ultrasonic probe and tissue which is sub-
merged in degassed water that has a significantly
increased cavitation threshold. The tissue can still be
W.W. Cimino
easily fragmented/emulsified by the device, even
though much of the cavitation has been suppressed.
One can also reduce the amplitude of the device until
cavitation is either greatly reduced or not present, and
then apply the device to submerged tissue. While
slower, the fragmentation/emulsification process is
still observable. Further still, one can excise a sample
of fatty tissue, say from an abdomen, with no infused
fluid, and apply the device directly in an open air envi-
ronment. The fatty tissue will still dissolve or fragment
quickly. Thus, while cavitation may be present, it is
not the predominant tissue interaction.
A thermal theory has been advanced. This theory
holds that ultrasonic energy essentially melts the
adipose tissue. Certainly it is possible to generate
heat with an ultrasonic probe device. However, this is
the opposite of the surgical and treatment objectives.
The addition of copious amounts of wetting solution
and proper probe motion will ensure that no significant
heat is generated. Some small amount of heat will
always be generated by a high-frequency vibrating
probe. However, the amount and distribution of the
thermal energy can be easily controlled and managed
such that the fragmentation/emulsification process can
occur without untoward thermal effects. The amount of
heat generation has been measured and quantified [1].
The mechanical theory holds that when the rapidly
moving metal tip of the ultrasonic probe encounters
tissue, it creates high-energy vibration-induced impact
and flow conditions that fragment/emulsify adipose
tissue. High and low pressures, rapid acoustic stream-
ing, and impacts with fast-moving metal surfaces, indi-
vidually and in combination, are enough to fragment/
emulsify the tissue [2, 3].
All three types of interaction are likely to be present
in most situations, to varying degrees. The design of
the instrumentation and the technique used by the sur-
geon will influence how much of each interaction is
present. With regard to design, probes that are run at
excessive amplitudes, or which have smooth overall
shapes, are inefficient and will result in more thermal
energy deposition and less mechanical fragmentation.
Probes with flat or concave front surfaces will gener-
ate excessive cavitational energy that ultimately con-
verts to thermal energy and also have very high energy
densities along these surfaces. Mechanical efficiency
is optimized by probe designs with many surfaces per-
pendicular to the axis of vibration and the elimination
of sharp edges. With regard to surgical technique, use
29 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications
of sufficient wetting solution and consistent probe
movement will eliminate thermal issues. The vibrating
tip should not be strongly pressed into any tissue as
this removes the protective fluid and strongly couples
the ultrasonic energy to the tissue, resulting in a strong
thermal energy deposition (end-hit). Large diameter
probes should be avoided as they possess excessive
vibrational energy and require significant pushing to
get through the tissue unless the amplitude is turned
way up, again resulting in excessive vibrational energy
applied to the tissues.
29.4 Results from Ultrasound
Instruments
This section focuses on results enabled by use of
ultrasonic instrumentation from the perspective of the
physics and tissue interactions. Results based on before
and after pictures from lipoplasty surgeries are widely
available elsewhere.
With proper design and proper surgical technique,
the mechanical tissue interaction discussed above can
be made to dominate the tissue interactions. The
advantage of such a combination is that the ultrasonic
energy can be made to be tissue selective. The basis for
the tissue selectivity is the strength of the various
tissues relative to the strength of the ultrasonic
energy [2, 3]. Figure 29.3 shows the fundamental situ-
ation. As the tissue strength increases, the effect of the
ultrasonic energy decreases. The ultrasonic energy
level can be adjusted so that tissues with lower strengths
are fragmented/emulsified (fatty tissues) while tissues
with higher strengths are relatively undamaged. This is
the key to success with ultrasonic instrumentation.
Whereas suction-assisted avulsive trauma is not selec-
tive (anything pulled into the suction port is torn and
removed), properly designed ultrasonic instrumenta-
tion can be tissue selective. This phenomenon is the
basis for the use of ultrasonic energy in the neurosur-
gery field where similar-type ultrasonic devices are
used to fragment and aspirate brain tumor tissue while
sparing as much nervous tissue and vascular tissue as
possible. In fact, this phenomenon was the genesis of
the application of ultrasonic energy to the lipoplasty
procedure.
When done properly, ultrasound-assisted lipoplasty
fragments the adipose tissue and creates a soft emul-
sion. Figure 29.4 shows the soft emulsion in an
455
Fat
Increasing
fragmentation Muscle
Collagen
Bone
Increasing tissue strength
Fig. 29.3 The effect on increasing tissue strength on
fragmentation rate
Fig. 29.4 Soft emulsified tissue and fluids subsequent to
application of ultrasonic energy
abdominoplasty sample where an incision has been
placed to reveal the emulsified tissues, subsequent to
the application of the ultrasonic energy. The sparing
of the collagen structures, vessels, and nervous tissue
is shown in Fig. 29.5. Because the emulsified tissue/
fluids can be more easily removed with less avulsive
trauma than with traditional suction-assisted lip-
oplasty, more of the tissue matrix can be spared, as
shown in Fig. 29.5. The body thus experiences less
tissue trauma than if the visible tissue matrix was
extensively torn, resulting in faster healing, smoother
results, and less pain. Further, the reduced tissue matrix
trauma results in significantly reduced blood loss, as
has been shown when comparing use of third-genera-
tion technology to suction-assisted lipoplasty in the
back [4]. This study found six to seven times less
blood in the aspirate for the third-generation technol-
ogy versus SAL.
Because the ultrasonic instrumentation is less trau-
matic to the tissue matrix, it can be used to enhance
456
a the structures in this layer are torn or removed, leaving
b technology and technique used must result in minimal
c achievement of these objectives, as described above in
Fig. 29.5 (a, b, c) Spared collagen and vessel tissue
skin retraction in lipoplasty. Skin retraction is
maximized when the superficial fatty layer (underside
of the dermis to one centimeter below the underside of
the dermis) is thinned but minimally traumatized,
meaning that the connective tissue and vascular struc-
ture in this superficial layer remain as undamaged as
possible. If this superficial layer is thinned with
suction-assisted lipoplasty devices, the result is that
W.W. Cimino
the skin less attached to the lower layers. The skin
therefore does not experience the contractive loading
of the connective tissue and tends to settle on the lower
layers and scar/heal in place with very little contrac-
tion. In the alternative, if the superficial layer can be
successfully defatted resulting in a volume reduction
in the superficial layer but leaving the majority of the
tissue matrix intact, then the skin will settle/heal sub-
ject to the elastic loading generated during the healing
process to eliminate volume. There are two keys to
successful defatting of the superficial layer: (1) the
trauma to all tissues except the adipose cells; and (2)
the technology and technique used must be applied
uniformly and evenly in the superficial layer.
The objective of proper application of ultrasonic
energy to the lipoplasty procedure is to reduce avulsive
trauma to the tissue matrix which thereby promotes
smoother results with more skin retraction, faster heal-
ing, less bleeding, and less pain. These results can be
produced only with proper and appropriate application
of ultrasonic energy. Early generation UAL devices
had many design characteristics that precluded the
Basic Physics and below in Complications.
29.5 Complications
This section discusses complications related directly
to the design and use of ultrasonic instrumentation for
lipoplasty. Complications related to surgical error or
judgement for lipoplasty surgery or patient-specific
situations are not discussed.
Complications can be lumped into two general
categories: (1) pilot error which are complications due
to a surgeons lack of knowledge concerning (a) proper
use of the ultrasonic instrumentation, (b) tissue effects,
(c) surgical endpoints, (d) energy delivery; and (2) ultra-
sonic instrumentation design issues such that result in
excessive energy delivery or inefficient energy delivery.
Pilot error issues can be described as technique issues,
and the design issues can be described as technology
issues.
By far the largest concern and most frequent com-
plication can be described as skin burns. This type of
complication is most often a pilot error, but can also
be related to design. Both are discussed below.
29 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications
29.5.1 Burns at the Incision Site
An ultrasonically vibrating probe will create heat
through friction when pressed into the skin. The single
most important factor is called coupling. In short,
this refers to how hard the vibrating probe is pressed or
torqued into the skin. An incision site acts as a fulcrum
point. During suction-assisted lipoplasty, the surgeon
frequently and commonly torques or lifts the suction
cannula about the incision fulcrum, largely without
complication, although skin abrasion and stretching
will occur. With an ultrasonically vibrating probe, such
a technique will result in immediate heating of the
edges of the incision, especially if the incision is too
small and the skin is tightly sphinctered around the
vibrating probe. Skin ports have been designed to insu-
late the vibrating probe from the skin incision edges
and do a very good job. However, even skin ports will
heat if the vibrating probe is torqued about the incision
site and will thus heat the skin edges through the skin
port. The proper technique is to avoid torquing and
lifting of the vibrating probe about the incision point.
Straight radial strokes without torquing eliminate cou-
pling at the incision fulcrum and heating of the skin
edges. Common mistakes include lifting the probe to
try to reach around a curved body area or pushing the
probe to extend the action of the tip beyond the reach
of the probe. Additional incisions easily solve these
problems. Torquing at the incision is by far the most
common mistake of surgeons early in their experience
with ultrasonic instrumentation, especially if they are
classically trained in suction-assisted lipoplasty.
29.5.2 External Burns Away
from the Incision Site
The vibrating probe can be pressed into unprotected
skin away from the incision site and will cause a fric-
tion burn. It usually appears as a line blister where
the probe was momentarily pressed into the skin and
most often happens where rounded areas of skin are
contacted when the surgeon tries to keep the probe flat
and parallel to the skin. The most frequent areas are
the pouch between the suprapubic area and the
umbilicus when the surgeon is working in the epigas-
trium through the umbilicus and the buttock when
working in the banana rolls or medial thighs. This
type of skin burn is 100% preventable with proper
457
placement of a protective towel so that when the probe
is moved to a position such that it would be in contact
with skin, it is instead pressing on the towel. One layer
of towel is usually not sufficient as it will conduct heat
rapidly to the skin below. A folded towel with two
to three layers provides sufficient protection in almost
all instances. The towel may be wet or dry as long as
sufficient layers (folds) are used.
29.5.3 End-Hits
End-hits are simply pressing (poking) the vibrating tip
of the probe into the underside of the dermis. This
most often happens when the anatomy curves away
from a flatter area and the probe is advanced so that the
tip pokes into the skin, resulting in a concentration of
energy at the tip of the probe. End-hits will most often
leave small points of hyperpigmentation that heal over
time. End-hits are 100% avoidable by maintaining a
probe orientation as flat as possible with the skin
surface and by avoiding the tendency to reach around
a corner.
29.5.4 Contribution of Excessive Amplitude
As the amplitude of vibration in the probe is increased,
the potential to generate heat through friction also
increases. Amplitude should be set at the minimum
value which allows for graceful gliding motion of the
probe without significant hanging or drag. Directly
related to this issue is the proper choice of the probe for
the type of tissue. One style of probe is not appropriate
for all tissue types. Fibrous tissues require smaller diam-
eter probes and probes with less coupling. Softer tissue
allows for larger probe diameters and probes with more
coupling. If a larger diameter probe is used in fibrous
tissue, excessive vibration amplitude will be required to
get the probe to pass through the tissue. This is the
source of many of the complications associated with
first- and second-generation ultrasonic instrumentation.
29.5.5 Complications Associated
with Volume of Wetting Solution
Ultrasonic instrumentation requires more wetting
solution than suction-assisted lipoplasty. The wetting
458
solution provides thermal protection to the tissues,
aids in forming a soft emulsion for removal with aspi-
ration cannulae, and ensures wide and uniform distri-
bution of epinephrine for vasoconstriction. Two of
these three benefits are not required for suction-
assisted lipoplasty. When insufficient wetting solution
is used, patients may experience prolonged edema,
induration, a tingling/burning sensation, or increased
pain. Use of sufficient wetting solution will largely, if
not completely, eliminate these problems. Suction-
assisted lipoplasty generally and widely uses a 1:1
ratio for wetting fluid in to estimated aspirate out,
most commonly referred to as the superwet tech-
nique. Other techniques use more wetting solution,
with upper ranges as high as 2:1 or 3:1. Ultrasound-
assisted lipoplasty requires a range of 1.5:1 to 2:1.
This amount of fluid generally eliminates the potential
complications discussed above and is widely and
successfully used in ultrasound-assisted lipoplasty
surgery. Other than skin burns, the most frequent com-
plaint related to use of ultrasound-assisted lipoplasty
devices is prolonged healing or edema, or pain. This
result can almost always be directly correlated with
use of insufficient fluid. Suction-assisted lipoplasty
surgeons are often slow to adopt the increased require-
ments for wetting solution in ultrasound-assisted
lipoplasty, believing that the familiar 1:1 should be
sufficient. It is important to the final result and to the
comfort of the patient postoperatively that sufficient
wetting solution be used.
29.5.6 Complications Associated
with Aggressive Aspiration
Once the adipose tissue has been emulsified, it does
not require aggressive avulsive aspiration. Special can-
nulas have been designed to rapidly remove the emul-
sified tissues and fluids with minimal avulsive trauma.
When the emulsified tissues and fluids have been
removed, an amount of traditional suction-assisted lip-
oplasty with its attendant avulsive trauma may be
required to achieve the final contour. If the avulsive
suction phase is pursued aggressively, it will destroy
the benefit and gains of the ultrasonic phase, namely
the emulsification of the adipose tissue with no avul-
sive trauma. Thus, it is important not to use overly
aggressive aspiration subsequent to the ultrasonic
emulsification phase.
W.W. Cimino
29.5.7 Complications Associated
with Overapplication
of Ultrasonic Energy
Any energy source can be overused or overapplied,
and the same holds true for ultrasonic energy. Safe
and effective guidelines for ultrasonic energy ampli-
tude and duration have been developed and are sup-
plied as general guidelines with the instrumentation.
Generally speaking, 1 min of ultrasonic time per
100 mL infused into an area results in good emulsifi-
cation and no postoperative problems. With experi-
ence and sufficient wetting solution, 1 min and 30 s
of ultrasonic time per 100 mL of infused wetting
solution is commonly used. As ultrasonic time
approaches 2 min per 100 mL of infused wetting
solution, the complications described above related
to the volume of wetting solution begin to become
more pronounced. Fortunately almost all of the
targeted adipose tissue can usually be addressed
before the 1 min 30 s per 100 mL infused limit is
reached. It is important to note that not all ultra-
sonic instrumentation can be treated similarly in this
regard. First- and second-generation UAL devices are
generally much too powerful to be used with these
time/amplitude guidelines and should be adjusted
accordingly.
29.5.8 Complications Associated
with Instrumentation Design
The original ultrasonic instrumentation for lipoplasty
was the SMEI Sculpture system. This system had large
diameter probes with blunt smooth ends. Such a
design has no area of ultrasonic activity except the
central portion of the hemispherical tip, a very small
area. This design was so inefficient that extended
application was required to produces emulsification.
This design thus resulted is unnecessarily extended
application times.
Second-generation devices added a central lumen
to the vibrating probes for aspiration. The central
lumen was approximately 2 mm in diameter on a
5-mm probe. Usually a 1.82.0-mm aspiration can-
nula is much shorter than the 2732-cm lengths of
these ultrasonic probes, specifically because aspira-
tion with such a small diameter lumen is extremely
slow and applicable to only small volumes. Thus, a
29 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications 459

very slow aspiration system was combined with large

and powerful 5-mm ultrasonic probe. Surgeons had
the mistaken concept that the aspirated tissues that
they were seeing in the suction tubing was immedi-
ately related to the effect of the ultrasound that they
were applying to the tissues happening as they were
visualizing the aspirant. This is not correct. The tran-
sit time for the aspirant up the 2-mm lumen was on
the order of 25 s while the tip was vibrating at
22,00027,000 times per second. Only a single to a
few hits of the vibrating probe are required to frag-
ment the adipose tissue in a particular area, requiring
only thousandths of a second. Thus, surgeons tended
to continue apply excessive ultrasonic energy because
they were working with a time constant of 25 s or
more (visual) and the ultrasound was effective with a
time constant of a few thousandths of a second.
Further, adipose tissue and saline were essentially
frothed in the vibrating aspiration channel, chang-
ing the color and texture of the aspirant relative to the
actual emulsified tissue/fluids in the body, further dis-
torting the perception of the surgeon. Further still, the Fig. 29.6 A 5-mm hollow golf-tee ultrasonic probe
vacuum at the tip of the vibrating probe pulled tissue
up against the vibrating probe tip and strongly
increased coupling, unnecessarily damaging tissue. lipoplasty. These are pictures of bad surgery, not
Ultrasonically vibrating probes generate an acoustic pictures of results of ultrasonic instrumentation for lip-
pressure that pushes tissue away from the probe, thus oplasty. If indeed these pictures are the result of a sur-
minimizing excessive application of energy unless gery where ultrasonic instrumentation was used, the
the probe is pressed strongly into the tissue. All third- disastrous results could have been easily avoided with
generation ultrasound technology for lipoplasty is (1) sufficient use of wetting solutions (2) appropriate
solid probe technology for these reasons, and the application of ultrasonic energy addressing both duration
complications associated with a central lumen for of application and amplitude of vibration, and (3) proper
aspiration have been eliminated. and reasonable aspiration of the emulsified tissues, thus
A golf-tee type tip design was introduced with the limiting the avulsive trauma of the suction cannula.
second-generation Lysonix 2000 system (Fig. 29.6).
This design had a concave tip with a central lumen and
a reasonably sharp edge around the edge of the tip. 29.6 Conclusions
When vibrated at ultrasonic frequencies, the sharp
edge becomes very sharp, in fact making this probe Ultrasound-assisted lipoplasty is now a stable and
design a powered curette. This design is thus respon- growing method of lipoplasty. Applications have been
sible for many of the reported complications with early expanded from basic body contouring to contouring of
generation UAL systems. the face and neck, breast, and other delicate areas such
For the past decade, there has been wide circulation as the knees and ankles. New applications and treat-
of certain photos showing large areas of necrosed skin ments are under investigation such as for the perma-
related to the use of ultrasonic instrumentation for nent treatment of axillary hyperhidrosis. Complications
lipoplasty. While such a result could be produced resulting from first- and second-generation ultra-
through improper and excessive use of ultrasonic instru- sonic technology/devices have been largely elimi-
mentation, the same result could be produced through nated; firstly, by significantly improved third-generation
improper and excessive use of suction-assisted instrumentation design, and secondly, by significantly
460
improved information and understanding of proper
techniques and surgical endpoints when using ultra-
sonic instrumentation for lipoplasty. Published studies
now show the substantial decrease in blood loss when
using third-generation UAL technology compared to
SAL. Ultrasonic technology for lipoplasty has pro-
gressed from initial high excitement with rudimen-
tary first-generation technology to waning excitement
with second-generation technology to stable and grow-
ing acceptance and utilization with third-generation
technology.
W.W. Cimino
References
1. Cimino WW (2001) Ultrasonic surgery: power quantification
and efficiency optimization. Aesthet Surg J 21(3):233240
2. Cimino WW, Bond LJ (1996) Physics of ultrasonic surgery
using tissue fragmentation: Part I. Ultrasound Med Biol
22(1):89100
3. Bond LJ, Cimino WW (1996) Physics of ultrasonic surgery
using tissue fragmentation: Part II. Ultrasound Med Biol
22(1):101112
4. Garcia O, Nathan M (2008) Comparative analysis of blood
loss in suction-assisted lipoplasty and 3rd-generation internal
ultrasound-assisted lipoplasty. Aesthet Surg J 28:430435
 Facial Recontouring
with Liposuction
Alberto Di Giuseppe and George Commons
30.1 Introduction
In the last decade, the demand for aesthetic procedures
has increased, but for less invasive, less traumatic tech-
niques. Patients look for a faster return to work/life,
and mostly they seek a youthful, smooth, nonpulled
appearance.
30.2 Technologies
Results with liposuction were generally good, but
inconsistent, and with insufficient skin retraction.
Earlier generations of ultrasonic devices were poten-
tially too powerful or aggressive for easy, safe, and
meticulous head and neck applications. Complications,
although minimal, were more threatening.
Vaser technology represents an advanced tool,
available on the market since 2001, which offers guar-
antee of safety and quality and allows great results in a
simple manner in expert hands. Training with Vaser for
face and neck is not difficult, but requires technical
skills and finesse in working close to the subcutaneous
layer with a fine (2.2-mm diameter) titanium probe
(Fig. 30.1).
A. Di Giuseppe (*)
Institute of Plastic and Reconstructive Surgery,
School of Medicine, University of Ancona, Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
G. Commons
Plastic Surgery Center of Palo Alto, Palo Alto, CA, USA
e-mail: gwcommons@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_30, Springer-Verlag Berlin Heidelberg 2013
30
30.3 Technique
The probe is always the 2.2-mm diameter, utilized with
30% continuous mode for fibrous tissue, or 30% Vaser
mode. Generally, between 2 and 3 min of application is
sufficient to fully undermine each sector of the head
and neck area (jowls, chin, mandible, cheeks, etc.).
If the neck is heavy with a lot of local fat to be emulsi-
fied for facial debulking and contouring, allow another
1 min minimum for the deeper fat layer.
To remove emulsified fat or to remove infiltrated
solution, perform gentle aspiration with a 1.8-mm can-
nula at low aspiration power. Gentle manual shaping
and pressure are utilized to help the solution to come
out. Tumescence is a temporary status, and in the face
and neck, fluids are absorbed faster than elsewhere.
Heavy faces occur in many of the potential candi-
dates for Vaser facial contouring. Overweight and
obese patients often require a general thinning or soft-
ening of the cheeks and lower third of the face
(Fig. 30.2). Figure 30.3 is a patient with an undefined
face, fatty cheeks and chin, no mandibular line defini-
tion, no orbital cheek sulcus, and no preparotid natu-
ral depression. This patient underwent a Vaser face
contouring of cheeks, jaw line, chin, and nasolabial
folds. A total of 400 mL tumescent fluid was infused
and 8 min Vaser applied. Seventy-five milliliters of
fat was aspirated. The result appears natural and well
defined.
Figure 30.4 is patient with heavy neck and cheeks,
mostly obese or overweight, and with no definition at
chin and neck due to fat accumulation over platysma
muscle. There is a double chin and no neck and jaw
definition or cheek orbital protrusion. Extensive Vaser
461
462 A. Di Giuseppe and G. Commons

Fig. 30.1 Vaser probes

2.2 mm 1015 cm. Skin
protectors and 1.8-mm
aspiration cannula

emulsification gives a better look, younger and fitter
appearance, and more pleasant face. All areas were
softened and redraped.
North American population is a mix of different
ethnic races, including Hispanic, Afro-Cuban, Latin,
Asian, and others. The patient in Fig. 30.5 is a 44-year-
old Hispanic overweight woman whose natural appear-
ance of the face was unable to be improved with a
hypocaloric regime. With Vaser of the neck, chin, and
jaw, the areas were reduced in volume of fat. The skin
was fully mobilized in order to redrape nicely. Even
the orbital nasal area, cheeks, and preparotid areas
were softened and redefined.
30.4 Complications
In over 500 cases operated on by two surgeons, there
were no significant complications such as nerve defi-
cits, burns, or skin necrosis. The results were pleas-
ing to patient and surgeon. No surgical redo was
requested.
30 Facial Recontouring with Liposuction 463

Fig. 30.2 (a) Preoperative patient with a heavy face. (b) Postoperative following Vaser debulking
464 A. Di Giuseppe and G. Commons

Fig. 30.3 (a) Preoperative

patient with heavy face,
a
cheeks, chin, and mandible.
(b) Postoperative following
Vaser

b
30 Facial Recontouring with Liposuction 465

Fig. 30.4 (a) Preoperative patient with heavy face, neck, and cheeks. (b) Postoperative after Vaser of the chin, cheeks, and neck.
Note the new mandibular line and submental and chin contouring
466 A. Di Giuseppe and G. Commons

Fig. 30.5 (a) Preoperative

44-year-old Mexican type, a
Spanish profile, and bulky
face. (b) Postoperative
following Vaser contouring of
the neck, cheeks, and chin

b
 Chin, Cheek, and Neck Vaser
Liposculpture
Alberto Di Giuseppe, George Commons,
and Alessandro Scalise
31.1 Introduction
Vaser-assisted face and neck contouring should only
be performed by surgeons experienced with the Vaser
system for fatty tissue emulsification. At least ten cases
of standard Vaser-assisted lipoplasty are recommended
before moving to application to the face and neck.
31.2 Indicated Patients (Fig. 31.1)
Patients seeking contouring of the neck and jowl areas
who have heavy neck and/or chins with moderate to
good skin tone and where extra volume is expected to
be excess fatty tissue.
31.3 Informed Consent
Include use of photos for educational purposes.
31.4 Technique (Figs. 31.231.7)
31.4.1 Preoperative Marking and Planning
There should be a strategic plan for volume removal
(locations).
A. Di Giuseppe (*) A. Scalise
Department of Plastic and Reconstructive Surgery,
University of Ancona, Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
G. Commons
Private Practice, Palo Alto, CA, USA
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_31, Springer-Verlag Berlin Heidelberg 2013
31
31.4.2 Incisions
Incisions are placed under the chin and in front of/
behind ears (bilaterally). Possible bilaterally in the
neck at the lowest anticipated level of treatment.
31.4.3 Infusion
The face/neck are more vascular and have more inner-
vations than typical fat layers in the body. Epinephrine
at 1:500,000, Lidocaine at 0.30.5%. Wait 810 min.
Infuse with a small-diameter blunt infusion cannula
(2.0 mm or smaller, 14 gauge or smaller), not a nee-
dle. Infuse uniformly and evenly into any and all
locations where the Vaser or the suction cannula may
be used. Typical expected infusion volume is 200
400 mL in total (both sides and submental), depend-
ing on size of patient and areas to be treated. Infuse
slowly: 100 mL/min.
31.4.4 Skin Protection
Used in each incision. Use the black skin ports with
the orange silicone discs. Suture the skin port disc
into place (three anchor sutures) using 3-0 or 4-0
nylon. Make sure the knots are tight as the silicone
disc tends to cause the knots to unwind. These skin
ports protect the incision edges and greatly reduce
visible incision scarring. Stretch the incisions and
tissues below the incision with a hemostat to ease
insertion.
467
468 A. Di Giuseppe et al.

INDICATED PATIENTS
Patients seeking contouring of the neck and jowl areas
who have heavy neck and/or chins with moderate to
good skin tone and where extra volume is expected to be
excess fatty tissue

Fig. 31.1 Patient indications

MARKING AND INCISIONS

Strategic plan for volume

removal and associated
marking.
Landmarks
Lower border of
mandible
Cricoid
Thyroid cartilage
Divide neck into thirds
infiltrating about 100cc
in each

Fig. 31.2 Marking and incisions

31.4.5 Emulsication Fig. 31.3 Neck and chin is divided into four sub-units. Each
allows around 50 mL of tumescent solution or less

A 2.2-mm diameter (17 cm long) or 2.2-mm diameter

(8 cm long) probes, 2040% amplitude, Vaser mode. amplitude for a moderate/average fat. Move to 40%
Begin with the short 2.2 probe if possible. Twenty per- amplitude if face is fibrous. Never exceed 40% with
cent amplitude if face/neck is very soft. Thirty percent the 2.2 mm probes, they may break. Apply Vaser until
31 Chin, Cheek, and Neck Vaser Liposculpture
Fig. 31.4 Vaser 2.2 mm in action, set at 30% of power, through
earlobe incision
Fig. 31.5 Vaser undermining in a classic face lift
targeted fat is emulsified, likely 23 min total per side
depending on volumes, with an additional 23 min
under the chin depending on how the Vaser was applied
on the sides. Total Vaser time 610 min depending on
patient and infused volumes. Try to achieve the tar-
geted 610 min of Vaser time to minimize aspiration
trauma.
469
Fig. 31.6 Tunnels as appear after Vaser undermining
31.4.6 Aspiration
A 2.4 mm cannula with gentle port patterns. Avoid
aggressive use of suction. Apply the suction only as
long as it takes to remove the emulsified fluids and
tissue. Expected aspiration volumes are 25125 cm3,
depending on infused volume, size of patient, and
areas treated. Suction phase should be as short and
atraumatic as possible. Remember: its not what you
take out but what you leave behind that is the key to
smooth and even skin redrape and retraction. Two
small stab incisions are sometimes placed in the lat-
eral aspects of the neck at the lowest point of treat-
ment and left open for drainage purposes. A small
suction cannula with no vacuum applied is passed
through the stab incisions to open channels into the
treated areas.
31.4.7 Massage/Press
Massage and press the treated areas to push any
remaining free fluids out of incisions.
31.4.8 Postoperative Taping/Dressing/
Support
The key is gentle, even compression to help the skin
redrape and settle into position and to prevent ripples
or folds in the skin. Consider the following options:
cotton pads with elastic wraps, cold compresses, and
470 A. Di Giuseppe et al.

a
31 Chin, Cheek, and Neck Vaser Liposculpture
Fig. 31.731.9 (continued)
Figs. 31.731.9 (a) Preoperative 50-year-old patient, with
heavy neck, heavy chin, lack of cheek definition, neck laxity,
and upper and lower blepharochalasis. (b) Preoperative mark-
ings. (c) Starting tumescent infiltration with blunt needle and
syringe. (d) Tumescent in central neck. (e) Tumescent in man-
dible region. (f) Temporary suture of chin incision to avoid fluid
reflow. (g) Suturing on place skin protector. (h) Other skin pro-
tector at the ear lobe incision. (i) After 11 min, the surgeon starts
Vaser 2.2 mm probe undermining on the superficial layer. Power
is set at 30% of total. (j) Vaser on action from chin incision on
the deeper layer, to emulsify fat. (k) Right hand guides the probe,
471
while left hand controls depth of action. Movements have to be
gentle, avoiding too deep action. (l) Treating the lateral side. (m)
Using Ventex 1.8 mm suction cannula to evacuate emulsion. (n)
Continuing aspiration. (o) Vaser system. Timing: 9.40 min of
action. (p) Completing aspiration, removing skin adhesion,
checking undermining and free skin. (q) Checking thickness of
the neck flap. (r) Procedure ended. (s) Suture of skin incision
with 60 nylon. (t) Postoperative garment, to be worn 3 days full
time and then for 2 weeks night time. (u) Postoperative jowl-
chin-neck contouring
472 A. Di Giuseppe et al.

e f

g
h

Fig. 31.731.9 (continued)

31 Chin, Cheek, and Neck Vaser Liposculpture 473

k l

Fig. 31.731.9 (continued)

474 A. Di Giuseppe et al.

q r

s t

Fig. 31.731.9 (continued)

31 Chin, Cheek, and Neck Vaser Liposculpture 475

Fig. 31.731.9 (continued)

476 A. Di Giuseppe et al.

Fig. 31.8 (a) Preoperative 38-year-old patient. (b) Postoperative following jowl-chin-neck contouring
31 Chin, Cheek, and Neck Vaser Liposculpture 477

a b

Fig. 31.9 (a) Preoperative 37-year-old patient. (b) Postoperative after jowl-chin-neck contouring

a b

Fig. 31.10 (a) Preoperative 27-year-old male. (b) Postoperative after jowl-chin-neck contouring
478 A. Di Giuseppe et al.

Fig. 31.11 (a) Preoperative 42-year-old patient. (b) Postoperative following jowl-chin-neck contouring, blepharoplasty, and malar lift
31 Chin, Cheek, and Neck Vaser Liposculpture 479

Fig. 31.12 (a) Preoperative 42-year-old female. (b) One year postoperative following jowl-chin-neck contouring
480 A. Di Giuseppe et al.

a b

Fig. 31.13 (a) Preoperative 45-year-old patient. (b) Postoperative neck-jowl-chin contouring

a b

Fig. 31.14 (a) Preoperative 38-year-old patient. (b) Postoperative after neck Vaser
31 Chin, Cheek, and Neck Vaser Liposculpture
Fig. 31.15 A preoperative 32-year-old patient with heavy face. Postoperative following Vaser debulking
silicone foam padding. Elastic face garments typically
applied for 24 days, then overnight for 12 weeks,
depending on preference. Keep head elevated at night.
31.4.9 Follow-up
One day, 1 week, 6 weeks, 6 months, as needed.
External ultrasound and light massage may be benefi-
cial. Protocol for external ultrasound: setting of 10 W
481
for 5 min with small head, twice a week for a minimum
of 3 weeks.
31.5 Discussion
Usually the technique is performed under local tumes-
cent anesthesia and intravenous sedation. The opera-
tion is an office procedure. The procedure is simple,
and there are good results (Figs. 31.831.17).
482 A. Di Giuseppe et al.

Fig. 31.16 (a) Preoperative 45-year-old patient with heavy face. (b) Postoperative after Vaser chin, cheeks, and neck definition
31 Chin, Cheek, and Neck Vaser Liposculpture 483

Fig. 31.17 (a) Preoperative 25-year-old patient with heavy face. (b) Postoperative following Vaser facial contouring

General References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science, and clinical practice. Springer, Berlin
1. Shiffman MA, Di Giuseppe A (2006) Liposuction: principles
and practice. Springer, Berlin
 An Integrated Technique
for Facial Rejuvenation: Adaptation
to a Changing Clinical Environment
Moshe S. Fayman
32.1 Introduction
Changing aesthetic surgery market place environment
as well as deeper understanding of the mechanism of
facial aging led to a change in the authors philosophy
in planning and performing facial rejuvenation surgery
in recent years. The purpose of this presentation is to
share this experience.
In recent years, the public is being increasingly
exposed to media preaching minimally invasive proce-
dures as an alternative to traditional face lift per-
formed by plastic surgeons. The public is led to believe
that the results of the lesser interventions are similar to
those produced by surgery. Advantages cited for mini-
mally invasive techniques include lesser cost, lesser
risks, and minimal downtime required for recovery.
Face lift has been shown repeatedly to be the only cos-
metic operation in a downtrend when annual figures of
operation performed are being analyzed [1, 2]. In the
authors opinion, adaptation of the traditional face lift
to a smaller yet effective procedure is essential if plas-
tic surgeons strive to continue dominating the market
place of facial rejuvenation procedures.
Another interesting consequence of the ever-
increasing popularity of the use of fillers for facial
rejuvenation is the increasing recognition of selective
enhancement of facial aesthetic unit volumes as an
effective strategy in facial rejuvenation.
M.S. Fayman
Rosebank Clinic, Johannesburg,
South Africa
e-mail: info@doctorfayman.co.za
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_32, Springer-Verlag Berlin Heidelberg 2013
32
The process of facial aging is not yet fully understood.
Several researchers have shown in recent years that soft
tissue descent is probably not a major factor. Rather, a
complex process of boney and soft tissue deflation in
certain areas of the face (malar, submalar) and volume
increase in other areas (jowls, sub mental) is responsi-
ble for the aged face appearance. Therefore, volume
restoration becomes a logical way to restore a youthful
appearance [39].
The value of fat autotransplantation has been
advocated and popularized by several researches. Fat
grafting has been shown to successfully restore dep-
leting facial volumes on a long-term basis. The pres-
ence of stem cells within the transplanted fat offers the
added advantage of neovascularization of surrounding
tissues.
These considerations led the author to change
his philosophy and to develop an integrated facial reju-
venation surgical approach based on the following
principles:
1. Short incision preauricular, retrotragal, extended
around the caudal border of the sideburn [1012].
2. Limited subcutaneous undermining, essentially not
beyond anterior border of the parotid gland.
3. Development of a small superficial musculoaponeu-
rotic system (SMAS) flap that is vertically lifted
and suspended to the deep temporal fascia. The
anterior portion of the flap provides correction of
the jowls as well.
4. Liberal use of micro fat grafting over the malar
areas, nasolabial folds, marionette lines, and tear
troughs [13, 14].
5. Limited lateral brow lift done through a short inci-
sion in the caudal border of the temporal hair line.
485
486
a b
c d
Fig. 32.1 Photography. The importance of standardized pho-
tography is illustrated on this woman who had no surgery. (a)
Photo was taken with a soft light flash. (b) Photo taken with a
soft flash in upper gaze accentuating the fat lobules. (c) Image
6. Conservative upper blepharoplasty [15].
7. Pinch-type lower blepharoplasty, fat preserving,
and utilization of fat flaps to correct tear troughs
when applicable.
32.2 Surgical Technique
32.2.1 Preoperative Assessment
The consultation focuses on the patients concerns
and expectations. The aesthetic goal is defined at an
early stage to be rejuvenation restoration of a youth-
ful refreshed look, rather than an attempt to match an
idealized look. The patient is asked to bring a young
age images of the face to assist in determining the
M.S. Fayman
taken with a direct flash, softening the fat lobules. (d) Photo
taken with a soft flash. The patient was supine; fat lobules are
sinking into the orbits
aesthetic goals. If the patient photos are not available,
images of previous patients with similar aging fea-
tures are used to demonstrate the surgeons intents and
surgical plans.
Each patient has at least two consultations before
surgery to allow for various considerations time to
sink in. Patients who come from out of town are not
operated the same day to allow for a second consulta-
tion before surgery.
Risk assessment and management includes dis-
couraging smoking for at least two weeks before
surgery.
Examination focuses on documenting the individual
aging changes of the patient as well as standardized phys-
ical examination chart. Standardized photographic docu-
mentation is performed as well (Figs. 32.1 and 32.2).
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 487

a b

Fig. 32.2 Patient who had no surgery to her eyelids. (a) Soft flash producing a shadow which accentuates the fat bags. (b) Direct
flash photo camouflages the bag. The type of flash used is reflected in the pupils

32.3 Anesthesia incision is placed in the supratarsal skin crease with

Midazolam 7.515 mg orally is used for premedica-
tion. Alternatively, intravenous (IV) Midazolam is
used. Anesthesia employs Propofol infusion supported
with Ultiva at the time of local anesthetic infiltration.
The face is infiltrated with local anesthetic solution
consisting of 200 mL saline 0.9% with 20 mL of ligno-
caine 2% and 20 mL bupivacaine 0.5%. No adrenaline
is used. Sodium bicarbonate solution 0.5 mL is added.
The volume of solution used varies, usually in the
range of 160200 mL, depending on patients size and
extent of surgery. The eyelids are infiltrated with ligno-
caine 2% solution mixed with adrenaline 1:80,000.
the eyes closed. The extent of skin excision is deter-
mined when the patient opens his/her eyes. A mini-
mum of 25 mm of skin height is confirmed to be left in
the upper eyelid. Lower blepharoplasty incision is
marked in the subciliary skin crease and extends later-
ally into the inferior skin crease of the crow foot.
Excess for submental lipoplasty is gained through
stab wounds in the postauricular sulcus, through the
facelift incision, and/or through a stab wound in the
chin skin crease.
32.4.1 Skin Flap Undermining and SMAS
Flap Mobilization

32.4 Incision Flap undermining is limited to the anterior and inferior

The facial incision is preauricular, retrotragal, extend-
ing around the caudal border of the sideburn anteriorly
to a distance sufficient to avoid any dog ears after the
vertical lift of the facial skin (Fig. 32.3). The lateral
brow lift incision is placed in the temporal hair line,
approximately 15 mm long, with the center vertically
above the tail of the eyebrow. Upper blepharoplasty
border of the parotid gland. It is done in the subcutane-
ous plan only. A small SMAS flap is developed just
cephalad to the mandibular angle. The flap is devel-
oped anteriorly to the anterior border of the parotid
gland (Fig. 32.4). This flap is sutured with heavy 2-0
PDS sutures which are anchored to the deep temporal
fascia at the superior border of the zygoma arch. Three
of such sutures are used to accomplish differential lift
488 M.S. Fayman

a b

Fig. 32.3 Healed incision in two patients six months after surgery

a b

Skin incision

SMAS flap

Fig. 32.4 Small SMAS flap design. (a) The flap is confined to sutured to the Deep Temporal Fascia of the cephalad zygoma
the anatomical boundaries of the parotid gland 12 cm cephalad arch border with 2-0 PDS sutures
to the lower angle of the mandible. (b) The flap is lifted and
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment
of the neck, mandibular border, and jowl, respectively.
A fourth suture is sometimes employed at the supero-
anterior aspect of the wound. This suture is anchored
to the zygoma periosteum. It serves to pull the midface
soft tissue complex over the malar area [16]. No under-
mining of the temporal skin and no deep dissection
into the neck are performed. Skin lift is vertical. When
the patient presents with excessive neck skin laxity,
vertical creases form caudal to the ear lobe. Extension
of the postauricular incision is then required to address
this issue. On rare occasion (10%, usually patients of
more advanced age), an incision across the mastoid
skin is required. The lift is pure vertical. The wound is
closed with 4-0 Polyglecaprone 25 suture (Ethicon,
Monocryl) in key position and 6-0 rapid dissolving
plain gut (Ethicon 1916) running suture for skin. Small
suction drain is used for the first 24 h to avoid small
seroma formation.
32.4.2 Micro Fat Grafting
Micro fat grafting is liberally employed in the vast
majority of patients. Fat is harvested usually from the
abdomen. 0.9 mm blunt needle attached to a 1-mL
syringe with a Luer Lock is employed in filling the tear
trough, and slightly larger diameter needles are used for
the malar areas, nasolabial folds, marionette lines, and
upper and lower lips. Fat is injected deeply, just above
the periosteum of the tear trough (Fig. 32.5), into the
subcutaneous fat over the malar eminence, and into the
muscles in the area of the marionette lines. The injec-
tion technique involves approach from different direc-
tions and injections in different plans as to build a
structural volume of the transplanted fat. The volume
used varies according to patients requirements. Some
overcorrection is done. Typical volumes are:
Malar areas: 58 mL per side (Figs. 32.6 and 32.7)
Nasolabial folds: 24 mL per fold
Lips: 1 mL for each hemi lip (upper and lower) and
0.5 for the upper lip tubercle; superficial intra-
muscular injections is employed in the lips
Marionette line: 12 mL per side
A 2-mm liposuction needle attached to a 10-mL
syringe with a Luer Lock is used to harvest the fat. Fat
is transferred to a 1-mL syringe using a coupler. The
fat is injected gently as the needle is withdrawn. The
fat is not processed after harvesting because mechani-
cal processing increases fat cell membrane damage
489
and rupture rate (clinical observation unsupported with
scientific evidence).
When injected into perioral creases, the 1-mL
syringe is attached to a 22-gauge needle and injected
in a sub- or intradermal position as the needle is
withdrawn.
32.4.3 Lateral Brow Lift
Lateral brow lift has been simplified over the years
from the endoscope-assisted technique to the direct
subcutaneous approach. The expected course of the
temporal branch of the facial nerve is marked on the
skin. A 15-mm incision is performed in the temporal
hairline with the center placed vertically above the tail
of the eyebrow. Dissection is developed in a subcuta-
neous plan in a caudal direction to a distance of
1015 mm. The cephalad dissection is developed in a
subgaleal plan exposing the deep temporal fascia. A
40 Polyglecaprone 25 suture is used to suspend the
forehead skin to the deep temporal fascia. Elevation of
23 mm of the eyebrow tail is typically accomplished.
This stage is performed before final decision on amount
of skin excision of the upper eyelid is undertaken. The
wound is closed with 6-0 rapid dissolving plain gut
suture (Fig. 32.8).
32.4.4 Upper Blepharoplasty
The skin incision is performed and a sliver of orbicu-
laris oculi is resected laterally if excessive hooding is
present in that area. Resection of lateral muscle con-
tributes to a minimal elevation of the tail of the eye-
brow (1 mm or so). On occasion, a medially pedicled
muscle flap is used to fill a medial hollow appearance.
In most cases, only skin excision with underlying mus-
cle plication is used to restore youthful volume of the
upper lid (Figs. 32.9 and 32.10) [15].
Medial lobule of fat is removed when necessary.
Suspension of the lower lobe of the tear gland is rarely
required.
32.4.5 Lower Blepharoplasty
In most patients, subciliary incision is performed. Orbic-
ularis oculi muscle integrity is generally maintained,
490 M.S. Fayman

a b

Fig. 32.5 (a) Fat grafting to the tear trough is performed with a 0.9-mm blunt needle in the supraperiosteal plane. The fat is injected
as the needle is withdrawn. (b) Preoperative patient. (c) Nine months postoperative

predominantly the pre-tarsal muscle plate. Lobules of
fat, if present, are mobilized and used as small fat flaps
sutured over the tear trough just above the periosteum.
If fat lobules are too small to be used and tear trough
does present an aesthetic concern, fat grafting directly
over the periosteum is performed with a 0.9-mm blunt
needle attached to a 1-mL syringe with a Luerlock.
Lateral muscle suspension is used as a routine to sup-
port the eyelid past the peak of the swelling. Rapidly
absorbing suture (Vicryl 6-0 Ethicon V0032) is used
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 491

Fig. 32.6 Fat grafting to malar areas. (a) Preoperative 62-year-old patient. (b) Eight months after secondary rhytidectomy, 15 years
after her first operation. Seven milliliters of fat was grafted to each malar areas

for this purpose (Figs. 32.11 and 32.12). Skin excision
is conservative and performed in the lateral section of
the wound (pinch lower blepharoplasty).
In selective patients, a transconjunctival blepharo-
plasty is employed. Fat flap mobilization and suture
over the tear trough is accomplished (Fig. 32.13).
When indicated, midface advancement over the
malar area is accomplished through the lower lid inci-
sion, as described by Fayman et al. [16] (Fig. 32.14).
When the tear trough does not present an aesthetic
concern but the fat lobules are prominent, a septal
tightening suture is employed (Fig. 32.15). This is a
modification of the technique described by Sadove
[17]. In extreme cases, the fat lobules can be trimmed
(Fig. 32.15) or used over the orbital malar groove
(Fig. 32.16).
32.5 Results
Seven hundred and fifty-two consecutive patients
operated over an 8-year period were reviewed. There
were 631 (84%) women and 121 men (16%). A variety
of surgical steps were individually assembled to
492
Fig. 32.7 Fat grafting in a patient with asymmetrical facial fat loss/mild Romberg Syndrome case. She is presented 1 year after
single session of asymmetrical facial fat grafting
meet individual patients objectives. Follow-up varied
between 6 months and 8 years with median follow-up
of 3 years (Figs. 32.1732.29).
32.5.1 Complications
Incidence of hematoma was 0.5%. Long-term facial
nerve injury did not happen. Marginal mandibular
branch paresis occurred in two patients, both resolved
M.S. Fayman
spontaneously in less than a month and both were
attributed to liposuction cannula damage during
liposculpture of the submandibular triangle. Slow
wound healing at cephalad corner of the sideburn
wound occurred in one patient, healing spontaneously
in less than 2 weeks. The patient was a smoker who did
not quit before surgery.
Patients satisfaction was assessed by direct ques-
tioning during postoperative visits and documented in
patients charts. It is estimated to be very high.
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 493

32.6 Discussion similar to the surgical procedure but without the

The modern patient is characterized by the following
features:
1. Expectations are sky high.
2. The patients patience is reduced, and he/she expects
instant gratification. This characteristic is media
driven and is nourished by promises of nonsurgical
facial rejuvenation that can produce improvement
downtime required after surgery and without the
surgical risks involved.
3. The patient is typically well read after long research
of the internet and other media. Patients are often
misinformed by their own research.
4. The modern patient typically requests several pro-
fessional opinions before making up his/her mind
with regard to which surgeon to choose and what

a b

Fig. 32.8 (a) Preoperative. (b) Eight months after lateral brow after skin-only secondary blepharoplasty along with lateral
lift and excision of a lateral sliver of orbicularis oculi muscle is brow lift. She demonstrates a 2-mm elevation of the tail of her
demonstrated in this patient. Elevation of 3 mm of the tail of the eyebrow
eyebrow is evident. (c) Preoperative patient. (d) Four months
494
c d
Fig. 32.8 (continued)
technique to follow. The conflicting opinions often
lead to patients confusion and sometimes anxiety,
as the patient finds herself in a situation of having to
decide between conflicting professional views.
As a result, the concept of trust me, I am a Doctor
and I will do whats best for you is no longer market-
able. The consultation is more interactive. The patient
takes a more proactive part in planning the operations
compared to previous years. The author finds this
dynamics easy to adjust to and that the informed
consent has developed to a professional dynamics
well beyond its Medico-legal value.
M.S. Fayman
The approach presented employs certain principles.
The extensive subSMAS dissection [1822] has been
discontinued for several reasons:
1. Postoperative swelling has been significantly
reduced (shorter downtime).
2. The risk of permanent facial nerve damage has been
reduced to virtually nothing.
3. Results appear as good if not better than those
obtained with radical techniques. Long-term trophic
skin changes associated with extensive subcutaneous
dissection are presumably attributed to diminished
blood supply to the skin caused by the subcutaneous
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment
a b
Fig. 32.9 (a) Preoperative. (b) One year after skin excision
only in upper blepharoplasty followed with wound closure
results in folding of the underlying orbicularis oculi muscle,
scar tissue formation. These changes appear to be
less severe with the limited skin undermining tech-
nique. The lifting component of the surgery is
based on gliding rather than undermining tissue
planes as described by Mendelson [21].
4. The technique is simple, easy to master, and easy to
teach, yet it is highly effective. It addresses to the
concept of rejuvenation through filling deflated
selective fat compartments.
In recent years, the tear trough has been the focus of
attention of many publications. It is now well recognized
that several factors contribute to the tear trough forma-
tion. These factors include difference in skin texture,
thickness, and color present at the junction of the lower
lid and the cheek skin. Another factor consists of inden-
tation of the skin and over expansion/bulging of the
495
hence increasing the volume of the upper eyelid while maintain-
ing the integrity of the muscle
lower lid fat in the area of the nasojugal or orbital malar
depressions. It is this last group of patients who benefits
from injections of fillers or fat into the tear trough inden-
tation or tightening of the capsulopalpebral fascia [23].
Fat grafting is being used extensively. Fat is recog-
nized as valuable filler as well as a source of stem cells
which contributes to the refreshed look of the overly-
ing skin due to improved vascularity.
Incision length has been reduced, further improving
the perception of a smaller procedure.
This is a retrospective review of a large series of a
single surgeons experience aimed at developing and pre-
senting a personal philosophy of surgical facial rejuvena-
tion adjusted to changing target clientele demands. The
surgical strategy represents a large number of surgical
techniques assembled to a surgical plan individualized to
496 M.S. Fayman

a specific patients requirements. Careful analysis of the
patients desires and signs of aging are obviously manda-
tory for correct selection of the surgical technique.
Comparison to the historical controls indicates a
shorter time out of work and shorter time out of public
sight. Incidence of long-term facial nerve injury was
reduced to 0 in this series. Incidence of hematoma
formation was reduced from 1.8% to 0.5%. Incidence
of wound healingrelated issues was substantially
reduced as well.

Fig. 32.10 (a) Medially pedicled orbicularis muscle flap used to reduce upper lid lateral fullness and to increase the medial hollow
appearance. (b) Preoperative. (c) Six months after surgery
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 497

b c

Fig. 32.10 (continued)

498 M.S. Fayman

Arcus
Marginalis

b c

Fig. 32.11 (a) Upper and lower blepharoplasty with fat grafting blepharoplasty with fat grafting to the tear trough and lateral
to the tear trough and lateral lower lid suspension. (b) Preop- lower lid suspension
erative. (c) Six months postoperative following upper and lower

Fig. 32.12 (a) Utilization of the fat lobules as vascularized fat patient. (f) Postoperative after upper blepharoplasty including
flaps over the tear trough (b) Intraoperative mobilization maneu- skin and trimming of her nasal lobule of fat. Lower blepharo-
ver. (c) Preoperative. (d) One year after surgery. (e) Preoperative plasty included mobilization of fat lobules over tear troughs
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 499

c
500 M.S. Fayman

e f

Fig. 32.12 (continued)

32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 501

b c

Fig. 32.13 (a) Advancement of Zygomaticus major muscle origin and surrounding tissues in treatment of mild festoons as described
by Fayman et al. [16]. (b) Preoperative. (c) One year postoperative
502 M.S. Fayman

b c

Fig. 32.14 (a) Capsulopalpebral fascia tightening in the treat- (c) Seven months after surgery. (d) Preoperative. (e) One year
ment of lower lid bags without a prominent tear trough. 5-0 non- postoperative
absorbable suture is used to tighten the fascia. (b) Preoperative.
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 503

d e

Fig. 32.14 (continued)

504 M.S. Fayman

Fig. 32.15 (a) Preoperative. (b) Six months postoperative after trimming of fat lobules as indicated in severe cases. The lateral
suspension suture elevated the arcus marginalis by 23 mm
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 505

a b

Fig. 32.16 (a) Preoperative. (b) Five months postoperative after lower blepharoplasty, and a vascularized fat flap was used as filler
over the lateral orbital margin (arrows)

Fig. 32.17 (a) Preoperative. (b) Six months postoperative after The patient shows an elevation of 3 mm in the position of the tail
rejuvenation procedure consisting of the following components: of the brow. The temporal hairline scar is inconspicuous
skin-only upper blepharoplasty and bilateral lateral brow lift.
506 M.S. Fayman

Fig. 32.17 (continued)

Fig. 32.18 (a) Preoperative. (b) Nine months postoperative malar triangles, nasolabial folds, marionette lines, and upper and
after rhytidectomy that included bilateral upper blepharoplasty, lower lips. The incision was extended to the postauricular
bilateral lateral brow lift, submental lipectomy, and fat graft to sulcus

Fig. 32.19 (a) Preoperative. (b) Postoperative following the elevation, submental lipoplasty, and fat grafting to nasolabial
short incision rhytidectomy that included the following compo- folds and marionette lines
nents: bilateral upper blepharoplasty, bilateral lateral brow
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 507

Fig. 32.18 (continued)

b
508 M.S. Fayman

Fig. 32.20 Limitations

a
of the technique. (a)
Preoperative patient. (b) One
year after an operation that
included the following
components: face lift, upper
and lower blepharoplasty,
brow lift, fat grafting to
nasolabial folds and
marionette lines, extensive
submental lipectomy, and
perioral peel with Hershey
medium strength solution
(phenol/croton oil). At this
time, she was unhappy with
residual skin excess in her
submandibular triangle. (c)
This was treated with direct
excision under local
anesthesia. (d) One week
later, the patient satisfaction
was dramatically improved

Fig. 32.21 (a) Preoperative. (b) Postoperative after facial neck skin required extension of the incision up the postauricular
rejuvenation that included upper blepharoplasty and fat graft to sulcus and across the mastoid skin
tear troughs, nasolabial folds, and marionette lines. The heavy
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 509

c d

Fig. 32.20 (continued)

b
510 M.S. Fayman

a b c

Fig. 32.22 (a) Thirty years ago. (b) Preoperative showing orbicularis oculi during skin-only upper blepharoplasty and
aging changes. The loss of volume in her cheeks, upper eye- extensive fat grafting to her cheeks and lips that were successful
lids, and lips is evident. (c) Postoperative after folding of the in restoring her youthful features

Fig. 32.23 Small surgical intervention in this case included a small SMAS flap suspension and fat grafting to perioral areas. The
patient returned to near normal life style in a week
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 511

Fig. 32.23 (continued)

Fig. 32.24 (a) Preoperative 63-year-old patient. (b) One year lines; submental lipoplasty; and SMAS lift. Because of the
postoperative after rhytidectomy that included the following excess cervical skin, the incision was extended to the post
components: upper and lower blepharoplasty (skin only); fat auricular sulcus
grafting to malar triangles, nasolabial folds, and marionette
512 M.S. Fayman

Fig. 32.24 (continued)

Fig. 32.25 Similar extent surgery to the patient in Fig. 32.24 was performed in this case, with the exception of perioral peel with
Hershey medium to strong solution. One year follow-up is presented
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 513

Fig. 32.25 (continued)

a b

Fig. 32.26 (a) Preoperative

patient requesting facial
rejuvenation as well as
enhancement of her chin.
(b) Two years postoperative
following insertion of a small
chin implant that was wired to
the lower border of the
mandible. She shows
improved lower facial
harmony as well as sustained
rejuvenation
514 M.S. Fayman

Fig. 32.27 (a) Preoperative. (b) Eight months postoperative following a short incision facelift, upper and lower blepharoplasty, and
fat grafting to malar triangles and nasolabial folds
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 515

a b

Fig. 32.28 (a) Preoperative patient desiring minimal intervention. These patients often benefit from fat grafting only. (b) Six
months postoperative after a single session of fat grafting of 15 mL of abdominal fat per side

Fig. 32.29 (a) Preoperative patient in her late 40s. (b) Ten months after short incision rhytidectomy with minimal fat grafting.
Rhinoplasty was done at the same surgical session
516
Acknowledgment This work is dedicated with loving memory
to my father Yedidia. His wisdom, survival skills in face of
extreme adversities and his personal sacrifice have set the
platform to my achievements. Upon his giant shoulders I am
humbly standing.
The author gratefully acknowledges the art work and
illustrations produces by Dr. Estelle Potgieter.
References
1. DAmico R, Saltz R, Rubric RJ, Kinney B, Haeck P, Gold AH,
Singer R, Jewell ML, Eaves F 3rd (2008) Risks and opportuni-
ties for plastic surgeons in a widening cosmetic medicine mar-
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2. American Society of Plastic Surgeons (2009) Report on
2008 Statistics. Available at: http://wwwplasticsurgery.org/
Media/stats/2008-US-cosmetic-recostructive-plastic-
surgery-minimally-invasive-statistics.pdf. Accessed 21 Mar
2010
3. Stuzin J (2007) Restoring facial shape in face lifting: the
role of skeletal support in facial analysis and midface soft-
tissue repositioning. Plast Reconstr Surg 119(1):362376
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Cochran CS, Mutimer KL, Garza JR (1999) Concertina
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100(2):509513
11. Saylan Z (2002) Purse string-formed plication of the SMAS
with fixation to the zygomatic bone. Plast Reconstr Surg
110(2):667671
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rhytidectomies: analysis of results and complications. Eur J
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Plast Surg 19(2):401414
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(2008) Autologous fat grafts harvested and refined by the
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the eyelid crease in optimizing results in aesthetic upper
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Reconstr Surg 120(5):13671376
 Hair Restoration
Samuel M. Lam
33.1 Introduction
The field of hair restoration has evolved rapidly over
the past two decades from one of unsightly plug grafts
now to state-of-the-art, undetectable follicular hair
transplantation. Despite these advances, less than ideal
work is still being performed almost every day due to
unskilled practitioners, poor technicians, and/or uneth-
ical delivery of medicine. Although this chapter cannot
completely close ones knowledge gap, it can open vis-
tas for a prospective physician to seek knowledge else-
where and to learn via clinical exposure to experienced
physicians in the industry. In the book Outliers,
Malcolm Gladwell has suggested that it takes 10,000 h
in a discipline to achieve mastery of it [1]. The great
zen master, Lao-Tzu, has said that a journey of a thou-
sand miles begins with a single step [2]. Hopefully this
chapter will engage the reader enough to begin a jour-
ney towards 10,000 h and a thousand miles in a fasci-
nating, rewarding, and engaging field of cosmetic
enhancement.
33.2 Understanding Hair Loss
and Hair Replacement
Before a physician can even contemplate surgical hair
transplantation, he or she must first possess a requisite
knowledge of hair loss processes so as to select a
S.M. Lam
Willow Bend Wellness Center, Lam Facial Plastic Surgery
Center & Hair Restoration Institute, Plano, TX, USA
e-mail: drlam@lamfacialplastics.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_33, Springer-Verlag Berlin Heidelberg 2013
33
suitable candidate, educate that patient about the risks
and benefits of a procedure, discuss intelligently non-
surgical options that may support or replace surgical
hair restoration, and to understand the effect(s) of sur-
gical intervention. Knowing when not to operate can
be as important if not more so than when to operate.
This section touches upon the basics of hair loss and
what every physician should know to perform safe hair
transplant surgery.
33.3 Male Pattern Baldness and Medical
Options for Hair Loss
The most common indication for surgical hair trans-
plant surgery is male pattern baldness. Contrary to
what many claim that hair loss stems from ones mater-
nal grandfather, the precise inheritance pattern is poly-
genetic and also not clearly elucidated at this time.
However, one can clearly state with certainty that male
pattern baldness is not static but progressive in nature
with the pattern of loss, the extent of loss, and the onset
and rate of loss being variable. Due to the ongoing
nature of male hair loss, surgical hair transplantation
into a younger man, e.g., in his teens or early twenties,
can be fraught with risk since the transplanted hair
from the occipital region into the frontotemporal or
crown areas will remain for perpetuity while surround-
ing native hair continues to diminish. As the supply of
donor hair dwindles with each transplant, the area of
baldness will inexorably continue to expand such that
a transplanted pattern that appears natural at the time
of transplantation may become an unnatural one over
time that cannot be fixed if all donor hair is eventually
517
518
depleted. The metaphor of painting an ever-increasing
canvas with ever-diminishing paint is a good one to
understand this dilemma.
The psychological issue of transplanting a young
male patient who may be desperate in their pleas for
intervention makes resisting a surgical option even
more difficult. Although male hair loss may be unac-
ceptable to many men at any age group, it may be par-
ticularly difficult to bear for the younger male patient
who is both at his social prime as well as depressed
that he does not resemble his peers, most of whom
have not begun to experience hair loss. The conflict of
interest also arises in that the physician must decide
not to operate on a very young patient despite the
potential for financial remuneration for a procedure.
Whether to operate or not on a young male patient is
complex and is predicated upon multiple factors: age
of patient, pattern and rate of hair loss, psychology of
the patient, usable donor density and extent, among
other factors. The beginning surgeon is advised to be
careful with any patient below 30 years of age due to
the multiplicity of judgment required.
Today, we have nonsurgical options for male pat-
tern baldness that can be very effective in slowing
down the process of hair loss and also reversing early
signs of hair loss. Therefore, the two FDA-approved
medications, oral finasteride and topical minoxidil,
can be excellent solutions for almost every man losing
hair but be particularly beneficial to the younger male
patient just beginning to lose hair. Male pattern bald-
ness involves hairs that evolve from thick, terminal
hairs into wispy, fine vellus hairs that eventually then
disappear altogether. Finasteride and minoxidil work
to reconvert some of these fine vellus hairs back into
thick, terminal hairs. Once the individual is entirely
bald (so-called slick baldness), the medications have
little effect. In short, the earlier the medications are
started, the greater the impact on reversing and slow-
ing down ones hair loss. However, if the products are
eventually stopped, all the gains that occurred during
the use of the products evaporate.
Finasteride is an oral medication that at the 5 mg dos-
age (marketed as Proscar by Merck, Whitehouse Station,
NJ) is effective both for hair loss [3] as well as for pros-
tatic hyperplasia. Finasteride at the 1 mg daily dosage
(marketed as Propecia by Merck) is intended only for
hair loss with no greater benefit for alopecia with larger
doses than the recommended 1 mg [4]. The effect of
finasteride occurs by virtue of the medicine inhibiting
S.M. Lam
Type II 5-alpha reductase, the enzyme responsible for
converting testosterone into dihydrotestosterone (DHT).
In genetically susceptible men, DHT can lead to hair
loss in areas that are genetically programmed for hair
loss, e.g., the frontotemporal, midscalp, and crown
regions. By limiting the serum levels of DHT, the rate of
hair loss can be slowed down, and a proportion of vellus
hairs can be reconverted into thicker, terminal hairs.
Daily ingested finasteride takes about 612 months to
show the optimal desired aesthetic regrowth of hair with
ongoing maintenance of hair counts compared with
controls in studies that extend out 5 years following start
of taking the medication [5]. Finasteride has been asso-
ciated with clinical side effects that include diminished
libido, erectile dysfunction, decreased sperm count, and
breast tenderness, with a combined incidence of 3.8%
compared with 2.1% for placebo, reaching statistical
significance only when all side effects are combined.
Fifty-eight percent of men showed resolution of symp-
toms with ongoing usage and reversibility of side effects
with cessation [6]. Women of childbearing age should
not handle crushed pills, as ingestion of the product can
lead to teratogenic male hypospadia.
Minoxidil (marketed as Rogaine by Pfizer, New
York, NY) is topically applied twice daily to the scalp
and is now over the counter in the United States. It is
manufactured in two strengths 2% for women and
5% for men. The major side effect with the generic
minoxidil is a contact dermatitis that has been mark-
edly reduced in the foam version by removing the irri-
tant propylene glycol and is sold only in 5% strength,
which is still on patent by Rogaine. The side effect that
can be experienced in women is secondary hair growth
due to systemic absorption, which is the rationale for
the 2% lower concentration recommended for women.
The mechanism of action of Rogaine is not well estab-
lished but proposed that it acts as a potassium channel
agonist, an epidermal cellular stimulant, and/or a local
vascular stimulant. Unlike finasteride, minoxidil starts
to work faster between 6 weeks and 3 months but
with optimal gains like finasteride observed between
6 months and a year. The one caveat that should be
explained to patients is that minoxidil can convert hairs
from telogen into anagen phase, meaning that telogen
hairs can be actively shed in the first few weeks follow-
ing the start of minoxidil application.
As mentioned, minoxidil and finasteride each work
through independent mechanisms to counteract the
miniaturization, i.e., the conversion from terminal to
33 Hair Restoration
vellus hairs, but the two products can work synergisti-
cally for optimal gains. Men who can afford both the
cost and expense should consider using both together
to achieve best results. Studies in postmenopausal
women with finasteride have been equivocal in show-
ing any improvement [7, 8], and as stated, premeno-
pausal women should not take finasteride due to the
teratogenic risk.
For younger patients who may not be safe candi-
dates for hair transplant surgery, these medications
may be the safest and brightest hope to slow down and
somewhat reverse the hair loss process. However, these
medications can and should be considered for even
patients who are undergoing hair transplant surgery for
three reasons. First, the hair loss process is slowed
down, meaning that the need for another hair trans-
plant session may be staved off for a longer while.
Second, when the miniaturized hairs are converted
back into terminal hairs, the added effect can make the
hair transplant result look even better with added visual
density. Third, if there are a lot of miniaturized, vellus
hairs in the area for transplantation, several months of
medical management with minoxidil and/or finasteride
can minimize what is known as telogen effluvium, or
shock loss that occurs weeks to months after a trans-
plant procedure. For all of these reasons, medical inter-
vention can be an important adjuvant therapy even to
those who consider hair transplant surgery.
Male pattern baldness in the crown or vertex region
represents a distinct entity that should be discussed
separately. Although all hair loss is progressive, crown
hair restoration can be particularly challenging for sev-
eral reasons. First, the whorl pattern that must be recre-
ated can be technically much more difficult for a
beginning surgeon than covering baldness elsewhere
on the scalp. Second, the crown area will continue to
widen leaving a transplanted result exposed over time.
As a general rule to be conservative, a crown is not
transplanted unless the patient is over 35 years of age
to minimize the chance of depleting usable donor hair
to cover the expanding region of alopecia. Third,
because the crown rests on the vertical plane of the
scalp and has grafts that splay open in a whorl, the
same number of grafts allocated to the frontal scalp
will have a much less dense appearance in the crown.
A patient should be aware of the limited hair density
following a single session of hair transplant in the
crown unless the crown hair loss is not extensive to
begin with.
519
33.4 Female Pattern Baldness
Although male pattern baldness remains the most com-
mon indication for hair transplantation, female hair
transplantation has become increasingly more popular
owing to both improved techniques and burgeoning
public awareness of this option. The two most com-
mon indications for female hair transplant surgery
include hairline lowering for women born with a high
hairline and hair restoration for female pattern bald-
ness that involves loss of central hair density with or
without hairline reframing. Like with male hair loss,
the process of female pattern baldness must be under-
stood before a transplant procedure can be safely
undertaken. Given the more complex nature of female
pattern baldness, the physician must undertake a more
thorough preoperative investigation in many cases
before the decision for surgery may be made.
Almost a third of women after 30 years of age lose
some degree of hair, which can be emotionally as dev-
astating as for men if not more so since it is not socially
acceptable for a woman to lose hair. In addition, as hair
can be an alluring sign of female sexuality, hair loss
may impact a womans psyche more profoundly.
Oftentimes, hair loss in women can be partially
addressed with a metabolic evaluation that focuses on
common indications that predispose to female hair loss
including a low serum iron level (particularly ferritin),
hypothyroidism, and other hormonal imbalances (a
high dehydroepiandrosterone sulfate [DHEAS], lower
estrogen, etc.). Women should also be considered to be
placed on minoxidil during this investigation process
in order to attempt regrowth of hair but also because
postoperative hair shedding is much more common in
women than in men, which is stabilized by several
months of minoxidil application.
Female pattern baldness can be recognized in sev-
eral manifestations. The most prevalent type of hair
loss according to Elise Olsen is a Christmas tree pat-
tern: with the hair parted in the middle and the woman
looking downward, a pattern of hair loss with the apex
of the tree toward the crown can be observed [9]. The
hairline can be involved or spared in any pattern of
female hair loss. The Ludwig classification for hair
loss describes three grades of diffuse hair loss with
Grade 1 being minimal exposure to Grade 3 being
extensive in nature, so much so that a wig may be more
appropriate to achieve the desired result as a surgical
procedure will most likely fall short. The third type of
520
recognized female hair loss is a male pattern baldness
type with frontotemporal recession and less commonly
isolated crown hair loss.
When working with female pattern hair loss, it is
important to target areas of maximal deficiency and to
discuss with the patient realistic outcomes, as usable
donor hair can be less robust than in men. A primary
goal in women with diffuse central hair loss is to deter-
mine whether the procedure can be undertaken to
achieve a desirable result or whether the patient should
just wear a hairpiece. Further, if a transplant is enter-
tained, then it should be contemplated how to target
areas of hair loss in such a way that maximal hairstyl-
ing can be afforded. For example, a woman who parts
her hair in the center could have the central forelock
and the central part region focused on with a T-shaped
distribution of grafting or, alternatively, a woman who
parts from left to right could have the frontal region
transplanted and the left part filled in a more concen-
trated pattern to resemble an L-shape. Due to the com-
bination that is often present in women with extensive
hair loss and limited donor hair, these selective pat-
terns for transplantation may need to be undertaken to
achieve the desired results and women should be coun-
seled accordingly.
The other common (albeit less so) indication for
female hair transplant is female hairline lowering for a
woman who is born with a high hairline and desires a
more feminine-shaped hairline. The design for a female
hairline is almost the opposite in many respects to a
male hairline in that the hair angles are angled to repli-
cate a cowlick in the center and the frontotemporal
shape is curved and closed. The beginning surgeon
should not attempt to work with designing female hair-
lines until male hairlines are mastered, as female hair-
lines can be much more difficult to do well. A detailed
description of surgical technique lies beyond the scope
of this chapter. Also, as a counterpoint, women who
have high hairlines that are not receding can be consid-
ered suitable candidates at a young age since they are
not susceptible like men to rapidly advancing hairlines
and generalized hair loss.
33.5 Other Types of Hair Loss
Unless the reader is a dermatologist, conditions that
would be contraindicated for hair restoration would be
missed. Obviously, this monograph cannot hope to
encompass a thorough discussion of all types of hair
S.M. Lam
loss conditions other than a basic review of male and
female pattern baldness. Nevertheless, in order to be a
safe hair transplant surgeon, the reader should be well
versed with recognizing types of scarring alopecias
like discoid lupus and lichen planopilaris or nonscar-
ring alopecias like alopecia areata in order to avoid
operating on these patients who would fail a surgical
transplant [10]. It is not so important that the physician
correctly identifies each type of hair loss pattern and
treats it appropriately but that the hair loss pattern be
recognized to be a kind of hair loss for which a trans-
plant procedure would be unsafe so that a referral to a
dermatologist can be made prior to considering a trans-
plant or in lieu of one. At times, active scarring alope-
cias can be trichologic emergencies in which a delay in
diagnosis and therapy can lead to devastating and irre-
versible hair loss.
33.6 Hair Transplantation Step-by-Step
Technique
33.6.1 General Principles
In order to recreate natural hair patterns, a surgeon must
understand how hair naturally grows on the head, spe-
cifically in the hairline, central midscalp, temple/tem-
poral point [11], lateral hump, posterior midscalp
(vertex transition point), and crown [12]. These hair
directions are important to understand so that a physi-
cian can recreate the natural angle and orientation of
hair when he or she creates the recipient sites, which
will be further discussed in the appropriate section
(Fig. 33.1, Table 33.1). In addition, generalized patterns
of male hair loss must be recognized, and the reader is
encouraged to study the Norwood pattern of hair loss
that appears in almost every basic hair transplant text-
book. Looking at individuals with a full head of hair
and studying the hair angles can be very helpful, espe-
cially in someone with a relatively closely shorn head
where the exit angles are more apparent. Also, looking
at individuals with various patterns of hair loss will
help guide a physician to understand what patterns
appear in nature and what may appear surgical even to
the untrained eye because that pattern does not fit a
natural one. This basic study should be undertaken dili-
gently well before the first hair transplant is planned so
that the design can conform to the rigors of nature
rather than a preconceived notion of what nature is,
which may otherwise be wrongly envisioned.
33 Hair Restoration 521

a b

Fig. 33.1 These photographs show the angle (up and down tilt)
and direction (side to side orientation) of how hair grows across
various regions of the head, which should be mimicked when
designing recipient sites and followed during graft placement (see
Table 33.1). (a) The anterior hairline has a low anterior angle and
forward direction (black arrows). The midscalp has the same rela-
tively low angle and straightforward direction except in the lateral
centimeter in which the orientation changes to match the lateral
hump (top green arrow). The lateral hump shows a progressive
cascading downward with each successive row (green arrows).
Of note, the angles are very low. (b) The crown is designed in a
whorl pattern in which the angles are less acute vis--vis the scalp
than other regions (blue arrows; note: the direction is shown but
the angle is not clearly shown in this photograph)

Table 33.1 Angle and direction of recipient sites for each region of the scalp
Location Angle Direction
Anterior hairline Low (1030) Anterior
Temporal hairline Very low (010) Follow sweep of temple hair
Lateral hump Low (1020) Cascading from forward progressively
downward (Fig. 33.1)
Midscalp Medium (2030) Anterior
Vertex transition point Low (2045) Slight radial arrangement
Crown Medium to high (3045 for the upper half of the Whorl
whorl and 1520 for the lower half of the whorl)

33.6.2 Anesthesia ing the experience as comfortable and as pleasant as

Most offices perform hair transplant entirely under
local anesthesia with or without an oral sedative. Some
offices (like ours) prefer an intravenous sedation
combination of midazolam and fentanyl for improved
pain control and relative amnesia of the experience
(Fig. 33.2). Given the fact that hair restoration is often-
times a repeated procedure in a patients lifetime, mak-
possible is mandatory if the physician would like that
the patient return in the future. The sedation only needs
extend for several minutes to permit the physician to
infiltrate the first lidocaine ring block circumferentially
around the head (Tables 33.233.4). Once that is infil-
trated, the subsequent bupivacaine block performed at
the end of donor closure can be done without any dis-
comfort in most cases. Specific injectable anesthesia
522 S.M. Lam

Fig. 33.2 Room schematic

with the nurse sedation
provider about to administer
Level II anesthesia consisting
of midazolam and fentanyl.
Of note, the background
shows the back table where
medications are mixed, a
Mayo stand with the
instruments for donor
harvesting and closure, and
the dissection table with
magnifying visors and cutting
stations

Table 33.2 Surgical tray Table 33.3 Medications/injectable tray

Universal multiblade handle with 35 No. 10 blades
Spacers for the multiblade handle of varying sizes (2.0 mm,
2.5 mm, 5.0 mm, etc.)
No. 10 blade on a standard scalpel handle
Metzenbaum scissors
Tissue forceps
Microserrated scissors (for creation of a trichophytic incision)
3-0 nylon or 3-0 polypropylene suture
Suture scissors
Standard needle holder
Towel clamps (57)
Versi handle with solid wire needles (16G, 17G, 18G, 19G,
and 20G)
(Alternatively, standard 16G, 17G, 18G, 19G, and 20G
needles and a hemostat to bend the needles)
(Optional blades SP 90, SP 91, 2 mm chisel-point or
sharp-point blade, SM 62 if planned for MUG transfer)
Donor tumescent solution (250 mL 0.9% sodium chloride,
1.25 mL epinephrine 1:1,000, 12.5 mL lidocaine 2% plain)
(empty 10 cm3 syringe, 18G 1 needle to draw tumescent, 23G
1 needle to inject)
1% lidocaine with epinephrine buffered (9 mL lidocaine 1%,
0.1 mL epinephrine 1:1,000, 1 mL 8.4 sodium bicarbonate) 1
syringe with 27G 1 1/2 (for donor anesthesia)
1% lidocaine plain with added epinephrine (10 mL lidocaine
1%, 0.1 mL epinephrine 1:1,000) 1 syringe with 27G 1 1/2
(for recipient anesthesia)
Bupivicaine 0.25% with 1:200,000 epinephrine, 0.1 mL
triamcinolone 40 mg/mL (10 cm3 syringe filled with 25G 1
1/2 needle) (for donor area)
Bupivicaine 0.25% with 1:200,000 epinephrine (10 cm3
syringe filled with 25G 1 1/2 needle) (for recipient area)
Recipient tumescent solution (100 mL 0.9% sodium chloride,
0.5 mL epinephrine 1:1,000, 5.0 mL lidocaine 2% plain,
1.0 mL triamcinolone 40 mg/mL)

recipes (Tables 33.233.4) will be discussed in the
appropriate sections below as part of the surgical flow
algorithm.
Another feature of the surgical room is the operat-
ing chair that should be easily reclined and positioned
upright as well as all positions in between upright
and supine (Fig. 33.2). The headrest and shoulder
design should be relatively small and unobtrusive so
that the surgeon can work easily in this space. Also, for
the early stages of the procedure (ring block, donor
harvesting, and donor closure), the patient is seated
upright with the headrest removed or tilted out of the
way. For recipient site creation, the headrest is
returned to its original position, and the patient is
reclined supine for the frontotemporal region (Fig. 33.3)
and relatively upright for crown design (Fig. 33.4).
(These details are repeated in the recipient-site cre-
ation section).
A surgical light preferably mounted to the ceiling
(alternatively that could be on rollers and a pole) that
can be focused and positioned should be used to direct
light where it is needed on the scalp for every phase of
the procedure: donor harvesting, donor closure, recipi-
ent site creation, and graft placement.
33 Hair Restoration 523

Table 33.4 Suppliers A to Z specialty surgical www.atozsurgical.com 1-800-843-6266

Ellis Instruments, Inc. www.ellisinstruments.com 1-800-218-9082
Mediquip Surgical www.mediquipsurgical.com 1-800-951-9989

Fig. 33.3 In order to

facilitate relatively low angles
for the frontotemporal region,
the patient is placed supine
with the surgeon sitting
behind the patient. By doing
so, the surgeons hand
naturally is angled so that the
angle of the recipient-site
instrument is situated low
vis--vis the anterior scalp

Fig. 33.4 In order to angle

the crown hairs higher than in
the frontotemporal region, the
surgeon stands behind the
patient to make the crown
recipient sites with the
patients chair more in an
upright position

33.7 Hairline Design
Before anesthesia is administered, the hairline is
designed with the patient as fully awake as possible so
that the design and extent of reconstruction can be
mutually agreed upon before embarking on the proce-
dure itself. Hairline design requires artistic judgment
as much as understanding the parameters of a natural
hairline. For the sake of clarity and conciseness, the
rules for designing a white male hairline will be elabo-
rated. The variations for Asian, African, and female
hairlines lie beyond the scope of this writing.
With the patient sitting upright in front of the phy-
sician, the physician can use an eyebrow pencil to cre-
ate the preliminary outline of a hairline and finesse
the hairline until the patient and the physician are in
524
agreement. At that point, a black permanent marker
can be used to outline the hairline right in front of the
eyebrow pencil so that it does wipe off during the pro-
cedure. Nevertheless, the surgeon must always be
mindful of the marked line, as it is still liable of being
rubbed off with repeated wipes of the gauze.
The hairline is designed in general to match the
patients head, i.e., a narrower design for a narrower
head and a wider design for a wider head. The hairline
consists of two components, the frontal hairline (the
horizontal component) and the temporal line (or verti-
cal line that frames the hairline laterally). Temporal
reconstruction is an advanced topic, and the reader is
advised not to undertake temporal reconstruction until
the basic hairline design has been mastered. Creating
very flat recipient sites that are well angled and graft
placement with the correct curl of the graft (see the
Graft Placement section below for details on curl) are
mandatory for a natural temporal point reconstruction,
both of which are hard to master for the novice surgeon.
Accordingly, in order to make the hairline appear natu-
ral, the hairline cannot be placed too anteriorly if there
is significant temporal hair loss or the created horizon-
tal hairline will not match the absent temporal hairline.
This condition is known colloquially as a lid effect,
i.e., the hairline juts too far anterior vis--vis a lost tem-
ple. Temple and horizontal hairline unzip at a relatively
equal rate. That is why a hair system, also known as a
hairpiece or toupee, can look unnatural despite it being
a modern, woven variety if it is placed too far anteriorly
vis--vis a missing temporal hairline.
The opposite is true as well. If the horizontal hair-
line is positioned so conservatively that it is placed
very high on the horizontal plane of the scalp, then the
hairline will fail to provide a proper aesthetic frame to
the face. This very conservative design, albeit safe,
will not achieve one of the principal goals for a frontal
hair transplant, i.e., to make the face appear more
attractive by framing the upper border of it. In order to
determine the lowest acceptable anterior midline point,
the patient is viewed from profile and a point is drawn
that bisects the horizontal plane with the vertical plane
at a 45-degree angle (Fig. 33.5). This transition from
the horizontal scalp to the vertical scalp (or forehead)
is considered the lowest acceptable anterior point for a
hairline any lower would put hair unnaturally on the
forehead.
Once this position is determined, the surgeon then
defines the lateral termini of the horizontal hairline,
S.M. Lam
which coincide with a vertical line that arches upward
from the lateral canthus (Fig. 33.5). If the hairline
passes this lateral point, the hairline will appear unnat-
ural because any hair that resides lateral to the lateral
canthus is considered temporal hair, which has a dif-
ferent shape and direction than the horizontal hairline.
The patient is asked to look downward, and the sur-
geon then ensures that the two lateral points are at the
same lateral extent and at the same anterior posterior
position on the scalp, i.e., they appear symmetrical.
The reason for this examination is that many patients
have asymmetrical degrees of temporal hair loss, which
must be reconstructed so that a more symmetrical out-
come is achieved.
With these three points established, the surgeon
then draws a convex curve (convex side facing anteri-
orly) across the central anterior point, which can then
be gently curved in a concave manner at or just lateral
to the midpupillary line to reach the lateral points on
each side. When the three points are joined, the phy-
sician must first eyeball whether the line appears
symmetrical, natural, and well designed for the
patients anatomy, degree of hair loss, and age. This
latter point is more complex. If the patient is younger
with a greater degree of hair loss and poor donor den-
sity, the physician may opt for a more conservative
hairline because the patient may require multiple more
sessions in his lifetime and also risk running out of
usable donor hair to fill in future hair loss. Conversely,
an older patient with mild hair loss and robust donor
density may have a slightly more aggressive hairline
design all the while keeping in mind that appropriate
frontotemporal recession and hairline shape should be
constructed that would be natural for an older gentle-
mans age. Similarly, working with a younger patient,
some frontotemporal recession may be desirable in
order to ensure that the hairline ages well with ongoing
hair loss.
After the three points have been constructed, the
physician must look at the design from all angles to
make sure that the design appears natural. From the
frontal view, the lateral points should not be so low
that the hairline proceeds inferiorly from medial to lat-
eral. Similarly, from profile view (this point is critical),
the hairline must be either a flat line if it is a more
aggressive hairline or preferably slope upward from
the anterior midline point to the lateral point (Fig. 33.5).
In any case, it cannot slope downward from the ante-
rior midline point to the lateral canthal point. This is
33 Hair Restoration
a b
Fig. 33.5 (a) Drawn hairline in which X represents the lowest
acceptable midline point, and Y and Z are the two lateral points
defined as the lateral extent of the hairline, corresponding to a
vertical line drawn through the lateral canthus. Any hair lateral to
this design should be considered temporal hair. (b) Proposed
hairline. (c) Proposed hairline. Black lines indicate that the lowest
simply unnatural. The hairline should be observed
with the patient looking downward, and finally the sur-
geon should stand behind the patient and together
observe the hairline in a mirror. At times a hairline that
looks perfectly straight from in front of the patient
does not look that way from behind the patient while
peering at a mirror. The rationale for this is unclear, but
what is clear is that the patient who will only be exam-
ining his hairline in the mirror will be dissatisfied with
the hairline since this is the only vantage with which
525
acceptable point of the midline portion of the hairline should be
where the horizontal scalp intersects at a 45-degree angle to the
vertical forehead. Also of note, the drawn line should be either
flat or sloping upward toward the temple, never downward, i.e.,
the midline point must reside inferior to the lateral point when
viewed on profile. (d) Proposed hairline. (e) Proposed hairline
he will judge it. After the hairline has been confirmed
with the patient and the permanent marker used to
reinforce the initial drawing, the physician then looks
through the scalp to determine planned areas for recon-
struction (Fig. 33.6). Since this task is relatively
straightforward, the permanent marker can be used as
the initial ink. When the patients hair is wet and the
patient is supine, different areas of thinning will be
noted and the distribution can be adjusted. However, it
is important to mark planned areas of reconstruction
526
Fig. 33.6 Surgical markings performed at the start of the proce-
dure across the recipient area permit cordoning off regions for
different planned graft sizes and density distribution. The front
3 cm represents the hairline zone. The oval in the midline behind
the hairline represents the anterior central forelock. The circle
behind this oval represents the remainder of the central forelock
when the patient has dry hair and is still upright in a
sitting position for three reasons. First, that is the way
that the patient will view himself. Second, the surgeon
has a clear grasp of planned areas well before donor
harvesting. Third, the surgeon can use two mirrors to
confirm more absolutely with the awake patient that
the planned areas to be reconstructed are what the
patient desires. Also, the physician can then point out
areas that may be of secondary importance and rebuilt
only if sufficient grafts remain toward the end of the
operative case.
33.8 Donor-Site Selection
The donor site where the donor strip will be harvested
must be determined for shaving then harvesting. The
donor area must be evaluated for safety. Safety
implies that the area to be harvested will not be lost
with future hair loss regression, which will lead to two
S.M. Lam
problems: transplanted hair that is lost over time using
unsafe donor hair and also the potential for an exposed
scar. The widest area of safe donor hair resides about
two fingerbreadths above the helical rim no more ante-
riorly than the tragus and arches downward toward the
midline in the region of the occipital protuberance.
Again, this is considered the widest area of safe donor
hair but may be deemed relatively unsafe in a younger
patient who is rapidly losing hair or in an older patient
who already has hair loss into this region. Besides age
and degree of hair loss, the physician should study for
signs of anterograde hair loss (hair loss coming down
from the upper temple and the crown into the planned
donor harvest) as well as retrograde hair loss (hair loss
coming up from the neck and just above the helix).
These so-called whisker hairs or general thinning in a
retrograde fashion are ominous signs that hair loss will
eventually encompass the planned area of donor har-
vesting. Obviously, judgment must come with accu-
mulated experience to predict (or rather estimate) the
probability of future hair loss and what would be an
appropriate and acceptable donor area of harvest based
on these limitations. Although the surgeon can aim
more superiorly in the midline than the occipital protu-
berance for harvesting with the expressed limitation
of the anterograde crown hair loss that may encroach
on the donor site, the surgeon should not aim far below
the nuchal ridge, which represents neck skin and which
does not close well or heal well.
Typically, the donor strip should be planned for
approximately no greater vertical width than 1 cm and
can be even further contracted based on perceived ten-
sion and the history of multiple previous hair trans-
plant sessions that may compromise donor closure and
healing. It is advisable for the physician (whether nov-
ice or experienced) to always shoot for a more conser-
vative harvest and wish he could have taken more than
take too much and fail to close the wound without ten-
sion or worse at all. This is a very undesirable situation
in which to find oneself. As a cautionary tale, if the
wound does not close without tension, it should be left
open to granulate inward with daily return visits, wet-
to-dry dressings, and planned delayed secondary clo-
sure. Forced primary closure under tension and/or
concurrent wound undermining are contraindicated
and can lead to disastrous complications of irreversible
donor hair loss and/or poor wound healing.
A permanent marker can be used to outline the
planned trajectory for harvest so that the assistant can
33 Hair Restoration 527

shave just a few millimeters beyond the proposed har- a

vest area in preparation for donor harvesting. Before
shaving, the hair above the planned area for shaving is
taped upward with 1 clear plastic tape to facilitate
both shaving and harvesting. (Of note, the patient
should be reminded not to cut his hair shorter than 2
so that the donor wound is sufficiently covered during
the healing process.) The 1 clear plastic tape is then
used to pick up any loosed shaved trimmings from the
surgical field before donor harvesting. A loose ACE
bandage is then placed around the head immediately
below the shaved donor area, and a folded 4 4 gauze
is inserted circumferentially around the head to cap-
ture any blood that may trickle down during donor har-
vesting. The patient is now ready for sedation and the
start of the procedure.
b

33.9 Donor Harvesting and Closure

With the intravenous line started and the patient sedated,

10 mL of 1% lidocaine with 1:100,000 epinephrine is
used to infiltrate the posterior half of the head immedi-
ately below the planned area for harvesting (Fig. 33.7)
and an additional 10 mL of 1% lidocaine with 1:100,000
epinephrine is infiltrated into the front half of the head
below the planned hairline to anesthetize the hair-
line (Fig. 33.7). At this point, the patients head may
be unsteady, and the assistant can be used to hold the
patients head steady, as the surgery proceeds.
Before the donor strip can be harvested, the donor
area must be aggressively tumesced with donor tumes-
cent solution (250 mL 0.9% sodium chloride, 1.25 mL
epinephrine 1:1,000, 12.5 mL lidocaine 2% plain) in
order to minimize hair transection (by aligning the
hairs) and by reducing the risk of nerve and blood
supply damage (Fig. 33.8). The mechanism by which
the underlying nerve and blood supply are protected
with tumescence is that the harvesting blade will be
positioned so that there is a cushion between the donor
hairs and the nerve and blood supply below. As a meta-
phor, think of a ship floating over the corals at high
versus low tide. At low tide the ship will scrape and
damage the corals, and at high tide the ship will not
touch the corals. The ship is the blade; the water or
tide is the tumescence; and the corals are the nerve and
vasculature.
Donor harvesting should only begin when the area
is blanched, flat, and feels firm to the touch. Typically
Fig. 33.7 (a) With the intravenous line started and the patient
sedated, 10 mL of 1% lidocaine with 1:100,000 epinephrine is
used to infiltrate the posterior half of the head immediately
below the planned area for harvesting and (b) an additional
10 mL of 1% lidocaine with 1:100,000 epinephrine is infiltrated
into the front half of the head below the planned hairline to anes-
thetize the hairline
for a 2530 cm harvest, approximately 150250 mL of
tumescent fluid is required to accomplish this task. It is
important to tumesce not only the 1 cm planned donor
strip but also above, below, and to the lateral extent of
the donor strip so that there are no curved edges where
transection would be more likely. Further, the tumes-
cence is injected into the subcutaneous plane and not
subgaleally as the intention is to expand the subcutane-
ous plane away from the subgaleal plane. However,
with sufficient tumescence, it is inevitable that some of
the tumescent fluid will be absorbed into the subgaleal
plane, which is expected. As the tumescence is rapidly
absorbed, it is important to have the Versi blade with
528
a transected, the Versi handle is adjusted slightly upward
b the observed harvesting depth, i.e., just below the hair
Fig. 33.8 (a) Photograph shows the appearance of the donor
area during early tumescence and (b) at the end right before
donor harvesting when approximately 200 mL of tumescence
has been infiltrated
blades outfitted ready to harvest before tumescence is
initiated.
Typically, today we prefer a Versi blade outfitted
with two blades spaced between 9.5 and 9.75 mm
apart, which allows a single pass of both blades to har-
vest a strip of equal width (Fig. 33.9). In the past, mul-
tiple blades were used for harvesting but increased the
risk of transection, albeit facilitating graft dissection.
Using single blades at a time is more time intensive but
also increases the risk that the incision width will be
variable throughout the harvest. Personna No. 10
blades are preferred over Bard-Parker No. 10 blades
due to the sharpness of the former over the latter.
A right-handed surgeon begins the harvest from the
right side of the patients head and proceeds toward the
left side of the head. The initial entry of the blade should
be matched to the observed exit angle of the hair folli-
cles and passed a centimeter forward to determine
whether the angle creates a clean harvest or engenders
transection (Fig. 33.10). If the hair bulbs appear to be
S.M. Lam
until the harvest appears to be yielding untransected
hairs. Conversely, if the upper hair shafts appear more
transected, the Versi handle is adjusted downward until
the strip harvest appears free of transection. Accordingly,
harvesting should be a precise, slow, and deliberate
process with constant checking and rechecking for
transection and depth. The depth of the blades should
be such that they are deep enough to pass through the
base of the follicles but not so deep as to pass near or
worse yet through the galea. The depth of each blade is
adjusted depending on the depth of that blade vis--vis
follicles but just above the galea. Fine fingertip control
rather than broad hand movements should be used so
that maximal control is exercised for a harvest with
minimal transection. Large transection of hair follicles
creates three definable problems: (1) poor yield so that
the aesthetic result may be compromised, (2) difficult
graft dissection in which many transected follicles must
first be removed, and (3) poor donor wound healing in
which entrapped, transected follicles can create cysts
and disturb ultimate wound healing. In order to further
facilitate donor harvesting, loupe magnification is very
helpful to micro-evaluate hair transection during every
millimeter of the donor harvest.
At this point, the two ends of the donor strip are
joined with a free-hand Personna No. 10 blade follow-
ing the hair angles to minimize transection (Fig. 33.11).
The donor strip can also be truncated vertically at the
halfway point or a third of the way across so that graft
dissection can begin after a shorter strip is removed.
Using atraumatic tissue forceps, the donor strip is
grasped and retracted, and Metzenbaum scissors are
used to harvest the donor strip along the base of the
follicle leaving about 2 mm of fat below the bulb but
remaining well above the galea (Fig. 33.12). The
removal of the donor strip should proceed very slowly
and deliberately taking care to avoid transection of any
visible nerves or blood vessels. By minimizing transec-
tion of the underlying nerve and blood supply, postop-
erative discomfort (from nerve ensnarement or
transection) can be considerably lessened and wound
healing and graft growth (by leaving the blood supply
intact) can be optimized. It is ideal if in the majority of
cases that electrocautery is minimized or avoided
entirely, as cautery can risk nerve and blood supply
damage as well as follicular and skin injury (Fig. 33.13).
With solid donor tumescence and careful harvesting of
33 Hair Restoration 529

Fig. 33.9 A Versi blade

outfitted with 2 Personna No.
10 blades and separated by
spacers to a total width of
9.75 mm

Fig. 33.12 Using atraumatic tissue forceps, the donor strip is

Fig. 33.10 Donor harvesting progresses at a slow, deliberate
pace, constantly checking and adjusting for any hair transection,
as well as proper depth of each blade. Note in the upper flap, the
clean harvest with limited transection of hair shafts
grasped and retracted, and Metzenbaum scissors are used to har-
vest the donor strip along the base of the follicle leaving about
2 mm of fat below the bulb but remaining well above the galea

Fig. 33.13 Donor strip removed and relatively bloodless field

achieved by virtue of meticulous harvesting. The goal is to avoid
Fig. 33.11 The two ends of the donor strip are joined with a injury to the neurovascular supply by bluntly dissecting the
free-hand Personna No. 10 blade following the hair angles to donor strip from nerve and blood vessels and to minimize or
minimize transection eliminate cautery use
530
the donor strip, electrocautery should be able to be
avoided in over 90% of operative cases. Immediately
when the donor strip is removed, it must be placed into
a chilled saline bath within which it remains until it is
ready for dissection.
Before donor closure, judgment should be rendered
as to whether a trichophytic closure should be under-
taken. A trichophytic closure can help to minimize the
visibility of the scar by permitting hairs to grow
through the scar and thereby limit the linear aspect of
the scar itself. However, a trichophytic closure does
not guarantee a good outcome. Sometimes scars still
widen. In fact, meticulous donor harvest with minimal
transection and a careful wound closure are more
important factors for good wound healing than a
trichophytic closure performed at the end of donor har-
vesting. Trichophytic closures are not uniformly a
good solution in every case. The wound edge itself if
reharvested can create distorted hair follicles, increas-
ing transection during graft dissection and more unus-
able grafts. Because the wound is now separated by an
additional 1 mm, wound tension is increased. Therefore,
the author does not perform a trichophytic closure in
individuals with high wound tension or have a planned
procedure in the near future, e.g., if the frontotemporal
region was transplanted and the plan is for a crown
transplant in a year or two.
The trichophytic closure is performed by removing
a single millimeter of the inferior epidermal wound
edge at a tangent using sharp, microserrated scissors
and toothed forceps for countertraction. The raw edge
created should be relatively uniform to minimize the
risk of cyst formation and poor wound healing. After
the trichophytic edge is created, the depth of the wound
is copiously irrigated with saline solution and any skin
edges or transected follicles are removed with toothed
forceps under loupe magnification, as foreign bodies
can create undesirable cysts and compromise wound
healing. After this evaluation, towel clamps are used
along the entire length of the incision to align the
wound edges and remove tension from the wound
edges by forcing residual tumescent fluid out of the
wound prior to closure (Fig. 33.14).
If there is tension in the wound, then a two-layer
closure can be contemplated. A 3-0 polyglactin suture
is passed without a knot at the end temporarily held by
a clamp at one end of the wound as it is passed in the
subcutaneous plane immediately below the follicular
bulb and weaved back and forth from one side of the
S.M. Lam
Fig. 33.14 Towel clamps are used along the entire length of
the incision to align the wound edges and remove tension from
the wound edges by forcing residual tumescent fluid out of the
wound prior to closure
wound to the other until the wound is closed. Whether
a one or two-layered closure is performed is controver-
sial. The author chooses to perform a two-layer closure
only when discernible tension is observed. Otherwise,
in over 80% of wound closures, a single 3-0 nylon
suture is used in a running, nonlocking fashion to close
the wound. If a trichophytic closure is performed, the
upper epidermal edge must overlie the lower raw
wound edge appropriately. If not, the wound edges
should be aligned flush without tension. The terminal
knot for the 3-0 nylon should be placed as an air knot
to allow some release of tension through slack. Also,
the knot should be positioned just distal to the incision
line so that the knot does not put pressure on the inci-
sion during sleep, which can be uncomfortable for the
patient. The needle is passed through the midfollicular
level to minimize strangulating or inverting the follicle
with too deep a bite. Each suture throw is placed at 45
(Fig. 33.15) so that the skin suture will lie perpendicu-
lar to the skin edge, which is particularly helpful to
ensure wound edge overlaps in a trichophytic closure.
Towel clamps are then progressively removed as the
suture closes the incision length.
After the donor incision is closed, the patient is
administered a long-lasting ring block consisting of
9 cm3 of bupivicaine 0.25% with 1:200,000 epineph-
rine with 0.1 cm3 of triamcinolone 40 mg/mL into the
posterior half of the head below the donor closure
and 10 cm3 of straight bupivicaine 0.25% with
1:200,000 epinephrine along the anterior half of the
33 Hair Restoration
Fig. 33.15 Each suture throw is placed at 45 so that the skin
suture will lie perpendicular to the skin edge. The depth of the
needle is situated at the midfollicular level to minimize ensnare-
ment of the follicles in the wound
Fig. 33.16 After the donor incision is closed, the patient is the
administered a long-lasting ring block consisting of 9 mL of
bupivicaine 0.25% with 1:200,000 epinephrine with 0.1 mL of
triamcinolone 40 mg/mL into the posterior half of the head
below the donor closure and 10 mL of straight bupivicaine
0.25% with 1:200,000 epinephrine along the anterior half of the
head below the proposed hairline along the same trajectory as
the initial ring block
head below the proposed hairline along the same tra-
jectory as the initial ring block (Fig. 33.16). The ACE
bandage around the head holding the folded 4 4
gauzes used to soak any trickling blood is removed
off the head. Then the hair around the incision site is
checked for any hairs trapped under the sutures,
which are pulled free from ensnarement. Finally, the
donor incision is cleaned with a saline spray bottle
531
Fig. 33.17 Grafts dissected into 1-hair, 2-hair, 3-hair, and
multiple follicular unit grafts (from left to right). Also, standard
needles bent to the depth of the graft length are paired with their
respective grafts. In this case, the 19-G needle lies next to the
1- and 2-hair grafts; the 18-G, with a 3-hair graft; and the 16-G,
with a graft containing two follicular units
before the patient is placed in a supine position being
readied for recipient site creation. A cushioned neck
support is a valued amenity for patient comfort when
the patient reclines back during the recipient-site
phase of the procedure.
33.10 Recipient Site Creation
Recipient site creation is the pinnacle of artistry that a
physician can express in that the pattern created reflects
the artistic interpretation and judgment based on avail-
able graft yields to make the proposed design. Recipient
sites are the slits or holes into which the hair grafts will
ultimately be placed. In order to create excellent recip-
ient sites, the physician must have a good understand-
ing of how hair angles and directions naturally flow on
a nonbalding scalp. Further, the physician must be able
to allocate the proper sized grafts that would create a
natural result (grafts with finer hairs and fewer hairs of
12 hairs per graft) along the anterior hairline, central
crown, and temple and a visually dense result (grafts
with thicker hairs and greater number of hairs of 34
hairs per graft along the central midscalp) (Fig. 33.1).
As a point of clarification, hairs that grow on the head
do not grow as discrete single hairs but grow instead in
1-, 2-, 3-, and 4-hair clusters known as follicular units
(Fig. 33.17). For the sake of clarity, we will discuss
graft dissection and recipient site creation in terms of
532
follicular unit distribution rather than breaking follicu-
lar units into smaller divisions or making larger grafts
containing several follicular units.
The fundamental prerequisite to understanding
recipient sites is knowledge of how hair naturally
grows on the head. The angle and direction are the two
ways to describe how the recipient site can be created
to match this natural pattern (Table 33.1). The angle
refers to the tilt of the recipient site anterior to poste-
rior. The direction refers to the turn of the recipient site
from left to right. Table 33.1 shows the angles and
directions for each part of the scalp. In the anterior
hairline, it is very important that the angle be very low,
i.e., angled anteriorly very acutely, because hairs that
are tilted too far perpendicularly can look grafty and
also increase visual see-through (Fig. 33.1). The rea-
son that a low angled graft looks more natural is that
the viewer has a much harder time seeing the insertion
point of the graft, where it can look unnatural. In addi-
tion, the reason that the low angled graft adds to visual
density is that it casts a shadow on the bald scalp like
an awning, whereas a vertically positioned graft fails
to do that. Always remember that grafts along the ante-
rior hairline and anterior midscalp should be angled as
low as possible to improve naturalness and visual den-
sity. One can almost not go too low in angulation but
easily can create too high an angle. The opposite is
true for the crown region (which is an advanced topic).
The angulation for the recipient sites in the crown
should be relatively higher so that the grafts create a
volume effect and shadow as it arches upward. The
direction in the hairline and midscalp is straightfor-
ward with no turn to the left or right. It is a natural
tendency for the hand to curve to the left on the left
hand side and curve to the right on the right side of the
head. This splaying of the recipient sites creates grafts
that splay open like a book, which limits visual density
and exacerbates ease of hair combing. The grafts must
be aimed directly forward except for the lateral 35 mm
where the grafts can gently turn laterally to match the
sweep of the temporal hair. In order to facilitate a lower
angulation of grafts, the patient is positioned com-
pletely supine with the surgeon sitting behind the
patient so that the surgeons hand naturally creates a
low angle (Fig. 33.3). The opposite is recommended
for the crown. In order to keep angles of the crown
higher, the patient is kept sitting somewhat upright and
the physician stands behind the patient to make the
recipient sites (Fig. 33.4).
S.M. Lam
Another important concept besides angle and
direction is the distribution of recipient sites relative to
one another, i.e., how they are positioned vis--vis one
another and how tight (or dense) they are made. All
recipient sites should be interlocked rather than placed
in a parallel arrangement (Fig. 33.18). Interlocking
one row behind the next can create less visible see-
through, more tightly pack the recipient sites together,
and allow more easy graft placement (since the grafts
will not compete for the relative same physical space).
The density of how close to space the recipient sites
relative to one another is a matter of judgment and
experience. In general, the hairline should not be too
open or the grafts may be visible as distinct grafts. In
addition, areas of primary importance for visual den-
sity should be more tightly arranged like the central
forelock, the region that lies in the midline immedi-
ately behind the hairline. The central forelock is an
area of priority because it reinforces the hairline and
since it is situated in the midline creates visual density
for a viewer looking at the patient from almost every
frontal angle: straight on, being situated to the left of
the patient or to the right.
As mentioned, 1-hair follicular unit (FU) grafts
need to be distributed along the hairline, 2-hair FU
grafts placed immediately behind 12 hairs of single
hair FUs, followed by a region of 3-hair grafts then
4-hair grafts. This increasing size of grafts matches the
way hair gradually becomes visually denser on a natu-
ral scalp. There are many ways to create recipient sites.
The easiest, least expensive method is to take standard
16-, 18-, 19-, and 20- G needles and bend them so that
they can be used to make the recipient sites (Fig. 33.17).
Generally, 16G accommodates a 4-hair graft or larger;
an 18G, a 3-hair graft; a 19G, a 2-hair graft; and a 20G,
a 1-hair graft. Obviously, hair caliber will determine
the exact needle size that will fit a certain FU size. The
surgeon should examine a dissected graft to determine
the length of the needle matched to the length of the
graft, which is then bent twice: once to the length of
the graft and the second time to make the needle
straight again. The double bending of the needle also
facilitates having a hub to check the depth of the inci-
sion. Once 23 sites are made with a needle for each
needle size, the surgeon and assistant test that the dis-
sected graft easily but snugly fits into the respective
recipient site. The graft should not slide too deeply
into the site and should snugly fit into the site without
being compressed. If all the different sized recipient
33 Hair Restoration
a b
c d
Fig. 33.18 (a) The first line of the central forelock is created as
the first step in recipient site creation. (b) The central forelock
and the posterior midscalp are then completed from front to back
prioritizing density in the anterior portion (central forelock)
from the remaining midscalp posteriorly. (c) Left side: The hair-
line transition zone that will consist of smaller 3-hair to 2-hair
grafts is built forward from the initial front line of the central
sites correctly match the graft sizes and no readjust-
ment is needed, then the surgeon can begin to make
all of the recipient sites according to calculated graft
yields.
Before endeavoring to create all of the recipient
sites, the physician should infiltrate the recipient bed
with recipient tumescent fluid (100 mL 0.9% sodium
chloride, 0.5 mL epinephrine 1:1,000, 5.0 mL lido-
caine 2% plain, 1.0 mL triamcinolone 40 mg/mL).
Unlike the donor tumescence, the physician can
sequentially tumesce each region that he or she is
working on and continue to add tumescence as the sur-
geon progresses to each adjacent area. The reason for
the tumescence is the same as for the donor tumes-
cence, i.e., to protect the underlying neural and vascu-
lar supply for optimal graft growth and minimal
trauma. In general, about 50100 mL of total recipient
533
forelock. The hairline is completed with a finely irregular undu-
lation of only 23 mm in span including isolated sentinel hairs
that are situated anterior to the anterior hairline to further soften
the hairline appearance. The reader should note how the direc-
tion of the recipient sites all face directly forward, i.e., no splay-
ing, and also are tightly interlocked relative to one another.
(d) The hairline completed on the right side
site tumescence is infiltrated sequentially from start to
finish in 10-mL increments.
At this point, as the surgeon begins to create all of
the recipient sites, he or she must prioritize critical
areas, e.g., the hairline and central density, before
working on less critical regions like the posterior mid-
scalp before grafts run out. However, to create a natu-
ral hairline, the actual hairline cannot appear to be a
rigidly straight line. In order to accomplish this task,
the central forelock is created first from front to back
and then the hairline is created forward from the first
row of the central forelock (Fig. 33.18). The physician
must think of the hairline like a coastline: from a dis-
tance it appears relatively straight but on close inspec-
tion there is an irregular jaggedness. This irregularity
should not span more than 23 mm in distance, as a
hairline that is too saw-toothed can look as artificial as
534
too straight a line. Also in the first row of the hairline
in order to further soften the look, so-called sentinel
hairs should be placed consisting of one-hair grafts
that occasionally jut out 12 mm in front of the formal
first row of the more solid hairline (Fig. 33.18).
Temporal point, female hairline, and crown recon-
struction are more advanced topics that fall outside of
the scope of this narrative. However, a component to
lost hair known as the lateral hump is worth discuss-
ing. In severe cases of baldness, not only can the hair-
line recede and the crown be exposed but the hair that
falls on the side of the head can also become exposed
over time. This region that falls along the sides of the
head is known as the lateral hump, or parietal hump. It
is the region that lies immediately behind the anterior
temporal hairline. The design and shape of the lateral
hump must be recognized and treated differently than
from the central midscalp in that the hair angle and
direction are distinctly different. Unlike the adjacent
midscalp in which almost all hairs are directly straight
anteriorly, the upper portion of the lateral hump is
directed anteriorly then gradually begins to fall down-
ward with each successive row until the angle for the
5th6th row approximately will become almost straight
downward facing (Fig. 33.1). The lateral hump is tech-
nically not as difficult to reconstruct but it is still a rela-
tively advanced region to treat. In more advanced cases
of hair loss, the lateral hump actually looks like a
hump, i.e., like an inverted U-shape that touches or
does not touch anymore the U-shape of the lateral mid-
scalp. Depending on the degree of donor hair density
and the patients expectations, the lateral hump can
just be built upward to touch the midscalp in a U-shape
configuration or built upward to the point that there is
more confluence between the lateral midscalp and the
lateral hump. The angulation of the scalp for the lateral
hump should be quite low in order to minimize the hair
sticking upward into the hair unnaturally.
33.11 Graft Dissection
Graft dissection (taking the donor strip and converting
it into individual hair grafts) and graft placement (plac-
ing the dissected grafts into the recipient sites) are
typically the preserve of the hair transplant assistant
team. Therefore, a detailed exposition of technique
falls beyond the scope of this chapter. Nevertheless, a
S.M. Lam
Fig. 33.19 Slivering involves dissecting a single row of follicular
units by breadloafing the donor strip. It is the first step necessary in
graft dissection before individual grafts can be dissected out
basic review of technique should be undertaken so that
the physician understands what is entailed with graft
dissection and graft placement.
What is important is to recognize how critical
superlative graft dissection is to the process of a natu-
ral and properly growing transplant result. If the grafts
are left out to desiccate, heavily and arbitrarily manip-
ulated, or poorly cut, the results will be poor growth,
kinky hair growth, or hair compression/failure to
growth, respectively. Having an excellent graft dissec-
tion team must be a priority for any physician working
in the field. Unlike cosmetic rhinoplasty for example,
the assistant team is heavily influential to the ultimate
outcome of the procedure for the above-enumerated
reasons.
Here are the principles of good graft dissection. In
preparation for graft dissection, the grafts are always
kept in a chilled saline bath, or equivalently con-
trolled osmotic-balanced solution. They are not left
out to desiccate. During graft dissection, the grafts
are frequently sprayed with a saline spray bottle to
maintain a moist environment. If the grafts begin to
appear matte-like in appearance, they have been left
too long unattended and risk failure to grow when
transplanted. The first step during graft dissection is
to sliver the donor strip, a process in which the initial
cut is transverse across the donor strip like cutting a
loaf of bread (Fig. 33.19). After slivering, the indi-
vidual slivers that contain one layer of undissected
33 Hair Restoration 535

grafts can then be cut into individual grafts. The act

of slivering requires gentle, nonforceful pressure to
glide the No. 10 Personna blade through the donor
strip so that one layer of nontransected hairs is pro-
duced. The blade is gently run back and forth through
the donor strip constantly changing angles slightly so
that the knife passes to reveal a single layer of grafts
without damage to the hair shafts during slivering.
After slivering, the grafts are dissected into indi-
vidual follicular unit grafts of 14 hairs (Fig. 33.17),
counted, and separated into these respective size hairs
for later placement. The extra fat below each graft is
dissected away to leave 1 mm of fat below the hair
bulb. Using microscopic aid or illuminated magnifica-
tion for all phases of graft dissection (including sliver- Fig. 33.20 For a right-handed placer standing on the patients
ing), the assistant is always mindful only to grasp the right side of the head and placing on that right side, placement is
relatively easier. For the right-handed placer standing on the
epithelial edge of the graft without pinching any part patients left side to fill in the left side requires special skill in
of the hair shaft, which can cause the hair either to which the hand hovers above to tuck in the graft
grow poorly or to grow out kinky due to the manipula-
tive damage. As always, the grafts are kept moistened
at all times. When the grafts are separated into their
respective sizes, they are folded into a moistened Telfa
pad and placed back into a chilled saline bath in prepa-
ration for graft placement.

33.12 Graft Placement

Graft placement represents the final stage in hair resto-

ration in which the dissected grafts are then placed into
the created recipient sites. Meticulous care for graft
placement will ensure an excellent outcome given that
all the previous constraints have been met. With visor
loupe magnification, the assistant positions the patient
upright and places grafts one at a time into the recipi-
ent sites based on matching graft to recipient-site size.
For a right-handed placer standing on the patients
right side of the head and placing on that right side,
placement is relatively easier. For the right-handed
placer standing on the patients left side to fill in the
left side requires special skill in which the hand hovers
above to tuck in the graft (Fig. 33.20). All graft place-
ment should be undertaken with great care and requires
a level of maturation and experience.
The assistant places the Telfa pad carrying the
grafts of a certain size on the dorsum of the nondomi-
nant hand for easy access. Then using a #5 Jewelers
forceps, the assistant holds onto the epidermis and
Fig. 33.21 With visor loupe magnification, the assistant posi-
tions the patient upright and places grafts one at a time into the
recipient sites based on matching graft to recipient-site size.
Using a #5 Jewelers forceps, the assistant holds onto the epider-
mis and atraumatically inserts the graft into the recipient site
atraumatically inserts the graft into the recipient site
(Fig. 33.21). The graft should be placed a little shy of
1 mm above the surrounding tissue. If it is placed
too high above the surface, the graft will desiccate and
fail to survive or alternatively create a cobblestoned
appearance with an uneven epithelial surface. If the
graft is placed flush to the surrounding skin or below,
the graft will look pitted, which is also unnatural. Also,
536
epidermal cysts can form since the graft was buried
under the skin. This problem can be significantly worse
if the assistant fails to recognize that he or she is stack-
ing one graft under another graft that becomes more
deeply buried, a complication that arises from this
incorrect piggybacking method. Also, significant time
delay in graft dissection and placement leads to hours
of time that the grafts remain ex vivo, which can in
turn compromise longevity. However, with proper han-
dling and submersion in an appropriate chilled bath,
grafts should not suffer any significant compromise if
dissected and placed within 812 h of harvest time.
One more technical detail is that grafts have a natu-
ral curl, meaning that the hair typically does not
grow out straight from the epidermis but has a gentle
curve. The curl should be aimed so that the curl aims
downward toward the scalp for proper growth and not
upward or side-to-side.
At the end of graft placement, the physician and
team should reevaluate all sites to make certain that all
the recipient sites are properly filled and that the grafts
appear undisturbed and placed correctly according to
size and depth. The patients scalp should be gently
cleaned with saline spray being careful not to disturb
the grafts during this final process.
33.13 Postoperative Care and Follow-Up
33.13.1 Postoperative Care
Following a hair transplant procedure, the patient is
likely to experience some minimal swelling (at times
significant) for several days to a week and if the nerves
were protected only mild to moderate achiness or dis-
comfort in the donor incision. Ice packs applied to the
donor incision and forehead (but not onto the recipi-
ent-site area itself) can help relieve some discomfort
and/or swelling. Narcotic prescription may help on an
as-needed basis for further pain relief. Generally, a
prescription is given and the patient advised to fill it
just in case it becomes necessary.
The patient is advised not to shower for 24 h and
immersive bathing is not permitted in any situation for
the first few weeks following a transplant procedure.
The shower must be performed with minimal shower-
head pressure and only blotting with a towel rather
than wiping of the scalp. The patient is advised that a
brush with short bristles rather than a comb is preferred
S.M. Lam
in which the comb is gently run across the hair at a
distance away from the scalp to limit injury to the
donor and recipient areas. The patient should also
refrain from hair-care products for the first 3 days.
Minoxidil should be ceased 2 days prior to hair trans-
plant and resumed no sooner than 5 days afterward. If
the patient has never been on minoxidil, it is worth a
72-h skin test with the product on a nonsensitive area
like the chin area to eliminate the possibility of an
unexpected contact dermatitis in the region of trans-
planted hairs.
The reason that a low-concentration of steroid is
mixed into the recipient tumescence is that it has been
found that injectable steroid has a greater impact on
limiting postoperative edema than almost any other
factor. That being said, there is no consensus on patient
positioning to limit postoperative edema with some
purporting that a semi-inclined position is preferable,
whereas others contend that a fully recumbent position
is desirable.
On the tenth postoperative day, the patient returns
for suture removal. At this office visit, the patient is
also evaluated for any residual scabbing. If so, the
patient is counseled on gentle methods to remove the
remaining scabbing in an atraumatic fashion. Soaking
the hair in gentle lotion for 510 min before entering
the shower will help condition the scabs more readily
to fall off. With this method, all scabs should be gone
by several days after suture removal. Also, all ques-
tions are answered, and the patient is given a return
visit of 4 months after to evaluate how grafts may be
beginning to appear.
33.14 Timing for Hair Growth
Hair typically begins to grow more visibly between 6
and 12 months following a procedure. However, at
34 months many patients are showing signs of early
hair growth, with only a minority having a robust
result that is already apparent. A few patients require
a longer time before the hair growth becomes substan-
tial with a full expression of the final or near final
result occurring between 18 and 24 months following
the transplant procedure (Fig. 33.22 and 33.23). Hairs
normally grow on the head in an asynchronous pat-
tern, i.e., some hairs are in anagen, whereas others are
in telogen and catagen, and need to relearn this
asynchrony after hairs have been transplanted. This
33 Hair Restoration 537

a b

Fig. 33.22 (a) Preoperative 41-year-old male. (b) Fourteen months following a single hair transplant session in which approxi-
mately 5,000 hairs were transplanted into the frontotemporal region

a b

Fig. 33.23 (a) Preoperative 47-year-old male. (b) Two years following a single hair transplant session in which close to 5,000 hairs
were transplanted into the frontotemporal region

readjustment takes 1824 months to occur. Therefore, 33.15 Conclusions

there may be periods like 1012 months afterward
that hair growth may actually seem to lessen or the Hair restoration is as much an art as it is a science. Too
result dip somewhat based on these normal fluctua- often cosmetic surgeons look at it as a stepchild of
tions until asynchrony is restored. other cosmetic procedures. This bastardized approach
538
can lead uniformly to poor outcomes. Superior hair
restoration is predicated on substantial experience, art-
istry, but most of all commitment and passion for
excellence without compromise.
Acknowledgment The author has no financial affiliation
whether direct or indirect with any of the stated companies but
has listed the contact information simply in order to aid the
reader.
References
1. Gladwell M (2008) Outliers: the story of success. Little
Brown and Co, New York
2. Tzu L (2006) Tao Te Ching: a New English version. Harper
Perennial Modern Classics, New York
3. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R,
Bergfeld W, Price VH, Van Neste D, Roberts JL, Hordinsky
M, Shapiro J, Binkowitz B, Gormley GJ (1998) Finasteride in
the treatment of men with androgenetic alopecia. Finasteride
Male Pattern Hair Loss Study Group. J Am Acad Dermatol
39(4 Pt 1):578589
4. Roberts JL, Fiedler V, Imperato-McGinley J, Whiting D, Olsen
E, Shupack J, Stough D, DeVillez R et al (1999) Clinical dose
ranging studies with finasteride, a type 2 5-alpha-reductase
S.M. Lam
inhibitor, in men with male pattern hair loss. J Am Acad
Dermatol 41(4):555563
5. Kaufman KD, Girman CJ, Round EM, Johnson-Levonas AO,
Shah AK, Rotonda J (2008) Progression of hair loss in men
with androgenetic alopecia (male pattern hair loss): long-
term (5-year) controlled observational data in placebo-treated
patients. Eur J Dermatol 18(4):407411
6. Merck-sponsored study. For information, contact Merck
directly: Merck and Co., Inc., Professional Services-DAP,
WP127, PO Box 4, West Point, PA 194860004
7. Price VH, Roberts JL, Hordinsky M, Olsen EA, Savin R,
Bergfeld W, Fiedler V, Lucky A, Whiting DA, Pappas F,
Culbertson J, Kotey P, Meehan A, Waldstreicher J (2000)
Lack of efficacy of finasteride in postmenopausal women
with androgenetic alopecia. J Am Acad Dermatol 43(5 Pt 1):
768776
8. Iorizzo M, Vincenzi C, Voudouris S, Piraccini BM, Tosti A
(2006) Finasteride treatment of female pattern hair loss. Arch
Dermatol 142(3):298302
9. Olsen EA (2001) Female pattern hair loss. J Am Acad
Dermatol 45(3 Suppl):S70S80
10. Shapiro J (2002) Hair loss: principles of diagnosis and man-
agement of alopecia. Martin Dunitz, London
11. Mayer ML, Perez-Meza D (2002) Temporal points: classifi-
cation and surgical techniques for aesthetic results. Hair
Transplant Forum Int 12:147158
12. Ziering C, Krenitsky G (2003) The Ziering whorl classifica-
tion of scalp hair. Dermatol Surg 29(8):817821
 Jowl and Neck Remodeling
with Ultrasound-Assisted
Lipoplasty (VASER)
Alberto Di Giuseppe and George Commons
34.1 Introduction
The author has utilized internal ultrasound solid probe
to face and neck since 1996 in order to defat heavy
faces or to undermine neck lax skin and possibly
achieving skin retraction. At that time, sculpture ultra-
sound device (by SMEI, Italy), with a solid probe of
2.5 mm diameter and 17 cm long, was used [1]. When
utilizing the solid probe in the face, the power admin-
istrated was 30% of the total potential of the ultra-
sound tool in order to reduce undesired side effects of
ultrasound energy (heat, essentially). The aim of the
technique was:
1. To reduce numbers and extension of scars of the
face for remodeling procedures of face and neck.
2. To perform under local tumescent anesthesia, essen-
tially the majority of facial contouring surgery.
3. To induce skin retraction, in face and neck, even in
lax skin, avoiding major open surgery operation
such as standard face-lift.
4. To undermine and induce skin retraction with a
minimal trauma by utilizing a solid probe and the
ultrasound energy instead of an open approach and
a scalpel.
5. To debulk heavy faces, neck, jowls, with a smooth
device able to emulsify fat in specific target with
A. Di Giuseppe (*)
School of Medicine, Institute of Plastic and Reconstructive
Surgery, University of Ancona, Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
G. Commons
Plastic Surgery Center of Palo Alto, Palo Alto, CA, USA
e-mail: gwcommons@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_34, Springer-Verlag Berlin Heidelberg 2013
34
minimal trauma, low energy, and safe surgical
planes.
6. To contour difficult areas such as the mandible
border, the neck line, and the chin.
7. To access to facial surgery even in patients who
refused major open surgery operations, which
normally leads to a longer recovery time.
Under those circumstances, what was called the
harmonic lift was offered as an alternative technique
in facial contouring surgery.
34.2 Patient Selection
The harmonic lift can be used in young patients with
fatty necks and cheeks as well as in older patients with
loose skin and wrinkles. Each patient is evaluated as to
the aims of surgery such as treatment of crows feet,
nasolabial and commissural folds, jowls, and waddle
neck.
The procedure is appropriate in the following type
patients:
1. Face- and neck-lift in Fitzpatrick type 46, thus
avoiding keloid formation and post-inflammatory
hyperpigmentation that may occur with skin rejuve-
nation with laser or peel.
2. Young patients who require only treatment of
chubby cheeks and double chin.
3. To enhance neck definition with chin augmentation.
4. To substitute for endoscopic forehead-lift in balding
scalps.
5. To achieve dermal stimulation and retraction in the
neck beyond areas amenable to laser resurfacing.
6. To release acne scarring of the cheeks.
539
540
7. In secondary and tertiary face-lifts when partial
removal of the skin is a questionable procedure but
the central face needs further tightening.
Other indications include rhytids in the malar area,
crows feet, frontal, nasolabial, glabella (horizontal
and vertical), and neck as well as descent of the cheek
fat, ptosis of the lateral eyebrows, laxity of the upper
lids, jowls, and diffuse acne scarring of the cheeks and
neck.
34.3 Technique of Facial Liposculpture
Lines are drawn on the face to show the full area of
undermining, the vectors of muscle tension, relaxation
creases and folds, and crisscrossing lines of tunneling
and dermal stimulation. Incisions are placed at differ-
ent sites to allow ease of access depending on the target
areas (Fig. 34.1). In the forehead, incisions are vertical
to avoid nerve damage and are at the hairline, midline
or frontal recess. Temporal incisions are parallel to the
hairline while submental incisions are at the submental
crease. Preauricular incisions are made at the earlobe,
and upper and lower eyelid incisions are at blepharo-
plasty sites.
The use of the tumescent technique reduces bleed-
ing and bruising and decreases surgical time. Modified
Kleins solution [2] used contains 1,000 mL of |normal
saline with 1 mL epinephrine (15 mg), and 500 mg
lidocaine. Intravenous sedation is generally utilized,
but when general anesthesia is used with lidocaine, it
is reduced to 200 mg and sodium bicarbonate is elimi-
nated. Approximately 350500 mL of solution is uti-
lized on each side. A blunt-tipped, 14-gauge cannula is
used to infiltrate the subcutaneous tissues of the neck,
jowls, cheeks, temple, and brow. Digital pressure aids
in directing and expanding the fluid evenly.
34.3.1 Ultrasonic-Assisted Dissection
Ultrasonic dissection is performed with a titanium
solid probe (sculpture by SMEI, Italy) that is 15 cm in
length [3, 4]. The areas include frontal from the hair-
line to the brow, glabella, dorsum of the nose, temple,
lateral canthal region (crows feet), cheeks to nasola-
bial grooves, chin, jowls, and anterior neck from chin
to sternal notch (anterior triangles). The probe is
A. Di Giuseppe and G. Commons
Fig. 34.1 Incision lines
advanced subdermally, and the tip of the probe tents
the skin while it is withdrawn. Blanching of the skin
occurs with treatment and is more noticeable in the
patient with ruddy complexion. The skin softens and
smoothes following use of the probe.
The sequence of dissection starts with the submen-
tal area and neck from the submental and earlobe inci-
sions. The probe is then used over the mandible, cheek,
and temple reaching the nasolabial fold, side of the
nose, and the crows feet in a radiating fashion through
the earlobe incision. An upper eyelid incision allows
access to the glabella and central portion of the fore-
head releasing the cutaneous insertion of the corruga-
tor and procerus muscles without altering skin
sensation. The rest of the forehead is dissected through
a separate hairline incision (Fig. 34.2).
The fat emulsion and tumescent fluid are evacuated
by gentle massage of the areas. When the incisions are
closed with skin sutures, epifoam is applied to the skin,
and a chin strap is also applied. Ice packs are used on
the face and orbital regions are not covered by the
foam. A supporting garment is applied for 1 week, and
then for 2 weeks more, nighttime (Fig. 34.3).
Any other cosmetic procedure can be performed at
the same time including upper and lower blepharo-
plasty, platysmaplasty, face-lift, neck-lift, chin or cheek
implants, temporal-lift, forehead-lift, skin rejuvenation
with laser or chemical peel, and fat transfer.
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER)
Fig. 34.2 Tension lines of action
Fig. 34.3 Face-supporting garment
34.3.2 Complications
Two patients developed postoperative hematomas, which
required aspiration; however, both were hypertensive
and noncompliant with their medications. Contour
deformities of the neck were noted in three patients with
541
two of them improving over 2 months. One patient
required surgical release of the subdermal scar and asked
for a more extensive surgery, a standard open face-lift
with SMAS. There were no instances of nerve injury,
alopecia, or a vascular necrosis. The ultrasonic-assisted
facial rejuvenation was safe, effective, and reproducible.
The results were comparable to more extensive, difficult
surgeries with higher morbidity, risks, and costs.
34.4 Technique of VASER (Vibration
Amplication of Sound Energy
at Resonance) Neck Lipoplasty
34.4.1 Indications
Heavy neck and/or chin with moderate to good skin
tone and where extra volume is expected to be excess
fatty tissue. Patients may seek good predictable aesthetic
outcome (contouring of the neck/jowls) with maximum
safety, fast recovery, and minimum downtime.
The protocol establishes that VASER-assisted neck
contouring should only be performed by surgeons
already experienced with the VASER system for fatty
tissue emulsification, which means at least 20 cases
of standard liposelection are recommended before
moving to application to face and neck. Indicated
patients are those who are seeking contouring of the
neck and jowl areas, who have heavy neck and/or chins
with moderate to good skin tone, and where extra
volume is expected to be excess fatty tissue.
34.4.2 Marking and Incisions
There should be a strategy plan for volume removal
and associated marking. Landmarks include the lower
border of mandible and thyroid cartilage.
34.4.3 Anesthesia
The neck is divided into thirds, and local tumescent
fluid is infiltrated, about 100 mL in each third.
The face and the neck are more vascular and have
more innervations of typical fat layers in the body.
The concentration of adrenaline should be increased
to 1:500,000 and the concentration of lidocaine to
542
0.30.5% in order to guarantee enough analgesia and
vasoconstriction of the area.
34.4.4 Incisions
Incisions are placed under the chin, and in front of or
behind ears (bilaterally), earlobe, chin, and lower neck
(Fig. 34.2). Possible placement may be bilaterally in the
neck at the lowest anticipated level of treatment. The
surgeon must wait between 8 and 10 min before starting
the surgery until the effects of lidocaine and adrenaline
begin. It is advisable to infuse with a small-diameter
blunt infusion cannula (2. 0 mm or smaller, 14 gauge or
smaller). Never use a needle. The infusion should be
uniform and into all locations where the VASER or the
suction cannula may be used. The infusion should be
slow, 100 mL per min, with gentle action.
34.4.5 Skin Protection
Skin protection should be used in all incisions, utiliz-
ing the black skin parts with the orange silicone discs.
The discs should be stitched into place (three anchor
sutures are necessary) using 30 or 40 nylon. The sur-
geon must make sure the knots are tight as the silicon
disc tends to cause the knots to unwind. The skin ports
protect the incision edges and reduce visible incision
scarring. Stretch the incisions and tissues below the
incision with a hemostat to ease insertion.
34.4.6 Emulsication
Utilize the 2.2-mm diameter (18 cm long) or 2.2-mm
(11 cm long) probes, initially with the VASER mode at
20% or 40% maximum of the power of the system.
The 20% amplitude in face and neck works well when
the tissues encountered are soft. The 30% amplitude is
better for moderate/average fat. The 40% amplitude is
indicated if face is fibrous. Never exceed 40% with the
2.2-mm probes, they may break. Apply VASER until
targeted fat is emulsified, likely 23 min total per side
depending on volumes, with additional 23 min under
the chin depending on how the VASER was applied on
the sides. The total VASER time is 610 min depend-
ing on patients and infused volumes. The surgeon must
try to achieve the targeted 610 min of VASER time to
minimize aspiration trauma.
A. Di Giuseppe and G. Commons
34.4.7 Aspiration/Cleaning
Two small stab incisions are sometimes placed in
the lateral aspects of the neck at the lowest point of
treatment and left open for drainage purposes. A small
suction cannula with no vacuum applied and passed
through the stab incisions to open channels into the
treated areas. At the end, it is advisable to massage
and press tissues to express emulsified tissues and
fluids out of incisions. The emulsified fat and fluids
can be massaged out or will drain out of the incisions
on its own.
34.4.8 Postoperative
The recommended dressing will make a gentle
compression to help the skin redraped and settle into
position and aid to prevent ripples or folds in the skin.
The options include cotton pads with elastic wraps,
cold compresses, silicon foam padding, elastic face
garments typically applied for 24 days, than over-
night for 12 weeks, depending on preference. Keep
head elevated overnight for 4 weeks to help edema to
last quicker. The typical follow-up is 1 day, 1 week,
6 weeks, 6 months, and as needed. Protocol for external
ultrasound and for light massage (LPG Endermologie)
or just lymphatic massage may be beneficial.
External ultrasound 10 W for 5 min with small head
twice a week for 34 weeks is recommended as an
alternative to endermologie, to soften tissue.
34.5 Discussion
There has been a lot of interest in the use of ultrasonic
liposuction for body contouring. Skin retraction has
been reported as a result of the concomitant use of
internal ultrasound from the large amount of fat
removed, removal of subdermal fat, skeletonization of
the superficial fascial system, and thermal effects on
the subdermal surface and collagenous structures of the
superficial fascial system [58]. The theories of the
cause of skin contraction include collagen constriction
due to thermal injury, defatting the superficial layer
results in contraction of the retained structures (skin),
and gentle stimulation allows contraction through
controlled damage.
Facial aging is due to fat and skin ptosis and not
muscle or facial ptosis. Therefore, the supra-SMAS
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER)
plane is ideal for the harmonic lift with ultrasonic
rejuvenation of the face. The osteofascial dermal
ligaments can be released or attenuated in this plane
allowing direct contouring of the malar, nasolabial,
jowl, and submental fat collections. Fat removed close
to the under surface of intact skin results in skin retrac-
tion with permanent contour changes.
Postoperative care requires careful nursing assis-
tance, punctilious wound protection, and prolonged
seclusion of elaborate makeup. Recovery time varies
from 4 to 14 days. The postoperative care is limited to
the use of Reston foam and elastic compression ban-
dages that are changed by the patient. Although there
are no histological examinations in this study, there
have been previous reports on the results of subdermal
ultrasound and liposuction [9, 10]. The long-term
results have not been evaluated and are probably
related to the type of skin, patients age and sex, and
the long-term effect of ultrasound energy.
Disadvantages are the cost of ultrasonic machine,
increased hassle factor in the operating room, and
machine dependency, but after achieving proficiency
in using the machine, there is no turning back because
it is addicting. The conclusion, at that time, was that
the harmonic lift is a safe, effective, and reproducible
form of skin remodeling. It can be performed under
local, regional, or general anesthesia and can be
repeated with no increase in surgical difficulty or
cumulative effect. Advantages include negligible blood
loss and pain, short and uncomplicated recovery, and
simple postoperative care. The results are comparable
to those obtained with more extensive surgery that fre-
quently involves overnight stay, higher risks, increased
morbidity, and higher costs.
The author has found a lot of skepticism around the
utilization of ultrasound energy in the face, mainly
related to the potential risks of burns. In the USA, from
1995 to 2000, a series of articles published in medical
literature pointed out the increasing number of compli-
cations related to body contouring procedures when
ultrasound energy was involved [11].
The analysis of all these complications, though
there is a difficulty in assembling all the clinical data,
brought to the following results:
1. Seroma (30% of body contouring cases)
2. Delayed wound healing (18% of clinical cases)
3. Prolonged edema (15% of clinical cases)
4. Dysesthesia (12% of clinical cases)
5. Fibrosis (8% of clinical cases)
6. Asymmetries (4% of clinical cases)
543
7. Skin necrosis (0.3% of clinical cases)
8. Burn (0.2% of clinical cases)
Despite the fact that burn and skin necrosis were
largely the less common related complications, and
represented really a rare issue, the potential risk of
these two complications was overemphasized. A major
issue was introduced by many authors in literature,
probably because these two related to procedure com-
plications were not seen with the other technique of
liposuction (superficial, traditional, power assisted).
The task force established by the American Society
of Aesthetic Plastic Surgery (ASAPS), by the American
Society of Plastic and Reconstructive Surgery
(ASPRS), by the Educational Foundation, etc., met
many times in order to establish safety criteria of utili-
zation of ultrasound energy in body contouring
surgery.
The first safety indication, to prevent complications
such as burn and skin necrosis, was to avoid the utiliza-
tion of the ultrasound probe close to the underlying
skin dermis that was really, on the contrary, the most
important step of the harmonic lift. However, only
working superficially with a solid ultrasound probe,
the surgeon can undermine the cutaneous and subcuta-
neous layers, assembling a skinny but vascularized flap,
more prone to retract and adapt to a reduce body vol-
ume. The great misunderstanding in those years, which
led to and created confusion and mixing of clinical
data, was due to the fact that all the complications-
related data came through the utilization of the two
most diffused ultrasound tools, in the U.S. market: The
Contour Genesis, by Mentor (Santa Barbara, California),
and the Lysonics (by Inamed Corporation).
These two ultrasound tools have similar technical
characteristics:
1. High energy
2. Hollow probes, with simultaneous ultrasound energy
administration, thus emulsification and simultane-
ous, subsequent aspiration
3. 5.0-mm large probe
The SMEI sculpture tool was a less powerful tool,
with solid titanium probes, with no aspiration at time
of emulsification (which were, and are, two different
clinical phases).
In 2001, Cimino [12] published an article on power
quantification and efficiency of ultrasound energy.
This article was of capital importance to understand
all the mistakes made by the two main American
manufacturers in assembling the two most common
ultrasound tools.
544
Fig. 34.4 Sculpture by SMEI
(bottom) and infiltration
peristaltic pump (top)
1. Too much energy which produced an unnecessary
overheating, which increased the side effects of
ultrasound (seroma, mainly) without enhancing the
results and the clinical outcomes.
2. Too large probes, with low efficacy in transmitting
energy to the tip, and thus reducing the emulsifica-
tion rate.
3. Poor design of the tip of the probe due to lack of
technological research, with a reduced efficacy of
the system in order to raise the rate of emulsifica-
tion; the manufacturer increased the power of the
tools.
The two main ultrasound devices were far from a
good technical standard, technologically were low-
developed machines, and the majority of complica-
tions came from these limits. As a matter of fact, with
the sculpture SMEI machine, the author has never
had the complications pointed out in the literature in
those years, which progressively destroyed the name
A. Di Giuseppe and G. Commons
of the ultrasound technique for fat emulsification
(Fig. 34.4).
Fortunately, in 2001, a new ultrasound device,
called VASER, (by SST-Denver, Colorado, USA), was
introduced in the U.S. market (Fig. 34.5). This new
tool has new features as:
1. New designed probes, of different caliber and shape.
2. The tip is designed (with one, two, three rings), to
increase the efficiency of the emulsification, which
now affects not only the tip, but also the sites of the
last part of the shaft (Fig. 34.6).
3. The number of rings is related to the efficacy of the
emulsion depending on the type of tissue encoun-
tered (more or less fibrotic, type of fat, more or less
dense).
4. New generator of ultrasound energy, with less power,
but with optimization of the distribution of energy at
the different frequencies and wave length. High effi-
ciency with less energy, which means less-related
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER) 545

Fig. 34.6 Different probes with one, two, and three rings at the
top of the shaft

Fig. 34.5 VASER system ultrasound (top), Ventex aspiration

(bottom), and infiltration (top right)

complications due to overheat of the system. So far, in

the last 5 years of the VASER Ultrasound Generation,
no report of burn or skin necrosis has been published.
An insignificant percentage of seroma was reported.
5. New aspiration system, the so-called Ventex, with a
new pathway expressly designed for increasing the
rate of aspiration, without damaging the tissue, thus
aspirating noble structures, as vessels nerves,
elastic tissue, and impossible to be blocked by undue
aspiration of wrong tissue. Skin protector, expres- Fig. 34.7 Skin ports
sively designed to prevent tissue damages from fric-
tion injuries, related to the consecutive passages of
the probe from the same entrance point (Fig. 34.7). The role of dermis in the subcutaneous anatomical
6. Reduced extension entrance scar of skin, to allow structure has been under valuated in the past.
introduction of the solid titanium probes that are Rudolph (1977) [13] first described the importance
smaller in diameter (standard probe varies from of the dermis layer for skin retraction. In plastic
2.2 mm to 3.7 mm). The facial probe is 2.2 mm large. surgery, it is commonly known that a split skin graft
Even the site of entrance is now compatible with the (no dermis left) is not really indicated to cover joint
typical diameter of the standard liposuction cannulas areas (as elbow) for the possibility of leading to skin
(between 2 and 4 mm of diameter). retraction, thus functional problems to the area. If a
546 A. Di Giuseppe and G. Commons

Fig. 34.8 The thinner the

subcutaneous fat, the greater
the contraction

The thinner the

subcutaneous fat, the
greatest retraction
is achieved

UAL solid titanium probe

works close to the dermis,
to thin the subcutaneous
fat, and achieves contraction

Fig. 34.9 Layers of Layers of subcutaneous emulsification with vaser UAL

subcutaneous emulsification
with VASER UAL

S=superficial

I=intermediate

P=deep

full thickness graft is utilized (with a layer of dermis
but no fat), the same area is less prone to contraction
and to functional problems (Fig. 34.8).
This aspect has never been considered in skin
contraction after ultrasound-assisted body contouring
[14, 15]. Emulsifying the body fat, and thus conserving
the connective, supporting structure of the subcutane-
ous tissue (Fig. 34.9), the skin retracts much more than
in standard condition. If the surgeon can harvest a
well-vascularized skin dermal flap with the auxiliary
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER) 547

use of an instrument that helps preparing such a surgi-
cal plane, the potential of skin retraction is maximized
in a safe procedure (Fig. 34.10).
The surgeon using the VASER technique for face
and neck contouring can emulsify fat areas (chin,
jowls, neck) or just extensively undermine the
interested areas, counting on a deep, severe, intense
skin retraction and simulating the effect of a subcuta-
neous rhytidectomy but without cutaneous scars [16]
(Fig. 34.1134.15).

Fig. 34.10 Fat thickness Fat thickness varies in different body areas
varies in different body areas
Thigh and abdomen are the thickest
area
Back anf face are the thinnest

Back Thigh

Fig. 34.11 (a) Preoperative 38-year-old male. (b) Postoperative following jowl, chin, and neck contouring
548 A. Di Giuseppe and G. Commons

Fig 34.11 (continued)

a b

Fig. 34.12 (a) Preoperative 37-year-old patient. (b) Postoperative after neck, chin, and jowl contouring
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER) 549

Fig. 34.13 (a) Preoperative 28-year-old male with heavy cheeks and chin retrusion. (b) One month following VASER of cheeks
and neck for contouring and intraoral chin implant
550 A. Di Giuseppe and G. Commons

Fig. 34.14 (a) Preoperative 43-year-old male with neck and chin hypertrophy. (b) Postoperative after cervical UAL and chin
implant
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER) 551

a b

Fig. 34.15 (a) Preoperative 44-year-old obese female. (b) Postoperative following neck, jowl, and cheek UAL

References 9. Pitman GH (1993) Liposuction and aesthetic surgery.

1. Di Giuseppe A, Menna G (2000) The harmonic lift: ultrasonic
assisted skin remodelling. Int J Cosm Surg Aesth Dermatol
2(2):125131
2. Klein J (2000) Tumescent technique. In: Klein J (ed) Tumescent
anesthesia & microcannular liposuction. Mosby, St Louis
3. Grotting JC, Beckestein MS (1999) The solid probe tech-
nique in ultrasound-assisted lipoplasty. Clin Plast Surg 26(2):
245254
4. Rohrich RJ, Beran SJ, Kenkel JM (1998) Ultrasound assisted
liposuction. Quality Medical Publishing, St. Louis
5. Illouz YG (1990) Study of subcutaneous fat. Aesthetic Plast
Surg 14(3):165177
6. Gibson T (1990) Physical properties of skin. In: McCarthys
plastic surgery. W.B. Saunders Co, Philadelphia
7. Gibson T, Kenedi RM (1970) The structural components
of the dermis. In: Montagna W, Bentley JP, Dobson L,
Montagna W, Bentley JP, Dobson L (eds) The dermis.
Appleton-Century-Crofts, New York
8. Southwood WF (1955) The thickness of the skin. Plast
Reconstr Surg 15(5):423429
Quality Medical Publishing, St. Louis
10. Fodor PB, Watson J (1998) Personal experience with ultra-
sound assisted lipoplasty: a pilot study comparing ultrasound
assisted lipoplasty with traditional lipoplasty. Plast Reconstr
Surg 101(4):11031116
11. Scheflan M, Tazi H (1996) Ultrasonically assisted body
contouring. Aesthetic Surg J 16:117122
12. Cimino WW (2001) Ultrasonic surgery: power quantifica-
tion and efficiency optimization. Aesthetic Plast Surg J
21(3):233241
13. Rudolph R, Guber S, Suzuki M, Woodward M (1977)
The life cycle of the myofibroblast. Surg Gynecol Obstet
145(3):389394
14. Becker H (1992) Subdermal liposuction to enhance skin
contraction: a preliminary report. Ann Plast Surg 28(5):
479484
15. Gasparotti A (1992) Superficial liposuction: a new applica-
tion of the technique for aged and flaccid skin. Aesthetic
Plast Surg 16:141153
16. Shiffman MA, Di Giuseppe A (2006) Liposuction: princi-
ples and practice. Berlin, Springer
Part IV
Breast
 Breast Augmentation
Lina Valero De Pedroza
35.1 Introduction
Over the past 20 years, the author had the opportunity
to operate on different social profile women: fashion
models, beauty contestants, executive working women,
and housewives. Each group needed a specific breast
augmentation surgery. Over the last two decades, the
anatomy of breast implants has evolved bringing
patients and surgeons the possibility of having better
results with surgery. The demanding patient is perma-
nently in contact with virtual information and is often
pushing her surgeon for a better and natural result.
Today and in the future, thanks to technology, we as
surgeons will address the problems of breast augmen-
tation with better cosmetic and anatomical results.
35.2 Consultation
One of the most frequent requests from patients plan-
ning breast augmentation is the normal appearance of
the new breast. Size of the breast has always been a
normal size please for every individual when search-
ing for breast augmentation. Cup for the bra size is a
constant question, and every patient has to define her
own size or the desired one.
Consultation concerns itself with these and other few
concerns about complications, durability of the implant,
surgical approach, medical fees, and economical
L.V. De Pedroza
Plastic and Reconstructive Surgery, Universidad del Valle,
Bogota DC, Colombia, S.A
e-mail: lvalero@lafont.com.co
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_35, Springer-Verlag Berlin Heidelberg 2013
35
cost of surgery. Before surgeon and patient decide to
have the surgery performed and sign the patients
informed consent, in the authors experience, a spe-
cialized consultation in plastic aesthetic and cosmetic
surgery of the breast has to go through seven steps:
1. Medical record
2. Psychological interview
3. Photographic computerized imaging
4. Actual vs. future breast size
5. Deciding which implant the patient needs
6. Surgeons suggestions
7. Patients informed consent
35.2.1 Medical Record
A complete medical record is important in order to
visualize any physical condition that will place the
patient in an adequate condition to avoid complications
in the immediate postoperative period. These condi-
tions include urinary infection, diabetes, pregnancy,
autoimmune diseases, and others that should be cleared
during consultation. It is of great help to standardize
the medical record and ask the patient to fill it in.
35.2.2 Psychological Interview
After finishing an accurate medical record, the patient
is asked to have a psychological interview with a psy-
chologist; whose aim is to distinguish any psychotic,
neurotic, obsessive compulsive traits, or even a body
dysmorphic disorder. Once this interview ends, the
psychologic profile enables us to continue the consul-
tation and schedule the surgery.
555
556
35.2.3 Photographic Computerized
Imaging
This wonderful tool of photographic technology guides
the clinical evaluation for performing an aesthetic
diagnosis of the patient and to visualize her desired
final result in terms of size of the new breast, position
of the nipple-areola complex, and diameter of the are-
ola. Patients who undergo this session gain a better
understanding of their anatomy, their future change
after surgery, and finally, they end the process by exer-
cising their minds placing a tactile image of themselves
in a paper. Computer imaging has been often misun-
derstood and should never be used to show the patient
the final result, but to have the patient show us how
they would like to appear!
This photographic session is given to the patient
with a legend below. The following photographs are
not intended to show you a result; they are a techno-
logical tool to understand your minds image and per-
form a surgery according to your requests.
35.3 Actual Versus Future Breast Size
In the next interview with the patient, the surgical
approach is explained for the individual case; the
patient is sized with her own bra and often different
sizes of bra, running from 32 to 40 and cups from A to
DD. This method helps the author to understand the
patients actual size and the new size desired, while
asking her to wear a blouse with the new bra on. Again,
this step helps the patient visualize her future breast
enlargement in vivo before surgery.
35.4 Deciding Which Implant
the Patient Needs
It is often helpful to keep many samples of different
kinds of implants that include smooth, textured, micro-
textured, anatomical, high profile, medium profile,
saline. With those samples, patients understand quality
and shape of those selected for them. Then the author
suggests the kind of implant chosen for every individ-
ual patient depending on the amount of breast tissue
she has and the pocket placement in the subglandular
or submuscular position.
L.V. De Pedroza
We find that the best results in terms of reaching an
aesthetic anatomical appearance are achieved with
implants with high profile, soft touch gel, microtex-
tured, and round shaped when the volume does not
exceed 450 mL. When the expected volume needs a
volume more than or equal to 500 mL, the author
prefers anatomical devices in order to avoid the
undesirable bulging in the superior pole and, on the
other hand, obtain a better natural shape and a fuller
inferior pole.
35.4.1 Surgeons Suggestions
During this last consultation step, the author suggests an
approximative volume in terms of cup size that will look
better in the patient. We never compromise the proce-
dure by suggesting a determined volume of the implant
prior to surgery, it will be given after surgery with all the
literature and attachments on the implant box.
Patients leave the operating room with the desired
breast shape and size after a meticulous process guided
by the anterior steps related.
35.4.2 Patients Informed Consent
At this time, the patient is informed about the surgical
procedure, possible complications, breast device,
recovery, medical fees, coast of the implant, prepara-
tion before surgery, and postoperative instructions.
Surgery is scheduled for at least 6 days after the first
consultation. During this period, patients may have
time to understand their new appearance and some-
times a few questions arise before surgery in one more
interview with the surgeon.
35.5 Processes to Optimize the Surgery
Following the processes in the consultation steps
enables surgeons to optimize breast augmentation
which transforms the procedure as an objective approach
and not a subjective (surgeons) surgery, as performed
in the past. Engineering processes are the tools to qual-
ity control; surgeons can evaluate and apply these tech-
niques to redefine patients long-term outcomes and
obtain a satisfactory result and a satisfied patient.
35 Breast Augmentation
1. Prioritize and project the patients tissues by choos-
ing implant pocket location to assure optimal long-
term tissue coverage of the implant and by avoiding
implant sizes or projection that are likely to cause
excessive stretching, tissue thinning, and parenchy-
mal atrophy.
2. Implement objective, tissue-based clinical evalua-
tion, preoperative decisions, operative planning,
and implant selection.
3. Prioritize and consider implant design, filler distri-
bution dynamics, and implant-soft tissue dynamics
during operative planning.
4. Design and dissect the implant pocket to fit the
implant selected.
5. Minimize trauma and bleeding and apply prospec-
tive hemostasis principles.
35.6 Principles in Breast Augmentation
Dr. Ralph Millard introduced the author to the
principles in plastic surgery; the philosophical
rationalization of acting and thinking when per-
forming a surgical plan.
1. Correct the order of priorities.
2. Diagnose before treating.
3. Know the ideal beautiful normal.
4. Seek insight into the patients true desires.
35.6.1 Correct the Order of Priorities
Performing breast augmentation is a complex surgery
that involves: (1) tissue coverage, (2) incision place-
ment, (3) pocket placement, (4) volume desired by the
patient, and (5) volume suggested by the surgeon. All
decisions should be placed together to produce breast
enlargement and breast shaping.
35.6.2 Diagnose Before Treating
An accurate diagnosis of breast condition will guide
the surgeon to perform the indicated surgery. Dis-
tinguishing from atrophic breast tissue, hypotrophic
breast, asymmetries, skin appendage and thickness,
elasticity, weight, gravitational, and aging influences
will help differentiate what the patient is facing.
557
35.6.3 Know the Ideal Beautiful Normal
Since Normal is our goal, any Plastic and Recons-
tructive surgeon must know normal beauty. Each
decade brings new patterns, but beauty by itself has its
own meaning. According to Plato (420348 B.C.),
beauty and function in their perfect expression are syn-
onymous. St. Thomas Aquinas, concept known as
Angelical Doctor, was one of the great philosophers
of the Catholic Church in the thirteenth century. He
proclaimed beauty to be Integritas, proportion et
claritas Harmony, proportion, and clarity. Kant
claimed that beauty is simplicity. Mortimer Adler,
University of Chicago philosopher, stated that beauty
brings pleasure, and life without beauty is not enriched.
David Hume, 200 years ago, stated beauty is not only
a quality of things, it exists only in the mind who con-
templates it, every mind perceives beauty differently.
Probably, the most important key to what each of us
sees as beautiful is our previous experience.
35.6.4 Seek Insight into the Patients
True Desires
Frequently, a Plastic Surgical Aesthetic consultation
involves four determinations: diagnosis, plan of treat-
ment, fees, and scheduling of the surgery. There is a
subtle fifth dimension that is more important than all the
other four: The surgeon must get on the same wave
length as the patient, so that he has insight into the
patients true desires. This is not necessarily what the
patient says she wants, not what most patients want, not
what you want, it is what she (the patient) really wants!
35.7 Clinical Evaluation
and Aesthetic Diagnosis
Optimizing any process to evaluate the patient during
consultation will enable surgeons to perform a breast
augmentation surgery with the best choice for approach,
selection of breast implant design, implant pocket
location, assure optimal long-term tissue coverage of
the implant, adapt implant dynamics to the patients
anatomy depending of skin quality, avoiding over pro-
jection, avoiding excessive stretching, tissue thinning,
and parenchymal atrophy.
558
The ultimate objectives of any breast enlargement
runs between speedy recovery, reducing complications
and reoperation rates, and minimizing negative aes-
thetic results such as displacement, capsular con-
tracture, enlargement of the nipple-areola complex,
retractions of the incision approach, or noticeable scar
when placing it at the submammary fold instead at the
expected new one. The surgeon may have a meticulous
vision of these items, enough tools to perform a natural
enhanced breast enlargement, but in failing to transmit
this expectation to the patient, he dooms the surgery.
Should patient expectations exceed reality, no matter
how brilliant the surgery and its results turn out to be,
the patient will never be happy, and the procedure has
thus failed in its primary goal.
Two categories of breast augmentation exist: breast
enlargement (breast stuffing) and breast enlargement
(filling and shaping the breast) with optimal control of
distribution of fill and long-term aesthetic results,
while minimizing tissue compromises and reoperation
rates. Stated another way, augmentation can either
optimally fill a breast acknowledging breast dimen-
sions and tissue characteristics (fit and fill) and force
tissues to a desired result.
Understanding excess skin elasticity and breast tis-
sue atrophy most commonly present at the postpartum
and postfeeding periods will give guidelines to distin-
guish a ptotic breast from an atrophic one when per-
forming a subglandular implant location.
1. Rippling is often produced by a textured and low
filling gel implant with a poor tissue coverage.
2. Breast stuffing reveals both poor tissue coverage and
poor pocket dissection accompanied by an incorrect
excess volume implant and poor skin elasticity.
Finally, breast augmentation depends on anatomi-
cal dimensions of the chest of the patient, inframam-
mary fold position, cleavage, breast tissue (either
muscle or glandular) coverage, skin elasticity, and
breast position on the chest (ptosis).
35.8 Patients Prole
Not every woman has the same professional or social
profile, it may also depend on her age, height, and
weight. We as surgeons deal with different kinds of
breast enlargements, and in the globalized world we
live in, different culture groups that must be recog-
nized. A professional business woman of ages ranging
L.V. De Pedroza
from 24 to 37 years old, often with at least one or two
pregnancies, what is found usually its an atrophic
breast tissue. The enlargement goals often seek an
objective: natural filling and shaping of her breast,
searching for what was lost, when she had a youthful
filled breast. Volume desired in these cases may fit a
bra cup sizes B and/or C. A housewife concerning
about breast augmentation may have different expecta-
tions and depending of the height and weight, what is
a common request between these patients is to recover
a lost volume and younger appearance, usually obtained
by mixing a breast lifting with a breast augmentation.
In the authors experience in performing surgeries
to fashion models and beauty contestants, these
patients ages range between 17 and 24 years old, and
breast augmentation seeks full cup B, never trespass-
ing to a C cup. Their natural low profile breasts are like
the angelical, innocent, and child in an adult body
appearance in a thin frame.
Also, after the age of 50, skin elasticity is excessive;
ptosis may be the rule and breast enlargement is often
a combination with breast lifting. When combining
these two procedures, the use of a mammary implant
means a tool to fill a lost youthful appearance.
35.9 Surgical Approaches
35.9.1 Periareolar Incision Location
The periareolar incision approach to breast augmenta-
tion is very popular in some areas of Europe and South
America. Surgeons can place implants in all pocket
locations via this technique. No valid scientific studies
confirm the option that the periareolar incision pro-
duces a superior or best incision compared to the infra-
mammary incision location. Advocates of this location
incision often state that visualization and control of
pocket dissection provides an excellent access. The
authors opinion is that patients with an areola diame-
ter less than 3 cm are not the best candidates for this
approach. This means that our incision should be at
least 2 cm long, and tissues will not have the flexibility
to permit the insertion of an implant base width over
10 cm, risking torn skin, and enlarging the incision to
a visible position. The trauma produced to the skin
edges often results, under these conditions, in a hyper-
trophic scar. Inserting any breast implant via periareolar
approach exposes the implant to more endogenous
35 Breast Augmentation
bacteria in the breast parenchyma, compared to other
approaches. However, scientific studies fail to confirm
higher infection rates and capsular contracture pathologic
scarring. When planning to choose an implant base
width exceeding a diameter of 10 cm or more, a stable
cohesive gel implant, or a small diameter areola, the
periareolar incision location is impossible. The
approach is also not an optimal choice for patients with
any history of parenchymal breast disease.
35.9.2 Umbilical Incision Location
This today is the least used approach for breast aug-
mentation. One of the most valid reasons in the authors
experience is how distant from the breast unit the inci-
sion is located and how excellent management of the
endoscopic instrumentation is needed for the surgeon
to expose the tissues with this approach. Published
reports and observation during live surgery demonstra-
tions of the techniques point out difficulties in predict-
ing and assuring precise pocket locations.
The umbilical approach limits implant options to
inflatable implants, and inflatable implants leave a
Fig. 35.1 (a) Preoperative. (b) Fourteen years after axillary approach, submuscular pocket with round, microtextured, and high
profile implants. (c) Axillary close up of the left and right axila after 14 years of surgery, notice that you can barely see the scars
559
substantially higher device failure rate over time
compared to latest generation form stable, silicone cohe-
sive gel implants.
35.9.3 Inframammary Incision Location
This approach most frequently used through North
America requires that surgeons preoperatively plan the
location of the new inframammary fold. Advocates of
this technique state that it provides the best direct
vision access, achieves a less traumatic access, requires
no specialized instrumentation, is applicable to all
types of implants with maximal accuracy and options,
and no additional incision is required for secondary
procedures.
35.9.4 Axillary Incision Location
(Figs. 35.1 and 35.2)
The axillary incision approach is the closest location to
reach both the submuscular and the subfascial pocket.
Surgeons with optimal skill sets can place many kinds
560
Fig. 35.1 (continued)
of available implants accurately and precisely via the
axillary approach. Only anatomic shaped implants
cannot be precisely placed, as well as the foam coated
implant due to its known high adhesivity thus creating
misplacement of the implant at the end of the
procedure.
L.V. De Pedroza
This approach facilitates the off visible location of
the incision and permits a well-hidden scar, which in
the experience of the author performing this procedure
for more than 20 years, there was a 0.0001% rate of
hypertrophic scar occurrence perhaps due to lack of
tension of tissues.
35 Breast Augmentation 561

Fig. 35.2 (a) Preoperative 22-year-old female. Three years postoperative using submuscular axillary approach and inserting
375 mL extra-high profile, microtextured, and round-shaped implants

Critical neurovascular structures such as the axillary
artery and vein and the brachial plexus are adjacent to
the axillary incision site, and rare injuries to these
structures have been reported. The intercostobrachial
and medial brachial cutaneous nerves course through
the axillary fat, and injuries to these structures occur
when surgeons dissect excessively posteriorly in the
axillary fat pad.
Potential tradeoffs of the axillary approach that are
usually temporary and nevertheless cause postopera-
tive morbidity include: (a) transient axillary fluid col-
lections, (b) difficulty and delay in shaving the axilla,
562
a b
Fig. 35.3 (a) Periareolar incision and submuscular placement. (b) Severe retraction of the areola due to deficient closure technique
(c) transient sensory loss in the axilla and upper arm,
(d) and fibrous bands in the axilla. Even if the incidence
of these tradeoffs is extremely low, surgeons should
inform the patient of those when discussing incision
alternatives.
The axillary approach is not an optimal choice for
patients with glandular ptosis and does not provide
optimal control for correction of tubular breast as well
as for severe constricted lower pole breasts.
35.10 Complications and Management
Breast augmentation is a totally elective cosmetic sur-
gery. When a patient is choosing a breast enlargement,
she is choosing to place a medical device that is not nec-
essary to place into the body. Patient education through
consultation will transform knowledge and understand-
ing to difficult situations that may occur in the postop-
erative period. Most frequently, these complications
arise when surgeons did not predict enough tissue cov-
erage, did not recognize previous ptotic or constricted
breast, did not follow an atraumatic surgical procedure
avoiding bleeding, or taking care of aseptical measures
at the time of placing the implant inside the pocket.
35.10.1 Retraction at the Site of Incision
(Fig. 35.3)
Suturing technique during closure of the wound may
avoid unpleasant retraction mostly present at the peri-
L.V. De Pedroza
areolar incision location. The subareolar skin is sur-
rounded by an orbicular smooth fiber muscle, this
functional anatomy should be reconstructed at the
moment of closure avoiding future disability in terms
of contracture of the areola.
Surgeons can definitely impact surgical-related fac-
tors by implementing quantitative tissue assessment
and proven processes for implant selection, optimizing
techniques that preclude the necessity of unnecessary
postoperative adjuncts, and following a predetermined
surgical plan process.
35.10.2 Wrinkling
Wrinkling is a frequent cosmetic unpleasant result
often produced by: (1) poor tissue coverage, or (2)
poor design and dissection of the pocket, which does
not fit the implant and remains tight at the moment of
surgery. These two conditions make a wrinkling aspect
often requiring reoperation that could be avoided eas-
ily in the preoperative planning pocket placement and
dissection.
35.10.3 Asymmetry
(Figs. 35.435.6)
Mislocation of one or both implants respond to migra-
tion in the immediate postoperative period mostly
when pocket dissection at the submuscular plane is
poor and liberation of the inferior costal margin of the
35 Breast Augmentation 563

muscle was not performed. A poorly defined surgical
procedure in relation with the fit and fill pocket
placement and dissection will end in asymmetries that
should be corrected by a secondary procedure, also
predictably avoided creating better skills for surgery
and optimizing surgical techniques.
35.10.4 Ptosis and Augmentation
Mammaplasty (Figs. 35.7 and 35.8)
When ptosis is not diagnosed, skin elasticity becomes
worse. Glandular atrophy does not mean good tissue
coverage, and any devices weight enhances the

a b

Fig. 35.4 (a) Poor definition of pocket dissection. (b) Inferior border of the muscle pulls the implant in an upward position
(right breast)

Fig. 35.5 (a) Preoperative. Both implants are located at the emply inferior pole. (b) One week postoperative after correction
superior pole due to poor dissection and lack of liberation of with periareolar approach and submuscular pocket placement
the muscle costal insertion. Notice the superior bulging and the
564 L.V. De Pedroza

Fig. 35.5 (continued)

a b

Fig. 35.6 (a) Excessive pocket dissection creating symmastia. (b) Lateral migration of the implant

preexisting ptosis. This is the best opportunity to sug-
gest a lifting augmentation mammaplasty during the
consultation period and avoid an unpleasant result and
an unhappy patient.
35.10.5 Double Bubble Deformity
Double bubble deformity is usually present under the
events such as:
1. Lack of diagnosis of a lower pole constricted
breast.
2. Lowering the inframammary fold too far down dur-
ing a submuscular dissection and leaving the sub-
mammary constricted lower pole attached to the
muscle. Correction of this deformity needs a sec-
ondary revision mammaplasty that includes:
(a) Opening the constricted lower pole and sub-
mammary fold.
(b) Lifting the unnatural abdominal skin coverage
of the implant.
(c) Fixation of a new, anatomical upper placed sub-
mammary fold to the costal edges, often fifth to
sixth rib edge, nevertheless lower.
35 Breast Augmentation
a b
Fig. 35.7 (a) Poor pocket dissection keeping a tight implant in
a preexisting ptosis. The device has been located very medially
and inside the anterior axillary line, leaving empty the lateral
35.10.6 Capsular Contracture
(Figs. 35.935.11)
Understanding dynamics of scarring tissue or fibrous
tissue will clarify a respectable position back of the
ring to prevent capsular contracture. Fibrous scarring
tissue is a contractile and retractile tissue formation in
response to an injury. It is an adhesive cement
incharged to close an open wound or repair an injury
to tissues. Prolonged inflammation and excessive pro-
liferation of fibroblasts are natural responses to exces-
sive tissue damage during surgery. Bleeding, excessive
cautery, seromas, and bacterial contamination help the
formation of a hard nonelastic contractile capsule
around the implant, no matter any excellent product
device used.
This dynamic tendency to contraction can be pre-
ventable by designing a fit and fill pocket, minimizing
565
poles. This is considered a severe cosmetic deformity. (b) Ptosis
before surgery becomes worse with a subglandular pocket
trauma and bleeding, eliminating contamination of the
implant during insertion, and by creating an ample but
fittable pocket thus creating favorable conditions for
scarring tissue formation in order to prevent excessive
contractility of the capsule.
35.10.7 Infection
It is clear that infection tends to be more and more
infrequent due to protocols of surgery steps and asep-
tical measures of managing implants during insertion.
Should this dangerous situation occurs, it is an imper-
ative indication to remove both implants, debride tis-
sue, and apply intravenous antibiotic therapy, selected
by antibiogram and cultivation of the pathogenic
germ. Replacement of the implants is suggested after
6 months of the healing process.
566 L.V. De Pedroza

Fig. 35.8 (a) Preoperative a

34-year-old patient seeking
augmentation mammaplasty.
Large areola diameter and
grade II ptosis and
periareolar glandular atrophy.
(b) One month postoperative
after periareolar mastopexy,
subglandular pocket, and
round, ultra-high profile, and
textured implants
35 Breast Augmentation 567

Fig. 35.8
(continued) b
568 L.V. De Pedroza

Fig. 35.9 (a) Preoperative patient with capsular contracture grade IV in a subglandular position and with large areola diameter.
(b) Two months postoperative with reduction of the areolar diameter and implants in the submuscular position
35 Breast Augmentation
Fig. 35.10 Severe calcification of the capsular tissue
Fig. 35.11 Low profile, smooth, and
round implant from the subglandular
pocket, total capsulectomy was performed
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Roehl K, Craig ES, Gmez V, Phillips LG (2008) Breast reduc-
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Rohrich R (2004) The limited scar mastopexy: current concepts
and approaches to correct breast ptosis. Plast Reconstr Surg
114(6):16221630
Seify H, Sullivan K, Hester TR (2005) Preliminary (3 years)
experience with smooth wall silicone gel implants for a pri-
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Spear S (2006) Synmastia after breast augmentation. Plast
Reconstr Surg 118(7 suppl):168S171S
Spear S (2007) Breast reduction inverted-T technique. In:
Thorne CH (ed) Grabb and Smiths plastic surgery, 6th edn.
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Spear S, Boehmler JH 4th (2006) Clemens MW augmentation/
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L.V. De Pedroza
Spear S, Howard MA (2003) Evolution of the vertical reduction
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Spear S, Giese SY, Ducic I (2001) Concentric mastopexy revis-
ited. Plast Reconstr Surg 107(5):12941299
Tebbetts JB (2001) Patient evaluation, operative planning, and
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and reoperations in breast augmentation. Clin Plast Surg
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Tebbetts JB (2002) A system for breast implant selection based
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 The Inverted Dual Plane
Mastoplasty Technique
Giovanni Di Benedetto, Luca Grassetti,
Davide Talevi, Daniele Bordoni, Manuela Bottoni,
and Alessandro Scalise
36.1 Introduction
Breast augmentation is one of the most common pro-
cedures in plastic surgery. In the USA, almost 300,000
mammary augmentations are performed yearly. Aes-
thetic breast augmentation is usually performed in a
retromammary plane (behind the breast parenchyma),
when breast parenchyma is enough to cover the implant
or in case of active sport patients, or in a retropectoral
plane (behind pectoralis muscle and serratus) in all
other cases. In some cases, where mammary gland is
mostly located on the lower pole, the implant can be
partially placed behind the pectoralis major muscle
and partially behind the breast parenchyma [1] (partial
retropectoral). This technique originally described by
Tebbetts [2] is better known as dual plane augmentation
technique.
The technique, as it was originally described, consists
in positioning the prosthesis partially behind the pecto-
ralis major muscle on the upper pole and partially behind
the breast parenchyma in the lower pole [3]. Using this
procedure, the results obtained appear more natural
looking and has a very nice pear-shaped breast. The
authors describe a modified dual plane technique, mostly
indicated when a mastopexy has to be performed.
G. Di Benedetto (*) L. Grassetti A. Scalise
D. Talevi D. Bordoni M. Bottoni
Department of Plastic and Reconstructive Surgery,
Marche Polytechnic University Medical School, Ancona, Italy
e-mail: dibenplast@hotmail.com; lucagrassetti2000@yahoo.it;
a.scalise@univpm.it; davidetalevi@yahoo.it; tlvdvd@yahoo.it;
danyburdo@hotmail.it; mbottoni@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_36, Springer-Verlag Berlin Heidelberg 2013
36
The dual plane inverted technique consists, such as in
the classical dual plane method, in positioning the pros-
thesis partially under the pectoralis major muscle and par-
tially under the mammary gland. The difference,
compared to the classical method, consists in covering the
implant using the lower third of the pectoralis major mus-
cle, thus leaving the implant to be covered by the mam-
mary gland on the upper two thirds, so creating a kind of
lifting of the breast, obtaining a mastopexy effect [4].
36.2 Technique
The short version of the technique includes performing
the skin incision, and the gland is passed through until
the pectoralis major muscle layer is reached. An inci-
sion through the muscle fibers, respecting their direc-
tion, is then performed, creating a submuscular pocket
mostly located under the lower third of the muscle
itself. After that, the implant is inserted, the lower part
been located under the undermined muscle, the upper
part been located under the mammary gland. Before
suturing the gland with single sutures, covering the
muscle and the implant, a suction drain is inserted.
Subcuticular and skin suture is performed. Mild dress-
ing of the lower pole of the breast is finally performed.
In one case, a 50-year-old patient was seen after a
subglandular mastoplasty in 2003, followed by vertical
scar mastopexy in 2007. The surgical problems included
(1) recurrence of breast ptosis (sternal notch-areola
border distance, 22 cm on the right side, 25 cm on the
left side), (2) widening of periareolar and vertical scars,
and (3) mammary parenchyma with 3-cm ptosis
(Fig. 36.1). The procedure consisted of undermining
the lower third of the pectoralis major muscle and
571
572
a b
Fig. 36.1 Preoperative patient front view (a) with 3 cm ptosis of the mammary parenchyma, mostly visible in the lateral view (b)
Tower third of
the Pectoralis
Major Muscle
Fig. 36.2 The lower third of the pectoralis major muscle is
undermined, and a pocket is prepared underneath the muscle
preparing a pocket underneath the muscle (Fig. 36.2).
The prosthesis is inserted under the lower third of the
muscle (Fig. 36.3). The final position of the prosthesis
is the upper two thirds subglandular and the lower third
submuscular (Fig. 36.4).
The technique in detail includes preoperative mark-
ing (Fig. 36.5) of the infraclavicle notch and a straight
line to the umbilicus. The new position of the nipple
(19-20 cm from the notch), the new areola (4-cm size
of diameter) and the inframammary fold are marked.
General anesthesia is used. The new areola
is defined with marker (Fig. 36.6). A vertical
incision is used to remove old scar (Fig. 36.7).
De-epithelialization is performed with scalpel
G. Di Benedetto et al.
Prosthesis
Lower third of
the Pectoralis
Major Muscle
Fig. 36.3 The prosthesis is inserted under the lower third of the
muscle
(Fig. 36.8). Once dermal tissue is reached, the scal-
pel deepens through mammary tissue (Fig. 36.9).
Glandular dissection is done (Fig. 36.10) until the
muscular fascia and undermining of the Chassaignac
space between gland and muscular fascia. Implant
is removed from submuscular plane. Preparation of
pocket is done by initial partial splitting of the pecto-
ralis major muscle following muscle fibers direction.
Dissection is done to create an inferior muscular
pocket (Fig. 36.11). Suction drainage is placed in the
submuscular plane (Fig. 36.12). Prosthesis implanta-
tion (Fig. 36.13) with the mentor HP highly coesive
gel CPG Low 323, 260 mL, is performed. The implant
is positioned in the submuscular pocket after ade-
36 The Inverted Dual Plane Mastoplasty Technique 573

Prosthesis

Lower third of
the Pectoralis Fig. 36.6 New areola defined with marker
Major Muscle

Fig. 36.4 Final position of the prosthesis is subglandular in the

upper two thirds and submuscular in the lower third

Fig. 36.7 Vertical incision to remove old scar

Fig. 36.5 Preoperative drawing: marking the infraclavicle
notch and straight line to umbilicus. A clear asimmetry of the
breast is observed

quate undermining (Fig. 36.14). The split pectoralis
muscle sling is sutured to the glandular layer with
an upward rotation in order to re-create the lower
pole new fold, reinforced (Fig. 36.15). Lower pole
covering is with upward rotation of the split pectora-
lis major muscle (Fig. 36.16). The lower-pole pocket
is sutured (Fig. 36.17) with 3/0 Vicryl interrupted
suture. The deep dermis is sutured with 3/0 Vicryl.
The four cardinal points are sutured for the areola
(Fig. 36.18). Multiple layers are sutured (Fig. 36.19)
by interrupted Vicryl 3/0, 4/0, and subcuticular con-
tinuous Monocryl 4/0.
574 G. Di Benedetto et al.

Fig. 36.9 Once dermal tissue is reached, the scalpel deepens

through mammary tissue

Fig. 36.10 Glandular dissection until muscular fascia and

undermining of the Chassaignac space between gland and mus-
cular fascia. Implant removal from submuscular plane (silicone
smooth gel round implants 220 mL)

Fig. 36.8 (a) De-epithelialization starts in a superficial dermal

layer. (b) De-epithelialization is completed. (c) Care must be
taken to tiny skin island removal
36 The Inverted Dual Plane Mastoplasty Technique 575

b Fig. 36.12 Prosthesis implantation of Mentor HP highly cohe-

sive gel CPG low 323, 260 mL

Fig. 36.11 Preparation of pocket. (a) Initial partial splitting of

the pectoralis major muscle following muscle fibers direction.
(b) Dissection to create an inferior muscular pocket. Suction
drainage placed in the submuscular plane Fig. 36.13 The implant is positioned in the submuscular pocket
after adequate undermining

The old areola scar is excised (Fig. 36.20). The new

areola is marked (Fig. 36.21). The pectoralis major
muscle is incised following muscle fibers direction
(Fig. 36.22). Monopolar electrocautery is utilized for
splitting the muscle (Fig. 36.23). Partial capsulectomy
is performed after removing the old implant
(Fig. 36.24). After completing the capsulectomy
(Fig. 36.25), suction drainage is positioned in lateral

Fig. 36.14 The split pectoralis muscle sling is sutured to the

glandular layer with an upward rotation in order to recreate the
lower pole new fold, reinforced
576
Fig. 36.15 Lower pole covering with upward rotation of the
split pectoralis major muscle
Fig. 36.16 Suturing the lower pole pocket with 3/0 Vicryl
interrupted suture
axilla (Fig. 36.26). The skin is sutured (Fig. 36.27).
The results after 3 and 6 weeks are good (Fig. 36.28).
36.3 Clinical Cases
1. A 35-year-old patient with mild breast type 2 glan-
dular ptosis and mild breast asymmetry postpar-
tum underwent the inverted dual plane technique
with inframammary approch, inserting 280 mL
G. Di Benedetto et al.
Fig. 36.17 Deep dermis suture with 3/0 Vicryl
Fig. 36.18 Four cardinal points suture for areola
of round, highly cohesive gel breast implants
(Fig. 36.29).
2. A -25-year-old patient with bilateral breast
hypotrophy, breast asymmetry, right breast smaller
than left, and inframammary crease displacement,
right side higher than left. She had an inverted
dual plane technique performed through infra-
mammary approach with placement of anatomic
breast implants 320 mL on the right and 280 mL
on the left (Fig. 36.30).
36 The Inverted Dual Plane Mastoplasty Technique 577

Fig. 36.19 (a) Multiple

layers suturing by interrupted
a b
Vicryl 3/0 and 4/0, and (b)
subcuticular continuos
Monocryl 4/0

Fig. 36.20 Old areola scar

Fig. 36.22 Pectoralis major muscle is incised following the

direction of the muscle fibers

Fig. 36.21 Marking the new areola

578 G. Di Benedetto et al.

Fig. 36.25 Breast after having completed the capsulectomy

Fig. 36.23 Monopolar electrocautery is utilized for splitting

the muscle

Fig. 36.26 Suction drainage positioned in lateral axilla

Fig. 36.24 Partial capsulectomy is performed after old implant

removal

Fig. 36.27 Sutured to the skin

36 The Inverted Dual Plane Mastoplasty Technique 579

Fig. 36.28 Early result:

(a) Three weeks
a
postoperative. (b) Six
weeks postoperative
580 G. Di Benedetto et al.

Fig. 36.28 (continued)

b
36 The Inverted Dual Plane Mastoplasty Technique 581

a b

Fig. 36.29 (a) Preoperative 35-year-old patient, with mild nique, with inframammary approach. Breast implants selected:
breast type 2 glandular ptosis and mild postpartum breast asym- 280 mL, round, highly cohesive gel implants
metry. (b) Postoperative following inverted dual plane tech-
582 G. Di Benedetto et al.

a b

Fig. 36.30 (a) Preoperative 25-year-old patient with bilateral nique through inframammary approach using anatomical breast
breast hypotrophy, breast asymmetry, right breast smaller than implant 320 mL on the right and anatomical breast implant
left, and inframammary crease displacement, right side higher 280 mL on the left side
than left. (b) Postoperative following inverted dual plane tech-
36 The Inverted Dual Plane Mastoplasty Technique 583

References 3. Khan UD (2007) Muscle-splitting breast augmentation: a

new pocket in a different plane. Aesthetic Plast Surg 31(5):
553558
1. Regnault P (1977) Partially submuscular breast augmenta-
4. Esposito G, Gravante G, Marianetti M, Delogu D (2006)
tion. Plast Reconstr Surg 59(1):7276
Reverse dual-plane mammaplasty. Aesthetic Plast Surg
2. Tebbetts JB (2001) Dual plane breast augmentation: optimiz-
30(5):521526
ing implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg 107(5):12551272
 Remodeling Breast and Torso
with Combined Fat Liposuction
and Grafts
Alfredo Hoyos
37.1 Introduction
A feminine body that is aesthetically pleasing involves
different concepts of beauty. These concepts are as old
as humanity itself. A rounded, well-shaped breast, nar-
row waist, and wider hips are symbols of fertility,
encoded in our human brains to preserve the species.
The delicate equilibrium between these different ana-
tomical features has been modified by external factors
like race, trends and fashion, and ultimately, by health.
Mainly the relationship between the breast size and
shape and the contour of the hip-waist line are the key
for obtaining a good result.
The improvement of these features can be accom-
plished in many ways. The use of implants in the breast
area is the gold standard: the results are aesthetically
pleasant, reproducible, and reliable in most patients.
Nowadays, there is an increasing demand for aesthetic
enhancement in the breast area; some factors can lead
to think alternatives of implants. The use of fat grafts
in the breast area has been spread in recent times.
Using free-fat autologous grafts as a filling material
was first proposed in 1893 by Neuber, the idea rapidly
gained enthusiasm and endorsements. Since then, fur-
ther clinical works by Guerrerosantos [4,5], Bircoll
[6], Coleman [710], and others [1124] have shown
A. Hoyos
Santa Barbara Surgical Center,
Bogota, Colombia
e-mail: info@alfredohoyos.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_37, Springer-Verlag Berlin Heidelberg 2013
37
that it is possible, by careful handling of transplanted
fat, to improve the survival of this tissue. Fat has many
attributes of the ideal filler, although the long-term
results are technique-dependent, especially on the breast
area, achieving divergent results [1]. Also, the concern
of misguidance in cancer detection should be taking
into account [2,3].
The waistline can be easily molded by liposuction.
However, the waist is influenced mostly by the bony
structures of the rib cage and the hip bones, and above
all, of the distance between these two. The more the
distance, the narrower the waist can be. The goal is to
narrow the upper back and enhance the hip area to emu-
late the desired hour-glass shape in female, with a wider
apex on the hip line. To augment the hip region, the
only option is the use of fillers, specifically fat grafts
and reshaping through liposuction of the waistline.
37.2 Anatomy (Fig. 37.1)
An appealing feminine shape tends to preserve the
hour glass, conferring special attention to the breast
and hip areas. The breast has a rounded shape as
defined by the breast gland contour. Some of the ana-
tomical features surrounding the breast gland are
important to enhance the shape and the relative volume
of the gland: the triangular area between the subclavic-
ular line in junction with the deltoid muscle, the axil-
lary portion of the gland, or Spence tail; and the area
surrounding the lateral pole of the gland, which should
be absent of fat following a lazy S. The breast itself
for this purpose is divided into upper and lower poles.
585
586 A. Hoyos

Fig. 37.1 Anatomic areas of

the breast. The upper (blue)
and lower (green) poles. The
subclavicular negative space
(orange). The surrounding
tissue around the gland
(purple)

Fig. 37.2 Hip-thorax distance and ratio, indications for fat requires waist liposuction, in some cases even hip liposuction.
grafting on the short torso (left) combined with waist and upper There is a correlation between the V- (short), square- (intermedi-
back liposuction. Intermediate torso (center), indication for ate). and A-shaped (long) torso with the Hip-thorax distance and
waist liposuction + optional fat grafting. Long torso (right) only ratio
37 Remodeling Breast and Torso with Combined Fat Liposuction and Grafts
Fig. 37.3 The axillary and
inframammary crease
approach to multilayer fat
grafting (submuscular,
intramuscular, subglandular).
Notice the upper pole as the
only point for subdermal
filling
The torso is considered as an aesthetic unit that has
many factors of influence: one is the full length of the
torso, so the female torso can be divided into short,
medium, or long. In the hip area, the indication for fat
grafting is defined by the relationship between the tho-
rax and the hip. In a posterior view, the ideal feminine
shape is when the thorax is smaller than the hip. There
are three basic contours (Fig. 37.2):
1. A shape when thorax-hip ratio is < 1
2. Squared when the ratio is 1:1
3. V shape: > 1
Square and V shape are indication for fat grafting.
Additionally, a V shape should be treated by extensive
liposuction and waist liposuction. Also, the distance
between the rib cage versus iliac crest determines the
indication for fat grafting and/or upper back liposuction.
37.3 Surgical Technique
Marking: in stand up position, outline the gland. Mark
the areas that need more projection (specially the supe-
rior pole of the breast), to be treated with fat transplan-
tation. The surrounding area of the breast, essentially
the lateral and lower portion, to be resected by liposuc-
tion. In the hip area, the point of maximum projection
587
in the posterior view, and the trochanteric depressions
are marked.
Deep layer lipoplasty: Under general anesthesia,
proceed to infiltrate tumescent solution with 1,000 mL
of normal saline, 50 mL of lidocaine 1%, and 1 ampule
of epinephrine 1:1,000. The ratio of infiltration and
volume of fat removed is approximately 2:1. The aspi-
ration of fat includes all the major contour deformities.
Special attention is paid to the waistline and the lateral
axillary region.
Superficial lipoplasty: in the superficial layer, aspi-
ration sculpting the anatomical muscular lines is per-
formed. In VASER patients, it was used in 80% pulsed
mode using a 2.9-mm probe (Sound Surgical Technologies,
Denver, CO). Subdermal liposuction is performed fol-
lowing the muscular limits using ventX cannulas (Sound
Surgical Technologies, Denver, CO). This can produce a
better result through a better skin retraction [25,26].
37.4 Fat Grafting (Figs. 37.3, 37.4)
Fat is harvested with 4-mm blunt cannula from other
sites to an empty sterile bottle trap. One gram of cefa-
zoline is added to the trap. Decantation was the only
process used to separate the fat cells from the saline
588 A. Hoyos

a b

Fig. 37.4 (a) Preoperative. (b) Postoperative after fat removal grafting has been performed yet. (c) Axillary approach for fat
in the surrounding area of the breast. Notice the improved shape grafting: pinching the pectoralis muscle in order to differentiate
and the augmentation appearance by subtraction of the fat, no fat the supramuscular and submuscular layers

and serosanguineous components. In the breast area,

axillary approach allows fat grafting in the supramus-
cular and submuscular layers. The average of injec-
tion is 100250 mL per side. In the hip region the
access is made by combining lateral and gluteal fold
incisions, with an average of 50150 mL per side.

37.5 Results

The combined multi lamellar lipoplasty plus fat graft- Fig. 37.5 Preoperative left breast and postoperative right breast
ing resulted in safe and effective results (Fig. 37.5) showing the combination of fat removal in the lateral portion
Combined fat grafting and extraction is a safe, low cost, surrounding the breast and the immediate result after fat graft-
ing. In this patient, periareolar reduction was performed
and effective alternative to implants or liposuction
alone. In the hip area, the combination of liposuction
and fat grafting in an anatomical approach led to a more
feminine shape in most patients (Figs. 37.637.10).
37 Remodeling Breast and Torso with Combined Fat Liposuction and Grafts 589

a b

Fig. 37.6 (a) Preoperative. (b) Six months postoperative after fat liposuction in a lazy S and grafting in the breast in anatomical
areas, plus fat grafting in the supramuscular and submuscular layers. Periareolar reduction was performed at the same time

a b

Fig. 37.7 (a) Preoperative A

shape in hip-thorax ratio. (b)
Postoperative following only
liposuction in the waistline
and hip areas
590 A. Hoyos

Fig. 37.8 (a) Preoperative

a b
patient with a squared shape
in hip-thorax ratio. (b)
Postoperative after the
combination of fat extraction
in the waist line and fat
grafting in the hip areas

a b

Fig. 37.9 (a) Preoperative

patient with a V shape in
hip-thorax ratio. (b)
Postoperative after the
combination of fat extraction
in the waist line and fat
grafting in the hip areas.
Additional fat extraction was
performed in the thoracic area
to create an hour-glass shape
37 Remodeling Breast and Torso with Combined Fat Liposuction and Grafts 591

Fig. 37.10 (a) Preoperative

a b
patient with a V shape in
hip-thorax ratio. (b)
Postoperative following the
combination of fat extraction
in the waist line and fat
grafting in the hip areas.
Additional fat extraction was
performed in the thoracic area
to create an hour-glass shape
592 A. Hoyos

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 Breast Augmentation and
Reconstruction with Fat Transfer
Todd K. Malan
38.1 Introduction
38.1.1 The Longstanding Bias Revisited
Fat transfer breast augmentation has remained a highly
controversial procedure following its introduction in
the late 1980s. Lipo-aspiration was in its infancy with
protocols and techniques rapidly evolving when in
1987, Bircoll and Novak [1] described the use of mod-
erate volumes of lipo-aspirated fat for the purposes
of breast augmentation and reconstruction. Their
attempts to advocate lipo-remodeling of the breast
were not well received [24]. Early fat grafting stud-
ies had demonstrated less than optimal survival
rates of 2550% leading opponents to conclude that
multiple lipo-augmentation procedures would be
required to provide even modest results. In addition,
there was strong disapproval regarding the potential
risks of microcalcifications and cysts that could inter-
fere with mammography. All despite a lack of good
scientific data to support their concerns and without
mention of studies that clearly demonstrated the same
concerns of mammographic interference in well-
accepted procedures such as breast reduction, recon-
struction, and augmentation with implants. This
controversy culminated into the 1987 ASPS New
T.K. Malan, M.D.
Innovative Cosmetic Surgery Centers, Scottsdale, AZ, USA
e-mail: drmalan@mac.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_38, Springer-Verlag Berlin Heidelberg 2013
38
Procedures Ad-Hoc Committee position paper in
which they deplored the use of autologous fat injec-
tion in breast augmentation. Their conclusion, which
was merely an opinion of the committee members,
was made without reference to any scientific studies.
Despite this lack of rigorous and objective evalua-
tion, nearly all research and experimental studies
came to a halt.
In the following decades since, many advances in
fat harvesting and lipo-remodeling techniques have
resulted in a renewed interest in utilizing fat for breast
reconstruction and augmentation. The demonstrated
improved viability of grafted fat using strict protocols
such as established by Coleman [5, 6] and the demon-
strated ability to differentiate postsurgical change from
premalignant calcification utilizing the latest standards
in breast imaging [7] have bolstered the argument to
reevaluate this long standing bias. This resurged inter-
est culminated following the latest ASPS/Plastic
Surgery Educational Foundation task force report of
March 2009 in which was stated that
Fat grafting may be considered for breast augmentation
and correction of defectshowever results are dependent
on technique and surgeon expertiseFat grafting to the
breast could potentially interfere with breast cancer
detection; however, no evidence was found that strongly
suggested this
Clearly we are witnessing a new era of objective
and scientific-based approach to fat transfer breast
augmentation and at a time when we have the advantage
of utilizing recent advancements in fat harvesting
techniques and the use of adipose-derived stem cell
therapy. The future truly looks bright for this alternative
approach to standard implant augmentation.
595
596 T.K. Malan

38.2 Operative Technique

38.2.1 Indications

Fat transfer may be considered to be a viable alternative

to implants in the majority of patients seeking
cosmetic breast augmentation. The ideal candidate is
the patient who has developed focal filling defects of
her breast as a result of normal age-related fat atro-
phy, childbearing, breast-feeding, or weight loss. In
these cases, transferred fat acts to merely replace lost
volume. Poor graft survival as a result of hypoxia
caused by tissue tension is for the most part avoided
in these patients with ample empty space. For the
patients seeking to enlarge their breast, certain con-
Fig. 38.1 Breast measurements
siderations should be addressed. A modest increase
of a 12 bra cup size or 220 mL of breast volume
change is a realistic expectation. Fat transfer does not
correct ptosis and is of limited value in tubular defor-
mities without the use of tissue expanders. Fat will
enhance the natural shape of the breast but should not
be used to create the artificial appearance of the
implant that has become so socially accepted and for
some patients a desirable result. A historically sig-
nificant concern had been the availability of ade-
quate fat stores for a graft specimen. This is
becoming less of an issue given the improved viabil-
ity of graft specimen utilizing recent advances in
fat-harvesting technology. Although protocols have
not been widely accepted, it is prudent to con- Fig. 38.2 Preoperative breast marking. Upper of the breast
sider baseline breast mammography, ultrasound, divided into four quadrants and lower into two quadrants.
and magnetic resonance imaging (MRI) evaluation Areas of greatest deficiency noted in green marker. Frequently,
prior to lipo-augmentation. this will be in the upper outer quadrants. The notation above the
left breast is a reminder that 30 mL of extra fat is to be placed in
this smaller breast based on a base width which is 1.5 cm less
than on the right
38.2.2 Preoperative Planning

Patients are provided with preoperative counseling
with an emphasis on ensuring that they understand the
variability of outcomes inherent with fat transfer due to
the ability to harvest adequate volumes of fat, the ulti-
mate fat survival, and the patients own fluctuations of
weight postoperatively. Patients should understand and
agree to the importance of continued annual postoper-
ative breast monitoring with mammography, ultra-
sound, and perhaps MRI. A fair and balanced review
of the advantages and disadvantages of the widely
accepted method of implant augmentation should be
discussed with the patient.
Careful photo documentation and measurements
should be performed. A determination of the degree of
breast ptosis and asymmetry should be ascertained.
The base width measurement of the breast will aid
in determining the degree of asymmetry and assist in
calculating the volume of fat needed to correct asym-
metry. The author has found that as a general rule,
20 mL of fat should be used to correct each 1 cm of
discrepancy between breast base widths (Fig. 38.1).
The preoperative marking of the breast must be indi-
vidualized to the surgeons own style, but dividing the
breasts into multiple quadrants and clearly marking the
38 Breast Augmentation and Reconstruction with Fat Transfer
areas of greatest volume deficit will assist in ensuring
the best aesthetic outcome (Fig. 38.2).
As with any liposuction procedure, fatty deposits that
will be used for harvesting should be well marked and
photo documentation performed. The widely accepted
concept of fat memory should also be considered.
Very commonly patients will have particular fat reserves
that are the first areas in which they gain weight and the
last areas in which they lose weight. These storage cen-
ters can provide a graft specimen that will respond
similarly regardless of its newly transplanted position.
Anesthesia options should be based on the comfort
level of the surgeon and the patients expressed desires.
In my experience, the majority of patients tolerate
adipose harvesting under local tumescent anesthesia
followed by syringe-based fat transfer utilizing tumes-
cent technique with or without a combined breast block
anesthetic technique. One of the major factors deter-
mining the volume of potential graft to be injected is
the free space available in which fat can be placed
without causing tissue tension leading to hypoxia.
Tumescent technique will result in some of this valuable
space being utilized by the anesthetic media. Con-
sideration should be made to tumescence the breast
early in the procedure utilizing the lowest volume of
safe high concentration solution to allow a degree of
absorption while harvesting is undertaken. Other seda-
tion techniques such as general anesthesia or intrave-
nous (I.V.) sedation may also be considered.
38.2.3 Atraumatic Fat Harvesting
and Preparation
Recent advancements in lipo-harvesting techniques
and equipment have provided the surgeon with many
alternatives to the poor graft survival resulting from
longstanding high-pressure standard cannula extrac-
tion techniques. Although considerable controversy
exists over the preferred method, in general, it is widely
believed that to improve graft survival, consideration
should be made to achieving the following:
38.2.3.1 Low-Pressure Technique
of Fat Aspiration
Several studies have demonstrated the adverse effects
on cell viability utilizing high-pressure suction tech-
niques [811]. It is generally accepted that a pressure
of less than 15 in. of mercury (inches Hg) is desirable
597
Fig. 38.3 Reinjection cannula with Leur lock syringe for rein-
jection. Similar lumen sizes prevent clogging and tissue trauma
[12]. In a recent study [13], manometer testing of a
standard lipo-aspiration pump technique resulted in
pressures that exceeded 20 in. Hg. A syringe-based
method utilizing a 60-mL spring or clicker lock
resulted in pressures exceeding 18.5 in. Hg. The meth-
ods described by Coleman of utilizing a 10-mL syringe
with no more than a 2 mL of negative pressure result
in approximately 3 in. Hg of negative pressure.
Clearly the Coleman method appears to be the most
advantageous in regard to minimizing pressure; how-
ever, this method is considered slow and cumbersome
by many surgeons. More recently, manufacturers
have focused on developing equipment to enhance
atraumatic loosening of the fat utilizing ultrasonic,
hydrostatic, and infrasonic forces. The resulting small
particulate fat samples thus require less negative pres-
sure to harvest and significantly decrease the harvest-
ing time. With these devices, pressures of less than
10 in. Hg are sufficient to rapidly extract small par-
ticulate loose fat.
38.2.3.2 Atraumatic and Anaerobic
Fat Handling
The use of specifically designed and well-made har-
vesting cannulas free of internal surface irregularity
and with distal openings that do not exceed the lumen
diameter of the standard Luer lock will help to mini-
mize trauma to harvested tissue and prevent clogging
during reinjection (Fig. 38.3). Historically, it has been
a common practice to centrifuge fat in an effort to
remove excess blood, tumescent solution, and free
oils that could occupy valuable space in the breast and
enhance inflammatory response, which may decrease
598
Fig. 38.4 Microdroplet deposition of fat
graft survival. However, even minimal centrifuging
will lead to torsional damage of the adipocytes [14, 15].
Filtering and washing of the fat-utilizing devices such
as the PureGraft system (Cytori, Inc.) will permit the
removal of unwanted excess contaminates and fluid in
a sterile-closed system thus avoiding the need for
harmful centrifuging.
38.2.4 Transferring Fat
Revascularization is essential in promoting graft reten-
tion. Multiple factors must be considered when deter-
mining the selection of harvesting tools, fat processing
techniques, transfer techniques, and the site of implan-
tation. The overall objective should be the microde-
position of fat into the areas of greatest vascularity.
Appropriate harvesting and preparation should yield
small droplets of fat ready for injection. It is essential
to deposit fat in small individual particles as clumping
will simply result in necrosis (Fig. 38.4). Multilayer
injections utilizing 3-mL syringes and transfer cannu-
las with a single directed small opening assist in con-
trolling the location and volume of fat placed. The
author prefers the use of a curved 2-mm cannula with
a spatulated tip and a single opening directed upward
Fig. 38.5 Curved 2-mm
cannula with a spatulated tip
and a single opening directed
upward
T.K. Malan
(Fig. 38.5). The curved shape and spatulated tip aids in
ensuring the cannula placement in the subdermal and
slightly deeper subcutaneous plane. The cannula is
advanced, and deposition of fat only occurs during with-
drawal. Small syringes help the surgeon to control the
amount of fat deposited as well as the use of a thumb
pump maneuver wherein the surgeon lightly and
intermittently places pressure on the plunger as the
cannula is withdrawn. Although classic fat injection
relies upon intramuscular placement as the preferred
vascular bed, this is largely avoided in fat transfer
breast techniques. Deep muscular injection into the
pectoralis is difficult and results in increased surgical
risks, postoperative pain, and less than ideal distension.
The arborization of vessels near the subdermal layer
helps to ensure adequate blood supply to graft depos-
ited there (Fig. 38.6). In addition, a similar volume of
fat injected superficially will provide greater distention
and filling effect then when placed intramuscularly.
Likewise, much smaller volumes of fat are needed to
create the same filling effect of a large submuscular
implant. Placement of fat in the breast parenchyma
should be avoided. This is not the ideal vascular plane
and may cause unnecessary confusion on breast imag-
ing studies. Cysts and calcifications that may occur
with subcutaneous placement will aid in the radio-
graphic differentiation from premalignant parenchy-
mal disease. Of primary concern is to not overfill the
breast. Classic teaching employed the use of over dis-
tension to compensate for inevitable loss of some
degree of graft due to necrosis. This is not ideal in a
closed space such as the breast. Overfilling results in
clumping of fat, necrosis, and increased tissue pressure
inhibiting venous return. Even a few extra mL of fat
over ideal may result in the death of many times as
much fat. Avoid creating a peau dorange effect.
Avoid continuing to inject while the tissue is under
such high pressure that fat passively extrudes from
incisions.
38 Breast Augmentation and Reconstruction with Fat Transfer 599

Fig. 38.6 Fat injected in the

subdermal and immediate
subcutaneous layers. Prevents
fat drifting after injection,
maximizes volume changes,
and improves blood flow to
graft

38.2.5 Technique (Figs. 38.738.18)

Following marking (Fig. 38.2), the fat is removed from

Fig. 38.7 Body-Jet system with Lipocollector (Eclipse
Medical) being used to harvest fat under low pressure (12 in.
Hg). Smooth, slow, even passes of harvesting cannula with care
taken to not torque the tissue or to rapidly vent cannula causing
splash injury as fat rushes into collector
the donor site with the Body-Jet system with Lipocollector
(Eclipse Medical) to harvest the fat under low pressure
(12 in. Hg). Smooth, slow, even passes of harvesting can-
nula with care taken to not torque the tissue or to rapidly
vent cannula causing splash injury as fat rushes into
collector. The Lipocollector drains excess tumescent
solution utilizing a 300-micron filter leaving minimally
processed fat (Fig. 38.8). The fat is transferred to the
PureGraft (Cytori, Inc.) bag where it is washed,
filtered, and degree of tissue wetness controlled,
thus avoiding harmful centrifuging (Fig. 38.9 38.10).

Fig. 38.8 (a) Lipocollector

drains excess tumescent
solution utilizing a
300-micron filter leaving
minimally processed fat (b)
Minimally processed fat
ready for transfer to
Puregraft (Cytori, Inc.)
600 T.K. Malan

Fig. 38.9 Fat is transferred to the PureGraft (Cytori, Inc.) bag

Fig. 38.8 (continued)
where it is washed, filtered, and degree of tissue wetness con-
trolled, thus avoiding harmful centrifuging

With the PureGraft discard bag, free oil, cellular debris,

blood, and excess fluid are discarded. Filtered and
washed fat is transferred into 3-mL Luer lock
syringes.
Periareolar incisions are made with 16-gauge
needle. A syringe with curved, spatulated, 15 cm,
2 mm, and single superficially directed opening is
placed in the immediate subdermal plane and the fat
injected with 3-mL syringes into the subdermal and
subcutaneous layers. First one side is filled, and then
the other side is filled to match the first side.

Fig. 38.10 PureGraft discard bag. Free oil, cellular debris,

blood, and excess fluid are discarded
38.3 Discussion

Recent studies have recognized the importance of
adipose-derived stem and regenerative cells (ADRCs)
in fat graft survival, repair, and regeneration of dam-
aged tissue, as well as a source for multipotent stem
and mesenchymal stromal cells [16, 17]. Through the
use of paracrine signaling and endogenous growth
factors, ADRCs aid in preventing early graft apopto-
sis, macrophage recruitment, and inflammatory
response. Perhaps most promising is the demonstrated
ability of ADRCs to aid in revascularization of tar-
38 Breast Augmentation and Reconstruction with Fat Transfer 601

Fig. 38.13 Syringe with curved, spatulated, 15 cm, 2 mm, and

single superficially directed opening placed in the immediate
subdermal plane

Fig. 38.11 Filtered and washed fat being transferred into 3-mL
Luer lock syringes

Fig. 38.14 Fat injection into subdermal and subcutaneous

layer

Fig. 38.12 Periareolar incisions made with 16-gauge needle Fig. 38.15 Changes seen following injection
602 T.K. Malan

Fig. 38.16 Fat prepared

for injection into 3-mL
syringes. Recording
of volumes used

patient compliance, and the induced temporary tissue

distention can lead the surgeon to incorrectly over-
fill the breast thus leading to venous stasis and graft
hypoxia.
Autologous fat transfer for breast augmentation
and reconstruction is once again a viable option to
traditional implants and reconstruction. Further stud-
ies and continued advances in techniques and tech-
nology are currently progressing at a rapid pace.
Fig. 38.17 Right breast filled
Perhaps soon this longstanding bias will become but
a historical footnote from which valuable lesson may
be learned regarding decisions based on opinion as
opposed to facts.

References
Fig. 38.18 Both breasts filled
geted tissue. Although widely used in Europe and
Asia, these techniques are in their infancy in the United
States. Our early results have been encouraging and
may well have a significant impact on the recognition
of fat as preferred filler in the near future.
Recently, much attention has been given to the use
of external breast tissue expanders to aid in creating
greater potential space for graft placement. Although
interesting in concept, in our experience these devices
add significant cost to the procedure and have a poor
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tion employing liposuction techniques. Ann Plast Surg
18(4):327329
2. Linder RM (1987) Fat autografting [letter to the editor].
Plast Reconstr Surg 80(4):646
3. Hartrampf CR Jr, Bennett G (1987) Autologus fat from
liposuction for breast augmentation [letter to the editor].
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Plast Reconstr Surg 80(4):646
5. Coleman SR (1995) Long-term survival of fat transplants.
Aesthetic Plast Surg 19(5):421425
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7. Pierrefeu-Lagrange AC, Delay E, Guerin N et al (2006)
Evaluation radiologique des seins reconstruits ayant
beneficies dun lipomodelage. Ann Chir Plast Esthet
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309317
 The Staple-First Technique
for Simultaneous Augmentation 39
Mastopexy for Moderately
to Severely Ptotic Breasts

Ted S. Eisenberg

The Challenge
39.1 Introduction

Even the most experienced surgeon finds simultaneous

augmentation mastopexy surgery to be very challeng-
ing, so much so that some physicians advocate a staged
approach doing the lift first, followed at least several
months later by the breast augmentation. The goal of
augmentation mastopexy in moderately to severely
ptotic breasts [1, 2] is to remove as much lax skin as
possible after placement of the implants without com-
promising the circulation to the skin. The challenge
(Fig. 39.1) comes from knowing how much tissue to
remove in the face of opposing tissue forces or vectors
[3]: The skin is first stretched out by the implants and
then, during the lift, removed and tightened to make
the breasts as firm as possible.
For many years, Eisenberg did a one-stage or simul-
taneous augmentation mastopexy for moderately to
severely ptotic breasts, using the common skin patterns Fig. 39.1 Opposing vectors: Augmentation stretches skin;
[46] that have been developed to accomplish this goal. mastopexy tightens skin
This approach involved having to do multiple trim-
mings of skin on one breast and back to the other to the final shape before making an incision. The outside
achieve maximum tightness and symmetry. of the skin staples is marked, the staples removed, and
In 2003 Eisenberg reversed the approach of draw- then the skin deepithelialized within these marks. This
ing a pattern, deepithelializing skin within the pattern, area to be deepithelialized is much greater than any
and then tailor tacking tissues together [7]. Now the prior pattern.
tailor tack of all the tissues is used first to previsualize This approach eliminates multiple skin trimmings
and simplifies the challenge. It allows the surgeon to
accurately determine the amount of tissue to be
removed regardless of the implant size, degree of pto-
sis, and quality of tissue [8]. It also provides maximum
T.S. Eisenberg
Nazareth Hospital, 2375 Woodward Street, Suite 102,
tightening without compromising circulation to the tis-
Philadelphia, PA, 19115 USA sues and addresses any degree of asymmetry without
e-mail: info@lookingnatural.com relying on any predetermined pattern.

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 605

DOI 10.1007/978-3-642-21837-8_39, Springer-Verlag Berlin Heidelberg 2013
606 T.S. Eisenberg

Fig. 39.2 The preoperative Suprasternal

markings are made in the a Notch
sitting position. Note that
the inframammary markings

Bisecting Line
are made with the arms raised
m
3c
-2
Horizontal cm
Line of Apex 21
of New NAC
2 cm above
Nipple Mark

Inframammary
Crease
(IMC)

Lateral Medial

8cm - 9cm lines

Inframammary Marks with Arms Raised

39.2 Technique partially resemble the inverted-T pattern [9], they are
only guidelines and not an actual pattern.
39.2.1 Preoperative Markings Each breast should be bisected with a line regardless
of the position of the nipple (Fig. 39.2). This line cor-
The patient should be marked while in the standing or relates with the center of the width of each breast. The
sitting position. Although my preoperative markings nipple position is marked (approximately 1921 cm for
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 607

shorter women and 2123 cm for taller women) from

the suprasternal notch to this bisecting line. I cross-
reference the nipple location made on the bisecting line
by placing my finger behind her breast at the inframam-
mary crease (IMC) and projecting an imaginary point
from there to the anterior surface of the breast. I then
pick whichever is the higher point, between the bisect-
ing nipple location and the anterior projected point for
the new nipple position. While nipple location should
be tailored to the individual, a sternal notch-to-nipple
distance of 2123 cm and an inferior limb distance of
57 cm have been considered average or desirable mea-
surements [10].
The apex of the new nipple areolar complex (NAC)
is marked 2 cm above the nipple mark on the bisecting
line. In order to identify this apex mark of the new
NAC position after tailor tacking, a horizontal line is
Fig. 39.3 Breast augmentation is performed with saline
drawn at this time to designate this upper limit of the implants in a subpectoral (dual plane) position
nipple placement. Lines are drawn from the apex of
the new NAC to either side of the existing areola;
these lines should measure approximately 89 cm. The augmentation is always done prior to mastopexy.
These guidelines will eventually represent the vertical The implants are placed in the dual plane (subpec-
distance from the apex of the NAC to the IMC (4 cm torally) through the central area of the IMC line; the
for the NAC and approximately 45 cm from the base incision is approximately 34 cm with saline implants
of the NAC to the IMC). and 56 cm with silicone gel implants. This incision
The best way to mark the medial and lateral edge lim- is closed with 2-0 and 4-0 Vicryl (Fig. 39.3). The skin
its of the (IMC) incision is to have the patient raise her is not closed at this time. I have used a range of saline
arms above her head. Then a mark is made where the implants from 375 to 775 mL, with an average of
breast fold meets the IMC medially and laterally, and a 500 mL, and with the greatest asymmetric disparity in
line is drawn to connect these two marks in the IMC. a patient being 225 mL (left breast 700 mL, right breast
This is the maximum horizontal component of the 475 mL).
inverted T. Eisenberg often shortens the edge limits
approximately 1 cm on each side.
39.4 Mastopexy: Invagination of Tissues
and Stapling
39.3 Intraoperative Preparation
and Augmentation Then, mastopexy begins (Figs. 39.439.6) by placing
three surgical staples (Weck Visistat 35W-Teleflex
The patient is placed in the supine position with arms Medical; Research Triangle Park, NC): one at the
abducted 90 from her sides to create maximum stretch medial and one at the lateral edges of the newly drawn
of the breast skin. I believe it is critical to do this so inframammary line and one at the apex of the new
excessive skin is not resected. Antiembolic lower NAC. I do this instead of drawing the actual inverted-T
extremity sequential compression devices are placed pattern; I then use these three marks as the starting
prior to the patient being anesthetized. Also, 5,000 points of my stapling.
units of subcutaneous heparin are given to minimize The distal point of the medial 89-cm line (drawn
the chance of pulmonary embolism. A Foley catheter to the existing areola) is stapled to the middle of the
and perioperative antibiotics are used, and postopera- newly drawn IMC (MM1) (Figs. 39.7 and 39.8). Then,
tive nausea and vomiting (PONV) [11] precautions are the distal point on the lateral line (Figs. 39.7 and 39.9)
administered. is stapled to the same place (LL1). The redundant
608 T.S. Eisenberg

a b

Fig. 39.4 The apex of the new nipple areola complex (NAC) is stapled first

a b

Fig. 39.5 The medial border of the inframammary crease (IMC) is stapled second

a b

Fig. 39.6 The lateral border of the IMC is stapled third

39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 609

Fig. 39.7 After the distal

Bisecting Line
point of the medial and lateral
areolar line is stapled to the
center of the IMC, first lateral
and then medial invagination
of breast tissues and stapling
commence

Apex
Staple
Lateral Medial

Direction of
invagination
and stapling

L M

Lateral L1 M1 (IMC)
(IMC) Medial
Staple Staple

Middle of the IMC incision

a b

Fig. 39.8 The medial areolar line is stapled to the middle of the IMC

breast tissue is then pulled and invaginated in an inf-
eromedial direction (Fig. 39.10), and stapled from the
lateral IMC staple to the middle of the IMC. This
sequence of stapling allows maximum lateral tighten-
ing and maintains maximum medial breast fullness.
This process is then repeated from the medial staple to
the middle of the IMC (Fig. 39.11). This allows for the
greatest projection of the breast mound.
The same process of invagination and stapling,
whether by fingers or with forceps, is performed from
the apex of the new NAC in an inferior direction to the
middle of the IMC, keeping the nipple buried and out of
harms way (Fig. 39.12). The same sequence is followed
on the opposite breast. Excess tissue (a dog-ear) com-
monly appears at the NAC apex staple. To smooth and
flatten it, the apex staple is pulled in an inferolateral
610 T.S. Eisenberg

Fig. 39.9 The lateral areolar line is stapled to the middle of the
IMC b

b
Fig. 39.11 (a) Medial breast invagination and (b) stapling.
This creates maximal breast projection

direction and stapled. The same apex staple is then

Fig. 39.10 (a) lateral breast invagination and (b) stapling. This
creates medial fullness
pulled in an inferomedial direction and stapled
(Fig. 39.13). This maneuver reduces a bunching of
excess tissue at the apex of the new NAC.
A nipple areola marker (3842 mm), or cookie
cutter, is bathed with methylene blue using a Q-tip
and placed on the breast mound; the 12 oclock posi-
tion of the cookie cutter coincides with the apex staple
(Fig. 39.14). Both breasts and nipple positions are
checked for symmetry.
With a sterile skin marker, all of the staples are
outlined in one continuous line (Fig. 39.15). It is
not necessary to draw a line below the staples at
the IMC, because the IMC line was already drawn
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 611

preoperatively. To assist in reapproximation, guideline 39.5 Deepithelialization

marks are placed medially and laterally at the base
of the NAC (X, X1) and again approximately 4 cm
inferior to the NAC at the juncture of the inverted T
(Y, Y1).
All staples are then removed (Fig. 39.16).
The skin of one breast is infiltrated with a local anes-
thetic containing a vasoconstrictor of 1:400,000 epi-
nephrine. To minimize compromising the circulation
to the nipple, infiltration around the NAC is not done.

a a

b
b

Fig. 39.12 (a) Central breast invagination and (b) stapling. Fig. 39.14 New areola position is marked
from apex to IMC

Fig. 39.13 Apex suture is stapled to manage dog-ear Fig. 39.15 (a, b) The staples are then outlined with a skin marker,
and guideline marks (X, X1, Y, Y1) are made
612 T.S. Eisenberg

Fig. 39.15 (continued)

b

Bisecting Line
Horizontal
Line of Apex
of New NAC

Apex
Staple
Lateral Medial

Cookie Cutter
for New NAC

X X1

Y Y1

Lateral Medial
Staple Staple

Middle of the IMC incision

The existing NAC is minimally stretched to prevent
excessive flattening and then marked with the cookie
cutter. Next, the new NAC is tattooed in the 12, 3,
6, and 9 oclock positions with a 20-gauge needle
and methylene blue. This is done to facilitate proper
orientation of the nipple and reapproximation of the
nipple to its new position.
The cookie cutter mark is now incised with either a
10- or 15-blade scalpel. Next, the skin within the new
staple markings not outside the markings is incised
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 613

with a 10-blade scalpel. Then, deepithelialization is

performed inferiorly to superiorly in a one-piece en
bloc resection with hemostats and a 20-blade scalpel;
of course, care is taken not to deepithelialize the nipple
itself (Fig. 39.17).
For easier closure, the cautery is used to make
a relaxing incision through the dermis to allow mob-
ilization of the NAC and the skin. These relaxing
incision areas are approximately 0.5 cm in from the
medial and lateral limbs and 2 cm below the NAC
(Fig. 39.18).

Fig. 39.16 All staples are removed

Bisecting Line

A
Lateral Medial

G1 G1

D2
D A1

X x1
E G G E1

D1
C B
Y Y1

H F

Fig. 39.17 (a) The shaded

area of the diagram represents C1 B1
the skin to be resected.
(b) The corresponding
pictures show this area of
skin, (c) which has been H1 F1
deepithelialized in one step
(en bloc). Notice the nipple
has been preserved Middle of the IMC incision
614 T.S. Eisenberg

b with 3-0 Vicryl (Ethicon) (AA1). The inferomedial point

(BB1) of the medial limb is sewn with 3-0 Vicryl suture
to the middle of the IMC and reinforced with an adjacent
suture. Next, the inferomedial point of the lateral limb is
sutured in a similar fashion (CC1). The 6 oclock posi-
tion of the NAC is then sutured with 3-0 Vicryl to the
superior medial aspect of both the medial and lateral
limbs as a corner stitch (DD1D2). Then, the medial
and lateral limbs (EE1), which represent the vertical
component from the base of the NAC to the IMC, are
approximated to each other with buried 3-0 Vicryl suture
in an interrupted fashion. This is followed by alternating
closure between the medial segment (FF1) of the IMC,
the quadrants of the NAC (GG1), and the lateral segment
(HH1) of the IMC, also in an interrupted fashion. The
skin is approximated with 5-0 Monocryl (Ethicon) in a
running suture along each segment. Attention is then
turned to the other breast, duplicating the entire technique,
c starting again with the infiltration.
The NACs should be pointing downward app-
roximately 510 because the vertical limb from the
NAC to the IMC will stretch sometimes twice its ini-
tial distance of 45 cm to 810 cm. This causes the NAC
to eventually have the illusion of being raised upward.

39.7 Dressings and Final Result

Fig. 39.17 (continued)
The incisions are dressed with dry sterile Steri-Strips
(1/2 4 in. Suture Strip Plus, Derma Science, Princeton,
NJ) (Fig. 39.19i), Bacitracin-impregnated Adaptic
gauze, and an ABD pad secured loosely with 3-in.
paper tape. Drains were not used for this patient and, in
general, are not recommended. Patients are placed in
their support bras in the recovery room.
Postoperatively, the implants are pressed flat and
high by being in a limited space, flattened by the pec-
toral muscle, and raised by the mastopexy. It takes
approximately 912 months to see the final settled
position of the implant and breast shape, but approxi-
mately 80% of the appearance is apparent at 3 months
(Figs. 39.2039.22).
Fig. 39.18 Relaxing incisions are made through the dermis as
described

39.8 Possible Complications

39.6 Skin Closure (Fig. 39.19)
Special attention is then paid to the sequence of skin clo-
sure, which is performed first in the areas of highest tissue
tension. The 12 oclock position of the NAC is sutured
The downside of the modified inverted-T closure
is that it is not uncommon to have a small area of
dehiscence at the juncture of the inverted T in the
inframammary fold. In my experience, the largest area
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 615

Bisecting Line
Horizontal
Line of Apex
of New NAC
(A-A1)

Lateral Medial

(G-G1) (G-G1)

(D-D1-D2) corner stitch

X X1
(E-E1)

Y Y1

(B-B1)

(C-C1)

(H-H1) (F-F1)

Middle of the IMC incision

Fig. 39.19 (a) In alphabetical order, all corresponding points are
reapproximated from the areas of tightest to loosest closure with
subcutaneous 3-0 Vicryl suture. (b) The 12 oclock position of the
areola suture in the picture correlates to AA1. (c) Inferomedial
skin closure correlates to BB1. (d) Inferolateral skin closure
correlates to CC1. (e) A corner suture reapproximates the
6 oclock position of the NAC to the superomedial/superolateral
skin points, correlating to DD1D2. (f) Medial limb closure
correlates to EE1. (g) Subcutaneous closure with 3-0 Vicryl
suture alternates between the areas designated FF1, GG1, and
HH1. (h) Subcuticular closure with 5-0 Monocryl suture. (i)
Steri-Strip closure
616
b c
d
Fig. 39.19 (continued)
measured approximately 1 cm and spontaneously
healed within a couple of weeks with the use of topi-
cal Silvadene. Eisenberg attributes this complication
to having been more aggressive in the initial surgeries
with the skin resection. By following the inside lines
(of the new marking made around the staples) rather
T.S. Eisenberg
e
than the outside lines, this skin dehiscence may have
been prevented. Placing the arms in abduction may
also help minimize this complication.
Scar hypertrophy is rare, but if it develops, it can be
managed with topical creams, such as Mederma, or
topical compression with gel sheets. Another approach
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 617

h i

Fig. 39.19 (continued)

a b

Fig. 39.20 (a) Preoperative 36-year-old, 5-foot and 5-inch, 145-lb patient. (b) Ten months postoperative following bilateral aug-
mentation/mastopexy with 575-mL (left) and 625-mL (right) saline implants

is an intradermal steroid injection with Kenalog-10,
with or without surgical excision of the scar.
One study suggests that major complications can
occur, such as skin or nipple loss [12]. The most
common complications reported in one series of 186
augmentation mastopexy patients [13] reviewed were
saline implant deflation (5.9%), areola asymmetry
(2.7%), recurrent ptosis (1.92.2%) [14], capsular
contracture (2.2%), and poor scarring (2.2%), and the
overall revision rate over a 42-month follow-up period
was 16.6%. The revision rate for 150 mastopexy-only
patients with a 3-year follow-up was 8.6%. Their con-
clusion is that this procedure is safe and effective.
Eisenberg had no incidences of nipple areolar
malposition because the approach allowed for previ-
sualization, which assists in creating more symmetry.
There was no recurrent ptosis. Some surgeons have
expressed concern that removing only skin for the
mastopexy may not provide enough support to the
lifted breast and may possibly allow for bottoming
out. In fact, it has been suggested that interposition-
ing a dermal graft might minimize or eliminate recur-
rent ptosis [15]. The Eisenberg has not found this
bottoming out to be the case and suggests that per-
haps the current methods and patterns do not permit
for the maximum resection of tissues. Maximum
resection is needed to compensate for the natural
limited stretching of the vertical component (or NAC
to IMC distance), which is the culprit area of recurrent
ptosis or bottoming out.
618 T.S. Eisenberg

a a

b b

c c

Fig. 39.21 (a) Preoperative. (b) Thirteen days postoperative. Fig. 39.22 (a) Preoperative. (b) Three months postoperative.
(c) One month postoperative. Shows an early progression of (c) Nine months postoperative. Shows a later progression of
breast shape that is a reflection of the muscle relaxing and the breast shape
skin stretching
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts
39.9 Discussion
In the staple-first approach, tailor tacking with staples
permits maximum skin tightening and allows for pre-
visualization of symmetry before a one-piece skin
resection. Stapling should precede any committed
excisions of the planned skin designs [16].
Previsualization by stapling gives the surgeon an
extra measure of reassurance and confidence that the
tissues will come together, the vascular supply of the
tissues will not be compromised, and the breasts will
be symmetric. Plus, by eliminating the need for multi-
ple skin trimmings, the procedure is quicker.
The modified inverted-T pattern is preferred to be
used as a guideline for mastopexy deepithelialization;
however, a surgeon can choose whatever pattern he or
she prefers and still utilize the staple-first technique to
get the maximum resection of tissue. A disadvantage of
preoperative skin markings drawn not as a guideline but
as a template for deepithelialization is that these pat-
terns can stretch dramatically when the implants are
placed, thereby rendering the markings obsolete [17].
The staple-first approach is effective for both augmen-
tation mastopexy and straight mastopexy. To determine
which surgery is needed, at the preoperative consultation,
the patients are asked, When you are standing in front of
a mirror with your bra on, are you happy with the size of
your breasts and how you fill out your bra, or do you wish
they were a little bigger? If the response is, I am happy
with how I look in my bra, then Eisenberg recommends
mastopexy only. If the desire is to be bigger, then mas-
topexy with augmentation are combined. On occasion, a
woman wants to be smaller, then mastopexy is discussed
with a small breast reduction.
The implant should always be placed before any tis-
sue is removed for mastopexy [16]. Eisenberg has
found, and it has been reported, that at times after
implantation, there is a false sense of adequate lifting
of the NAC and breast when the patient is supine as
opposed to sitting up. You should proceed with the
preplanned mastopexy and not let this implant place-
ment change your mind. If mastopexy is not performed,
the preoperative ptosis will reappear when sitting [2].
Although implants can be placed in the subglandu-
lar plane, I preferred to place them in the subpectoral
dual-space plane, because it looks more natural when
the pectoralis muscle covers the upper portion of the
619
implant. Also, there is less chance of capsular contraction
and less interference with mammographic evaluation.
Furthermore, subpectoral placement may be preferable
for women with thin or weakened breast tissue. There
is also less chance of infection [18]. The final closure
resembles that of the inverted T, which is preferred
because the horizontal scar in the IMC can be minimal
and the closure allows for adequate vertical raising of
the NAC and horizontal shortening of the lower breast.
One study, with a patient satisfaction rate for the
inverted T of 92%, reported that this technique was
advantageous in getting a better aesthetic result because
it compensated for the excess skin laterally in the infra-
mammary fold and significantly corrected the mam-
mary tissue in both the superior and inferior mammary
poles [2].
This versatile stapling technique allows for the use
of a wide variety of implant sizes. This technique has
also been used for patients who had bilateral mas-
topexy only. It is also useful in correcting asymme-
tries, for example, a unilateral hypomastia and/or a
unilateral ptosis. This previsualization technique might
prove useful in other areas of cosmetic surgery where
bilateral symmetry is the goal, such as a facelift or
brachioplasty.
39.10 Conclusions
The staple-first technique takes the guesswork and
anxiety out of augmentation mastopexy. With the
adage of measure twice, cut once, it is very comforting
to preview the end result before having to cut skin
when performing this complex surgery. This approach
has significantly simplified what was for me a very
challenging operation, allowing me to achieve consis-
tent symmetry regardless of the implant size used or
the amount of skin to be resected.
References
1. Regnault P (1976) Breast ptosis. Definition and treatment.
Clin Plast Surg 3(2):193203
2. Cardenas-Camarena L, Ramirez-Macias R (2006)
Augmentation/mastopexy: how to select and perform the
proper technique. Aesthetic Plast Surg 30(1):2133
620
3. Spear SL, Giese SY (2000) Simultaneous breast augmentation
and mastopexy. Aesthetic Surg 20:155164
4. Wise RJ, Ganon JP, Hill JR (1963) Further experience with
reduction mammoplasty. Plast Reconstr Surg 32:1220
5. Kirwan L (2007) Breast autoaugmentation. Can J Plast Surg
15(2):7376
6. Regnault P (1966) The hypoplastic and ptotic breast: a com-
bined generation with prosthetic augmentation. Plast
Reconstr Surg 37(1):3137
7. Whidden PG (1978) The tailor-tack mastopexy. Plast
Reconstr Surg 62(3):347354
8. Parsa AA, Jackowe DJ (2010) A new algorithm for breast
mastopexy/augmentation. Plast Reconstr Surg 125(2):75e77e
9. Marchac D (1990) Reduction mammoplasty with a short
horizontal scar. In: Goldwyn R (ed) Reduction mamma-
plasty. Little, Brown and Co, Boston, pp 317336
10. De la Torre JI, Vasconez LO (2005) Breast mastopexy.
Available at: http://emedicine.medscape.com/article/1273551-
overview. Accessed 16 Dec 2008
11. Eisenberg TS (2008) Breast augmentation: minimizing post-
operative nausea and vomiting (PONV), maximizing patient
satisfaction. Am J Cosmet Surg 25:264268
T.S. Eisenberg
12. Spear S (2003) Augmentation/mastopexy: surgeon, beware.
Plast Reconstr Surg 112(3):905906
13. Stevens WG, Stokes DA, Freeman ME, Quardt SM, Hirsch
EM, Cohen R (2006) Is one-stage breast augmentation with
mastopexy safe and effective? A review of 186 primary
cases. Aesthet Surg J 26(6):674681
14. Stevens WG, Freeman ME, Stoker EA, Quardt SM, Cohen
R, Hirsch EM (2007) One-stage mastopexy with breast aug-
mentation: a review of 321 patients. Plast Reconstr Surg
120(6):16741679
15. Karacaoglu E (2009) Single stage augmentation mastopexy:
a novel technique using autologous dermal graft. Ann Plast
Surg 63(6):600604
16. Spear SL, Dayan JH, Clemens MW (2009) Augmentation
mastopexy. Clin Plast Surg 36(1):105115
17. Pinsky MA (2005) Radial plication in concentric mastopexy.
Aesthetic Plast Surg 29(5):391399
18. Eisenberg TS (2009) Silicone gel implants are back so
what? Am J Cosmet Surg 26:57
 Circumareolar Nipple-Areola Complex
Mastopexy and Areolar Shifting 40
Robert A. Shumway

40.1 Introduction

Cosmetic breast surgery has become an extremely

important and pervasive global phenomenon. Virtually,
all aesthetic surgeons who practice this amazing sur-
gical art of breast enhancement possess one vitally
important and common goal, i.e., we try to make each
and every pair of human female breasts appear attrac-
tive and symmetrical. Lejour said breast surgery is one
of the most difficult operations in cosmetic surgery
because we should produce a beautiful, symmetrical,
and durable result with minimal scars [1]. Therefore, it
behooves every cosmetic breast surgeon to become an Fig. 40.1 A semicircular or a complete/full circle intradermal
incision is appropriately designed around the NAC and excised
expert in creating aesthetic looking breasts without
in the shape of a crescent or donut
excessive scarring. The circumareolar and periareolar
lifts have been developed and designed to achieve
this rather lofty goal.
Periareolar and circumareolar mastopexy surgeries
are utilized to optimize the position, shape, size, sym-
metry, and location of the nipple-areolar complex
(NAC) on breast mounds. A semicircular or a com-
plete/full circle intradermal incision is appropriately
designed around the NAC and excised in the shape
of a crescent or donut (Fig. 40.1). The resulting
breast skin envelope defect retains the reticular dermis
fully intact for a suitable and strong closure (Fig. 40.2).
The wound is securely closed with several layers of
sutures in a way that will afford a shift in the posi-
tion, shape, or size of the NAC (Fig. 40.3). The result- Fig. 40.2 The resulting breast skin envelope defect retains the
ing translocation of the NAC should produce a more reticular dermis fully intact for a suitable and strong closure

favorable NAC shape and an improvement in the

R.A. Shumway
Surgery, Scripps Memorial Hospital Campus, HM Poole
Building, La Jolla, CA, USA
e-mail: bshumway@live.com, shumwayinst@sbcglobal.net
appearance of the breast (Fig. 40.4).
Furthermore, breast augmentation coupled with
Benelli or crescent mastopexies is also a very compatible

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 621

DOI 10.1007/978-3-642-21837-8_40, Springer-Verlag Berlin Heidelberg 2013
622 R.A. Shumway

a b

Fig. 40.3 (a, b) The wound is securely closed with several layers of sutures in a way that will afford a shift in the position,
shape, or size of the NAC

a b

Fig. 40.4 (a) Preoperative. (b) Postoperative the resulting translocation of the NAC should produce a more favorable NAC shape and
an improvement in the appearance of the breast

procedure. An augmented breast may need NAC
repositioning or shaping because the larger breast will
now exhibit different physical proportions and dimen-
sions. Thus, improved breast appearance and geometry
is an achievable goal of the coupled NAC Shift and
breast augmentation operation (Fig. 40.5) [2].
The Benelli concentric mastopexy is highly useful
because it is surgically reproducible and always repeat-
able [3]. Cosmetic surgeons from all around the world
can master these aesthetic techniques and surgically
repeat this procedure without creating extensive cica-
trix. This type of lift and shift is very effective for
patients who possess pseudoptosis, glandular ptosis, or
Grade I ptosis (Fig. 40.6). Even Grade II ptosis can
be adequately treated with the circumferential NAC
mastopexy matched with a suitable breast implanta-
tion [4]. This combination can create a very satisfac-
tory cosmetic result (Fig. 40.7). In short, the overall
beauty of female breast appearance is greatly improved
by achieving bilateral symmetry with appropriate
NAC size and position on properly sized breast mounds
possessing well-camouflaged scars.
40.2 Technique
Anesthesia for NAC mastopexies is relatively simple.
Monitored conscious sedation anesthesia in a certified
surgical facility coupled with local anesthesia is the
authors choice of anesthesia options because local
injections are painful. To be sure, it is very wise to
minimize or eliminate any patient discomfort from all
cosmetic breast surgery. Local intradermal infiltration
of the previously marked periareolar skin is accom-
plished by using a thin 27-gauge needle and injecting
1% lidocaine with 1:100,000 epinephrine buffered
by a one-tenth volume of 8.4% sodium bicarbonate
solution. After waiting a full 10 min, a sterile breast
procedure, complete with intravenous (IV) access and
perioperative antibiotics, is now initiated.
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting
Depending on circumstances, excision of periareolar
skin can be great or relatively small for circumareolar
mastopexy (Fig. 40.8). Because there is always asym-
metry between breasts, i.e., Breasts are sisters, not
twins (Mangubat AE, American Board of Cosmetic
Surgery Review Course, Dallas, March 4, 2000, personal
Fig. 40.5 Improved breast appearance and geometry is an
achievable goal of the coupled NAC shift and breast augmenta-
tion operation
Fig. 40.6 This type of lift and shift is very effective for patients who possess pseudoptosis, glandular ptosis, or Grade I ptosis.
(a) Preoperative. (b) Postoperative
623
communication), one breast will usually require more
skin excision relative to the contralateral side (Fig. 40.9).
Accordingly, even after appropriate augmentation, the
breasts will still possess some asymmetry. Therefore, the
breast with the most NAC ptosis or asymmetry is always
lifted or shifted first followed by a matching lift to the
other side. As a general rule of thumb, a nipple posi-
tion that is centered on the breast mound and located about
midway between the elbow and the shoulder will usually
provides a nice aesthetic result. Please remember that
after the first breast has been lifted and secured by a
strong suture closure, the opposite NAC is lifted and/or
shifted to match the position and size of its sister.
Circumareolar lifts come in all sizes (Fig. 40.10).
Of course, breasts with a very high degree of ptosis
will require much greater breast skin excision and sub-
sequent lift. However, a standard half-depth crescent
skin incision (semicircular in nature) may be all that is
required to rotate or medialize a moderately asymmet-
rical NAC into a better overall position (Fig. 40.11).
This half-depth skin incision and subsequent upper
624 R.A. Shumway

a b

Fig. 40.7 Circumferential NAC mastopexy matched with a suitable breast implantation can create a very satisfactory cosmetic
result. (a) Preoperative. (b) Postoperative

Fig. 40.8 Depending on circumstances, excision of periareolar Fig. 40.10 Circumareolar lifts come in all sizes
skin can be great or relatively small for circumareolar mastopexy

Fig. 40.9 Because there is always asymmetry between breasts, Fig. 40.11 A standard half-depth crescent skin incision (semi-
one breast will usually require more skin excision relative to the circular in nature) may be all that is required to rotate or medialize
contralateral side a moderately asymmetrical NAC into a better overall position
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting
Fig. 40.12 The strong dermal connection to the superficial tho-
racic fascia (STF), the periareolar wound closure itself is very
supportive which creates the lift without undermining breast skin
Fig. 40.13 The TUBA approach to eliminate dissection through
breast parenchyma
skin removal will leave the reticular dermis in place
as the papillary dermis and epidermis are removed.
The resultant denuded skin defect is a tough reticular
dermis consisting of a strong bed of collagen fibers
that are closely attached to the underlying breast fat.
This remaining deep dermis is tightly bound to the
underlying superficial layer of the anterior superficial
thoracic fascia (STF) while Coopers ligaments link
this fascia through the breast and into the deep layer of
the STF [5]. As a result of this strong dermal connec-
tion to the STF, the periareolar wound closure itself is
very supportive which creates the lift without under-
mining breast skin (Fig. 40.12) [6].
The periareolar mastopexy is often used in con-
junction with breast augmentation. The author often
uses the TUBA approach to eliminate dissection
625
Fig. 40.14 A superior-medial periareolar incision for breast
implantation can be utilized. and the NAC incision is camou-
flaged within a crescent or en bloc lift
Fig. 40.15 After deepithelialization at the papillo-reticular
dermal junction, a white fibrous blanket of reticular dermis is
available for secure closure
through breast parenchyma (Fig. 40.13). However, a
superior-medial periareolar incision for breast implan-
tation can be utilized, and the NAC incision is camou-
flaged within a crescent or en bloc lift (Fig. 40.14).
After deepithelialization at the papillo-reticular
dermal junction, a white fibrous blanket of reticular
dermis is now available for secure closure (Fig. 40.15).
The surgical orientation and closure of the resulting
donut or crescent can now be used to achieve several
desirable results. These advantages may include NAC
reduction, NAC lifting, NAC reshaping, and NAC
shifting in any desirable direction. Additionally, any
combination of the above actions is possible for the
best cosmetic result (Fig. 40.16).
626 R.A. Shumway

Fig. 40.16 NAC reduction, NAC lifting, NAC reshaping, and Fig. 40.18 The author uses the circumareolar and the extended
NAC shifting in any desirable direction in any combination is crescent approach in order to achieve the most favorable results
possible for the best cosmetic result

Fig. 40.17 The diameter and circumference of each NAC must Fig. 40.19 The surgical goal is to create an even closure with-
be carefully measured and evaluated out excessive skin pucker

The diameter and circumference of each NAC must

be carefully measured and evaluated (Fig. 40.17). The
arc length of the crescent, extended crescent, or Benelli
lift will determine the extent of NAC movement and
shape of the closure. The author uses the circumareolar
and the extended crescent approach in order to achieve
the most favorable results (Fig. 40.18). The circumareo-
lar Benelli lift may also require a purse-string suture clo-
sure technique in addition to routine closure techniques.
However, it is important to know that the purse-string
suture closure technique may contribute to unfavorable
NAC deprojection. Regardless of this concern, the surgi-
cal goal is to create an even closure without excessive
skin pucker (Fig. 40.19). Since we are sewing a larger
circle to a smaller circle or a long semicircle to a shorter
Fig. 40.20 Since a larger circle is sewn into a smaller circle or
semicircle, there will always be some minor skin pleat- a long semicircle to a shorter semicircle, there will always be
ing of the tissues (Fig. 40.20). Fortunately, subsequent some minor skin pleating of the tissues
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting 627

a b

Fig. 40.21 Subsequent and progressive healing with a tincture of time will smooth out any minor tissue irregularity

a b

Fig. 40.22 Six- to nine-centimeter lifts are possible with extensive circumareolar lifts used upon larger breasts. (a) Preoperative.
(b) Postoperative

and progressive healing with a tincture of time will
smooth out any minor tissue irregularity (Fig. 40.21).
The shape, position, and extent of the breast skin
closure will determine your initial closure result.
For example, 6- to 9-cm lifts are possible with exten-
sive circumareolar lifts used upon larger breasts
(Fig. 40.22). Interestingly, there are many different
types of closure methods and a plethora of closure
materials, but a first- and second-layer closure of run-
ning and interrupted monofilament sutures seems to
function best. Braided suture, such as Vicryl, is not
used because it may eventually erode through the
skin and later extrude before it fully dissolves. A
combination of interrupted 2-0, 3-0, and 4-0 Monocryl
sutures can be used to first tack the wound together
(Fig. 40.23). It is important to bury the suture knots
with an initial deep dermal bite that becomes vertically
superficial as the stitch moves toward the epidermis
of the NAC (small circle). Next, include a generous
horizontal bite into the larger circles dermis in order
to evenly close the large circle to the small circle as
the closure proceeds to completion (Fig. 40.24). A
permanent running 2-0 or 3-0 subcuticular nylon can
be used in a purse-string fashion for improved clo-
sure and reinforcement. Alternatively, several subcu-
ticular nylon pull through sutures may be used and
later removed after several weeks of wound healing
(Fig. 40.25). Smaller 5-0 or 6-0 running or simple
interrupted nylon sutures may be added superficially
to reinforce and reapproximate the epidermis, as
needed, for perfect closure (Fig. 40.26). Also, during
closure, the bimanual anti-tension pinch maneuver
from your surgical assistant is paramount for obtain-
ing the best closures.
628 R.A. Shumway

Fig. 40.23 A combination of interrupted 2-0, 3-0, and 4-0 Fig. 40.25 Several subcuticular nylon pull through sutures
Monocryl sutures can be used to first tack the wound together may be used and later removed after several weeks of wound
healing

Fig. 40.24 A generous horizontal bite into the larger circles

dermis in order to evenly close the large circle to the small circle
as the closure proceeds to completion

There are several helpful supportive and protective

dressings that will help promote excellent would
healing. After suture closure of the NAC, use several
one-half-inch wide, flesh-colored, sterile, anti-tension
strips on the clean and dry incision. Suitably, cut
Telfa covered by clear Opsite works well to keep the
Fig. 40.26 Smaller 5-0 or 6-0 running or simple interrupted
nylon sutures may be added superficially to reinforce and reap-
proximate the epidermis, as needed, for perfect closure
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting 629

a b

Fig. 40.27 The patient must keep the NAC incisions clean and dry. (a) Preoperative. (b) Postoperative

a b

Fig. 40.28 Occasionally, a mixture of intradermal triamcinalone with one-tenth volume of 5-flourouracil solutions is injected on an
every-other-week basis into persistent hypertrophic scars. (a) Preoperative. (b) Postoperative

wound dry and sterile. Place and secure (using paper
tape) several sterile, soft 4 4 gauzes over each NAC.
Then, use a soft jog bra with gentle compression, as
needed, overnight. Check on the patient with a phone
call the evening of surgery and be sure to evaluate
your patient the next morning. Sterile Opsite and
Steri-strip dressing changes should occur, as needed,
throughout the healing process with appropriate oral
antibiotics. The patient must keep the NAC incisions
clean and dry. In the future, topical scar care with
New Gel or other topical treatments may eventually
become appropriate (Fig. 40.27).
If the periareolar incision heals in a suboptimal
fashion, the hypertrophic scars can always be excised
and re-excised, again and again. However, 36 months
of time may be necessary before revision is advis-
able. The use of monofilament suture material and
excellent postoperative wound care are very impor-
tant concepts to fully consider with any revision
cases. Occasionally, a mixture of intradermal triamci-
nalone with one-tenth volume of 5-flourouracil solu-
tions is injected on an every-other-week basis into
persistent hypertrophic scars (Fig. 40.28). But even
best of all, the periareolar mastopexy may be per-
formed on multiple occasions throughout the life of
the patient by using the techniques described.
40.3 Complications
Complications from circumareolar mastopexy are
generally much less severe than the complications
from traditional Wise pattern or vertical mastopex-
ies. Since there is no breast skin undermining with
630 R.A. Shumway

a b

Fig. 40.29 Periareolar scarring can be significant. (a) Preoperative. (b) Postoperative

a b

Fig. 40.30 Hyperpigmentation or hypopigmentation can be a problem. (a) Preoperative. (b) Postoperative

periareolar mastopexies, there are no failed glandular
flaps, fat necrosis, hematomas, seromas, or nipple
denervation. However, periareolar scarring can be
significant (Fig. 40.29), and hyperpigmentation or
hypopigmentation can be problematic (Fig. 40.30).
Wound infection and dehiscence or even NAC necro-
sis are distinct possibilities, but are rather rare. Breast
and NAC asymmetry may be related to breast volume
or NAC position, shape, and size. Thus, after about
6 months, all under-corrected or asymmetrical lifts
can be safely improved with redo surgery via IV
sedation or with just straight local anesthesia. Any
loss in nipple sensation from a circumareolar mas-
topexy is temporary in nature because the fourth
lateral intercostal cutaneous nerve to the nipple is not
violated. However, an implanted breast can cer-
tainly sustain permanent changes in nipple sensation
because breast augmentation surgery can most cer-
tainly affect the lateral intercostal cutaneous nerves.
Lactation and breast-feeding should not be affected
because glandular disruption does not occur with
NAC lifts.
40.4 Discussion
Now, let us compare the circumareolar mastopexy and
masto-shifting techniques to other mastopexy tech-
niques. The vertical, modified vertical, horizontal and
inverted T mastopexies are all better suited for the
surgical treatment of Renault Grade III ptosis because
they entail extensive and long surgical incisions with
probable undermining of breast tissue when performing
these mastopexies. However, these other mastopexies
are only available at a substantial price: a lot of scarring.
The resulting lollipop and anchor scars may be totally
unacceptable to many patients. Also, full mastopexies
are obviously plagued by much higher rates of wound
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting
dehiscence and postoperative discomfort. Breast aug-
mentation and the traditional mastopexy may well be a
Recipe for Disaster in some circumstances [7, 8].
True, breast reduction can be directly accomplished
with larger incision approaches, but you also must
absorb the risk of flap necrosis. On the other hand, the
extended crescent and Benelli mastopexy can safely be
combined with liposuction reductions of the breast or
with breast implant augmentation cases [4, 9]. Problems
with breast-feeding can occur with traditional mas-
topexy because of glandular incisions or resections that
cause sensitivity changes to the nipple itself [10].
Thankfully, sensitivity changes of the NAC are rarely a
problem with circumareolar mastopexy.
Revision surgery is more difficult with the standard
mastopexy. If surgical revision is required after a wise
pattern mastopexy, there can be extensive reopening of
the existing breast envelope scars and possible skin
pigmentation complications (hypopigmentation or
hyperpigmentation) or even hypertrophic scarring
[11]. Revisions for breast asymmetry can be difficult
to fully achieve using standard mastopexy approaches,
and flattening of the lower breast pole can create shape
deformities. Hematomas, seromas, delayed healing,
increased infection rate, necrosis, scarring, skin puck-
ering, mastitis, breast-feeding difficulties, and loss of
sensation all have to be taken into account again with
all revision procedures [12]. Alternatively, the cir-
cumareolar mastopexy is a repetitive procedure, in
nature, with less downtime or discomfort. Most impor-
tantly, all prospective patients who receive mastopexy
surgery must be warned of every possible complica-
tion [13]. In todays medicolegal environment, to err
on the conservative surgical approach may be the most
prudent. In other words, todays cosmetic surgeon sim-
ply cannot sustain major complications for elective
procedures [14].
40.5 Conclusions
Circumareolar NAC mastopexy and areolar nipple-
shifting procedures are very powerful surgical tools.
Furthermore, these lifts are reproducible by other cos-
metic surgeons throughout the world, and they can be
safely combined as multiple procedure operations
including augmentation mammaplasty or liposuction
reduction of the mammary glands [15]. Periareolar
breast lifts are extremely versatile and can be used to
631
shape, shift, size, position, and elevate the NAC as
needed. This type of surgery has a low complication
rate and provides for the best possible surgical scar.
The entire operation can be repeated as often as
needed and can be effectively taught to all cosmetic
breast surgeons.
If appropriately utilized, the circumareolar mas-
topexy elevates the patient and surgeon onto a new
cosmetic plateau. So, in this fashion, Dr. Benelli [3]
and other prominent cosmetic surgeons [16] have,
indeed, brought us just a little closer to our overall
worldwide goal: Beautiful and symmetrical breasts
without all the scars!
References
1. Lejour M (1999) Vertical mammaplasty: update and appraisal
of late results. Plast Reconstr Surg 104(3):771781
2. Shumway RA (2009) Crescent mastopexy. In: Shiffman MA
(ed) Mastopexy and breast reduction: principles and practice.
Springer, Berlin, pp 5563
3. Benelli L (1990) A new periareolar mammaplasty: the round
block technique. Aesthetic Plast Surg 14(2):93100
4. Elliott LF (2002) Circumareolar mastopexy with augmenta-
tion. Clin Plast Surg 29(3):337347
5. Cooper AP (1840) On the anatomy of the breast. Longman,
Orme, Green, Brown and Longmans, London
6. Lockwood T (1999) Reduction mammaplasty and mastopexy
with superficial fascial system suspension. Plast Reconstr
Surg 103(5):14111420
7. Handel N (2006) Secondary mastopexy in the augmented
patient: a recipe for disaster. Plast Reconstr Surg 118(7 Suppl):
152163
8. Spear SL (2006) Secondary mastopexy in the augmented
patient: a recipe for disaster. Discussion. Plast Reconstr Surg
118(7 Suppl):166167
9. Gruber R, Denkler K, Hvistendahl Y (2006) Extended
crescent mastopexy with augmentation. Aesthetic Plast Surg
30(3):269274
10. Craig RD, Sykes PA (1970) Nipple sensitivity following
reduction mammaplasty. Br J Plast Surg 23(2):165172
11. Cruz-Korchin N, Korchin L (2003) Vertical versus wise
pattern breast reduction: patient satisfaction, revision rates
and complications. Plast Reconstr Surg 112(6):15731578
12. Serafin D (1976) Anatomy of the breast. In: Georgiade NG (ed)
Reconstructive breast surgery. Mosby, St. Louis, pp 1829
13. Gurber RP, Jones HW Jr (1980) The Donut mastopexy:
indications and complications. Plast Reconstr Surg 65(1):
3438
14. Shiffman MA (2009) Medical legal aspects. In: Shiffman
MA (ed) Mastopexy and breast reduction: principles and
practice. Springer, Berlin, pp 681686
15. Lejour M (1994) Vertical mammaplasty and liposuction of
the breast. Plast Reconstr Surg 94(1):100114
16. Renault P (1976) Breast ptosis. Definition and treatment.
Clin Plast Surg 3(2):193203
 Mastopexy/Breast Reduction
with Short Inverted T Scar
Toma T. Mugea
41.1 Introduction
Breast surgery is one of the most difficult fields of aes-
thetic surgery because of the complexity of surgical
procedures and the relative guidelines defining the aes-
thetic perfect breast. Authors [17] present different
dimensions as representative for the aesthetic perfect
breast, which means something ideal, which needs no
further improvement! At the same time, it is impossi-
ble to impose a single standard of breast beauty to
women who are so entirely different from the point of
view of their height, weight, and constitutional type.
The essential goals of breast reduction or mastopexy
are to get a predictable result, to retain nipple sensitiv-
ity and the possibility of lactation, and to obtain an
excellent aesthetic appearance. There are many surgi-
cal procedures for reduction mammaplasty. Each pres-
ents particular advantages in terms of indications,
vascular preservation, technique design, ease of real-
ization, minimum scarring, maintenance of innerva-
tion, long-term results, and so on.
Strombeck [1] set a gold standard with his mam-
maplasty technique in 1960. A few years later, for
small reductions and for mastopexies, Pitanguy [2]
showed how to minimize the submammary scar and
T.T. Mugea, M.D, Ph.D.
Medestet Clinic, Cluj-Napoca, Romania and Professor
of Plastic and Aesthetic Surgery, Department of Plastic
and Aesthetic Surgery, Oradea Medical University,
Oradea, Romania
e-mail: drmugea@medestet.ro
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_41, Springer-Verlag Berlin Heidelberg 2013
41
how to improve the shape of the reduced breast and the
position of the nippleareola complex (NAC). Very
large breasts were better managed by the technique of
McKissock [3], in 1972. This replaced the widely per-
formed Strombeck [1] technique. Soon thereafter, in
1977, an inferior pedicle technique was proposed by
Robbins [4]. This technique became popular, and it is
still used for relieving breast hypertrophy and ptosis.
The author uses Robbins technique, with several tech-
nical variations that eliminate the main drawback of
the original procedure: the long submammary scar.
The modification includes a precise preoperative
breast assessment by a special computer program
based on TTM chart [5], precise planning and marking
prior to surgery, and several combined maneuvers
based on the breast fascial and ligamentous anatomy.
The inverted T method is the most commonly used
technique [14, 68]. It is regarded as predictable and
reliable in outcome, can be used in a complete range of
sizes, and is easy to learn. The short inverted T scar
procedure with inferior pedicle is indicated when the
degree of ptosis increased to grade II or grade III and
mild to moderate macromastia is present.
The skin is reduced and distributed to the required
size and shape in the same time with parenchyma,
which fills this new skin envelope. The horizontal
branch of the inverted T scar is shorter and situated
just above the inframammary fold line, being very well
hidden (Fig. 41.1).
To emphasize the accuracy of computer program
for breast reduction/mastopexy, and the predictable
result using Robbins technique, the full range of breast
dimensions, like in a panel, is presented. All the cases
show also the long-term results.
633
634 T.T. Mugea

a unit. Simple cutaneous flaps without dermoglandular

support are not used. Nipple sensibility, lactation, and
vascularization are preserved by the inferior pedicle,
including nippleareola complex (NAC) neurovascu-
lar pedicle and inferior breast mould.

41.2.3 Disadvantages

1. Good plan for the surgery needed.

2. Exact preoperative measurements must be done and
recorded in a special chart.
b
3. Computer assessment of patient data can take some
time (usually 3 min).
4. Longer learning curve because of preoperative
breast assessment by computer program.
5. Sometimes dog ears can be present at the end of the
horizontal T line (small revision needed).
Although the technique is suitable for the majority
of patients, problems can occur when there is a mild
ptosis and the breast tissue is very firm. The inferior
pedicle is short and does not fold enough behind to
lateral flaps, generating a tension in NAC, with a
droopy appearance when the pillars are sutured.
Fig. 41.1 Short inverted T scar appearance on (a) right and
(b) left breasts
41.2.4 Undesirable Patients

41.2 General Information About 1. Severe weight loss (more than 15 kg)
the Procedure 2. Low collagen quality
3. Smokers, drug abusers
41.2.1 Indications 4. Psychosocial problems
5. Unrealistic expectations
The primary indications of the procedure are:
1. Mammary hyperplasia of moderate to severe degree
2. Ptosis of moderate to severe degree 41.2.5 Operative and Postoperative Times
3. Young patient with good soft tissue elasticity and
tonus Operation time required averages 2 h and 30 min.
Hospital stay is for 24 h.
Drains usually stay in for 12 h.
41.2.2 Advantages Recovery is usually in 7 days.

1. Precise planning of the surgery

2. Predictable results 41.3 Breast Shape and Contour:
3. Patient satisfaction with good aesthetic result visi- Surgical Anatomy
ble next day after the surgery
4. Low incidence of complications Breast shape and contour are influenced by:
This technique provides a stable and long-lasting 1. The volume of breast parenchyma
suspension along an exactly defined line, using the 2. The amount and location of the subcutaneous and
glandular and fascial structures of the breast as one intraparenchymal fat
41 Mastopexy/Breast Reduction with Short Inverted T Scar 635

3. The body contour of the chest wall Subclavius muscle

4. The muscular covering and thickness First rib

5. The tightness and elastic quality of the skin Superficial layer Clavipectoral
The fascial attachments of the breast to the underly- of superficial fascia fascia
Second rib
Deep layer
ing chest wall also influence breast appearance. of superficial fascia
Pectoralis major
muscle
Superficial layer Pectoralis minor
of deep fascia muscle
Retromammary space
with suspensors ligaments Deep layer
41.4 Breast Fascias of deep fascia
Coopers ligaments

The breast develops and is contained within support- Breast mould

ing layers of superficial fascia. The superficial layer of
this superficial fascia is the outer layer covering the
breast parenchyma located near the dermis and is not
always distinct from it. More distinct is the superficial
fascias deep layer on the deep posterior surface of the
breast. A loose areolar area is interposed between the
deep layer of the superficial fascia and the superficial
layer of the deep fascia that covers the outer layer of
musculature chest wall.
The retromammary space will allow the breast tis-
sue to have a natural gliding over the chest. The super-
ficial layer of the deep fascia overlays the outer surface
of the pectoralis major, the upper portion of the rectus
abdominis, the medial serratus anterior, and the exter-
nal oblique muscle in the lower central breast. This
fascia is thinner over the muscular portions of the pec-
toralis major and serratus anterior [9].
The connective tissue that supports structures of the
breast (Coopers ligaments) runs from the deep muscle
fascia, through the breast parenchyma, to the dermis of
the overlying skin (Fig. 41.2). The attachments of
these suspensory ligaments between the deep layer of
the superficial fascia and the deep muscular fascia are
not tight and allow the breast mobility. These attach-
ments can be stretched and attenuated by weight
changes, pregnancy, and aging, which can result in
excess breast mobility over the chest and ptosis. This
is the main problem in performing mastopexy for
women who lose weight more than 20 kg in a short
time. Breast mound is gliding all over the chest, bor-
rowing skin also from the epigastric and hypochon-
drial areas, making the preoperative plan and drawing
more difficult.
At the upper pole of the breast, near the second rib
space, the pectoral fascia tightly connects with the
superficial fascia of the breast, and it is difficult to dis-
sect bluntly [10]. Here is the meeting point of three
fascias, hanging to the clavicle. The superficial layer of
the superficial fascia joins the deep layer of superficial
fascia (including between them the breast mould) and
Sixth and seventh ribs
Rectus abdominis muscle
inframammary crease ligaments
Fig. 41.2 Breast and pectoral fascias (After Nahai [9], modified)
the superficial pectoral fascia. At the upper and middle
pectoral fascia, many thin fibers are found between the
pectoral fascia and the deep layer of the superficial fas-
cia of the breast [11].
41.5 Breast Suspensor Ligaments
Breast suspensor ligaments, described by Wringer
[12], consist of a horizontal septum, which originates
and emerges from the pectoral fascia at the level of the
fourth intercostal space and traverses the entire breast
from medial to lateral, heading toward the nipple. This
is the central neurovascular pedicle of the breast. The
horizontal septum divides the gland into a cranial and
a caudal part, which are delimitated from each other by
loose connective tissue located above the horizontal
septum [13]. At its borders, the septum curves upward
into vertical ligaments, which attach the breast to the
sternum and axilla, guiding vessels and nerves to the
nippleareola complex also.
At the thoracic wall, the medial and lateral ligaments
each have a deep and a superficial origin. This suspen-
sory connective tissue not only connects the mamma to
the thoracic wall but also has superficial insertions into
the skin, both medially, laterally, and caudally. These
superficial ligaments determine the actual border of the
breast. Medially, the superficial ligament is rather weak,
but caudally, it connects with the inframammary crease
636
Fig. 41.3 Ligamentous
suspension of the mammary
gland (After Wringer [12],
modified)
Deep
Medial ligament
a b
Fig. 41.4 The lifting effect of the breast suspensory ligaments tightening during arm elevation
ligament [1416]. Laterally, it fulfills a strong suspen-
sory function by attaching to the axillary fascia along
the midaxillary line (Fig. 41.3).
The shaping effect of this suspensory connective
tissue was able to be demonstrated by increasing the
upward tension on the medial and lateral ligaments,
which resulted in a distinct lifting and shaping of the
entire breast (Fig. 41.4). The medial and lateral liga-
ments merge into the superficial mammary fascia from
an anterior direction. Thus, the ligamentous suspen-
T.T. Mugea
Deep
Cranial ligament
Deep
Lateral ligament
Superficial
Lateral ligament
Fibrous septum
c
sion also connects with Coopers ligamenta suspenso-
ria, which extended from the mammary fascia and
insert into the skin. So, even platysma contraction can
produce a mild lifting effect on the breast mould
through the breast suspensory ligament connections
(Fig. 41.5). Wringer [12] demonstrates that the breast
is a well-structured organ, and the courses of its main
vessels and nerves as well as its ligamentous suspen-
sion are predictable, and could be of value and rele-
vance in clinical application [14].
41 Mastopexy/Breast Reduction with Short Inverted T Scar 637

a b

Fig. 41.5 (a) No contraction of platysma. (b) Breast skin vertical gliding centimeters just during platysma (SMAS) contraction

41.6 Breast Development and Ptosis In the glandular ptosis, the breast and inframam-
mary fold glide over the chest.
In the normal growing phase, the breast can be consid- In the true breast ptosis, the breast and nipple glide
ered to have a hemispheric shape, with the nipple in over the chest, but the inframammary fold is at the
the middle, in the most prominent point (Fig. 41.6). same level [1517].
As the breast will gain weight, because of the gravity Botti [18] proposes a new classification scale of
and ligament tightening, the breast mould will trans- breast tissue and nippleareola complex ptosis,
late in the lower two-thirds of the breast vertical according to the distance between these and the infra-
meridian, together with the nippleareola complex mammary fold level. The breast ptosis degree is
(Fig. 41.7). assessed by the distance between the lower pole of
Age, gravity, breast volume, and decreased elasticity the breast and the inframammary fold level
contribute to a gradual lowering of the breast landmarks (Fig. 41.9).
over time as a woman gets older and experiences normal Nippleareola complex 1st degree = 01 cm
physiologic changes. The extent of this descent depends (NAC) 2nd degree = 12 cm
primarily on the volume of the breast and the elasticity of 3rd degree = 24 cm
the tissues. The breast mould and central pedicle will 4th degree > 4 cm
change the position, according to the gravity (Fig. 41.8). Breast tissue 1st degree = 01 cm
In breast pseudoptosis, only the breast mould is 2nd degree = 12 cm
hanging. The nipple and the inframammary fold are at 3rd degree = 24 cm
the same level like in the normal situation (Fig. 41.8). 4th degree > 4 cm
638
Fig. 41.6 Breast mould development and natural gliding on the
chest wall. (Left) Teenager. (Middle) Young female. (Right)
Adult female. The blue lines represent the breast mould limits,
Fig. 41.7 Breast hypertrophy
followed by breast ptosis as
the breast volume decreases.
(Left) Breast hypertrophy.
(Right) True breast ptosis
According to Botti, the NAC/breast ptosis degree
code could have different kinds of combinations
between 1/1 and 4/4.
To better define the position of the nippleareola
complex on the chest wall, we use two inverted trian-
gles, which are specific for the trunk as landmarks:
the Acromion Pubic Triangle (AcAcPb), defined by the
T.T. Mugea
and the red one the initial nipple level. Breast central and infe-
rior pedicles follow the breast mould in its descending
movement
lines between the acromion apophysis of scapula bone
and the superior edge of the pubic bone, and the Spino
Manubrial Triangle (SpSpMn), defined by the lines
between the manubrium (sternal notch) and the antero-
superior iliac spine points (Fig. 41.10).
Considering the natural evolution with aging,
normal nipple position is downward gliding, on the
41 Mastopexy/Breast Reduction with Short Inverted T Scar 639

Fig. 41.8 The three types of breast ptosis, according to the ptosis. The dotted line shows the breast upper pole level
nipple position and inframammary fold level [17]. (Left) (anatomical landmark); the continuous line shows the sixth rib
Pseudoptosis. (Middle) True breast ptosis. (Right) Glandular level, where normally is the inframammary fold level

a b

Fig. 41.9 Patient with right breast ptosis NAC 3/Breast 4 (Botti classification)
640
a b
Fig. 41.10 Normal nipple position related to the inverted triangles in (a) young female. (b) Mature female with breast ptosis
external margins of the inverted triangles, corre-
sponding to a high position in young teenagers and to
a low position in elder female patients. The aesthetic
perfect position is in the upper part of the triangles,
close to the junction point of the external margins
(Fig. 41.11).
The author noticed the difficulty in defining in a
unique way the breast volume, position, and propor-
tion related to the patient. Also, there are different
ways of defining breast hypertrophy as small, moder-
ate, or severe type, depending on the extra weight
added. The combination between glandular and fatty
tissue, for a defined volume, gives the breast weight,
which is difficult to be assessed before the operation.
Three-dimensional imaging of the breast including
mammography, biostereometric measurements, and
magnetic resonance imaging (MRI) have been reported
as accurate measurements of breast volume [19], but
require special equipments not always available to the
surgeon. The highest precision in volume calculation has
been showed by MRI [20, 21]. Recently, Descamps [22]
described preoperative anthropomorphic measurements
T.T. Mugea
and a simplified formula for determining the breast
weight: breast weight = (35 sternal notch to nipple dis-
tance + 60 nipple to inframammary crease distance)
1,240, and this can easily be calculated at the bedside.
The chart and computer program are able to pro-
vide the ideal aesthetic dimensions of that breast and
as Breast Golden Number [23]. In order to have a
basis for this new classification, we accept ten rules as
following:
1. All aesthetic breasts fit the Breast Golden Number.
2. Aesthetic breast volume (ABV) depends on BGN.
3. If the volume decrease = simply ptosis.
4. If the volume increase = breast hypertrophy and
ptosis.
5. All hypertrophic breasts are ptotic.
6. Breast hypotrophy = below aesthetic breast volume.
7. Small hypertrophy = ABV + 50% extra volume.
8. Moderate hypertrophy = ABV + 100% extra volume.
9. Severe hypertrophy = ABV + 150% extra volume.
10. Gigantomastia = ABV + over 200% extra volume.
In the breast hypertrophy diagram (Fig. 41.12), we
take as example an aesthetic breast with 350 cc, and
41 Mastopexy/Breast Reduction with Short Inverted T Scar
a b
Ac Mn Ac
Sp Sp
Pb
Fig. 41.11 (a) Nippleareola complex natural gliding process. (b) Aesthetic perfect position related to the inverted triangles
increase the volume with 50% for each type of hyper-
trophy up to gigantomastia. The final shape of the
breast depends on its weight over skin and suspensor
fibro-fascial element quality (Fig. 41.13).
Apart from the aesthetic breast, in strong connec-
tion with applied surgical procedure, we found six
types of breasts according to glandular volume and
ptosis (Fig. 41.14 and Table 41.1):
1. Type 0 small volume and skin excess (empty
breast)
2. Type I small hypertrophy
3. Type II moderate hypertrophy
4. Type III severe hypertrophy and tight soft tissue
5. Type IV severe hypertrophy and loose soft tissue
6. Type V gigantomastia
In type 0 ptotic breast, all ptotic breasts without sig-
nificant glandular volume, like empty breast founded
after severe weight loss or aging, are included. All the
following types of breasts (from type I to type V) can
be converted in one certain situation to this type 0, los-
ing volume by glandular hypotrophy. Mastopexy asso-
641
Ac Mn Ac
Sp Sp
Pb
ciated with autoimplant or breast implant is the
indication.
Because of skin and soft tissue quality, the aesthetic
outcome of the surgery is sometimes less predictable.
If there is no skin excess and only empty breast, breast
augmentation with implant is the choice, and this case
does not belong to this type of ptosis.
In type I ptotic breast, small hypertrophy is natu-
rally accompanied by ptosis, and usually these ladies
wear a B- or C-cup bra size. Mastopexy without glan-
dular excision is the solution. Short inverted T scar
or vertical scar technique will ensure a good and stable
aesthetic result.
In type II ptotic breast, moderate hypertrophy is
obvious accompanied by visible ptosis, and these
ladies wear a C-cup bra size. Mastopexy with small
glandular resection is necessary and allows good and
predictable results.
In type III ptotic breast, there is a severe hypertrophy
with tight soft tissue, indicating a heavy breast with the
elastic properties preserved. Usually, these ladies wear
642 T.T. Mugea

Breast Hypertrophy Diagram

100% = 350cc
example 50% 100% 150%

200%

350 525 700 875 1050

Gg CC Volume
Ae Sm Md SV

Ae - Aesthetic Breast Volume

Gg - Gigantomastia
Sm - Small Hypertrophy

Md - Moderate Hypertrophy

Sv - Severe Hypertrophy

Fig. 41.12 Breast hypertrophy diagram

a Breast Volume & Projection b Breast Volume & Projection

Gg
No Gravity ! + Gravity ! Ae - Aesthetic Breast Volume
Gg Ae - Aesthetic Breast Volume Sv Sm - Small Hypertrophy
Sm - Small Hypertrophy
Md - Moderate Hypertrophy
Md - Moderate Hypertrophy Md Sv - Severe Hypertrophy
Sv - Severe Hypertrophy
Sm Gg - Gigantomastia
Gg - Gigantomastia IMF - Inframammary Fold Level
Ae
Sm IMF - Inframammary Fold Level
Md Ae
SV IMF
IMF 200% Same Inframammary Fold Level
150%
100%
50%

Fig. 41.13 Breast volume and projection diagram according to gravity and suspensor fibro-fascial element quality. Inframammary
fold level glides downward up to the stretched limits
41 Mastopexy/Breast Reduction with Short Inverted T Scar 643

Glandular Volume & Ptosis

Classification

0 I II III IV
V
Type 0 - Small Volume & Skin Excess (Empty Breast)
Type I - Small Hypertrophy
Type II - Moderate Hypertrophy
Type III - Severe Hypertrohy & Tight Soft Tissue
Type IV - Severe Hypertrophy & Loose Soft Tissue
Type V - Gigantomastia

Fig. 41.14 Glandular volume and ptosis classification

Table 41.1 Glandular volume & ptosis classification in 10
words
All aesthetic breasts fit the breast golden number
Aesthetic breast volume (ABV) depend on BGN
If the volume decrease = simply ptosis
If the volume increase = breast hypertrophy & ptosis
All hypertrophic breast are ptotic
Breast hypotrophy = below ABV
Small hypertrophy = ABV + 50% extra volume
Moderate hypertrophy = ABV + 100% extra volume
Severe hypertrophy = ABV + 150% extra volume
Gigantomastia = ABV + over 200% extra volume
a D-cup bra size and have marks over the shoulders
accompanied by neck and back pain. The social life is
severely affected. This type of breast is a good indica-
tion for breast reduction with short inverted T scar.
In type IV ptotic breast, there is a severe hypertro-
phy with loose soft tissue. These cases derived from
type III when they lose weight. The skin and soft tissue
have no elasticity and do not retract after the breast
excision. The gland is hanging over the chest and can
be mobilized around its base. The upper pole of the
breast is empty, and the inframammary fold is longer,
as it used to be when the breast was full, and lower situ-
ated on the chest. Breast reduction with full horizontal
inverted T scar is usually necessary to drape the
breast mould and to avoid the dog ears of the scar.
In type V ptotic breast, we include gigantomastia, a
rare condition characterized by excessive breast growth
and can be physically and psychosocially disabling for
the patient. Symptoms include mastalgia, infection,
postural problems, back pain, and chronic traction
injury to 4th/5th/6th intercostal nerves with resultant
loss of nipple sensation. It is also associated with
decreased fetal growth during pregnancy [24]. Being
over D cup, bra wearing is usefuless.
Gigantomastia etiology can be idiopathic, obesity-
associated, juvenile, pregnancy-induced, or drug-
induced [24]. Unfortunately, this classification has no
direct impact on the surgical strategy adopted by the
plastic surgeon toward the correction of ptosis, the
644
amount of breast to be removed, and the technique to
be used [25]. It is commonly taught that an inferior
pedicle technique is only appropriate if the distance
from the nipple to inframammary fold is less than
15 cm (on the basis of a 2:1 ratio).
In reality, provided the pedicle is not completely
removed from the chest wall, there will be numerous
perforators entering into the pedicle along its length. In
addition, it does not necessarily follow that ptosis will
increase the nipple to inframammary fold distance
[12]. The author performed inferior pedicle reductions,
Robbins technique, on several gigantomastia patients
with good effect. There have been numerous reports
in the literature using inferior pedicle techniques and
showing no increase in complication rate with resection
weights of over 1,000 g [21, 26].
41.7 Consultation: Step by Step
41.7.1 Appointment
Usually, the patient will contact the clinic by phone or
e-mail and will receive an appointment in one day at
one specific hour.
At the moment, according to the National Medical
College and National Committee for Medical Clinic
Accreditation, the following points are defined:
1. No advertisement will be tolerated, except for per-
sonal information (to give the possibility for a sur-
geon to get known and to give some information on
his activities).
2. Advertisement should be objective and pertinent.
3. Any advertisement using a before/after argument
will be banned as well as those using a financial
argument (the ones promising a second intervention
free of costs, awards consisting in aesthetic surgery
devices or procedures).
4. Every advertisement should include a paragraph
explaining the risks, unwanted effects, and post-
treatment.
41.7.2 Waiting
Even if the patient came in time, he/she must spend
around 15 min in the waiting room, to relax, breeze,
accommodate with the place, watch and read the
exposed brochures according to the problem she came
T.T. Mugea
for, or to see what other procedures are offered.
Meantime, they can have a cup of tea, coffee, or water.
Also, they will be watched by the staff, and nervous,
easily irritable, demanding, or strange patients can be
noticed to the surgeon, to be more delicate and alert
about possible problem case.
41.7.3 Consultation
The secretary or the assistant will introduce the patient
in our office in a very polite and respectful way, and
standing up we present ourselves and shake hands with
the patient, inviting him/her to have a sit, in front of us,
but not too close.
The office is large enough (at least 25 m2), friendly,
well exposed to the light, decorated with artistic feel-
ing, including paintings, plants, some antiques (horo-
loge, etc.), and some of representative diplomas or
awards the author received. On the desk, some fresh
flowers with nice colors will give a piece of nature
inside, relaxing the atmosphere.
After usual ID medical records, the author starts
talking about the specific patient problem, encourag-
ing him/her to explain, in his/her own terms, com-
plaints and desires. If the patient is alone, especially
without relatives, it is better to try to understand the
real motivation for the surgery, the psychical status of
the patient, and how realistic are the complaints and
also the demands for the surgery. It is always better to
have an assistant (secretary, nurse, or doctor) during
the consultation and especially when the patient is
examined. This will take place in another room, close
and connected with the office, where the patient will
be invited to go and prepare (undressed) for the exam-
ination and let us know when he/she is ready by
knocking on the door. If the companion wants to
assist, he/she can do it but only with the patients
consent.
41.8 Patient Examination and Breast
Measurements
In order to achieve the best aesthetic results in breast
augmentation, using a simple kit (Fig. 41.15) the sur-
geon must evaluate each breast before the surgery, in
terms of position, proportion, symmetry, volume, soft
tissue elasticity, skin excess, and ptosis degree. Any
41 Mastopexy/Breast Reduction with Short Inverted T Scar
Fig. 41.15 During patient examination and measurements, a
simple set of instruments are used (ruler, caliper, marking pen,
pencil)
chest and breast scars or stretch marks will be recorded.
The areola diameter (vertical and horizontal) will be
also measured.
During patient examination, the surgeon and his
assistant will fill in the TTM chart, which includes
the breast and body parameters needed for an objec-
tive aesthetic evaluation of the breast (Table 41.2 and
Fig. 41.16, Fig. 41.17). The patient will be asked
about breast-feeding: how long it was, how easy (did
they use to milk by pump or manually), did they have
any inflammatory events, and since when did they
stop breast-feeding.
Special attention will be given for nippleareola
complex, in terms of pigmentation, widening, scars,
crusts, and discharges from the nipple. Breast mound
and axilla will be focused on clinical examination, to
detect any eventual lumps or nodules.
Standard breast photos are taken after examination,
and loaded in the patient electronic file version. These
include standing front, profile and oblique exposition,
645
with arms relaxed and lifted. In order to demonstrate the
inframammary fold level, useful also in tubular breasts
examination, special pictures are taken with breast sus-
tained and gently pulled by the assistant. For ptotic breasts,
we take also pictures with the body bended at 45, front
and lateral view, to demonstrate the gravitational effect on
the breast mould and the neck of the breast (the attach-
ment base to the trunk). After severe weight loss, breast
mould may look like rocks in socks (Fig. 41.17).
According to the TTM chart, the surgeon can docu-
ment and show to the patient breast problems, even
small asymmetries. Body height, weight, pregnancies,
weight loss, and pinch test are very important elements
in defining body mass index (BMI), skin, and soft
tissue quality.
After collecting the data in the chart, we fill the boxes
nominated in the TTM Computer Program for breast
reduction (Fig. 41.18), organized in similar sections
to the chart. The surgeon has to select the calculate
icon situated in the right upper corner of the table, and
automatically the computer will list, in red color, what
are the ideal breast dimensions for the patient. If the
patient is overweight (supraponderal), the computer
will list also the ideal dimensions for each parameter,
allowing the user to see and compare these at once.
Using this program, the surgeon can show to the
patient the connections between body height and
weight, trunk dimensions, and corresponding breast
dimension, simulating different cases. They will under-
stand that there are no standards in aesthetic surgery,
only proportions. Each case will have its own aesthetic
breast dimension, according to the body. This is the
Breast Golden Number (BGN).
The connections between BGN and other distances
found in aesthetic breasts are as follows:
BGN = ideal aesthetic triangle (between manubrium
and nipples)
BGN = inframammary fold length
BGN = breast horizontal meridian
BGN = breast circumference in the aesthetic
breast
BGN = breast vertical meridian
BGN: 2 = breast medial meridian
BGN: 2 = breast lateral meridian
BGN: 3 = breast inferior meridian
Until now, this is the only program available for
breast assessment, allowing precise preoperative plan-
ning for breast reduction or mastopexy in order to
achieve aesthetic results. This is used for every case,
646 T.T. Mugea

Table 41.2 Chart for Patient Name: Code: Date:

computer program

Hegiht (cm): Weight (Kg): Pregnancies: Weight Loss:

Pinch Test (cm): P= R= Tight: Normal: Loose:

Chest problems:

Ac Mn Ac Mn
Ax St Ax

Ni Ni
Ni Ni
Aesthetic Triangle Breast Horizontal Meridian
Sp Sp
Pp

Nipple Position

Breast Circumference Breast Diameters

Trunk measurements
Breast Verticall Meridian
Mn - Pb =
Ac - Ac =
Sp - Sp =
Ni
Chest Circumference
Inframammary Fold Length
Mx Ch =
Ni Ch =
Breast Inferior Meridian
Infra Ch =
Relaxed / Stretched
Notes:

demonstrating its accuracy in the last 10 years. At the
follow-up, the author can also demonstrate the present
situation of the breast and how it has evolved over time.
After the first consultation and examination, accord-
ing to the patient desires, based on photos and com-
puter program, and sometimes using free drawing on
the consultation file, the surgeon will explain in detail
what the problems are and what can be done to solve
them. If the patient understands the procedure, includ-
ing the risks of incidents and accidents and complica-
tions related to the anesthesia also, she will receive a
printed document containing these things and the lab
tests and other medical examination that will be neces-
sary. This will be done by accredited laboratories and
clinics, recommended by the surgeon or patients
general practitioner.
41.9 Examination and Investigations
Usually, before the surgery, there is a set of examination
and investigations that should be done (Table 41.3).
Full blood count (FBC): This will demonstrate ane-
mia. This increases the risk of intraoperative hypoxia
41 Mastopexy/Breast Reduction with Short Inverted T Scar 647

Fig. 41.16 Breast and trunk

measurements, during
a
examination

Mn - Pb:

distance between
Mn (Manubrium Notch) &
Pb (Pubis Superior Edge)

Ac - Ac:

distance between
Lateral Edges of the
Acromion Bones
648 T.T. Mugea

Fig. 41.16 (continued)

c

Sp - Sp

distance brtween the

Antero Superior Spina
of lliac Bone

Mn - Ni Triangle
41 Mastopexy/Breast Reduction with Short Inverted T Scar 649

Fig. 41.16 (continued)

e
Inverted Triangles

Nipple Areola Complex

Position

f
Soft Tissue Elasticity

Pinched (P) Relaxed (R)

P R
650 T.T. Mugea

Fig. 41.16 (continued)

g Breast Vertical Diameter
(BVD)

the distance between

Breast Upper Pole &

Inframammary Fold Level

h
Breast Horizonal Diameter
(BVD)

the distance between

Sternal and Axilar Edges

of the Infarmammary Fold

(measured wirh a caliper).

41 Mastopexy/Breast Reduction with Short Inverted T Scar 651

Fig. 41.16 (continued)

i
Axillary Chest Circumference
(Ax-Ch)

Chest Circumference

measured at

the Axilla Level

j Areola Diameters

Areola Vertical Diameter

Areola Horizontal Diameter

652 T.T. Mugea

Fig. 41.16 (continued)

k
Nipple Chest Circumference
(Ni - Ch)

Chest Circumference

measured over

the most projected points

of the breasts

l
Infra Chest Circumference
(Infra - Ch)

Chest Circumference

measured at

the Inframammary Fold Level

41 Mastopexy/Breast Reduction with Short Inverted T Scar 653

Fig. 41.16 (continued)

m
Breast Medial Meridian

St-Ni:

distance between

Sternal Inframammary Fold End

& Nipple

n
Breast Lateral Meridian

Ax-Ni:

distance between

Axillary Inframammary Fold End

& Nipple
654 T.T. Mugea

Fig. 41.16 (continued)

o Breast Horizontal Meridian

BHM

distance between

Sternal & Axillary End of the

Inframammary Fold,

over the Nipple

p Breast Circumferencre

BC

the Longer Distance between

Sternal & Axillary End

of the Inframammary Fold,

following the shape

of the breast
41 Mastopexy/Breast Reduction with Short Inverted T Scar 655

q
Inframammary Fold Length (Infra Length)

the distance between the Sternal and Axillary End

of the Inframammary Fold.

r
Breast Superior Meridian

BUP - Ni distance

Breast Upper Pole (BUP) at

the Horizontal Line of the

Axillary Chest Circumference

Fig. 41.16 (continued)

656 T.T. Mugea

Fig. 41.16 (continued)

s
Breast Inferior Meridian

Ni - IMF distance

Nipple to

Inframammary Fold

t
Breast Vertical Meridian

BVM

BUP to Inframmamary Fold

distance over the Nipple

41 Mastopexy/Breast Reduction with Short Inverted T Scar 657

Fig. 41.16 (continued)

u
Glandular Ptosis Score
(G.Botti)

Lower Pole of the Breast to

Inframammary Fold distance

v
Nipple Areola Complex
Ptosis Score (G.Botti)

Nipple to

Inframammary fold distance

658 T.T. Mugea

Fig. 41.17 Standard

preoperative photos for breast a b
surgery

c d
41 Mastopexy/Breast Reduction with Short Inverted T Scar 659

e f g

h i j

k l m

Fig. 41.17 (continiued)

660 T.T. Mugea

TTM program for Breast Reduction/Mastopexy

Fig. 41.18 TTM program for breast reduction/mastopexy, with actual and ideal dimensions and surgical plan

Table 41.3 Examination and investigations Liver function tests (LFT): Does the patient have any
Full blood count (FBC) Glycemia underlying malnutrition? This may affect the patients
Blood platelet count Transaminase ability to heal.
Group Protein electrophoresis Blood type: Anticipating that there may be a
Goagulation test Urea and electrolytes requirement for blood, but not routinely for this proce-
PCV Urinalysis dure, the patients blood type is identified and held,
Hemoglobin HIV, HbSAg, HCV pending a possible (later) request for units of blood or
ECG blood products.
Chest X-ray Clotting: Clotting and platelet function is relevant
Mamography for the many patients who take aspirin or warfarin and
Breast ultrasound also for patients with known clotting disorders. Some
patients used to take vitamins, supplements, and garlic
or increased cardiac workload. It is also useful as a which can induce coagulation problems. Also, dur-
baseline measure of hemoglobin if the proposed opera- ing full moon faze, amazingly, we noticed a higher
tion is expected to cause substantial blood loss. incidence of bleeding.
Urea and electrolytes (U&E): These detect underly- Urinalysis: Urine dipstick or analysis is useful to
ing renal deficiency and possibility of developing acute detect undiagnosed diabetes or urinary tract infection.
renal failure (ARF) after major surgery. They may also ECG, chest X-ray, mammography, and breast ultra-
influence the choice of drugs given within the anesthetic. sound: These are necessary.
41 Mastopexy/Breast Reduction with Short Inverted T Scar
Every breast must have in the files, before surgery,
sonologic examination including the mammography
and echography. Sometimes, an MRI (magnetic reso-
nance imaging) can be necessary, if the sonologist con-
siders. This can detect glandular problems, and the
surgery will be performed, according to the protocol,
by a team including the oncologic surgeon.
For patient safety, every segment of tissue excised
from the breast will be sent to the histopathology in
separate containers. Also, any fluid from a cyst eventu-
ally opened will be swabbed and sent to the bacteriol-
ogy for culture and antibiogram.
41.10 Airway Assessment (Done
by Anesthesiologist)
How easy or difficult it will be to intubate a patient
depends on the following points:
1. Are they obese?
2. Do they have a short neck and small mouth?
3. To what extent can they open their mouth?
4. Is there any soft tissue swelling at the back of
the mouth or any limitations in neck flexion or
extension?
41.11 Patient Information Sheet
The patient is given an information sheet in detail to
read at home. She can make notes about questions and
problems to discuss at the next consultation, before the
surgery (Table 41.4).
41.12 Final Preoperative Consultation
After the first consultation, the patient goes home and
digests the information and experience acquired dur-
ing the first visit to the surgeon. If she makes the deci-
sion to have the surgery and will do the medical
investigations recommended, she is scheduled for a
second appointment.
At the second consultation, the surgeon will check
the results from the recommended investigation and
will discuss in more detail the procedure, including
risks and unfavorable possible events. Special atten-
tion will be paid for scars and wound healing. In
front of the assistant, the patient will read and sign the
661
consent for the surgery and anesthetic procedure
(Table 41.5).
According to the clinic policy, the patient has to
pay the full price of the procedure at least 2 weeks
before admission. No discount, partial payment, or
bank guaranty will be admitted. For all the services
paid, the patient will receive a receipt. Patient bag-
ging for financial favors, promising that they will be
advertising our clinic and bring new patients among
their friends, will be erased from the list. Accepting
patients with this kind of behavior in private practice
is equivalent to an opened gate for problems after
the surgery. They will become demanding, unhappy
with the results, whatever will be, and will turn out
into an enemy and bad advertising person. According
to the patients desire, and waiting list, the surgeon will
schedule the date of the operation.
41.13 Patient Preparation
for the Operation
In the surgery day, the patient should come at least 6 h
before the procedure, with necessary personal things
for self hygiene and cosmetic makeup. After admis-
sion, the patient will have a shower, to clean the skin
and remove all ointments and change into the hospital
dressing. All the jewelries and values will be returned
to the relative or stored in a special safe compartment.
Nails will be cleaned and prepared for pulse oximeter
measurements. The nurse in charge will check the
blood pressure, heart rate, and temperature and will
have a talk with the patient, explaining how the things
will go before and after the surgery.
The surgeon will ask the patient to come in the
examination room, and the drawing will be done accord-
ing to the previous measurements, which will be
checked again, in front of the assistant. This will repre-
sent the surgical plan. Some experienced surgeons used
to do this on the operation table, with the patient sitting
in front of them, quickly, like a free hand work. The
author does not like this, because we must be concen-
trated on the plan, using a ruler and calipers, in an accu-
rate manner. This operation should be the most important
procedure for that operating day, and the team prepared
for this. Before the operation, the surgeon should have
1015 min to relax and clean the mind from all prob-
lems especially bad things. The surgical plan is always
done by the surgeon and not by his assistant.
662 T.T. Mugea

Table 41.4 Reduction mammaplasty Patient information sheet

Reduction mammaplasty is a surgical intervention meant to solve issues related to excessively big and/or drooping (sagging)
breasts. Oversized breasts are caused by excessive glandular tissue or fat. Excessive breast volume and size causes the stretching
and distension of mammary ligaments, and thus breast drooping and the loss of feminine shapes.
This state has a negative psychological effect upon women, similarly to undersized breasts which cause embarrassment and
frustration. Moreover, there are physical issues related to oversized breasts discomfort, spine, neck, shoulder, and back pain
which become prevalent. Participation in a normal social life is limited, patients suffering from mammary hypertrophy avoiding
dance, aerobic gymnastics, or other activities producing body swinging or graceless movement of the breasts.
If this state is not corrected before adulthood, it may affect posture (compensatory contraction of muscles causes spine deforma-
tion). Moreover, oversized breasts hinder normal ventilation of the inframammary fold and skin maceration, with bacterial or
mycotic suprainfection. Other problems, minor but still important, are the need for special lingerie (large-size bras) and
difficulties in finding clothes that fit properly.
The treatment of this condition is not new, and it has been practiced for more than 50 years. The purpose of this operation is to reduce
the volume and weight of ones breasts and to adjust their position. This involves removing mammary tissue and adjusting the contour
of the breasts. Moreover, it is necessary to adjust the areolanipple complex in conformity to the new shape of the breast.
In addition to usual medical tests, you are required to do a preoperative ultrasound and mammography, to identify any problems
related to the hypertrophied glandular tissue, and to be able to develop the therapeutic plan.
Being an operation of considerable significance, it is recommended that the patient be healthy, outside her period, and not
recovering from another condition. Any treatment with aspirin, vitamins, and garlic or administration of contraceptives must be
stopped at least 3 weeks before the operation. In addition, you are required to refrain from smoking 23 weeks before and 1
week after the operation. You are required not to eat or drink on the day of the operation.
The operation is performed under general anesthesia and takes about 23 h.
The scars will be inverted T shaped. From the circular scar around the areola, a vertical line runs toward the inframammary fold,
where there is a horizontal incision, with one end toward the sternum area and the other toward the side of the breast. However,
there will be scars, and if they are hidden in the natural contour lines, most of them will spontaneously meliorate within 6 months.
The position of these scars and all the other questions you might have shall be discussed in detail during the medical exam.
In order to prevent accumulation of blood in the operated area and complications related to this fact, you shall have a surgical
drain on each side of your body for 1 or 2 days. You shall be released from hospital as soon as no drainage will be noticed and
tubes tacked out. We are using high-quality resorbable sutures to make sure the scar is as small as possible. An adhesive
substance will be sprayed on the skin, and a special dressing will be applied to ensure an optimum healing. There will be no
stitches to remove.
Postoperative care
It is necessary that you remain one or two nights in the clinic. Postoperative medication shall include antibiotics, vitamins, and
analgesics, and normal diet shall be progressively re-introduced in the first 24 h. Antibiotic oral treatment shall be continued for
5 days. Moreover, if we identify the presence of anemia, you shall be administered oral iron supplements.
Postoperative pain is moderate in intensity and may be countered with analgesic medication, which may be administered as
many times as necessary. The postoperative protection dressing is to be changed daily for 7 days. In order to prevent postopera-
tive discomfort and ensure the optimum conditions for an aesthetic cicatrization, it is recommended that you avoid demanding
physical activity and wear a bra at all times for 6 weeks.
We recommend that you should not expose your skin to sunlight or UV tanning lights for the first 3 months after the operation.
It takes about 1 year for the scars to mature and the breast to reach its final shape.
We strongly recommend that you come for the follow-up and medical examinations at 1 and 6 months after the surgery.
Complications
Besides general complications, common to all surgical interventions (allergic reactions, hemorrhage, infections, necrosis of soft
parts), there may be complications specific to this type of operation.
Breast-feeding issues may sometimes arise after the operation. If you plan to have a baby in the future, it is recommended that
you postpone the surgical intervention because a new pregnancy will modify the shape and size of your breasts, and the final
aesthetic result may as well be partially affected.
It is recommended that mammary reduction be performed minimum 6 months after interruption of breast feeding, because only
after this interval breasts usually return to a functionally neutral state.
The sensibility of the areola may be partially or totally lost depending on the technique performed. There may be sometimes a
sensation of numbness in the scar area. The breasts might also be asymmetrical after the operation. However, considering the
fact that, even under normal circumstances, breasts are not usually identical, the wish to obtain a perfect postoperative symmetry
is sometimes unrealistic.
There are few cases in which scars are of a considerable size requiring postoperative revision.
The results of this operation are very good and full of satisfaction for the patient.
A typical comment after the operation is: If I knew how easy it is, I would have done long ago!
41 Mastopexy/Breast Reduction with Short Inverted T Scar 663

Table 41.5 Consent form for surgical intervention

1. The undersigned.I hereby consent to the treatment:
.
And I authorize Prof. Dr. Toma Mugea and his collaborators, to perform upon myself or the patient I am representing as
legal guardian, the surgical intervention and/or related treatments.
2. I hereby agree that the operation/procedures performed, which could support the progress of medical science or be used for
educational purposes only, be recorded, on condition that my/the patients identity remains confidential.
3. Prof. Dr. Toma Mugea has explained to me the purpose of the intervention, and all alternatives to the recommended
treatment have been presented, including the alternative excluding any treatment.
4. I have been offered the opportunity to ask questions, and I have received complete and satisfactory answers to all of my
questions.
5. Prof. Dr. Toma Mugea informed me of all risks and complications that may arise.
Besides general complications typical of all surgical interventions (allergic reactions, hemorrhage, hematoma, ecchymosis,
necrosis of soft parts, thrombosis, embolism) which may get worse and pose a threat to my life, there may be complications
specific to this type of operation.
These have been explained to me during the medical examination, and I have also read them in the documents I have been
given on that occasion. In addition, I have been informed on postoperative care.
6. I do understand that there might be unforeseen situations during the operation, which might require interventions different
from those agreed upon, and I hereby authorize Prof. Dr. Toma Mugea and/or his assistants to make appropriate decisions on
the best course of treatment.
7. I do agree to the administration of the indicated type of anesthesia, and I consent/do not consent to blood transfusion, if
required.
8. I hereby declare that I am not aware of suffering from a contagious illness or being infected with a virus which might
determine a contagious disease.
9. I am aware of and I know the fact that there are no guarantees with respect to the result of the intervention.
10. In case of litigation, the parties shall benefit from the provisions of the legislation in force.
The Medestet Clinic shall benefit from assistance from Romanian Aesthetic Surgery Society in pursuit of its interests.
11. I hereby declare that I have been informed on the contract terms, and being aware of the above-mentioned risks and
complications, I consent to the recommended treatment.
Patient... Signature. Date
Legal Trustee..
Witness. Address..
Signature..

To make the patient more relaxed, 2 hours before the
surgery, he/she will receive 7.5 mg midazolam tablet.
Midazolam is a short-acting drug in the benzodiazepine
class that is used for treatment of acute seizures and for
inducing sedation and amnesia before medical proce-
dures. It has potent anxiolytic, amnestic, hypnotic, anti-
convulsant, skeletal muscle relaxant, and sedative
properties. Midazolam has a fast recovery time and is the
most commonly used benzodiazepine as a premedication
for sedation. An intravenous (IV) line will be set up.
41.14 Surgical Plan
The entire procedure is designed before surgery, with the
patient sitting and arms placed to the sides. The follow-
ing clue points and lines are marked: manubrium, acro-
mion, supero-anterior iliac spine, and pubis. The
inframammary fold with its medial and lateral end point
is marked (Fig. 41.19). After marking these reference
points, the length of the inframammary fold is deter-
mined and the midpoint of the fold marked (Fig. 41.20).
To obtain a proportional breast in terms of position,
volume, and shape with the body, the distance of man-
ubrium to new nipple position and also the breast cir-
cumference should be equal to the length of the
patients actual inframammary fold. This is the key to
the breast mastopexy/reduction.
During the breast reduction, a significant part of
the mammary gland is removed, and the remaining
skin envelope will have a smaller weight to support
and will retract. This is called the coil spring rule in
breast surgery [27], and, in order to compensate, we
have to add 10% at the distance calculated for the new
664
a b
Fig. 41.19 Inframammary fold with its medial and lateral end points
Fig. 41.20 Inframammary fold length and the midpoint of the
fold marked
manubrium to nipple length. If not, the nippleareola
complex will have a higher location than planned.
The same 10% value should be added in the case of
breast ptosis, according to the pendulum rule
(Fig. 41.21) [27].
T.T. Mugea
Because the upper pole of the breast is flat at the
marking time, when the breast cone is filled, the nip-
ples new position with breast tissue behind it will be
pushed forward, like a pendulum, and the manubrium
nipple distance will become shorter (from an aesthetic
point of view), with the nipple situated in a higher
position than desired. To correct this, we add 10%
extra length to the calculated manubriumnipple dis-
tance for the new nipple position.
To define the new nipple location, the ruler passed
behind the neck to the nipples (Fig. 41.22), and a dot-
ted line marked the inner side of the ruler. The meeting
point between this line and MnNi distance, located
according to the 10% correction rule, will be the new
nipple position. In this case, it is 21 cm from the
manubrium notch (19 cm + 2 cm (representing
10%) = 21 cm).
Using a ruler, step by step points are marked situ-
ated at 9.5-cm distance from the medial and from the
lateral edges of the inframammary fold (Fig. 41.23).
This will define the level of vertical T branch and
represent half of the inframammary fold length
41 Mastopexy/Breast Reduction with Short Inverted T Scar 665

O (9.5 cm). The Wise pattern keyhole is selected,

corresponding to the 5-cm diameter areola, and hold-
ing the upper pole of the key at 2.5 cm superior to the
marked nipple point, the keyhole branches are
enlarged until these meet the dotted lines correspond-
ing to the vertical branches of inverted T
(Fig. 41.24). According to TTM chart, NiInfra dis-
tance should be 7 cm (1:3 from inframammary fold
length), and the length of each vertical T branch
will have, in this case, 5 cm because 2 cm came from
areola diameter (Fig. 41.25). At the inframammary
c line midpoint, a small triangle is defined with 1-cm-
O
+ 10% length branches (Fig. 41.26). This will dissipate the
suture tension from one to three points, when the final
B
A suture will be done to close the T. To close the hori-
zontal T branch, one larger triangle will be marked
10% on each side, from the end point of the vertical T
B branch to the inframammary midpoint triangle
(Fig. 41.27). With full marking done, a photo will be
taken for the files.

41.15 Surgical Technique

Fig. 41.21 Pendulum rule in the breast surgery. In mastopexy
and breast reduction, the bottom of the breast is pushed upward,
and as the result, the upper pole is pushed forward together with
the NAC. O = the midclavicular point, A = the inframammary fold
level, B = the new position for NAC without correction, C = the
NAC achieved position after the operation without position cor-
rection, D = the correct position of the NAC maintained at the
aesthetic planed level. The distance OD is 10% longer that OC
The operating theater should be clean, in order, and
large enough (2530 m2) to allow the devices, and
anesthetic and surgical team to work without fear of
touching somebody else. Inside the operating theater,
the temperature should be around 20C and fresh air
available by conditioning devices that will keep it at

Fig. 41.22 Defining the new nipple location

666
Fig. 41.23 Marking the level of vertical T branch
Fig. 41.24 The keyhole branches are enlarged until they meet the dotted lines corresponding to the vertical braches of inverted T
the desired parameters. A nice classical music in the
background will make a friendly ambiance for the
patient and also the operating team.
Patient comes into the operating theater with a dis-
posable cap and dressed with a large gown, which
will be removed by the nurse before sitting on the
table. In tranquility, the anesthetic team will proceed
to put an intravenous (IV) line and connect the patient
to the monitors. The anesthesia will be with oral intu-
bation. When the patient is asleep, the radiofrequency
bipolar electrocautery will be connected, and the
scrub nurse will prepare the table with instruments.
T.T. Mugea
41.16 Breast Ptosis Type 0: Small Volume
and Skin Excess (Empty Breast)
The patient is placed lying down (Fig. 41.28), with the
arms secured horizontally at 90. The operation field is
prepared with Betadine solution, and after covering
patient with sterile drapes, the key points are marked
by small intradermal injections with Methylene Blue
on both breasts. This is necessary to avoid the dissipa-
tion of the drawings during the operation. A special
cutting ring, with a hole centering the nipple position,
will mark the new areola diameter (Fig. 41.29).
41 Mastopexy/Breast Reduction with Short Inverted T Scar 667

a b

Fig. 41.25 The vertical T branch measurement

a b

Fig. 41.26 At the inframammary line midpoint, a small triangle is defined with 1-cm-length branches

According to the drawings we make on both breasts,
the intradermal incisions with No. 15 blade scalpel,
and start the deepithelialization, carefully, from the
inframammary fold level, using a sharp scissors
(Fig. 41.30). When the deepithelialization is com-
pleted, using the electrocautery, the transdermal inci-
sions are started, saving a 5-mm margin from the skin
(Fig. 41.31), which will be used at the closing sutures.
This marginal dermis will hold the skin in the suture
without tension, and will prevent the bed scars during
the healing process.
The author likes to do the glandular incision
(Fig. 41.32), using No. 21 cold blade. In this way, we
keep the margins clean, without thermal damage, and
allow a normal wound healing. To help in this maneu-
ver, the assistant holds the key points of the incisions
with skin hooks, and with the left hand we push gently
the lateral side of the gland, which is hanging, is pushed
668
Fig. 41.27 Inverted T
short scar marking
B
D
a b
Fig. 41.28 Markings on the operating table
gently medially. This incision should be done through
the gland mould, if possible, at once, down to the ret-
roglandular space, carefully not to open the muscular
pectoralis major fascia. This point is very important,
because along this retroglandular space, the breast
T.T. Mugea
Inverted T
Short Scar Marking
AB = BC + CD
central neurovascular pedicle runs to the nippleareola
complex. Also, in difficult cases with breast ptosis
after severe weight loss, the breast mound can glide
vertically and horizontally, over the chest cage, for
several centimeters, and the incision can fall into a
41 Mastopexy/Breast Reduction with Short Inverted T Scar
a a
Fig. 41.29 (a) Key points marking by small intradermal injec-
tions with Methylene Blue. (b) A special cutting ring will mark
the new areola diameter
wrong plane. Incisions are completed superiorly, and
the inferior pedicle is well mobilized (Fig. 41.33).
A key dermal suture with 2/0 Vicryl holds the are-
ola together with the lateral and medial cutaneous flaps
at the superior end of the vertical T branch
(Fig. 41.34), and bought breast pillars, lateral and
medial, are sutured with 2/0 Vicryl in front of the infe-
rior pedicle, holding the breast mould (Fig. 41.35).
The second layer is a reverse dermohypodermic suture
(Fig. 41.36), with 2/0 Vicryl, and includes the anterior
layer of the superficial fascia of the breast. This suture
technique allows minimal tension skin repair, with
more predictable scarring, using the two to three mar-
ginal deepithelialized area left close to the skin flap
669
Fig. 41.30 (a) Intradermal incisions with No. 15 blade scalpel
are made according to the drawings. (b) Deepithelialization is
started, carefully, from the inframammary fold level using a
sharp scissors
margin. Suction drain is placed in the retroglandular
space and attached to the sterile bag with mild negative
pressure.
The skin suture (Fig. 41.37) is performed with
intracuticular running stitch with 5/0 PDS. The whole
incision length is taped with SteriStrip changed every
7 days, for 36 weeks. Patients are asked to wear bras-
siere for 6 weeks.
Type 0 ptotic breast includes all ptotic breasts
without significant glandular volume, like empty
breast found after severe weight loss or aging. All
the following types of breasts (from type I to type V)
can be converted in one certain situation to this type
0, losing volume by glandular hypotrophy. Mastopexy
670 T.T. Mugea

a b

c d

Fig. 41.31 Transdermal incisions, saving a 5-mm margin from the skin

associated with autoimplant or breast implant is the
indication. Because of skin and soft tissue quality,
the aesthetic outcome of the surgery is sometime less
predictable. If there is no skin excess and only empty
breast, breast augmentation with implant is the
choice, and this case does not belong to this type of
ptosis.
Case 1
This is a patient (Fig. 41.38) with breast ptosis type 0
(Fig. 41.39). She had one pregnancy and lost 15 kg. Her
breasts look empty. No glandular excision is needed,
only volume redistribution. The horizontal T branch
is shorter than the inframammary fold length.
The patients body and breast actual parameters are
introduced into the computer program (Fig. 41.40), and
the computer listed in the red color what should be the
ideal dimensions of her breast to be aesthetic. In this
specific case, the Breast Golden Number is 20 cm.
Preoperative draw plan is done according to the sug-
gested breast dimensions. The new nipple position will
be located at the meeting point between the midclavicu-
lar to nipple line and the inverted triangles. Postoperative
breast dimensions (Fig. 41.41) and preoperative and
6-month photos can be seen in Fig. 41.42.
41.17 Breast Ptosis Type I: Small
Hypertrophy
In type I ptotic breast, small hypertrophy is naturally
accompanied by ptosis, and usually these ladies wear a
B- or C-cup bra size. Mastopexy without glandular
excision is the solution. Short inverted T scar or
41 Mastopexy/Breast Reduction with Short Inverted T Scar 671

a b

Fig. 41.32 Breast incision, down to the retroglandular space, laterally and medially

vertical scar technique will ensure a good and stable

aesthetic result (Fig. 41.43).

Case 2
This case presents a patient with small breast hypertro-
phy and glandular ptosis (Fig. 41.44). Breast actual
dimensions, ideal parameters (in red), and surgical
plan are shown in Fig. 41.45. A small amount of glan-
dular tissue has to be removed. For this, the inferior
pedicle is completely released from the superior and
central breast segments. Pedicle width is identical with
the horizontal T branch length (Fig. 41.46), which is
around half of the inframammary fold length.
The dermal incision is performed with radiofrequency
needle point, preserving 2 mm dermal margin close to the
skin (left picture). Vertical incisions are deep to the ret-
roglandular tissue (Fig. 41.47). Because in the upper pole
of the breast there is a small amount of glandular tissue,
usually there is no need for excision. In this area, we
excise only the skin and keep in place all the fatty tissue.

Fig. 41.33 Incisions are completed superiorly, and the inferior

pedicle is well mobilized
672 T.T. Mugea

a b

Fig. 41.34 Key dermal suture holds together the areola with lateral and medial cutaneous flaps at the superior end of the vertical
T branch

a b

Fig. 41.35 Both breast pillars, lateral and medial, are sutured in front of the inferior pedicle
41 Mastopexy/Breast Reduction with Short Inverted T Scar
a a
b
Fig. 41.36 Second layer is a reverse dermohypodermic suture
The glandular tissue to be excised is mainly located
in the central and lateral quadrants of the breast. From
the top of the dermoglandular flap, including the
nippleareola complex, the dissection progresses in a
caudal direction along the loose layer of the fourth
intercostal space by blunt preparation (Fig. 41.48).
Here, the retromammary space changes its direction
and merges into a layer of loose connective tissue in a
vertical plan, heading toward the nipple [14].
The caudal part of the gland together with the hori-
zontal septum is left intact. The glandular excess from
the central area is excised, preserving at least 2 cm of
tissue behind the NAC. The connection between the
673
b
Fig. 41.37 The skin suture is performed with intracuticular
running suture with 5/0 PDS
nipple and the thoracic wall is maintained by the hori-
zontal breast septum (Fig. 41.48) and its attached neu-
rovascular layers [12, 14].
To obtain a good breast projection and to avoid the
ptosis of the breast tissue, several reverse sutures with
2/0 Vicryl are used, deep in the lateral and medial
pillars tissue. This will include the medial and lateral
suspensor ligaments of the breast, sutured in front of
the dermoglandular pedicle of the nippleareola com-
plex (Fig. 41.49). Postoperative photos at 7 days
(Fig. 41.50) and breast dimensions are listed in
Fig. 41.51. New NAC location is in the aesthetic
position.
674 T.T. Mugea

Fig. 41.38 Preoperative patient

Fig. 41.39 Breast ptosis type

0 (empty breast) Breast PtosisType 0
Small Volume &
Skin Excess (Empty Breast)

Same Length of
Short TScar &
Pedicle Width
+

Authoprosthesis
?Breast Implant

resection is necessary and allows good and predictable

41.18 Breast Ptosis Type II: Moderate
Hypertrophy
In type II ptotic breast, moderate hypertrophy is obvi-
ous, accompanied by visible ptosis, and these ladies
wear a C-cup bra size. Mastopexy with small glandular
results Fig. 41.52.
Case 3
The patients breast dimensions and surgical plan are
in Fig. 41.53. Postoperative breast dimensions and
photos at 6 months are shown in Fig. 41.54.
41 Mastopexy/Breast Reduction with Short Inverted T Scar
TTM program for Breast Reduction / Mastopexy
Fig. 41.40 Actual breast dimensions, ideal parameters (in red), and surgical plan
41.19 Breast Ptosis Type III:
Severe Hypertrophy
and Tight Soft Tissue
In type III ptotic breast, there is a severe hypertrophy with
tight soft tissue, indicating a heavy breast with the elastic
properties preserved (Fig. 41.56). Usually, these ladies
wear a D-cup bra size and have marks over the shoulders
accompanied by neck and back pain. The social life is
severely affected. This type of breast is a good indication
for breast reduction with short inverted T scar.
Case 4
This case represents a 23-year-old young lady with
168-cm height and 68-kg body weight (Fig. 41.57).
She has severe breast hypertrophy and ptosis (Nipple
5/Gland 7), without any pregnancy or weight loss. In
her case, pinch test shows 3-cm soft tissue thickness
and for relaxed tissue test 6 cm, demonstrating that she
has normal skin elasticity.
675
Preoperative marking, with relaxed skin holding the
breast, shows 20-cm inframammary fold length and
not 22 cm as we measured in the consultation room,
without breast support. Based on this 20 cm, all mark-
ing has been done (Fig. 41.58). In this case, pedicle
width is shorter than horizontal T line, allowing
good skin and glandular excision, from medial and lat-
eral breast quadrants. Also, the horizontal T line
(11 cm) is shorter than inframammary fold length
(Fig. 41.59, 41.60).
41.20 Breast Ptosis Type IV:
Severe Hypertrophy
and Loose Soft Tissue
In type IV ptotic breast, there is a severe hypertrophy
with loose soft tissue (Fig. 41.61). These cases derived
from type III when they lose weight. The skin and soft
tissue have no elasticity and do not retract after the
676 T.T. Mugea

TTM program for Breast Reduction / Mastopexy

Fig. 41.41 Postoperative measurements

Fig. 41.42 Six months postoperative

breast excision. The gland is hanging over the chest lower situated on the chest. Breast reduction with full
and can be mobilized around its base. The upper pole horizontal inverted T scar is usually necessary to
of the breast is empty, and the inframammary fold is drape the breast mould and to avoid the dog ears of
longer, as it used to be when the breast was full, and the scar.
41 Mastopexy/Breast Reduction with Short Inverted T Scar 677

Fig. 41.43 Breast ptosis type

I: small hypertrophy
Breast Ptosis type l
Small hypertrophy

5 cm

5 cm

19 cm 9,5 cm

Same Length of
Short T Scar &
pedicle Width
+/- 5 cm
Glandular Excision
9,5 cm

19 cm

TTM program for Breast Reduction / Mastopexy

Fig. 41.44 Actual breast dimensions, ideal parameters (in red), and surgical plan
678
Fig. 41.45 Preoperative
a b
Fig. 41.46 Skin deepithelialization on the marked area
Case 5
This case and her twin sister have identical bodies
and breasts, and both lost more than 10 kg in a few
months, facing severe breast hypertrophy and pto-
sis. In this patient, the inframammary fold length
(22 cm) is larger than what she was supposed to have
in her condition, according to the chart (Fig. 41.62).
Because she lost weight, the breasts are smaller, but
the inframammary fold length is still larger. The skin
and inframammary ligaments changed their length,
shortening up to the elasticity limit. If the patient con-
tinues to lose weight, the breasts will look like empty
bags hanging over the chest, kipping the same dimen-
T.T. Mugea
sions. To prove it, the author did a simulation with the
computer program (Fig. 41.63), supposing that she
had 10 kg more, and in this case, the BGN became
22 cm (21.80 cm).
This case was done using a modified Robbins tech-
nique, following the preoperative planning in the TTM
program for breast reduction and mastopexy.
Postoperatively, the BGN is 22 cm, as supposed to be
according to the computer simulation (Fig. 41.64 and
Fig. 41.65, Fig. 41.66). Because this patient has a twin
sister, operated in the same day for a similar problem,
this is a very good example of computer program effi-
ciency allowing predictable results.
41 Mastopexy/Breast Reduction with Short Inverted T Scar
a a
Fig. 41.47 (a) Dermohypodermal incisions. (b) Vertical incisions
41.21 Breast Ptosis Type V:
Gigantomastia
In type V ptotic breast, we include gigantomastia, a
rare condition characterized by excessive breast growth
and can be physically and psychosocially disabling for
the patient (Fig. 41.67). Symptoms include mastalgia,
679
Fig. 41.48 The central breast pedicle and fibrous septum
infection, postural problems, back pain, and chronic
traction injury to 4th/5th/6th intercostal nerves with
resultant loss of nipple sensation. It is also associated
with decreased fetal growth during pregnancy [24].
Being over D cup, bra wearing is not useful.
Gigantomastia etiology can be idiopathic, obesity-
associated, juvenile, pregnancy-induced, or drug-
induced [24]. Unfortunately, this classification has no
680 T.T. Mugea

Fig. 41.49 (a) Internal brassiere made by suturing the medial final running intradermal suture, done with 5/0 PDS, starts from
and lateral pillars, including the medial and lateral suspen- the ends of the horizontal line of the scar to the center, with a
sory ligaments, in front of the NAC dermoglandular pedicle. shortening effect
(b) Internal brassiere with reverse dermohypodermic suture. The
41 Mastopexy/Breast Reduction with Short Inverted T Scar 681

Fig. 41.50 One week postoperative

TTM program for Breast Reduction / Mastopexy

Fig. 41.51 Postoperative breast measurements

682
Fig. 41.52 Breast ptosis type
II with moderate hypertrophy
Same Length of
Short T Scar &
Pedicle Width
+ 5 cm
Glandular Exision
direct impact on the surgical strategy adopted by the
plastic surgeon toward the correction of ptosis, the
amount of breast to be removed, and the technique to
be used [25].
It is commonly taught that an inferior pedicle tech-
nique is only appropriate if the distance from the nip-
ple to the inframammary fold is less than 15 cm (on
the basis of a 2:1 ratio). In reality, provided the pedicle
is not completely removed from the chest wall, there
will be numerous perforators entering into the pedicle
along its length. In addition, it does not necessarily
follow that ptosis will increase the nipple to inframam-
mary fold distance [12]. The inferior pedicle reduc-
tions, Robbins technique, have been performed on
several gigantomastia patients with good effect. There
have been numerous reports in the literature using
inferior pedicle techniques and showing no increase in
complication rate with resection weights of over
1,000 g [12, 26].
Case 6
This case represents a 33-year-old young lady, with a
70-cm height and 85-kg body weight, with gigan-
tomastia and severe breast ptosis (Nipple 6/Gland 8)
(Fig. 41.68). She had one pregnancy and lost only 4 kg.
T.T. Mugea
Breast Ptosis Type II
Moderate Hypertrophy
5 cm
5 cm
19 cm 9,5 cm
9,5 cm
19 cm
Preoperative planning has been done according to the
computer program (Fig. 41.69, 41.70).
Postoperative result at 7 days and breast measure-
ments correspond to the aesthetic result and Breast
Golden Number for her case. At 6 months, the breast
keeps the shape and proportion and has a natural
appearance (Figs. 41.71 and 41.72, 41.73).
41.22 After Surgery
The patient will go back to the ward, usually for 24 h,
and will receive painkillers, antibiotics (Cefalexin tab-
lets 500 mg, three times in a day), for 3 days, and if
necessary Clexane (Enoxaparin sodium Per syringe:
20 mg/0.2 mL). In patients with a moderate risk of
thromboembolism, the recommended dosage is 20 mg
or 40 mg once daily by subcutaneous injection. In
patients with a high risk of thromboembolism, the dos-
age should be 40 mg administered once daily by sub-
cutaneous injection.
Enoxaparin treatment is usually prescribed for an
average period of 710 days. Longer treatment dura-
tion may be appropriate in some patients, and the treat-
ment should be continued for as long as there is a risk
41 Mastopexy/Breast Reduction with Short Inverted T Scar 683

b TTM program for Breast Reduction / Mastopexy

5cm

5 cm

19 cm 9,5 cm

5 cm

19 cm

Fig. 41.53 (a) Preoperative. (b) Preoperative plan based on computer program for breast reduction

of venous thromboembolism and until the patient is
ambulatory.
Because we are doing the surgery in the afternoon,
the patient will stay in the clinic overnight, with monitor
for BP, HR, and a pulse oximeter. For next hours will
receive IV solutions (5% glucose, Ringers) according to
the body weight, and as soon the patient will tolerate,
will start natural feeding. The dressing will be done,
leaving in place the SteriStrips (adherent paper tape),
and the suction drain will be mobilized and removed in
684 T.T. Mugea

Fig. 41.54 Five months postoperative.

TTM program for Breast Reduction / Mastopexy

Fig. 41.55 Postoperative result with breast new dimensions

41 Mastopexy/Breast Reduction with Short Inverted T Scar 685

Fig. 41.56 Breast ptosis

type III: severe hypertrophy
and tight soft tissue Breast Ptosis Type III
Severe Hypertrophy &
Tight Soft Tissue

5 cm

6 cm

22 cm 11 cm

Short T scar
Narrower pedicle
+ 6 cm
Glandular &
Skin Excision 11 cm

22 cm

Fig. 41.57 (a) Preoperative. (b) Preoperative breast dimensions and surgical planning
686
b TTM program for Breast Reduction / Mastopexy
Fig. 41.57 (continued)
the next 24 h if the drainage is below 20 ml. Over the
SteriStrips, sterile cotton gauze will be applied and sus-
tained with the bra, adapted to the new breast size.
The patient will leave the clinic with oral antibiotics
for 3 days, sterile cotton gauze, and mild painkiller
treatment. Next day, they can have the shower without
dressing (the wound is protected by SteriStrips), and
after that the sterile cotton gauze is applied under the
bras. The patient can start to do her usual social activ-
ity in 23 days, and go back to work in 714 days.
They have to wear bras almost all the time for 6 weeks,
and after this time, they have to wear bras during the
day for 6 months.
First medical follow-up will be at 7 days. At the
first control, the SteriStrips are changed, and the
patient is taught how to do it at home, once a week
for the next 4 weeks, and to protect the wound and
ensure a good scar appearance. The patient comes
for a visit also at 1 and 6 months and at 1 year, and
T.T. Mugea
they are encouraged to come also whenever they feel
it is necessary. Patients do not start sportive activity,
especially rhythmic movements with a pendulum-
like shaking of the breasts, sooner than 6 months.
41.23 Possible Complications
Postoperatively, patients and surgeon can face differ-
ent problems, which can be included as complications
related to surgery, planning, or therapy. Breast asym-
metries, bottoming out, bed scars, or high position of
NAC are not considered as surgical complications, as
they are related to the surgeons preoperative planning
and intraoperative maneuvers.
Early complication after mastopexy can be:
1. Bleeding
2. Hematoma
3. Venous stasis on the NAC
41 Mastopexy/Breast Reduction with Short Inverted T Scar 687

Fig. 41.58 Preoperative marking (a) According to the pendu- Marking the end point of vertical line of inverted T. (c) Short
lum rule, the new nipple position will be at 22 cm from the inverted T scar limit (yellow arrow) and deepithelialized pedi-
sternal notch. (b) Horizontal T branch length marked at 11 cm. cle (red arrow)
Keyhole arms meeting the horizontal T branch at 7.5 cm.
688 T.T. Mugea

TTM program for Breast Reduction / Mastopexy

Fig. 41.59 Postoperative measurements

Fig. 41.60 (a) Forty-eight hours after surgery. (b) Thirty days after the surgery. (c) Six months postoperative. (d) Two years after
the surgery
41 Mastopexy/Breast Reduction with Short Inverted T Scar 689

Fig. 41.60 (continued)

690
Fig. 41.61 Breast ptosis
type IV: severe hypertrophy
and loose soft tissue
Full scar length
Narrow pedicle
+
Glandular &
Skin Excision
4. Ischemia
5. Necrosis
6. Infection
These complications have to be recognized as soon
as possible and treated without delay in the appropriate
manner. The surgeon must consider the patient safety
as a priority, without the shame to assume that compli-
cation. All these complications can be small, moder-
ate, or severe, and lack of attention can allow them to
pass into the next stage of gravity. The surgeon has to
assist himself at the first dressing, and keep an eye on
the patient if anything is not working as has to be. This
dressing is as important as the surgery itself, and
nobody can delegate this responsibility.
In our practice, even if we had a small incidence of
all kinds of early postoperative complications (less
than 2%), bleeding and hematoma was the main reason
for reintervention (Fig. 41.74). The common situation
is a small continuous bleeding and clots on the drain-
age tubes, which will lead to blood accumulation and
hematoma formation. The breast looks bigger, under
tension, with bruising around the scars and is tender.
Even if the bleeding stops, surgery has to be performed
with general anesthesia to evacuate the clots and check
the hemostasis (Fig. 41.75). The tissues are washed
with saline solution and Betadine, and a new pair of
drains are inserted through a new skin hole.
T.T. Mugea
Breast Ptosis Type IV
Severe Hypertrophy &
Loose Soft Tissue
5 cm
6 cm
22 cm 22cm
6 cm
11 cm
22 cm
At this kind of reintervention, two pairs of drains
are used to prevent clotting formation on the tubes and
to allow, if necessary, the wound irrigation. The first
intervention is a mild suction through the drains and
not a hard one, to prevent the tissues from locking the
tubes holes. In all the cases, after 24 h, the drains are
removed without problems. At 1 week after the sur-
gery, in this case, except for the skin oozing on the left
side, the breasts appear similar (Fig. 41.71b). Since the
patient lost weight after 1 year, mild ptosis is still
present.
For venous stasis on the NAC, which can be a pre-
liminary stage for intravascular thrombosis and skin
necrosis, we used to do, in mild cases, small stab inci-
sions with No. 11 blades. If the areola congestion is
significant, we will do tangential skin deepithelializa-
tion on the affected area. On the top of the areola, we
apply heparin-soaked gauze to allow the bleeding. This
dressing has to be changed every 23 h until the new
vascular connections allow the normal venous drain-
age. The areola skin will heal in several weeks without
significant scars. Also, leeches can be used.
Ischemia and tissue necrosis are the most danger-
ous complication after breast reduction and mastopexy.
If there is no infection over this necrosis, the wound
will heal by itself with secondary reepithelialization.
Small necrotic areas can be present usually at the
41 Mastopexy/Breast Reduction with Short Inverted T Scar
TTM program for Breast Reduction / Mastopexy
Fig. 41.62 Preoperative plan for patient with 50-kg body weight. In this situation, BGN is 20.46 cm (red arrow)
points of tension, where the flap corners meet.
Sometimes, the suture material passes through the der-
mal skin and becomes contaminated with bacteria. A
local infection started in this condition (Fig. 41.77). If
infection is present, the wound must be opened and
necrotic tissue excised. The wound will be washed
with hydrogen peroxide and Betadine solution. Boric
acid crystals, like a powder, is applied over the wound,
even if it is unpleasant for the patient. This acid will
keep away the wound contamination and will allow a
quicker reepithelialization. Usually, there is no need
for revision surgery in these cases.
If there is a severe infection and all mammary
glands involved, under general anesthesia, all the
sutures have to be removed, necrotic tissue excised,
and the flaps washed with hydrogen peroxide and
Betadine solution. The opened wound has to be cov-
ered with normal saline solutionsoaked gauze. As
soon as the suspicion of infection is present, swabs
691
with wound fluids have to be sent for the bacteriologi-
cal examination and antibiogram. The IV treatment
with identified antibiotics has to be completed with
anticoagulants because of high risks of thrombosis
and pulmonary embolism. All the dressings have to
be done under general anesthesia to be as aggres-
sive as the infection is. Usually, after 48 h, when the
patient is well and there are signs of local recovery,
with bleeding from the small granulating tissue present
and swabs adherent to the tissues, closing of the breast
wound can be performed. All the flap margins have to
be excised about 5 mm, up to the normal tissues, with
good bleeding, and the sutures done as initially. Drains
are necessary for 24 h.
Later, bad outcomes after mastopexy are related to
the surgical technique, patients tissue qualities, patient
following received advices, body weight changes,
physiological events (pregnancy, breast-feeding), and
aging.
692 T.T. Mugea

TTM program for Breast Reduction / Mastopexy

5cm

6 cm

22 cm 22cm

6 cm

11 cm
22 cm

Fig. 41.63 Computer program simulation for patient with 60-kg body weight. In this situation, BGN is 21.80 cm (red arrow)

Fig. 41.64 Preoperative pictures

41 Mastopexy/Breast Reduction with Short Inverted T Scar 693

Fig. 41.65 Forty-eight hours postoperative

TTM program for Breast Reduction / Mastopexy

Fig. 41.66 Preoperative breast dimensions

694 T.T. Mugea

Fig. 41.67 Breast ptosis

type V: gigantomastia
Breast Ptosis Type V
Gigantomastia

7 cm

10 cm

26 cm 26cm

Full scar length

Narrow pedicle
+
Large Glandular & 10 cm
Skin Excision 13 cm

26 cm

a b

Fig. 41.68 Preoperative patient with gigantomastia

1. Areola asymmetries 7. Bad scars, which can be:

2. Bed shape of the areola (a) Hypertrophic
3. Loss of areola sensitivity (b) Wide
4. Breast asymmetries (c) Keloidal
5. Breast bed shape (d) Painful
6. Breast volume not related to the patients body and (e) Hypo/hyperpigmented (Fig. 41.78)
trunk dimensions (f) With bed position, visible outside the bra
41 Mastopexy/Breast Reduction with Short Inverted T Scar 695

TTM program for Breast Reduction / Mastopexy

Fig. 41.69 Preoperative breast dimensions and computer program.

Fig. 41.70 Preoperative marking for breast reduction

696 T.T. Mugea

TTM program for Breast Reduction / Mastopexy

Fig. 41.71 Postoperative measurements

Fig. 41.72 Postoperative result at 7 days

41 Mastopexy/Breast Reduction with Short Inverted T Scar 697

Fig. 41.73 Postoperative 6 months after surgery

a a

b b

Fig. 41.75 Intraoperative, checking hemostasis. New drains

inserted through another skin opening

Fig. 41.74 Postoperative hematoma of the left breast

698 T.T. Mugea

Fig. 41.76 (a) Preoperative. (b) One week after the surgery and reintervention. (c) One year after the surgery

Usually, one complication is not alone and some- 41.24 Conclusions

times can be associated with many others, leading
to disasters (Fig. 41.79). In this situation, it is In breast aesthetic surgery, the most important things
almost impossible to correct the aesthetic outcome. are (Fig. 41.81):
Only a small improvement can be expected 1. Breast evaluation
(Fig. 41.80). 2. Patient desire
41 Mastopexy/Breast Reduction with Short Inverted T Scar 699

a b

Fig. 41.77 Local infection and wound healing after mastopexy

a b

Fig 41.78 Scar depigmentation in a case with vitiligo

700 T.T. Mugea

Fig. 41.79 Postoperative disasters in breast surgery

41 Mastopexy/Breast Reduction with Short Inverted T Scar 701

Fig. 41.80 (a) Preoperative patient with NAC situated too high, The long vertical scar from the top of the areola is the price for
wide scars, and ptotic breasts, type 0. (b) Surgical technique lowering the NAC position. If an implant will be inserted, NAC
for NAC repositioning and scar correction. (c) Postoperatively, will have again an upper position, because the lower pole of the
the breast is still empty, but the NAC is in the normal position. breast will be filled
702 T.T. Mugea

Glandular Volume & Ptosis Classification

0 I II III IV

V
Type 0 - Small Volume & Skin Excess (Empty Breast)
Type I - Small Hypertrophy
Type II - Moderate Hypertrophy
Type III - Severe Hypertrophy & Tight Soft Tissue
Type IV - Severe Hypertrophy & Loose Soft Tissue
Type V - Gigantomastia

Type 0
Small Volume & Skin Excess (Empty Breast)

Same Length of
Short T Scar &
Pedicle Width
+

Authoprosthesis
?Breast Implant

Type I Small Hypertrophy

5cm

5 cm

Same Length of 19 cm 9,5 cm

Short T Scar &
Pedicle Width
+/
5 cm

9,5 cm
Glandular Excision
19 cm

Fig. 41.81 The final concepts

41 Mastopexy/Breast Reduction with Short Inverted T Scar 703

Type II
Moderate Hypertrophy

5cm

5 cm

Same Length of 19 cm 9,5 cm

Short T Scar &
Pedicle Width
+/
5 cm

9,5 cm
Glandular Excision
19 cm

Type III
Severe Hypertrophy &
Tight Soft Tissue

5cm

6 cm

Short T scar 22 cm 11 cm
Narrower pedicle
+
Glandular &
Skin Excision
6 cm

22 cm
11 cm

Type IV
Severe Hypertrophy &
Loose Soft Tissue

5cm

6 cm
Full scar length
Narrow pedicle 22 cm 22cm
+
Glandular &
Skin Excision
6 cm

11 cm
22 cm

Fig. 41.81 (continued)

704
Fig. 41.81 (continued)
3. Accurate planning of surgical procedure
4. Simple surgical technique
5. Predictable results
6. Avoiding postoperative complications
7. Patient satisfaction
References
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2. Pitanguy I (1967) Surgical treatment of breast hypertrophy.
Br J Plast Surg 20(1):7885
3. McKissock PK (1972) Reduction mammaplasty with a
vertical dermal flap. Plast Reconstr Surg 49(3):245252
4. Robbins TH (1977) A reduction mammaplasty with areolar-
nipple based on an inferior dermal pedicle. Plast Reconstr
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5. Mugea TT (2001) A new system for breast assessment using
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6. Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D
(1999) Current trends in breast reduction. Plast Reconstr
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7. Hidalgo DA (1999) Improving safety and aesthetics in inverted
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8. Giovanoli P, Meuli-Simmen C, Meyer VE, Frey M (1999)
Which technique for which breast? A prospective study of
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(2006) Anatomy and clinical significance of pectoral fascia.
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gland. Plast Reconstr Surg 101(6):14861493
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Type V
Gigantomastia
7cm
10 cm
Full scar length 26 cm 26cm
Narrow pedicle
+
Large Glandular &
Skin Excision 10 cm
13 cm
26cm
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fascial system: a new approach for inframammary fold
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Inframammary fold: a histologic reappraisal. Plast Reconstr
Surg 105(2):549556
17. Regnault P (1976) Breast ptosis, definition and treatment.
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reduction: principles and practice. Springer, Berlin, pp 1921
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Schneider A, Endlich M, Mueller A, Schwenzer-Zimmerer
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 The Medial and Superior Pedicle
Mastopexy with Dual Plane
Inverted-T Augmentation
Tiberiu I. Bratu, Cristina Isac, Olariu Daniela,
Grujic Daciana, Dorina Mihaijlovic,
and Nicolae Antohi
42.1 Introduction
Augmentation mastopexy is a challenging operation
about which there are a variety of opinions. It is consid-
ered a difficult operation, implying the risk of compli-
cations; that is why many surgeons choose to perform
it as a two-stage procedure [1]. Adequate shape is still
T.I. Bratu (*)
University of Medicine and Pharmacy Victor Babes, County
Hospital Timisoara, Casa Austria, str. Bulbuca 10, Brol
Medical Center, str. Franyo Zoltan, 6, Timisoara, Romania
e-mail: office@brol.ro
C. Isac
Department of Plastic Surgery, University Hospital
for Plastic Surgery and Burns, University of Medicine and
Pharmacy Carol Davila, Calea Grivitei 218, Bucharest,
Romania
e-mail: ina@drisac.ro
O. Daniela D. Mihaijlovic
Brol Medical Center Private Clinic,
str. Franyo Zoltan, Timisoara 6, Romania
e-mail: office@brol.ro
D. Grujic
University of medicine and Pharmacy Victor Babes,
Brol Medical Center Private Clinic Timisoara, Romania
e-mail: office@brol.ro, dcalistru@yahoo.com
N. Antohi
University of Medicine and Pharmacy Carol Davila,
Bucharest, Romania
Department of Plastic Surgery, University Hospital for Plastic
Surgery and Burns, Calea Grivitei 218, Bucharest, Romania
e-mail: nantohi@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_42, Springer-Verlag Berlin Heidelberg 2013
42
difficult to achieve. Moreover, the technique has the
potential for serious complications, such as skin necro-
sis, NAC necrosis, and breast and implant infection. As
Spear stated, breast augmentation alone is a fairly
simple operation, mastopexy is a relatively simple
operation, but when performing augmentation mas-
topexy, his advice is Surgeon, beware! [2].
The goals of augmentation mastopexy procedure
are, besides enlargement of the breast to the volume
desired by the patient, elevation of the gland and NAC
and conversion of a ptotic, discoid-shaped breast into a
more youthful conical or slightly round breast [3].
The inverted-T or anchor pattern mastopexy is
the most widely used technique. Various pedicles have
been proposed, such as superior, inferior, superoinfe-
rior (McKissock), and lateral [4].
42.2 Preoperative
The preoperative assessment is performed with regard
to skin condition, degree of ptosis, and asymmetry. The
cup that the patient is wearing is determined by sub-
tracting the chest circumference at the inframammary
crease from the circumference of the breast measured
at the NAC while the patient is wearing a bra. The
degree of breast ptosis is established using Regnault
classification, and any asymmetry is recorded. The
approximate desired size of the breast is determined,
and the appropriate size of the implant is chosen, tak-
ing into account that a cup represents approximately
200 mL or 200 g of breast tissue and that during a mas-
topexy, some breast tissue needs to be removed in order
to avoid excessive lower pole fullness [5, 6].
705
706
Fig. 42.1 Rectangular cutaneoglandular flap to be excised
42.3 Marking Technique
This represents the most important part of any plastic
surgery procedure on the breast. With the patient in a sit-
ting or standing position, arms beside, a midsternal line
is traced from the sternal notch to the umbilicus. The
midmammary lines are then marked. These lines begin
from the midclavicular point (about 7 cm from the sternal
notch) and follow the meridian of the breast, parting the
base of the breast in two halves. They usually cross the
nipple, but this is not a necessary condition. The NAC
may be placed laterally or medially from the breast
meridian. The inframammary folds are traced. The ideal
nipple position is marked on the breast meridian, taking
into consideration the patients height and the position of
the inframammary fold. It is usually marked at or 1 cm
lower from the anterior projection of the inframammary
fold on the breast. The superior border of the areola is
marked 2 cm superior to the new nipple position, and
then the Wise pattern is used or the keyhole is marked
freely by pushing the breast to either side of the midline,
and the lateral and medial limits of the skin resection are
traced down from either end of the areolar arc.
The patient is then placed in the supine position. The
markings of the inframammary fold incisions are kept
as short as possible, and the extreme ends of these are
connected with the caudal points of the keyhole pattern.
A rectangular cutaneoglandular flap of the inferior pole
which is going to be excised is also marked (Fig. 42.1).
The NAC to be incised is marked with a standard
circular cookie cutter of various diameters, depending
on the dimensions of the breast and the patients desire.
T.I. Bratu et al.
Fig. 42.2 Glandular excision from the lateral part of the breast
Anyway, the diameter of the NAC should be larger
than the diameter of the keyhole in order to avoid
stretching of the NAC and widened scars.
42.4 Operative Technique
A circumferential cut is made around the NAC of the
desired size. The usual measurement in our cases is
between 38 and 42 mm. The skin within the markings is
deepithelialized, excepting the NAC and the inferior
rectangle (the latter is excised). Full-thickness cuts are
made across the inframammary fold and the lateral bor-
der of the deepithelialized area. The skin incisions are
completed, keeping 5 mm of dermis on the skin margin.
The glandular tissue is elevated off the pectoralis major
muscle. The incisions are deepened through the paren-
chyma towards the muscular plane. The dissection
should be kept in an oblique or perpendicular direction,
depending on the amount of existent glandular tissue and
trying to preserve an adequate size of the pillars.
Glandular excision from the lateral part of the breast may
be performed as necessary at this point (Fig. 42.2). The
caudal extension of the superomedial flap is progres-
sively detached from the muscular plane, beveling the
dissection cephalad and downward to the pectoralis mus-
cle. A glandular-adipose flap with a superior and medial
pedicle is thus raised. The cephalic extension of the sub-
glandular undermining is represented by the second rib.
The inferior insertions of the pectoralis major are
identified (Fig. 42.3) and the lateral border of the muscle
is incised, as well as the costal insertions. The submus-
cular pocket is formed and extended as needed
laterally to the anterior axillary line, superiorly to about
42 The Medial and Superior Pedicle Mastopexy with Dual Plane Inverted-T Augmentation
Fig. 42.3 Incision of the inferior costal insertions of the pectoralis
major muscle
Fig. 42.4 The submuscular pocket created
2 cm from the clavicle, and medially up to 1 cm from
the midline (Fig. 42.4). Only the inferomedial sternal
insertions of the pectoralis muscle are divided. The
implant is inserted after hemostasis is carefully per-
formed. As in a usual simple breast augmentation, it is
important to verify that the implant does not have any
folds or wrinkles, that it is well settled, and that both
implants are at the same level.
The areola is sutured into the keyhole with a two-
layer closure.
The glandular flap is sutured in its inferior part to
the thoracic fascia with 3-0 Monocryl. This represents
the key point of the technique, which ensures a stable
padding of the lower pole of the implant (Fig. 42.5).
The lateral part of the pedicle is sutured to the lateral
pillar in a similar manner (Fig. 42.6). A closed suction
707
Fig. 42.5 Superomedial glandular pedicle sutured
Fig. 42.6 Lateral closure of the pedicle to the pectoralis and
thoracic fascia in its inferior part
drain is placed and brought out through a stab wound
inferolaterally.
The opposite breast is then addressed in a similar
manner. The circumareolar skin is tightened down
using the round-block technique if considered neces-
sary. A permanent, braided, subcuticular running
suture is advanced under the skin at about 12-cm
intervals and then tied down as the skin is gathered
around. The knot is buried in a small hole performed in
the dermis. A 3845-mm stainless steel nipple marker
is used, depending on the desired dimensions of the
subsequent nippleareola complex. Otherwise, a
708
Fig. 42.7 Final result
simple double layer with absorbable sutures is per-
formed followed by running subcuticular suture.
The final skin closures are done using 4-0 absorb-
able PDS and 5-0 absorbable intradermal running
sutures (Fig. 42.7). The wounds are dressed with
SteriStrips. The breasts are supported with dressing
retention tape both on the upper and inferior pole.
42.5 Discussion
Between January 2004 and September 2009, 117 women
aged 1848 (mean 33 years) underwent surgery using
the technique described. The average follow-up period
was 1.5 years. All the patients presented with ptosis in
varying degrees. Round or anatomic implants were
used depending on the degree of ptosis and patients
preference (Fig. 42.8).
The degree of satisfaction with the aesthetic result was
89%. There were only minor complications, with an
overall incidence of 3%. The most frequent complica-
tions were scar widening, residual ptosis, hypertrophic
scarring, and flattening of the breast.
Mastopexy and simultaneous augmentation has
been a challenge to plastic surgeons in terms of ach-
ieving symmetry, natural shape, and long-lasting,
consistent results. Among the guiding principles of
mammaplasty, besides glandular modification, skin
redraping, and safe NAC transposition, a very impor-
tant one is achieving long-term stability of the breast
shape. There still is a lot of controversy about
combining augmentation and mastopexy in the
same surgical procedure [79]. As Hammond stated,
it proved to be one of the most difficult breast
T.I. Bratu et al.
procedures plastic surgeons currently performed
because nearly every variable that determines the
ultimate shape of the breast is being manipulated to
some degree [10]. The use of a proper surgical tech-
nique, besides providing aesthetic improvement,
greatly minimizes complications [11].
Among the factors that significantly affect both the
short- and long-term outcome of the mastopexy proce-
dure are skins elasticity, the degree of ptosis, and breast
asymmetry [12].
Various techniques of mastopexy have been described,
including crescent mastopexy, periareolar round-
block (Benellis technique) [13], Lassus [14] vertical
scar technique modified later by Lejour [15], Chiari
[16] short-scar mastopexy, and anchor or T types.
Any of the methods mentioned above can be associ-
ated with parenchymal reshaping and/or augmentation
by means of implants. Description of the first tech-
niques of breast lift was published in the 1950s, but
reports of the association of mastopexy with augmen-
tation did not appear until mid-1960s.
Breast augmentation mastopexy represents an alter-
native when augmentation is desired as an adjunct. It
allows achieving a nice shape of the breast by virtue of
a better fill of the envelope with the implant, while, at
the same time, limits the length of the scars, as there is
less skin to be excised, compared with the simple mas-
topexy technique. The implant can reduce the degree
of breast lift needed and may help preserve the lift
once it is performed, adding longevity to the result.
However, the added risks of augmentation mamma-
plasty to mastopexy must also be considered. The risks
include an increased chance of wound problems and
dehiscence if there is any tension on the suture lines,
infection, implant exposure, and excessive scarring.
The risk of implant extrusion is increased especially
at the inverted-T incisions. These problems can be
avoided by keeping skin resection to a minimum at the
beginning of the procedure and resecting more skin
after the implant has been put in place [17]. There is an
increased risk for nippleareola complex malposition
(too high or too low) and for nipple sensation loss.
Achieving the shape and the size desired is more
difficult in a simple mastopexy. There are also the
inherent risks of the implants (malposition, capsular
contracture rates for capsular contracture in the com-
bined procedure are not yet documented).
42 The Medial and Superior Pedicle Mastopexy with Dual Plane Inverted-T Augmentation
a b
Fig. 42.8 (a) Preoperative. (b) Forty-eight hours postoperative
The padding of the inferior pole of the implant is
an issue not frequently addressed. We consider this
issue a very important one, because the implant, due
to gravity, may cause inferior pole gland atrophy and
consequences on the skin in the long run. The secu-
rity provided by the inferior pole covering consists in
preventing tension over the T incision confluence
and reducing the risk of implant extrusion. It gives in
this way an extra support to the dermis and a good
implant coverage. A good padding of the inferior
pole provides not only a nice shape, but also a safe
and stable result.
Another important issue in our opinion is repre-
sented by the safety of the nippleareola complex. It
is well known that NAC blood supply could be pro-
vided by means of various pedicles. The blood sup-
ply to the nippleareola complex and the skin flaps
should be carefully considered before proceeding
with augmentation mastopexy, especially in those
women with severe ptosis when a formal Wise-
pattern mastopexy is to be performed. In their zeal to
correct a womans severe ptosis, surgeons must
remain vigilant of the blood and nerve supply in
relation to the incisions made for both the augmenta-
tion and the mastopexy parts of the procedure.
709
Whereas the neurovascular supply is usually not
compromised by formal mastopexy alone, the addi-
tion of the augmentation procedure may cause sig-
nificant alteration in blood supply to the NAC,
glandular tissue, or skin flaps [17]. If the NAC is
designed on two simultaneous pedicles, the NAC
survival safety increases considerably. We use this
procedure in our technique: we preserve two integral
pedicles (medial and superior ones) and insure a
good padding of the inferior pole with the entire
parenchyma kept on these two pedicles. Moreover,
the final shape of the gland is enhanced by the dual
plane technique in which the gland sliding on the
pectoral muscle permits a nice molding on the
implant, avoiding the double bubble deformity.
The complications encountered during augmenta-
tion mastopexy procedure include nipple-areolar
necrosis, poor scarring, implant infections, implant
malposition, and contour deformities. Some surgeons
consider that the risks of complications are increased
by combining augmentation and mastopexy [18].
However, in the hands of an experienced surgeon, sat-
isfying results can be achieved by means of a more
comfortable and less expensive procedure for the
patient (Figs. 42.942.12).
710 T.I. Bratu et al.

a b

Fig. 42.9 (a) Preoperative. (b) and (c) One year postoperative after one-stage mastopexy and 325 cc high-profile round Mentor
implants for breast ptosis, one year postop
42 The Medial and Superior Pedicle Mastopexy with Dual Plane Inverted-T Augmentation 711

a b

Fig. 42.10 (a) Preoperative. (b) and (c) 7 months postoperative 300 cc round Mentor implants and breast lift
712 T.I. Bratu et al.

a b

Fig. 42.11 (a) Preoperative. (b) 9 months postop. (c) Postoperative after 350 cc round high-profile implant for the left breast and
200 cc round moderate-profile implant and mastopexy for the right breast in a breast asymmetry and ptosis
42 The Medial and Superior Pedicle Mastopexy with Dual Plane Inverted-T Augmentation 713

a b

Fig. 42.12 (a) Preoperative. (b) and (c) 3 months postoperative 250 cc round Mentor implants and breast lift
714
42.6 Conclusions
The main goal in treating ptosis is the achieving a well-
shaped, well-proportioned, viable breast with intact
sensation. This goal can be achieved with proper selec-
tion of patients and careful planning and execution of
the surgical technique [19, 20].
Mastopexy associated with augmentation has his-
torically challenged plastic surgeons imagination. It is
true that mastopexy, plus implantation, is not as simple
as each of these surgeries alone, but, by taking into
consideration the details of a proper surgical technique,
good results are maximized [11].
Lifting and augmentation of the ptotic breast can be
done with various methods of skin pattern resection
(crescent periareolar, circumareolar, vertical, or anchor
type), each type also including an implant. The tech-
nique presented herein has the advantage of a safer
NAC pedicle, decreasing the risk of necrosis, and an
improved padding of the inferior pole of the implant,
which decreases long-term complications (skin isch-
emia and necrosis) and achieves a nicer shape of the
breast, leading to satisfactory results over the mid and
long terms.
The novelty of the technique described consists in
increasing the safety of augmentation mastopexy by
means of a double pedicle that provides a secure blood
supply to the NAC and, on the other hand, secures the
lower pole, preventing tension on the suture at the T
confluence and reducing the risk of implant extrusion
and palpability. In the same time a nicer shape is
achieved on a long-term basis.
References
1. Gorney M, Maxwell PG, Spear SL (2005) Augmentation
mastopexy, panel discussion. Aesthet Surg J 25(3):275284
2. Spear SL (2003) Augmentation/mastopexy: surgeon,
beware. Plast Reconstr Surg 112(3):905906
T.I. Bratu et al.
3. Persoff M (2009) Breast augmentation with mastopexy. In:
Shiffman MA (ed) Breast augmentation: principles and
practice. Springer, Berlin, pp 257275
4. Nicolle FV (1984) Reduction mammoplasty and mastopexy:
a personal technique. Aesthetic Plast Surg 8(1):4350
5. Persoff MM (2003) Vertical mastopexy with expansion aug-
mentation. Aesthetic Plast Surg 27(1):1319
6. Persoff M (2003) Mastopexy with expansion-augmentation.
Aesthet Surg J 23(1):3439
7. Nahai F, Fisher J (2007) Augmentation Mastopexy: To stage
or not. Aesthetic Surgery Journal 27(3):297305
8. Spear SL, Giese SY (2000) Simultaneous breast augmenta-
tion and mastopexy. Aesth Surg J, 20:155
9. Stevens G, Stoker D (2006) Is one-stage breast augmenta-
tion with mastopexy safe and effective? A review of 186
primary cases. Aesthetic Surgery Journal, 26(6):67481
10. Hammond DC (2006) Augmentation mastopexy: general
considerations. In: Spear SL (ed) Surgery of the breast: prin-
ciples and art, 2nd edn. Lippincott Williams & Wilkins,
Philadelphia, pp 14031416
11. Cardenas-Camarena L, Ramrez-Macas R (2006)
Augmentation/mastopexy: how to select and perform the
proper technique. Aesthetic Plast Surg 30(1): 2133
12. Elliott LF (2002) Circumareolar mastopexy with augmenta-
tion. Clin Plast Surg 29(3):337347
13. Benelli L (1990) A new periareolar mammaplasty: the round
block technique. Aesthetic Plast Surg 14(2):93100
14. Lassus C (1986) New refinements in vertical mammaplasty.
Chir Plast 6:8
15. Lejour M (1993) Vertical mammaplasty. Plast Reconstr Surg
92(5):985986
16. Chiari A Jr (1992) The L short-scar mammaplasty: a new
approach. Plast Reconstr Surg 90(2):233246
17. Grotting J (2006) Mastopexy. In: Mathes S (ed) Plastic sur-
gery, 2nd edn. Saunders Elsevier, Philadelphia, pp 4786
18. Spear SL, Pelletiere CV (2004) One-stage augmentation
combined with mastopexy: aesthetic results and patient sat-
isfaction. Aesthetic Plast Surg 28(5):259267
19. Auersvald A, Auersvald L (2009) Crescent mastopexy with
augmentation. In: Shiffman MA (ed) Breast augmentation-
principles and practice. Springer, Berlin, pp 277281
20. Borovikov A (2004) Use of myofascial flaps in aesthetic
breast surgery. Aesthet Surg J 24(4):331341
 Breast Augmentation
and Mastopexy
Toma T. Mugea
43.1 Introduction
From the aesthetic point of view, breast ptosis is simi-
lar with the hanging of the lower pole of the breast
below the inframammary fold level, without relation
with the breast volume, which can vary in this associa-
tion from type zero (empty breast) to type five (gigan-
tomastia). This new classification proposed by the
author is practical, defining the breast not only as a
bidimensional structure (the relative position of the
nipple and lower pole of the breast to the inframam-
mary fold level), but also as a tridimensional one,
including the breast volume into the skin envelope.
The big difference between breast ptosis with hyper-
trophy and breast ptosis with hypotrophy consists in
the surgical solution to solve the problem. If in the
hypertrophic ptotic breast the main surgical goal is to
reduce at the same time both the volume and skin sur-
face, in the hypotrophic ptotic breast, we have to deal
with two divergent objectives to increase the breast
volume and to reduce the skin surface.
For this reason, breast ptosis represents a continu-
ous challenge for plastic surgeons, difficult to be solved
when peoples are more demanding and expecting the
best results with minimal scars, less money, and short
postoperative recovery time.
T.T. Mugea
Department of Plastic and Aesthetic Surgery, Oradea Medical
University, Oradea, Romania
Medestet Clinic, Cluj-Napoca, Romania
e-mail: drmugea@medestet.ro
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_43, Springer-Verlag Berlin Heidelberg 2013
43
Breast ptosis etiology is not only related to the
natural evolution of the mammary gland during preg-
nancies, weight gain or loss, or aging, but also
induced by iatrogenic breast augmentation using
silicone implants. This new type of augmented
ptotic breast represents the most difficult problem
to be solved because we are dealing with a complica-
tion of breast augmentation, and usually these
patients are very careful with their own image. They
already had an aesthetic procedure, and they believe
that their breast should be the same as initially, with-
out thinking about body aging and implant weight
influence on soft tissues. Pitfalls in breast augmenta-
tion (Table 43.1) represent, sometimes, the first step
for an unending chain of problems for both patient
and surgeon.
The high rate of complications in this kind of proce-
dures (breast augmentation and mastopexy) done at
the same time demonstrates not only the technical
difficulties in selecting the appropriate surgical proce-
dure for each clinical case, but also the high risk of
jeopardizing the vascular supply of the nippleareola
complex or skin flaps, especially in revision secondary
cases.
Table 43.1 Pitfalls in breast augmentation
1. Wrong patient
2. Wrong indication
3. Wrong associated surgery
4. Wrong pocket dissection
5. Wrong IMF definition/suture
6. Wrong implant position
7. Wrong implant selection
715
716
There are relatively large number of possibilities to
do combinations between mastopexy techniques (peri-
areolar [1, 2], vertical [3], or Wise pattern [4] mark-
ings) and different ways to insert the implant, pocket
position (subglandular [5], partial submuscular [6], or
subfascial [7]), and implant selection in terms of vol-
ume, shape, and filler solution. Unfortunately, there is
also a larger list of possible associated complications
that can occur even in experienced hands. This is why
some surgeons name these combined procedures the
recipe for disaster [8, 9] in breast aesthetic surgery
(Fig. 43.1).
43.2 Breast Development and Ptosis
Breast shape and contour are influenced by:
1. The volume of breast parenchyma.
2. The amount and location of the subcutaneous and
intraparenchymal fat.
3. The body contour of the chest wall.
4. Its muscular covering and thickness.
5. The tightness and elastic quality of the skin.
In the normal growing phase, the breast can be con-
sidered to have a hemispheric shape, with the nipple in
the middle in the most prominent point. As the breast
gains weight, because of the gravity and ligament
tightening, the breast mound will translate into the
Fig. 43.1 Recipe for disaster cases after breast augmentation and mastopexy. (a) Patient with large scar. (b) Tubula breast corec-
tion. (c) Hanging breast over high sitated implant
T.T. Mugea
lower two thirds of the breast vertical meridian,
together with the nippleareola complex (NAC). Age,
gravity, breast volume, and decreased elasticity con-
tribute to a gradual lowering of the breast landmarks
over time, as a woman gets older and experiences nor-
mal physiologic changes. The extent of this descent
depends primarily on the volume of the breast and the
elasticity of the tissues. The breast mound and central
pedicle will change position according to gravity
(Fig. 43.2).
In breast pseudoptosis, only the breast mound is
hanging. The nipple and the inframammary fold are at
the same level like in the normal situation. In glandular
ptosis, the breast and inframammary fold glide over
the chest. In true breast ptosis, the breast and nipple
glide over the chest, but the inframammary fold is
at the same level. For this situation, according to
Regnaults classification [10], there are three grades of
ptosis, depending on the nipple and breast lower pole
position according to the inframammary fold level.
Grade 1: Nipple at the level of the inframammary fold,
above the lower contour of the gland.
Grade 2: Nipple below the level of the inframammary
fold, above the lower contour of the gland.
Grade 3: Nipple below the level of the inframammary
fold, at the lower contour of the gland.
The limit to Regnaults breast ptosis classification
is related to the difference between moderate and
43 Breast Augmentation and Mastopexy
Fig. 43.1 (continued)
severe ptosis situations, where only the nipple position
defines the severity of ptosis. The lower contour of the
gland level according to the inframammary fold level
has no influence in the definition of breast ptosis sever-
ity. This has been corrected by Botti [11] classifica-
tion, who proposes a new classification scale of breast
tissue and nippleareola complex ptosis, according to
the distance between these and the inframammary fold
level (Fig. 43.3).
Nippleareola complex 1st degree = 01 cm
(NAC) 2nd degree = 12 cm
3rd degree = 24 cm
4th degree > 4 cm
717
Breast tissue 1st degree = 01 cm
2nd degree = 12 cm
3rd degree = 24 cm
4th degree > 4 cm
According to Botti [11], the NAC/breast ptosis
degree code could have different kinds of combina-
tions between 1/1 and 4/4.
In daily practice, based on different classifications
from the literature [12], the author noticed the difficulty
in defining in a unique way the breast volume, position,
and proportion related to the patient. Also, there are
different ways of defining breast hypertrophy as small,
moderate, or severe type, depending on the extra weight
718 T.T. Mugea

Fig. 43.2 The three types of breast ptosis, according to the the continuous line show the sixth rib level, where normally is
nipple position and inframammary fold level [10]. The dotted the inframammary fold level
lines show the breast upper pole level (anatomical landmark);

a b

Fig. 43.3 Patient with right breast ptosis NAC 3/Breast 4 (Botti classification)
43 Breast Augmentation and Mastopexy 719

added. The combination between glandular and fatty
tissue, for a defined volume, gives the breast weight,
which is difficult to be assessed before the operation.
In the last version of the computer program, a personal
formula was used for breast volume assessment [13] based
on the Breast Golden Number [14], breast vertical merid-
ian, breast perimeter, chest circumference at the inframam-
mary fold level, chest circumference at the inframammary
fold level over the breasts, and the distance between lower
pole of the breast and inframammary fold level. This for-
mula is accurate only for breast ptosis cases.
Evaluation starts based on the chart and computer
program that are able to provide the ideal aesthetic
dimensions of that breast, as Breast Golden Number.
In order to have a basis for this new classification, ten
rules are accepted:
1. All aesthetic breasts fit the Breast Golden Number
2. Aesthetic breast volume (ABV) depends on BGN
3. If the volume decrease = simply ptosis
4. If the volume increase = breast hypertrophy and
ptosis
5. All hypertrophic breasts are ptotic
6. Breast hypotrophy = below aesthetic breast volume
7. Small hypertrophy = ABV + 50% extra volume
8. Moderate hypertrophy = ABV + 100% extra
volume
9. Severe hypertrophy = ABV + 150% extra volume
10. Gigantomastia = ABV + over 200% extra volume
In the breast hypertrophy diagram, take as example an
aesthetic breast with 350 mL, and increase the volume
with 50% for each type of hypertrophy up to gigantomas-
tia. The final shape of the breast depends on its weight
over skin and suspensor fibrofascial elements quality.
Apart of the aesthetic breast, in strong connection
with applied surgical procedure, there are six types
of breasts according to glandular volume and ptosis
(Fig. 43.4):
In type 0 ptotic breast, all ptotic breasts without
significant glandular volume are included, like
empty breast founded after severe weight loss or
aging. All the following types of breasts (from
type I to type V) can be converted in one certain
situation to this type 0, losing volume by glandular
hypotrophy. Mastopexy associated with autoim-
plant or breast implant is indicated. Because of
skin and soft tissue quality, the aesthetic outcome
of the surgery is sometime less predictable. If there
is no skin excess and only empty breast, breast
augmentation with implant is the choice, and this
case does not belong to this type of ptosis.
In type I ptotic breast, small hypertrophy is natu-
rally accompanied by ptosis, and usually these
ladies wear a B- or C-cup bra size. Mastopexy with-
out glandular excision is the solution. Short inverted
T scar or vertical scar technique will ensure a
good and stable aesthetic result.

Glandular Volume & Ptosis

Classification

0 I II III IV
Type 0 - Small Volume & Skin Excess (Empty Breast)
V
Type I - Small Hypertrophy
Type II - Moderate Hypertrophy
Type III - Severe Hypertrophy & Tight Soft Tissue
Type IV - Severe Hypertrophy & Loose Soft Tissue
Type V - Gigantomasia

Fig. 43.4 Glandular volume and ptosis classification

720 T.T. Mugea

a
Mn Ac Ac

MnPb: Ac-Ac:
Sp Sp:
distance between distance between the
Lateral Edges of the distance between the
Mn(ManubriumNotch) &
Acromion Bones Antero Superior Spina
Pb(Pubis Superior Edge)
of Iliac Bone

Pb Sp Sp

Breast Vertical Diameter Breast Horizontal Diameter

b (BVD) (BHD)
Areola Diameters

the distance between the distance between

BUP
Breast Upper Pole & Sternal and Axilar Edges Areola Vertical Diameter
AVD
Inframammary Fold Level St Ax of the Infarmammary Fold Areola Horizontal
IMF AHD Diameter
(measured with a caliper).

Nipple Chest Circumference Infra Chest Circumference

c (Ni-Ch) (Infra-Ch)
Breast Perimeter Length
BPL

Circular Breast Length

Chest Circumference
Chest Circumference at the
measured over
measured at Infarmammary Fold Level.
the most projected points

of the breasts the Inframammary Fold Level

d Breast Vertical Meridian Glandular Ptosis Score Nipple Areola Complex

(G.Botti) Ptosis Score (G. Botti)
BVM

BUP
BUP to Inframmamary Fold Lower Pole of the Breast to Nipple to
IMF
distance over the Nipple Inframammary Fold distance Inframammary Fold distance
Ni

Fig. 43.5 Breast and trunk measurements, during examination

In type II ptotic breast, moderate hypertrophy is
obvious accompanied by visible ptosis, and these
women wear a C-cup bra size. Mastopexy with
small glandular resection is necessary and allows
good and predictable results.
In type III ptotic breast, there is a severe hyper-
trophy with tight soft tissue, indicating a heavy
breast with the elastic properties preserved. Usually,
these women wear a D-cup bra size and have marks
over the shoulders accompanied by neck and back
pain. The social life is severely affected. This type
of breast is a good indication for breast reduction
with short inverted T scar.
In type IV ptotic breast, there is a severe hyper-
trophy with loose soft tissue. These cases derived
from type III when they lose weight. The skin and
soft tissue have no elasticity and do not retract after
the breast excision. The gland is hanging over the
chest and can be mobilized around its base. The
upper pole of the breast is empty, and the inframam-
mary fold is longer, as used to be when the breast
was full, and lower situated on the chest. Breast
43 Breast Augmentation and Mastopexy
reduction with full horizontal inverted T scar is
usually necessary to drape the breast mound and to
avoid the dog ears of the scar.
Type V ptotic breast, including gigantomastia, is
a rare condition characterized by excessive breast
growth and can be physically and psychosocially
disabling for the patient. Symptoms include mastal-
gia, maceration/infection, postural problems, back
pain, and chronic traction injury to 4th/5th/6th
intercostal nerves with resultant loss of nipple
sensation. It is also associated with decreased fetal
growth during pregnancy [12]. Being over D cup,
bra wearing is usefulness.
Standard breast photos are taken after examination
(Fig. 43.5) and loaded in the patients electronic file.
These include standing front, profile, and oblique posi-
tion with arms relaxed and lifted. In order to demon-
strate the inframammary fold level, useful also in
tubular breast examination, special photos are taken
with the breast suspended and gently pulled by the
assistant.
43.3 Breast Augmentation and Wise
Pattern Mastopexy for Breast
Ptosis Type 0
Breast ptosis type 0 (Fig. 43.6) is the most undesirable
situation a surgeon can dream to deal with if a breast
augmentation should be done in the same time with a
mastopexy procedure. The skin is in excess without
elasticity, and the marking for the excision and new
NAC location has to be done carefully, stretching the
skin as will be with the implant inserted. Except for
the cases where the periareolar mastopexy is indicated,
the Wise pattern skin resection is the most efficient
procedure by which both the horizontal and vertical
dimensions of the skin brassiere in the ptotic breast
can be reduced.
From a vascular point of view, the inferior pedicle
allows better lateral and medial reshaping than do
superior-based flaps [15]. This is because the inferior-
based flap originates from a dermoglandular pedicle
that is based on the fourth, fifth, and sixth intercostal
perforating vessels of the internal mammary vessel.
Even the dermis of the flap can be divided, as long as
the inferior portion of the transversely oriented septum
of the breast is not violated, because the perforators are
located along the septum [16].
721
Because mastopexy and breast augmentation are
being done, are going to be done in the same proce-
dure, the patient measurement data are introduced in
both computer programs, and so the computer can sim-
ulate what will be necessary to do. and the computer
can simulate on computer programs what will be nec-
essary to do. For mastopexy, the program (Fig. 43.6b)
shows not only the preoperative breast volume and
NAC location, but also the marking points and dis-
tances where to place the incisions in order to achieve
the Breast Golden Number (in this case, BGN = 20).
Breast augmentation computer program (Fig. 43.6c)
suggests in this case an anatomical implant CPG style
313 from Mentor chart with 240 mL, but our decision
was to insert a 323 style with 260 mL. This implant has
a narrow base and a bigger projection for the same height,
corresponding to our intention to better correct the severe
ptosis degree for the empty breast. Computer programs
show the preoperative breast volume as 181 mL.
43.4 Surgical Technique
According to the preoperative marking, the surgical
procedure starts with the deepithelialization of the
inferior NAC pedicle (Fig. 43.7). Using a radiofre-
quency needle, two transdermal vertical incisions are
made deep to the adipose tissue, at 5 mm to the skin
margin. This will allow NAC pedicle gliding upward
and lateral pillar advancement to the medial line. The
periareolar and vertical dermohypodermal sutures are
done at this moment using 2/0 Vicryl, in separate
reverse way.
A separate incision for retromusculofascial approach
will be done at the lateral branch of the inframammary
deepithelialized line (Fig. 43.8), and the procedure
will continue as in a routine retromusculofascial dual
plane breast augmentation [9, 18]. The retrofascial dis-
section will be done first up to the upper third of the
major pectoralis muscle in this specific case with type
0 breast ptosis (Fig. 43.9), to allow the free muscular
retraction after division. Also, the deep layer of super-
ficial fascia will be opened along the inframammary
fold, about 2 cm superior to the inframammary crease
ligament, like a glandular window to allow the
implant to fill the lower pole of the breast (Fig. 43.10).
This deep layer of superficial fascia is like a curtain
in front of the implant, quite significantly represented
in some cases.
722 T.T. Mugea

a Computer Program Breast Reduction / Mastopexy

Computer program Breast Augmentation

Fig. 43.6 (a) Preoperative patient with breast ptosis type 0. (b) Computer program for mastopexy to be done. (c) Breast augmenta-
tion computer program
43 Breast Augmentation and Mastopexy 723

b Computer Program Breast Reduction / Mastopexy

Fig. 43.6 (continued)

Transdermal
Incision
Deepithelialised
Skin
Retro musculo fascial
Approach

Fig. 43.7 (Left) Wise pattern inferior pedicle flap. (Right) Transdermal incisions for lateral flap mobilization and retromusculofas-
cial dual plane approach for implant pocket
724
Periareolar
Purse String
Suture
Retro Musculo Lateral Flaps
Fascial Approach Pillars Suture
Fig. 43.8 Separate incision for retromusculofascial approach at
the lateral branch of the inframammary deepithelialized line
Fig. 43.9 Major pectoralis level of division
The retropectoral dissection starts laterally, close
to the inframammary fold where the space is easiest
to enter because there are no attachments to pectora-
lis minor or serratus anterior and, is carried out supe-
rior up to the nippleareola complex, and then
medially. Now the pectoralis muscle is clean, with
two dissected spaces anterior and posterior to its
belly. Holding the pectoralis fibers with an anatomi-
cal forceps, the muscle origin division starts easily
T.T. Mugea
Purse String
Suture
Retrofascial
Dissection
Glandular
Window
Deepithelialized
Flap
Fig. 43.10 Retrofascial dissection with glandular window
from lateral to medial, parallel to the inframammary
fold and 1 cm above it. The pectoral muscle division
stops at the medial edge of the inframammary fold
(Fig. 43.9) joining the retrofascial dissection level.
The retropectoral dissection continues according to
the anatomical landmarks.
Especially in the cases with thin tissues, excessive
medial or superior release of pectoralis muscle risks
the creation of superior window-shading or unnatural
medial breast fullness. Sometimes on the sternal side,
there are muscular fibers placed like a curtain, in layers
with more lateral origin that the main muscular body,
over the ribs. This must be carefully divided after
bipolar cauterization, because they can cover and hide
intercostal perforators from the internal mammary
artery. Also this division will allow a good implant
position in the medial side of the pocket.
After meticulous hemostasis, a suction drain will be
placed for 24 h through a separate stab incision and
anatomical implant inserted in the pocket. The author
uses, in this case, Mentor anatomical implant CPG
style 323 with 260 mL. Digital control will check the
implant to be well placed, in a gentle tension, and cov-
ered by the major pectoralis muscle without twisting.
The wound closure will start suturing, with 2/0
Vicryl in separate points, the deepithelialized flap at
43 Breast Augmentation and Mastopexy
Retro Musculo
Fascial Pocket
Anatomical
Silicon
Implant
Dermal
Sling
Glandular
Window
Fig. 43.11 Postoperative position of anatomical structures.
Deepithelialized flap covers the thoracic fascia
the thoracic fascia (Fig. 43.11). This will give a stronger
support for the implant in the weaker point of the lower
pole of the breast, protecting also the inframammary
fold suture from tension. The second suture layer will
approximate the thoracic fascia to dermis using 2/0
Vicryl reverse stitches in separate points. The final
shape of the breast can now be seen, and the wound
closure completed easily by a continuous running
suture with 5/0 resorbable PDS, for all areas.
The whole incision length is taped with SteriStrips
changed every 5 days, for 36 weeks. A gentle hold-
ing adherent bandage will be applied starting with sev-
eral horizontal loops at the inframammary level,
followed by several loops covering the upper pole of
the breasts in an alternative way (left breast and right
breast). This dressing will hold the whole structure as
a unit for several days. Usually, the suction drains are
removed at 24 h.
Patients are asked to wear brassiere for 6 weeks.
Gentle touch of the breasts is permitted but without
massage which can lead to an implant rotation.
725
The follow-up should be done at 7 days and at 1 and
6 months after the surgery. The patient has to come for
breast assessment, including pictures and measure-
ments at 1 and 3 years. Patients are encouraged to
come whenever they feel it is necessary, especially if
something changes in their biological life (weight,
pregnancy).
43.5 Postoperative Result
Postoperative consultation will include breast mea-
surements (Fig. 43.12) and standard photos, which
will be transferred to the computer program as con-
trol file (Fig. 43.13). Breast volume increased from
preoperative volume 181 mL to postoperative vol-
ume 413 mL, after breast augmentation with 260 mL
silicone implant. There is no arithmetic addition of
volumes, because the soft tissues have been com-
pressed by the device. Computer program shows that
postoperatively the Breast Golden Number was almost
achieved for this case. Nice natural appearing breasts
with stable result even at 6 months demonstrate the
accuracy of the planning and of the surgical procedure
(Fig. 43.14).
43.6 Mastopexy and Breast
Reconstruction for Subcutaneous
Mastectomy
This is a particular case of a 45-year-old female
(Fig. 43.15a) who came asking for a breast reposi-
tioning without breast augmentation. The preopera-
tive pictures and breast measurement introduced into
the computer program (Fig. 43.15b) guided the preop-
erative marking. The operation start as a short inverted
T scar mastopexy and turned out to be for the right
breast would start as a short inverted T scar mastopexy
(Fig. 43.16) and for the right breast a reconstruction
with mastopexy.
The patients medical history and clinical exami-
nation did not show any breast problem. The
mammography was described as according to the nor-
mal group of age, and the patient was scheduled for the
operation, without ultrasound medical report, which
was supposed to come later.
Even with preoperative checking list, because of a
human error, this case escaped without full senologic
726 T.T. Mugea

Computer Program BreastAugmentation

Fig. 43.12 Postoperative breast measurements in the computer control file

Fig. 43.13 One month postoperative

43 Breast Augmentation and Mastopexy 727

Fig. 43.14 (a) Preoperative patient. (b) One month postoperative (c) Six months Postoperative
728 T.T. Mugea

b Computer Program Breast Reduction / Mastopexy

Fig. 43.15 (a) Preoperative patient. (b) Computer program for mastopexy and preoperative measurements

examination documents at the file, and the surgeon dis-
covered the fibrocystic aspect of the right breast only
during the operation, when the inferiorly based NAC
pedicle was already prepared. Facing this tight situa-
tion, with multiple cysts full with fluids discharging in
the wound and the mastopexy with inferior NAC pedi-
cle done by half, it was a hard decision to take what to
do next. As the ultrasound report confirmed the intra-
operative findings for the right breast, the left one
being normal, we decided to do a subcutaneous mas-
tectomy with immediate breast reconstruction with an
anatomical silicone implant (Fig. 43.17).
After subcutaneous mastectomy, for the right breast
reconstruction, a retropectoral pocket was prepared.
Knowing the breast diameters and preoperative left
breast volume as 269 mL, a 225 mL Mentor anatomical
implant CPG style 323, high projection was chosen.
A suction drain was placed for 48 h. The surgical
procedure for the left breast went without incidents,
following the short inverted T scar technique [14].
43 Breast Augmentation and Mastopexy
NAC
Dernal pedicle
Fig. 43.16 (Left) Wise pattern for mastopexy, with deepitheli-
alization. (Right) NAC inferior pedicle
Retro Muscular
Pocket
Subcutaneous
Mastectomy
Anatomical Shape
Silicon Implant
NAC Dermal Flap
Fig. 43.17 Postoperative position of the anatomical structures
The right breast was taped with adherent paper
around the base (Fig. 43.18) to decrease the free space
around the implant and prevent early displacement.
Tangential areola deepithelialization has been done in
several points to allow the bleeding and decrease venous
congestion until the local circulation reestablished
(Fig. 43.18). Also, on the top of the areola, heparin-
soaked gauze was placed for about 3 days to prevent
729
blood coagulation on the deepithelialized areas. Every
23 h, some drops with diluted heparin solution were
applied on the first gauze layer, changing only the top
layer gauze. Leeches for medical use were not available
at that moment. Except for a small area of areola necro-
sis, the wound healed without aesthetic problems
(Fig. 43.19).
The postoperative result at 6 months (Fig. 43.20)
shows an acceptable breast volume, shape, and posi-
tion since the patient did not want any breast
augmentation.
This particular case is presented to emphasize the
ability of inferior dermal pedicle to support NAC
vascularization, like a randomized flap. The few favor-
able points for this outcome were:
1. Length and width of the flap was quite similar
(11/10 cm).
2. NAC flap was deepithelialized on the whole sur-
face, allowing vascular drainage.
3. Areola congestion management using tangential
deepithelialization and heparin-soaked gauze.
4. Taping the breast with adherent paper allows a good
contact between NAC dermal pedicle and skin flaps,
for capillary circulation reestablishment.
5. Active suction drain prevents fluid accumulation
and further complications related to it.
43.7 Breast Augmentation and
Periareolar Mastopexy Revision
Surgery
Breast augmentation is one of the most demanded aes-
thetic surgery procedure in private practice, and now
we are happy to do this from a financial point of view.
But we do not have to forget that now we are also oper-
ating on cases done years ago, with old types of
devices, old technology, and with old surgical
techniques.
Influenced by media, people usually are asking for
big implants without paying attention to the breast
and trunk proportions and without thinking for the
future. As the population of augmented women ages,
and also had physiological transformations during
pregnancy, breast feeding, or weight changes, greater
numbers will require some combination of breast
uplift, capsular surgery, and implant exchange. Also,
the adverse effects of implant weight on breast anat-
omy and physiology like tissue atrophy, thinning, and
730
Fig. 43.18 Tangential areola deepithelialization to allow bleeding and decrease venous congestion
a b
Fig. 43.19 Wound healing of the right breast areola. (a) Seven days. (b) One month. (c) Six months
stretching, combined with reduction of blood supply
to the skin and nipple, are the main factors increasing
the risks of combined secondary surgery and merit
careful attention [8].
In the case of a patient with retroglandular breast
augmentation done 15 years ago (Fig. 43.21), with
saline-filled round implant in a skinny patient through
a wide inframammary approach, turned out to look
like hanging rocks on the chest. Mentor, one of the
twon FDA-approved breast implant manufacturers,
performed a study that documented patients
complications with the product. In an FDA meeting
presentation in March 2000, they found that 43% of
saline implant patients reported a complication within
3 years [17]. Ten percent of those complaints were of
severe capsular contracture.
Even the implants shape had rippling, defined quite
obvious and covered with a very thin soft tissues the cap-
sular contraction corresponds to stage Baker III (grade
III the breast is firm and looks abnormal) the patient
did not have any other complaint regarding the breast
T.T. Mugea
c
augmentation except the aesthetic appearance and did not
know the device trademark or the volume used.
The computer program for mastopexy is designed
only for Wise pattern technique, but can be used
for breast volume evaluation and future NAC location
(Fig. 43.21).
43.8 Preoperative Plan and Surgical
Technique
Because of the patients preoperative poor condition
with very thin soft tissue cover on the implant, prepec-
toral implant position, and inframammary scar, a peri-
areolar mastopexy was planned combined with old
implant removal and new implant insertion through
the same inframammary approach (Fig. 43.22). The
pocket had to be changed from prepectoral to dual
plane retromuscular capsular position.
After preoperative preparation of the patient,
according with the markings (Fig. 43.23), the surgery
43 Breast Augmentation and Mastopexy
Fig. 43.20 (a) Preoperative. (b) Six months postoperative
is started with dermal incision to delimitate the
deepithelialized areas on areola. The second step of
the procedure started with areola deepithelialization
and marginal dermohypodermal incision, saving a
5-mm margin from the skin, which will be used at
the closing sutures. This marginal dermis will hold
the skin in the suture without tension and will pre-
vent poor scars during the healing process. Areola
released and undermined like a mushroom about
0.5 cm around the dermal edges of central pedicle
(Fig. 43.24a).
The wound diameter will be decreased to the desired
diameter of 5 cm using a purse string suture with 2/0
Vicryl and then sutured to the dermohypodermic layer
of the new skin margin with reverse separate 2/0 Vicryl
731
sutures and running intradermal suture with 5/0 PDS
(Fig. 43.24b).
The surgery continued with inframammary
approach. Old scar will be excised in an elliptical
shape with 6/0.5 cm dimensions, followed by capsular
incision of the same length. A small amount (few mL)
of synovial-like fluid discharge and was been sent to
the lab for bacteriologic examination. The capsule was
about 2 mm thick, close to the skin, and not adherent
to the implant. Implant removal has been done without
incidents, and the measured volume (done by immer-
sion in a certain amount of water) show 400 mL of
saline. A specimen from the periprosthetic capsule,
including a few millimeters of soft tissue close to it,
was sent for histopathology, for records.
732
The pocket looked clean, with some fibrotic bridges
between cupola and the floor at the medial and lateral
edges. The capsule floor, including pectoral fascia, had
been removed up to the level of the superior edge of
the pocket, followed by several 34-cm-long radial
incisions of the capsular cupola.
The pectoralis major muscle looks very thin and
has been divided close to the sternal origin [18],
preserving about 1-cm-small inferior stump. A suction
drain with mild negative pressure was placed using a
lateral stab incision. Considering the computer
program advice, experience, and local conditions, it
was decided to insert a Mentor CPG anatomical
implant, style 323 with 260 mL, and 5.3-cm projection
in a retromuscular capsular position (Fig. 43.25a). The
Fig. 43.21 (a) Preoperative patient. (b) Breast measurements and computer program for mastopexy. (c) Breast measurements and
computer program for implant selection
T.T. Mugea
wound was closed in two layers using 2/0 Vicryl inter-
rupted sutures.
The whole incision length is taped with Steri-Strips
changed every 7 days, for 36 weeks. Patients are
asked to wear a special brassiere for 6 weeks to hold
the implant in the same position. Postoperatively, mild
venous congestion was noted on some areas of the
areola, which healed without problems (Fig. 43.25b).
The suction drains are removed in 36 h, and patient is
discharged in 48 h after the operation with oral antibi-
otics (cefalexine) for 3 days.
The postoperative follow-up at 7 days and 30 days
show an acceptable result, with good breast position
and proportion with the chest, achieving the Breast
Golden Number (Figs. 43.25c and 43.26).
43 Breast Augmentation and Mastopexy 733

b Computer Program Breast Reduction / Mastopexy

c Computer Program Breast Augmentation

Fig. 43.21 (continued)

10 years previously. For the first 5 years, the postopera-

43.9 Breast Augmentation and Wise
Pattern Mastopexy Revision
Surgery
This patient (Fig. 43.27) had a retroglandular breast
augmentation with 230 mL saline-filled Polytech
Silimed implant through an inframammary approach
tive outcome was fine, without problems, and the patient
was happy with the result. After a pregnancy with 12-kg
body weight variation and 2 months breast feeding, the
breast become ptotic, with folds visible on the upper
pole and implants palpable close to the skin in the lower
pole. She came with the implant passport and discharge
letter from the clinic where she had the operation done,
734 T.T. Mugea

Periprosthetic
Capsula
Periprosthetic
Capsula

Retro Musculo Capsular

Dual Plane Pocket
Periareolar
Deepithelialized Skin

Inframammary
Approach

Fig. 43.22 (Left) Preoperative position of breast implant. (Right) The operation plan

a b c

Fig. 43.23 Preoperative marking for periareolar mastopexy

a b
Periareolar
Purse
String Suture

Inframmary
Scar

Fig. 43.24 (a) Round block periareolar mastopexy (areolar release). (b) Periareolar mastopexy with purse-string suture
43 Breast Augmentation and Mastopexy 735

a b
Retro Musculo capsular
Dual plane pocket

Anatomical
Silicon lmplant

Periprosthetic
Capsula

Dermo Capsular
Flap

c Computer Program Breast Augmentation

Fig. 43.25 (a) Postoperative position of breast implant and anatomical structures. (b) Twenty four hours postoperative showing
partial areolar venous congestion. (c) Postoperative result with Breast Golden Number achieved

and the senologic examination confirmed the saline-
filled silicone implant with the retroglandular pocket
and a thin preprosthetic capsule (Fig. 43.28). A small
line of intracapsular fluid was detected.
Clinical consultation and breast measurements lead
to the decision to perform a Wise pattern mastopexy
with short inverted T scar (Fig. 43.29) and implant
replacement with a silicone gel device (Fig. 43.30) in a
new retromuscular capsular pocket (Fig. 43.31).
Preoperative marking (Fig. 43.32) was done with
the computer dimensions. According to the preop-
erative marking, the surgical procedure starts with
736 T.T. Mugea

Fig. 43.26 (a) Preoperative. (b) Seven days postoperative. (c) One month postoperative
43 Breast Augmentation and Mastopexy
a b
d e
Fig. 43.27 Preoperative patient in standard positions
the deepithelialization of the inferior NAC pedicle
(Fig. 43.33). Using a radiofrequency needle, two trans-
dermal vertical incisions are cut, deep to the adipose
tissue, at 5 mm to the skin margin (Fig. 43.33). This
will allow the NAC pedicle to glide upward and lateral
pillars advancement to the medial line. The periareo-
lar and vertical dermohypodermal sutures are done at
737
c
f
this moment using 2/0 Vicryl, in separate reverse way,
covering the dermocapsular inferior NAC pedicle. The
final intradermal suture will be done at the end of the
surgery. A separate incision (5 cm length) for implant
removal and new pocket creation will be done at the
lateral branch of the inframammary deepithelialized
line (Fig. 43.34), using the radiofrequency device.
738 T.T. Mugea

A small amount of synovial-like fluid was found

in the pocket and samples were sent to bacteriol-
ogy for examination. The thin periprosthetic capsula
(Fig. 43.35) covering the implant was not adherent
to the device, and the pocket looks to be a little bit
larger, allowing the implant to move gently inside.
Periprosthetic
Capsula The implant shield had a textured surface covered with
multiple spots of white fibrotic tissue (Fig. 43.35) that
condensed behind the valve. In one case, a condensed
band was found connected to the periprosthetic cap-
sule (Fig. 43.36) lifting the implant valve and allowing
the saline fluid leaking from the device.
The host reaction to the implant as a foreign body
includes three layers:
1. First layer represented by the periprosthetic capsule.
2. Second layer is the synovial-like fluid inside
periprosthetic capsule.
3. Third layer covers the implant texture and is inti-
mately adherent to it.
A specimen from the periprosthetic capsule, including
few millimeters of soft tissue close to it, was sent to the
histopathology, for records. The removed breast implants
Fig. 43.28 Preoperative patient with implant in place had the volumes unchanged from the initial operation,
230 mL. The pocket looked clean, without fibrotic bridges

Computer Program Breast Reduction / Mastopexy

Fig. 43.29 Breast and trunk measurements and computer program for mastopexy
43 Breast Augmentation and Mastopexy 739

Computer Program Breast Augmentation

Fig. 43.30 Patient measurements and computer program for breast augmentation

Retro Musculo The pectoralis major muscle that looks thin was
Capsular Pocket divided close to the sternal origin, preserving about
1-cm-small inferior stump. A suction drain with mild
Periprosthetic negative pressure was placed using a lateral stab inci-
Capsula sion. Considering the computer program advice, our
experience, and local conditions, it was decided to
insert a Mentor CPG anatomical implant, style 323
with 195 mL, and 4.8-cm projection in a retromusculo-
Deepithelialized capsular position.
Periareolar Skin The wound closure will start suturing, with 2/0
Dermo Cutaneous
Lateral Flaps Vicryl in separate points, the corresponding deepithe-
lialized flap and periprosthetic capsule to the thoracic
fascia (Fig. 43.37). This will give a stronger support
Inframammary for the implant in the weaker point of the lower pole of
Approach
the breast, protecting also the inframammary fold
suture from tension.
The second suture layer approximated the thoracic
fascia to dermis using 2/0 Vicryl reverse sutures in
Fig. 43.31 Operation plan separate points. The whole wound closure was com-
pleted by a continuous running suture with 5/0 resorb-
between cupola and the floor. The capsule floor, includ- able PDS, for all areas. At the end of the surgery, the
ing pectoral fascia, was removed up to the level of the lower pole of the implant will be sustained by the NAC
superior edge of the pocket, followed by several 34-cm- dermal capsular inferior pedicle covered by the dermal
long radial incisions of the capsular cupola. cutaneous lateral flaps (Fig. 43.38).
740
a b
d e
Fig. 43.32 Preoperative marking for short inverted T scar mastopexy
The incisions lines were taped with Steri-Strips
(Fig. 43.39) changed every 5 days, for 36 weeks.
A gentle holding adherent bandage will be applied
starting with several horizontal loops at the infra-
mammary level, followed by several loops cover-
ing the upper pole of the breasts in an alternative
way (left breast and right breast). This dressing
T.T. Mugea
c
f
will hold the whole structure as a unit for several
days. Usually, the suction drains can be removed at
24 h. Postoperative result (Fig. 43.39) at 1 and
6 months shows a nice shape of the breast, with
good NAC position, and a breast volume well fitted
with the patients body weight and dimensions
(Fig. 43.40).
43 Breast Augmentation and Mastopexy 741

Deepithelialised Skin
NAC
Inferior Pedicle Transdermal
Incisio

Retro Musculo
Capsular Approach

Fig. 43.33 (Left) Wise pattern for mastopexy, with deepithelialization. (Right) NAC inferior pedicle

Periareolar
Purse String
Suture

Retro Musculo Lateral Flaps

Fascial Approach Pillars Suture

Fig. 43.35 (a) Periprosthetic capsule. (b) Removed saline-

filled silicone breast implants

Fig. 43.34 Separate incision for retromusculofascial approach

at the lateral branch of the inframammary deepithelialized line
742 T.T. Mugea

Retro Musculo
Capsular Pocket

Anatomical
Silicon
Implant

Dermo Capsular
Sling

Dermo
Capsular
Flap

Fig. 43.37 Postoperative situation of the breast implant and

anatomic structures

NAC

Fig. 43.35 (continued) Dermo cutaneous

Lateral Flaps
NAC
Dermo Capsular
Inferior Pedicle

Inverted T Scar

Fig. 43.38 Dermocapsular inferior pedicle covered by the lat-

eral dermocutaneous flaps

Fig. 43.36 Fibrotic tissue from the periprosthetic capsule lift-

ing the implant valve
43 Breast Augmentation and Mastopexy 743

Fig. 43.39 (a) Early postoperative result with Steri-Strip tapes over the suture lines. (b) One month postoperative. (c) Six months
postoperative
744
Computer Program Breast Augmentation
Fig. 43.40 Postoperative breast dimensions and volume correspond to the Golden Number
43.10 Conclusions
Several points have to be emphasized:
1. Breast augmentation has to be considered a high-
level procedure.
2. Breast augmentation is the beginning of a series of
revision surgery in most of the cases, sooner or
later.
3. The heavier the implant is, the higher the risk of
long-term complications will be.
4. The inframammary approach in first session of
breast augmentation is more convenient for a sec-
ondary procedure.
5. Retrofascial pocket for breast implant is the first
choice, allowing a revision surgery with retropec-
toral switch.
6. Periprosthetic capsule can be used as a comple-
mentary support of the breast implant.
7. Combined operations in the same procedure have
a high risk of complications.
8. Revision surgery for breast augmentation and mastopexy
has to be carefully planned for vascular risk.
T.T. Mugea
9. Preoperative patient evaluation and combined
computer program for breast augmentation and
breast reduction are useful for a good planning
and postoperative assessment.
10. To share our experience with difficult cases,
recognizing our mistakes is more useful than a pre-
sentation with huge series with excellent results.
References
1. Benelli L (1990) A new periareolar mammoplasty: the
round block technique. Aesthetic Plast Surg 14(2):93100
2. Bartels RJ, Strickland DM, Douglas WM (1976) A new
mastopexy operation for mild or moderate breast ptosis.
Plast Reconstr Surg 57(6):687691
3. Lejour M (1994) Vertical mammoplasty and liposuction of
the breast. Plast Reconstr Surg 94(1):100114
4. Wise RJ (1956) Preliminary report on a method of planning
the mammoplasty. Plast Reconstr Surg 17(5):367375
5. Cronin TD, Gerow RM (1964) Augmentation mammoplasty:
new natural feel prosthesis. In: 3rd international congress of
plastic surgery, excerpta medica international congress series
no. 66. Excerpta Medica, Amsterdam, 1964, pp 4149
43 Breast Augmentation and Mastopexy
6. Regnault P (1977) Partially submuscular breast augmenta-
tion. Plast Reconstr Surg 59(1):7276
7. Graf RM, Bernardes A, Rippel R, Araujo LR, Damasio RC,
Auersvald A (2003) Subfascial breast implant: a new proce-
dure. Plast Reconstr Surg 111(2):904908
8. Handel N (2006) Secondary mastopexy in the augmented
patient: a recipe for disaster. Plast Reconstr Surg 118
(7 Suppl):152S163S
9. Spear S (2003) Augmentation/mastopexy: surgeons beware.
Plast Reconstr Surg 112(3):905906
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11. Botti G (2004) Mastoplastiche estetiche, atlante di chirurgia
plastica pratica. SEE Nicodemo & C snc, Firenze, p 251
12. Dancey A, Khan M, Dawson J, Peart F (2008) Gigantomastia
a classification and review of the literature. J Plast Reconstr
Aesthet Surg 61(5):493502
13. MugeaTT (2010) Computer program for breast reduction
and mastopexy. In: Presented at the 12th international
745
congress of oriental society of aesthetic plastic surgery,
Tokyo, 13 Nov 2010
14. Mugea TT (2009) Breast reduction algorithm using
TTM chart. In: Shiffman MA (ed) Mastopexy and breast
reduction: principles and practice. Springer, Berlin, pp
275289
15. Loustau HD, Mayer HF, Sarrabayrouse M (2008) The owl
technique combined with the inferior pedicle in mastopexy.
Aesthetic Plast Surg 32(1):1115
16. Widgerow AD (2005) Breast reduction with inferior pedicle
fascial suspension. Aesthetic Plast Surg 29(6):532537
17. FDA (2004) Section on complications, FDA breast implant
consumer handbook
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augmentation. In: Shiffman MA (ed) Breast augmentation:
principles and practice. Springer, Berlin, pp 415429
 Periareolar Mammaplasty
for the Treatment of Massive
Gynecomastia with Breast Ptosis
Marco Tlio Rodrigues da Cunha
44.1 Introduction
Gynecomastia surgeries have continued to evolve, but
treating massive and excess skin male breasts with
minimal incisional scarring is still challenging.
Simon et al. [1], in 1973, described a clinical clas-
sification after analysis of 77 cases of gynecomastia:
Grade 1, small, visible breast enlargement without skin
redundancy; Grade 2A, moderate breast enlargement
without skin redundancy; Grade 2B, moderate enlarge-
ment with skin redundancy; Grade 3, marked breast
enlargement with marked skin redundancy.
The first description of a surgical treatment was
made by Paulus of Aegina [2] (A.D. 635690) using a
semilunar inframammary incision. Dufourmental [3],
in 1928, described an infra-areolar marginal incision,
divulged by Webster [4] in 1946. The transareolar mam-
mary incision was published by Pitanguy [5] in 1966.
Many surgical difficulties are found in Group 2B
and 3, where excess skin is present. Some authors
describe excess skin resection using a half-moon
located at the borders of areola [6]; others utilize verti-
cal [7, 8], transverse [2], or oblique [9] skin ellipses.
Free graft [10] as well as superior pedicle [7] and
bipedicle flaps [2] are employed to elevate the nipple-
areola complex in large gynecomastia. Joseph [11], in
1925, published a method of female mammaplasty, in
two stages, where the nipple-areola complex is trans-
planted by means of an inferior pedicle flap.
M.T.R. da Cunha
Department of Plastic Surgery, Federal University
of Tringulo Mineiro, Uberaba, MG, Brazil
e-mail: cunhamarco@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_44, Springer-Verlag Berlin Heidelberg 2013
44
Andrews et al. [12], in 1975, described a periareolar
approach for breast reduction. Ribeiro [13], in 1975, used
an inferior pedicle flap with the aim of projecting the mam-
mary cone and stabilizing its shape. Davidson [14], in 1979,
removed excess skin in concentric circles limiting the final
scar to a circle at the periphery of the areola. Benelli [15],
in 1988, presented a permanent periareolar circling to avoid
late widening of the nipple-areola complex. Martins [16],
in 1991, described a periareolar mammaplasty with flap
transposition. Kornstein and Cinelli [17], in 1992, reported
an inferior pedicle flap associated to a superiorly based
chest wall flap to reposition the nipple-areola complex,
resulting in a periareolar and inframammary scar.
The authors reported the use of the periareolar
mammaplasty, with an inferior pedicle flap including
the nipple-areola complex, to correct a male breast
ptosis, as prior note in 1993 [18].
The aim of the present technique is to evaluate
the use of the periareolar skin approach associated
with inferior or superior pedicle flaps that include the
nipple-areola complex.
44.2 Technique
The criteria adopted for patient selection were: breast
ptosis, massive gynecomastia, and skin excess.
Skin markings (Fig. 44.1) are performed with a
longitudinal line dividing the breast in two equal
halves (meridian), as well as the inframammary crease.
The breast meridian is marked:
Point A, 1726 cm from the sternal notch
Point B, 46 cm or more (in special cases) proxi-
mally to the inframammary crease
Point C, half the distance between points A and B.
747
748 M.T.R. da Cunha

a are joined, obtaining an oval-shaped form. The new

areola is marked with 3 cm diameter.
The breast meridian line was not always marked
passing on the nipple-areola complex. This allowed for
replacing the areola more medially or laterally when
necessary.
The surgery is performed under general anesthesia

CM
and topic infiltration with saline 1:400,000 epineph-

26
rine solution (Fig. 44.2). Liposuction is performed

17 using a 3-mm cannula at pectoral fascia plane and
A then superficially. This avoids dish-like deformity
and makes easier to remove the excess adipoglandu-
lar tissue from adjacent tissues. The excess skin
D C E
LINE marked is removed in its total thickness. The infra-
C areolar area is carefully deepithelialized preventing
injuries in the pedicle of the flap. An inferior pedicle
B 4 6cm
is made embodying the nipple-areola complex (used
in 8 of 19 cases) or a superior pedicle is used (in 11
INFRAMAMMARY cases). The flap thickness is reduced to that of the
CREASE patients subcutaneous tissue and its width to approx-
imately 5 cm. The flap is freed from the remnant skin
BREAST that covers it anteriorly, undermining it until next to
MERIDIAN inframammary crease in inferior pedicle cases. In the
superior pedicle cases after skin removal, a hemi-
circular incision is made distal to the nipple-areola
b complex. The excess adipoglandular tissues are easily
removed next to the flap, inside and outside the area
of skin resection. Hemostasis is carefully made under
direct vision. The tip of the flap is fixed to the anterior
pectoral fascia with four cardinal sutures, 1726 cm
from the sternal notch, in the breast meridian. The
superior pedicle nipple-areola complex does not need
to be sutured to the pectoral fascia or to be freed from
the remnant proximal skin. Double permanent peri-
areolar circling is made using 5-0 monofilament
nylon, closing the purse until 3 cm in diameter.
A catheter for suction drainage is placed through an
inframammary stab.
Fig. 44.1 Preoperative markings in patient with Grade 2B Sutures in U unite the areola to the periareolar
enlargement according to Simons classification (a) representa- purse-string skin. An occlusive dressing, lightly
tional drawing. (b) Clinical case compressive, is applied.

A transverse line, perpendicular to the breast merid- 44.3 Postoperative Care

ian, is marked passing on point C (line C). On line C,
the points D and E are marked by means of bidigital
pinching, bringing them near, equidistant from the
breast meridian line. Excessive tension should be
avoided in this maneuver. The points A, D, B, and E
1. Suction drainage is maintained for 25 days.
2. The sutures are removed on the seventh to twelfth
postoperative day.
3. Compressive dressing is kept for 28 weeks.
44 Periareolar Mammaplasty for the Treatment of Massive Gynecomastia with Breast Ptosis
a c
b d
Fig. 44.2 (a) Left breast with point A at 21 cm from sternal
notch. (b) Liposuction is performed deeply at pectoralis major
fascia and then superficially to make easier the glandular resec-
tion and to avoid the dish-like deformity. (c) Pinch test after
liposuction showing the differences between right breast and
still not operated left breast. (d) Skin incisions keeping the are-
ola with 3 cm diameter. (e) Excess skin deepithelialized around
749
the areola. (f) Aperture to remove residual adipoglandular tissue.
(g) Incision on inferior pole of the deepithelialized area. (h) Two
purse-string sutures are made to prevent from late widening of
nipple-areola complex. (i) Closure of purse-string sutures leav-
ing 2.5 cm circular raw area. (j) Half-buried horizontal mattress
sutures complete the procedure
750 M.T.R. da Cunha

e f

g h

i j

Fig. 44.2 (continued)

44.4 Complications 4. Infection: 1 case

5. Bulging in the inferior pole of the breast:
1. Postoperative bleeding: 1 case 2 cases
2. Seroma: 2 cases 6. One patient with skin hypoesthesia that lasted for
3. Areola enlargement: 1 case 30 days
44 Periareolar Mammaplasty for the Treatment of Massive Gynecomastia with Breast Ptosis
44.5 Discussion
Most of the difficulties in the surgical treatment of the
gynecomastia are due to the restrict size of the incision
that prejudices the illumination of the operative field
and the hemostasis. The transareolar mammary [5] and
infra-areolar marginal incisions [3, 4] are not always
efficient to correct gynecomastia with marked skin
redundancy and to elevate the nipple-areola complex.
Skin resections by means of inverted T technique
[11] and vertical [7, 8] and transverse [9] skin ellipses
result in long scars and can leave the breast cone like.
The illness stigma is replaced by a scar stigma, espe-
cially in patients with hairless chest wall.
The authors used the periareolar mammaplasty with
skin markings similar to those described by Martins
[16], in 1991, associated with an inferior pedicle flap
including the nipple-areola complex. The fixing of the
flap to the anterior pectoral fascia did not significantly
reduce the areola mobility due to its contact with the
flap pedicle and not directly with the fascia.
One of the greatest disappointments of the periareo-
lar mammoplasties in female patients is due to the
flattening of the breast cone. This is one of the least
desired events in gynecomastia operation.
The authors believe that the widening of the nipple-
areola complex resulted from a small undermining of
the remnant skin and tension in the suture by insuffi-
cient closure of the permanent periareolar circling.
Fig. 44.3 (a) Preoperative patient with severe gynecomastia. (b) Skin markings (right breast) for superior pedicle technique keeping
more medial toward the breast meridian to keep the nipple-areola complex medially. (c) Three months postoperatively
751
When there is marked tension in the suture, the purse
string should be closed approximately 20% more
than the desired areolar diameter. In our hands, this
procedure was not always effective. It is important that
the diameter of the skin that will be removed should
not exceed twice that of the new areola in regular cases.
In massive gynecomastia, the amount of skin to be
removed is only limited by tension on bidigital pinch-
ing and by position of the areola. The patient should be
advised about the possibility of a second-stage proce-
dure to remove residual skin and adipose tissue.
The redundant adipoglandular tissue in the inferior
pole of the breast is credited to the fear of thinning
excessively the base of the inferior pedicle flap.
The use of 2-0 monofilament nylon suture in the
periareolar purse string in our first cases led to extru-
sion of the suture material and infection in one case.
This problem was solved with the use of 5-0 monofila-
ment nylon and performing a tensionless purse string.
The marking of point B, 4 cm proximal to the infra-
mammary crease, seemed to limit its elevation until
the desired position of nipple-areola complex in some
cases. Its marking, 12 cm higher or more if necessary,
would be better to adequately bring the purse string to
the new position of the areola.
The use of the periareolar skin resection associated
to inferior or superior pedicle flaps gave a high index
of satisfaction to our patients and would be another
option in well-selected cases (Figs. 44.3 and 44.4).
752 M.T.R. da Cunha

Fig. 44.3 (continued)

44 Periareolar Mammaplasty for the Treatment of Massive Gynecomastia with Breast Ptosis 753

a b

Fig. 44.4 (a) Preoperative patient with massive gynecomastia. (d) One year postoperative. (e) Periareolar scar and just proxi-
(b) Intraoperative wide operative field and superior pedicle mally a hypertrophic scar from the removal of a dysplastic mel-
with a medially positioned areola. (c) Immediate postoperative. anocytic nevus
754 M.T.R. da Cunha

References 10. Wray RC, Hoopes J, Davis GM (1974) Correction of

extreme gynaecomastia. Br J Plast Surg 27(1):3941
11. Sinder R (1989) Mamaplastia redutora histrico.
1. Simon BE, Hoffman S, Kahn S (1973) Classification and
In: Ribeiro L (ed) Cirurgia Plstica da Mama. MEDSI, Rio
surgical correction of gynecomastia. Plast Reconstr Surg
de Janeiro, pp 135
51(1):4852
12. Andrews JU, Yshizuki MM, Martins DM, Ramos RR
2. Ward CM, Khalid K (1989) Surgical treatment of grade III
(1975) An areolar approach to reduction mammaplasty.
gynaecomastia. Ann R Coll Surg Engl 71(4):226228
Br J Plast Surg 28(3):166170
3. Dufourmental L (1928) Lincision arolaire dans la chirur-
13. Ribeiro L (1975) A new technique for reduction mamma-
gie du sein. Bull Mem Soc Chir Paris 20:9
plasty. Plast Reconstr Surg 55(3):330334
4. Webster JP (1946) Mastectomy for gynecomastia through
14. Davidson BA (1979) Concentric circle operation for massive
semicircular intra-areolar incisions. Ann Surg 124:557
gynecomastia to excise the redundant skin. Plast Reconstr
5. Pitanguy I (1966) Transareolar incision for gynecomastia.
Surg 63(3):350354
Plast Reconstr Surg 38(5):414419
15. Benelli L (1988) Technique de plastie mammaire: le round
6. Letterman G, Schurter M (1972) Surgical correction of
block. Rev Fr Chir Esth 13:711
massive gynecomastia. Plast Reconstr Surg 49(3):259262
16. Martins PA (1991) Mamaplastia periareolar com trans-
7. Hrinakova MF (1983) Reduction mammaplasty in seri-
posio de retalhos. Rev Bras Cir Plast 6:810
ous gynecomastias using a single superiorly based flap.
17. Kornstein AN, Cinelli PB (1992) Inferior pedicle reduction
In: Transaction of the VIII international congress of plastic
technique for larger forms of gynecomastia. Aesthetic Plast
surgery, Montreal, 1983, p 535
Surg 16(4):331335
8. Pers M, Breteville-Jensen G (1972) Reduction mammo-
18. Cunha MTR, Bento JFB (1993) Periareolar mammaplasty
plasty based on vertical vascular pedicle and tennis ball
for treating gynecomastia with breast ptosis. Prior note. Rev
assembly. Scand J Plast Reconstr Surg 6(1):6168
Soc Bras Cir Plast Est Reconstr 8(1, 2, 3):125130
9. Dufourmental C, Mouly R (1961) Plastie mamaire par la
methode oblique. Ann Chir Plast 6:45
 Reduction Mammoplasty:
The Piece of Art
Fahmy S. Fahmy and Mohamed Ahmed Amin Saleh
45.1 Introduction
The female breast is one of the most attractive aesthetic
areas in female anatomy. Representation of breasts in
fine arts is best represented in Ingres erotic paint Turkish
Bath (Fig. 45.1) and others. All paints are eloquent tes-
timonies to the important role that feminine beauty and
depiction of breasts play in societies. Our perception of
what constitutes beautiful and sensuous breasts have not
changed for the past 2,500 years. The size, shape, and
symmetry of the breasts can have a dramatic effect on the
womens well-being. Reduction mammaplasty is cer-
tainly one of the operations; plastic surgeons can signifi-
cantly contribute to a womans quality of life. Surgery
has repeatedly shown high patient satisfaction rate.
Many women with excessively large breasts might
suffer from poor self-esteem, altered self-image, and
other psychological effects. In addition, women whose
breasts are abnormally large relative to their body built
are frequently limited in their choice of clothing and
lifestyle. They may find it difficult to exercise, to play
sports, and to participate in other daily activities. In
short, a womans breast size can affect her attitudes,
career choices, and personal life in many ways.
Medical conditions like skin lacerations and inter-
trigo, chest tightness, chronic headaches as well as
breast, neck, back, and shoulder pain are common
F.S. Fahmy (*)
Department of Plastic Surgery,
Countess of Chester Hospital, Cheshire, UK
e-mail: plasticsurgfahmy@aol.com
M.A.A. Saleh
Plastic Surgery Department, Ain Shams University,
Cairo, Egypt
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_45, Springer-Verlag Berlin Heidelberg 2013
45
presenting complaints of women with excessively
large breasts. These symptoms are either eliminated or
markedly improved by reduction mammaplasty. After
surgery, many of these women enjoy a totally new out-
look, cured from their medical complaints and pursue
activities that were previously unavailable to them.
This chapter will review the anatomic basis for many
of the breast reduction operations, summarize most of
the literature, and discuss the senior authors (FSF) pre-
ferred technique on reduction mammaplasty.
45.2 History
Breast reduction surgery continues to evolve and is
being refined constantly with a large number of proce-
dures. Each presents particular advantages in terms of
indications, vascular preservation, technique design,
ease of realization, minimum scarring, maintenance of
innervation, and long-term results.
As early as the sixth century AD, Paulus Aegineta
described details of reduction mammaplasty for the
correction of gynecomastia. Hans Schaller performed
a reduction mammaplasty by breast amputation in
1561 [1]. Dieffenbach [2] was the first to perform a
reduction mammaplasty in a female, leaving the scar
in the inframammary fold. Thomas [3] and Guinard [4]
emphasized the inframammary fold as an entrance site
for the surgical correction of excessive breast tissue.
Most of the operations performed in the late 1800s
and early 1900s aimed at correcting ptosis. Various
types of skin and glandular excision were involved, all
of which attached or suspended the breasts into a
higher position on the chest wall, but without true nip-
ple-areola complex (NAC) transposition. The concept
755
756
Fig. 45.1 The Turkish Bath
painting by Ingres in 1862
of nipple-areola complex transposition was advanced
between 1909 and 1925. Morestin in 1909 [5] was prob-
ably the first to transpose the nipple-areola, followed by
Villandre, cited in 1925 and referring to patient whom
he operated on in 1911 [6], and Lexer [7].
The next stage in the evolution of breast reduction
surgery concentrated on the better understanding of
the blood supply of the skin, mammary gland, and
nipple-areola. The subdermal blood supply to the
breast skin and gland was carefully considered.
In 1937, Schwarzman [8] recommended leaving a
periareolar dermal ring to enhance arterial and venous
blood supply to the nipple-areola. This maneuver
improved viability of the nipple-areola complex, facil-
itated its transfer, and was a start for techniques involv-
ing deepithelialized nipple pedicle flaps.
The importance of preoperatively marking the inci-
sions was emphasized by Bames in 1948 [9]. The fol-
lowing year, Aufricht [10] remarked that ultimate breast
form is determined by the postsurgical skin brassiere.
Wise in 1956 [11] described a pattern for preoperatively
F.S. Fahmy and M.A.A. Saleh
marking the breast that produced accurate and
reproducible resection of parenchymal tissue with
minimal complications and satisfactory breast shape.
Subsequent refinements in breast reduction surgery
evolved around pedicle designs to preserve vascularity
and place the scars in more aesthetic sites. Various ori-
entations of the breast dermal and parenchymal pedicles
were described. Strombeck [12] described a horizontal
dermal bipedicle flap that helped maintain innervation
to the nipple-areola complex. McKissock [13] described
a vertical bipedicle flap; Weiner [14], a superiorly based
flap; Orlando and Guthrie [15], a superomedially based
flap; and Courtiss and Goldwyn [16] and Georgiade
[17] used inferiorly based flaps (Fig. 45.2).
Several authors since have described additional
innervation to the breast, Marchac [18], Ges [19],
Lejour [20], and Lassus [21], facilitating vertical and
short-scar reduction techniques. Although some of
these techniques were developed in the late 1960s and
1970s, its only been in the last few years that they
have gained widespread popularity.
45 Reduction Mammoplasty: The Piece of Art 757

45.3 Pathology remain quite small (9). The pathophysiology of breast

Massive breast enlargement or gigantomastia (juvenile
virginal hypertrophy of the breast) was first described
by Durston [22]. It is defined as yielding at least
1,800 g of tissue per side during reduction mamma-
plasty [23, 24]. It is characterized by massive enlarge-
ment of the breast tissue to enormous proportions,
predominantly manifests in early puberty between 11
and 14 years of age and most often manifests with the
first menses [23, 25].
Massive breast enlargement consists primarily of
fibrous tissue and fat, while the glandular elements
hypertrophy is thought to be an abnormal end-organ
response to circulating estrogens [2628]. Jabs et al.
[29] showed normal levels of estrogen and the usual
number of estrogen receptors in women with mam-
mary hypertrophy, evidence of some womens hyper-
sensitivity to the hormone.
Eliasen [30] noted changes consistent with atypical
ductal hyperplasia in the surgical specimens obtained
from five of nine young women who underwent reduc-
tion mammaplasty for hypertrophy, none of them
showed any signs of breast carcinoma. This study sug-
gests that ductal hyperplasia may also play a role in the

a b

c d

Fig. 45.2 Various

orientations of the breast
dermal and parenchymal
pedicles. (a) Horizontal
bipedicled flap. (b) Vertical
bipedicle flap. (c) Superiorly
based flap. (d)
Superomedially based flap.
(e) Inferiorly based flaps
758
Fig. 45.2 (continued)
e
etiology of breast hypertrophy. Kupfer et al. [31]
reviewed the literature of juvenile breast hypertrophy
and presented their experience in two patients, mother
and daughter, which suggested to them a familial pat-
tern to the disease.
45.4 Gigantomastia
The mainstay of treatment in gigantomastia is radical
surgery. Free nipple grafting is frequently required to
obtain an adequate reduction. Recurrence of gigan-
tomastia is a recognized risk, particularly among preg-
F.S. Fahmy and M.A.A. Saleh
nant women, and surgical reduction is the primary
therapy for recurrence [23].
A hormone assay is not indicated, especially in a
person who has normal secondary sex characteristics
[23].Although early studies showed that hormone sup-
pression was ineffective in the management of gyneco-
mastia, Baker and associates [32] reported a successful
experience with tamoxifen combined with reduction
mammaplasty.
The differential diagnosis of unilateral massive breast
hypertrophy in adolescent girls includes fibroadenoma,
cystosarcoma phyllodes, virginal hypertrophy (unilat-
eral), breast hamartoma, and trauma [23, 33, 34].
45 Reduction Mammoplasty: The Piece of Art
45.5 Indications for Surgery
Breast size that is out of proportion to body habitus has
a profound effect on the musculoskeletal system. Many
patients complain of neck and shoulder strain, head-
aches, breast pain, back pain, persistent rashes in the
intertriginous areas, a heavy anterior chest, and occa-
sionally, paresthesia of the ulnar side of the hand.
These women tend to show poor posture, with deep
shoulder grooving from bra straps, stretch marks, and
rashes under the breast. In extreme cases, degenerative
arthritis of the cervical and thoracic spine has been
noted. Letterman and Schurter [35] discuss the ana-
tomical basis for these signs and symptoms, and con-
cur with others that reduction mammaplasty may be
curative.
The psychological benefits of restoring propor-
tion between a womans breasts and her physique are
difficult to quantify, but most surgeons believe they
are considerable. Despite various studies of reduction
mammaplasty showing favorable results [3643], the
surgical indications for reduction mammaplasty remain
unclear and subject to different interpretations by third-
party payers. Surgery is the only real option available
to reduce the breast size. Hormonal therapy, as such, is
ineffective. Supportive brassieres are temporary mea-
sures to relief symptoms by transferring the discomfort
to other areas.
Netscher et al. [44] studied whether breast size
alone was responsible for the presenting complaints of
neck and back pain in patients seeking breast reduc-
tion. The authors found that symptomatic hypermastia
is better defined by a constellation of symptoms rather
than volume of tissue removed. There was no correla-
tion between a womans weight and symptoms associ-
ated with large breast size; overweight women had a
different symptom complex than those with large
breasts. The authors conclude that symptomatic hyper-
mastia can be defined by a set of disease-specific phys-
ical and psychosocial symptoms which are not related
to patient age or weight.
Kerrigan and coworkers [45, 46] investigated the
quality of life of women with breast hypertrophy. The
authors conclude that breast hypertrophy has a signifi-
cant impact on womens quality of life. Symptoms are
more important than breast volume in determining
which women have the greater health burden.
759
In a third prospective study, the authors examined
the effectiveness of surgical breast reduction in the
relief of established symptoms of macromastia [47].
Analysis showed that 50% of operative subjects
reported breast centered pain all or most of the time in
the upper back, shoulders, neck, and lower back preop-
eratively. This number decreased to less than 10%
postoperatively. Preoperatively, the study subjects had
recorded significantly lower scores in all the health
domains of the quality-of-life assessment tools and in
the mental and physical component summary scores.
Postoperatively, the operative subjects had higher aver-
age scores than the national norms in seven of the eight
domains and had significant improvement from their
preoperative evaluation in all eight domains (P < 0.05).
The authors conclude that breast hypertrophy has a
significant impact on womens health status and qual-
ity of life. Pain was found to be a prominent symptom
in this disease process, and both pain and overall health
status were considerably improved by reduction mam-
maplasty. They also concluded that patients with
symptomatic hypermastia treated with conservative
measures such as weight loss, special bras, and medi-
cations did not provide effective or permanent relief of
symptoms.
The above-mentioned studies, in contrast with pre-
viously published data, are very well-designed, pro-
spective analyses of randomized series that definitively
demonstrate the disease process and medical indica-
tions for reduction mammaplasty, as well as validate
the effectiveness of reduction surgery in the treatment
of symptomatic hypermastia. The aim will be to dis-
perse these data to third-party payers and have them
adopt these guidelines as they are making determina-
tions regarding breast reduction surgery coverage.
45.6 Aesthetic Concerns
There is great variation as regards heights, weights,
body shapes, and physical conditions of women seek-
ing reduction mammaplasty, no single breast dimension
will serve all. Surgeons should individualize each
patients desires regarding ultimate breast size and
shape in light of her age, physique, and surgical limita-
tions. Although all candidates for reduction mamma-
plasty want to have their breasts made smaller, most do
760
not wish their breast size to be out of proportion to
their build. Aufricht [10], Penn [48], and Berry [49]
caution against trying to recreate a virginal appearing
breast; rather, the goal of reduction should be a smaller
but slightly pendulous, mature looking breast.
As famously said by Sir Harold Gillies, much that we
do in plastic surgery involves a battle between beauty
and blood supply. Over the years, the battle extended to
include minimizing scars. Breast reduction is no differ-
ent. The underlying principles of breast reduction and
mastopexy surgery have evolved significantly in the past
20 years. Breast bottoming out occurs most frequently
with inferior pedicle techniques in which much of the
breast shape depends on skin tension. Other techniques
incorporate additional parenchymal support without
skin tension or skin shaping, and bottoming out can be
controlled for excellent long-term results.
The multitude of different techniques and modifica-
tions with regard to pedicle choice, scar position and
length, or breast shaping reflects the challenge for
every plastic surgeon to achieve an aesthetic shape
with long-term stability and with minimal scars in
mammoplasty. This inspired the senior author (FSF) to
describe his own breast reduction marking technique
and develop a new surgical approach.
45.7 Authors (FSF) Preferred Technique
The problem of macromastia has been the object of the
efforts of many plastic surgeons since late nineteenth
century. In the USA alone, nearly 40,000 women
undergo breast reduction each year [50]..
For the senior author (FSF), breast reduction pres-
ents both artistic and technical challenges. The surgery
aims to reduce the vertical and horizontal planes, shape
the parenchyma, reposition the nipple-areola complex,
and resect redundant skin. The surgery on paired
organs has the added challenge of symmetry. The
added effect of recumbence alters the shape and posi-
tion of the breast. The classic breast shape, as we know
it, exists in the erect posture. Much of the outcome of
our work as plastic surgeons is determined by preop-
erative planning and designing. The availability of
numerous marking techniques of breast reduction and
mastopexy and the abundance of further modifications
over the last decennia are clear indications that none of
the approaches have proven to be ideal.
The majority aim is to achieve some degree of
precision in determining the angle between the two
F.S. Fahmy and M.A.A. Saleh
vertical limbs. This ultimately affects the amount of
the tissue resected and the postoperative shape. Few, if
any, of such techniques have gained total popularity
or acceptance by the plastic surgeons. The freehand
marking technique is probably the most widely used
technique. Devices such as template [11, 16, 51],
shaped wires, goniometers, and geometrical techniques
have also been recommended [16, 5256]. Some of
these devices have stood the test of time; others have
been modified or abandoned.
The free hand technique, being the most widely
used, requires experience and practice in order to
achieve the desired results. Multiple devices have been
created to facilitate markings including templates,
keyhole patterns, goniometers, etc. The standard pat-
tern with a fixed angle of 110 between the two seg-
ments was further modified by McKissock [13] to
allow for adjustment of the angle to the widely vari-
able breast shapes. The Wise keyhole pattern marking
is influenced by the surgeons experience.
The standard patterns and devices are rigid methods
that may achieve symmetrical markings, not necessar-
ily symmetrical outcome. They do not account easily
to preexisting breast asymmetry. Devices may also be
not readily available in all hospitals. This factor could
be a disadvantage to the surgeon who practices in more
than one hospital.
The inherent difficulties of these techniques, the
lack of flexibility, and the need to memorize different
measures and mathematical calculations, on some
occasions, made me alter the approach of my preop-
erative marking. Over the last 15 years, the author
(FSF) has developed and evolved the Sitting, Oblique,
and Supine (SOS) marking technique. This method is
dependent on the natural breast fall and is aimed to
guide on the appropriate angle between the two verti-
cal limbs, each breast on its individual merits. It would
be applicable in most breast reduction and mastopexy
surgery; however, the author (FSF) used it largely in
the inferior pedicle technique.
45.7.1 Preoperative Marking:
The SOS Marking Technique
The patient is marked preoperatively in three
positions.
1. Sitting (Fig. 45.3)
This position is adopted to mark the midline, mid-
clavicular point (usually 7.5 cm from the sternal notch),
45 Reduction Mammoplasty: The Piece of Art 761

a b

Fig. 45.3 Patient in sitting position. (a) Gentle pressure on usually 7.5 cm lateral to the sternal notch. (c) The superior limit
the breast mound clearly defining the inframammary fold. of the vertical limb marked with reference to the inframammary
(b) The breast meridian marked from the midclavicular point, fold

and the breast meridian. The breast meridian is marked vertical limbs is then marked with reference to the
as a straight line joining the midclavicular point to the inframammary fold. This marks the possible future
current nipple-areola complex (NAC) extending down position of the NAC. The distance from the midclavic-
to the inframammary fold. The superior limit of the ular point to the superior limit of the vertical limbs is
762 F.S. Fahmy and M.A.A. Saleh

b c

Fig. 45.4 Patient in the supine position. (a) Marking of the inframammary fold, arrow pointing to the dart. (b) Marking of the
medial limb. (c) Marking of the medial limb completed

then measured, and the same measure is used to mark
the contralateral NAC.
2. Supine (Fig. 45.4)
The supine position is used to mark the inframam-
mary fold incision and the medial limb of the vertical
markings. Whilst the patient is lying flat, the infra-
mammary fold is marked, while applying very gentle
pressure on the breast mound. Every effort should be
made intraoperatively to minimize the length of the
future inframammary scar, start with a short incision
and extend as necessary, cut as you go approach. A
dart coinciding with the breast meridian is marked
along the inframammary incision line. This aids in
reducing tension on the wound at the time of skin clo-
sure. While remaining in the supine position, the breast
will naturally fall laterally. A straight line is drawn
45 Reduction Mammoplasty: The Piece of Art
b
Fig. 45.5 Patient in the oblique position. (a) Right oblique
position, marking the left lateral limb. (b) Left oblique position,
right lateral limb marked
joining the superior limit of the vertical limbs to the
dart. This will indicate the medial limb of the vertical
limbs.
3. Oblique: Left and Right (Fig. 45.5).
The oblique position is mainly to mark the lateral
limb of the vertical markings. The patient is marked in
the left and right oblique position. In the left oblique
position, the right breast will naturally adopt a medial
position. A straight line is marked joining the superior
limit of the vertical limb to the dart. This marks the
lateral limb of the right breast. While in the right
oblique position, the left breast will adopt a medial
position. A straight line is marked joining the superior
763
Fig. 45.6 Patient in sitting position marking the length of the
vertical limbs
limit of the vertical limbs to the dart. This marks the
lateral limb of the left breast.
Finally, the patient is returned to the sitting position.
The medial and lateral vertical limbs are measured at a
length of 7 cm from the superior limit of the vertical
limbs (Fig. 45.6).
The above are all the required preoperative mark-
ings. The author (FSF) now tends to join the vertical
limbs to the medial and lateral ends of the inframam-
mary marking intraoperatively. This is carried out in a
cut as you go fashion aiming at avoiding dog ears and
also minimizing the length of the inframammary scar.
The new NAC is usually marked at the end of the
procedure, after the resection is completed. The lower
margin of the NAC is approximately 45 cm cephalad
from the inframammary fold dart.
Over the years, the SOS marking has been found to
be a versatile technique dependent on the natural breast
fall. The breast is viewed as a dynamic organ requiring
the individual analysis of each breast (Figs. 45.745.9).
The natural fall of the breast spontaneously generates
the desired angle between the vertical limbs, accounting
for any existing asymmetries. Marking the patient in
the supine position has the added advantage of clearly
identifying the inframammary fold. Marking in the sit-
ting position only, as referred to in other techniques,
may present difficulty in defining the inframammary
fold in large ptotic breasts. There are no specific
764 F.S. Fahmy and M.A.A. Saleh

Fig. 45.7 (a) Preoperative. (b) Six months postoperative

a b

Fig. 45.8 (a) Preoperative. (b) Two weeks postoperative

45 Reduction Mammoplasty: The Piece of Art
a b
Fig. 45.9 (a) Preoperative. (b) Six months postoperative following resection of 1,800 g/side
devices required in this technique. There is no need to
memorize any particular reference points apart from
the three standard landmarks, the inframammary fold,
the sternal notch, and the midclavicular point. There is
minimal handling of the breast, hence minimizing
human errors.
Undoubtedly, there is a learning curve for any
new technique. The SOS in my view is relatively easy
to learn by the beginners and easy to adopt by the
experienced. It is readily available, not requiring major
alterations to our current practice and account for the
great diversities in the shape and size of the breasts.
45.7.2 Surgical Technique
Breast reduction is a constantly evolving surgery. For
the author (FSF), the inferior pedicle with the inverted
T-shaped scar stood the test of time. It is a versatile
technique, suitable for the small and large reductions,
gives flexibility in sitting the nipple-areola position,
hence minimizing the risk of a too high nipple-areola
complex. Over the years, as much as the author (FSF)
has developed the technique in the preoperative mark-
ing, the surgical approach changed with particular
765
emphasis on defined anatomical dissection planes,
respecting and understanding the principles of the vas-
cularity of the flaps. This has greatly reduced the post-
operative complications with minimal revision rate.
On those principles, the 3-plane dissection surgical
approach was developed, and the author (FSF) has also
been able to reduce the length of the inframammary
scar to be slightly longer than the width of the pedicle,
particularly in mastopexy and small reductions.
Preoperatively, the breasts are marked in the sitting,
oblique, and supine positions, as previously described
[57]. Intraoperatively, all the markings are scored
(superficially incised) using a #10 blade and #15 blade
for the nipple incision (Fig. 45.9). This is to avoid loss
by rubbing off the markings.
A large swab is used as a tourniquet around the
breast base (Fig. 45.10). This helps to stabilize the
breast during the deepithelialization and early part of
the dissection and reduces the intraoperative bleeding.
The base of the pedicle is approximately 7 cm wide.
The inferior pedicle is deepithelialized. On completion
of deepithelialization, the medial and lateral flaps are
raised using the 3-plane dissection modification.
Laterally, an avascular anatomical plane (mastec-
tomy plane) is created and followed between the breast
766
Fig. 45.10 Scoring and
incision of the nipple-areola
complex. A large swab is used
as a tourniquet around the
breast base
Fig. 45.11 Laterally, an avascular anatomical plane (mastec-
tomy plane) is created
and subcutaneous tissue down to the pectoralis fascia.
This plane is easier to locate laterally and follow
towards the breast meridian (Fig. 45.11). This yields a
lateral flap of adequate and uniform thickness, reducing
the risk of postoperative fat necrosis and avoids bulky
lateral flaps. This plane is more uniform and easier to
follow compared to the literature-recommended 1-cm
thickness of the flaps.
Medially, the breast is dissected in a perpendicular
fashion down to pectoralis fascia. This ensures medial
fullness and helps to create a breast cleavage. The tour-
niquet at the base of the breast is removed at this stage.
Centrally, a plane joining the medial and lateral por-
tions is created.
F.S. Fahmy and M.A.A. Saleh
Once dissection is complete following the planes, the
thickness of the lateral, central, and medial flaps should
be optimal with no need to excise tissue from any of the
flaps. The main bulk of the breast tissue will be on the
pedicle. Reduction or excision can then be performed
under direct vision, from the bulky pedicle, avoiding
any potential danger of compromising the vascularity of
the pedicle. At this stage, a marker suture is inserted at
the 12 oclock position of the nipple. This aids in allo-
cating the nipple and its correct orientation when deter-
mining its position after closure of the rest of the
incisions. Under no circumstances should pull be exerted
on this marker suture, to avoid compromising the blood
supply. The breast skin flaps are undermined medially
as far as the sternocostal junction and superiorly as far
as the clavicle. The author (FSF) tends to avoid lateral
undermining, to limit the lateral fullness. One vacuum
drain is inserted per side and sutured lateral to the infra-
mammary incision. The T-junction is sutured to the apex
of the dart along the inframammary incision, a few mil-
limeters above the inframammary fold thereby reducing
tension. The flaps are sutured as a composite unit includ-
ing the subcutaneous fat and the dermis to avoid deglov-
ing the skin from the underlying subcutaneous fat
(Fig. 45.12). These modifications reduce the risk of
skin necrosis and wound dehiscence at the T-junction.
Monocryl, 3/0, is used as a deep subcutaneous suture
and 4/0 Monocryl subcuticular. Generally speaking,
suturing should start from the medial and lateral sides of
the inframammary incision towards the breast meridian.
This helps to reduce the risk of dog ears.
45 Reduction Mammoplasty: The Piece of Art
a 45.7.3 Complications
b bination of the preoperative marking technique and the
Fig. 45.12 (a) Inappropriate suturing that may result in
T-junction breakdown as a result of degloving the skin from the
underlying fat. (b) The recommended suturing at the T-junction,
as composite flaps
Once all the incisions are sutured, 45 cm is
measured from the dart along the vertical limb of the
scar. This presents the base of the future nipple-areola
complex. The nipple-areola complex is approximately
4 cm in diameter. Once this is marked, the disk of skin
and underlying subcutaneous fat is excised, the previ-
ous nipple suture mark is followed, and the nipple is
delivered in its new position. Monocryl, 4/0, is used
for both the deep suturing and the subcuticular for the
nipple-areola complex.
Half-inch suture strips are used to support the suture
lines; a Mepore dressing is then applied. Finally, a
layer of Microfoam is applied as a supportive dressing,
cross your heart style. The dressings are reduced down
to Steri-Strips 1 week later. Two weeks postoperative,
all the dressings are removed.
767
The above approach has demonstrated a very low
complication rate over the years. Retrospectively,
review of 125 patients was performed. The age range
was between 18 and 68 years, with a mean age of 34.
The BMI range was between 21 and 35. This included
both smokers and nonsmokers. The mean resection
weight was 539 g per breast (range, 2551,600 g).
The overall complication rate including nipple
necrosis, hematoma, seroma, dog ears, wound dehis-
cence, fat necrosis, delayed wound healing/wound
dehiscence at T-junction, hypertrophic scarring, and
further surgical revision was less than 10%. The com-
refinement of the surgical approach have provided me
with a successful recipe and an excellent tool in the
utilization of the inferior pedicle in all types of reduc-
tion and mastopexy, accommodating well in existing
asymmetry and reducing the commonly known post-
operative complications.
The revision rate over the years has been kept to a
minimal. The intraoperative surgical modifications
demonstrated a lower complication rate compared to
other published data. The flaps are dissected in a fash-
ion that follows anatomical planes. The mastectomy
plane followed laterally and the perpendicular plane
medially down to pectoralis fascia, help to reduce the
risks of fat necrosis, enhances medial fullness, and
reduces lateral fullness that could result from thick
uneven flaps. The dart along the inframammary inci-
sion together with the composite suturing technique
helps to reduce tension on the suture line and main-
tains the vascularity of the apices of the flaps as one
unit. The reliability of the approach is supported by the
relatively low complication rate compared to other
published data.
The overall complication rate was shown to be less
than 10%, compared to the literature-reported rates
ranging from 13.6%, described by Bolger et al. in 1987
[58], to 50%, described by both Dabbah et al. [39] and
Davis et al. in 1995 [41]. A recent paper by Hunter and
Ceydeli in 2006 [59] reports a complication rate of
23.7%.
Dissections that follow the anatomical plane,
including the lateral mastectomy plane flaps together
with medial thick flaps down to pectoralis fascia, result
in more uniform flaps that have less likelihood of fat
necrosis. This is combined with the wound closure of
768
a a
b
Fig. 45.13 (a) Preoperative. (b) Five months after surgery
the skin flaps as a composite unit, maintains the vascu-
larity of the skin flaps, and avoids the potential deglov-
ing of the epidermis and dermis from the underlying
subcutaneous tissue. This reduces the morbidity of
such a common procedure and improve aesthetic out-
come (Figs. 45.1345.15).
45.8 Breast Size After Reduction
Mammoplasty
Regnault [60] states that the amount of tissue that is to
be removed during reduction mammaplasty depends
on the ratio of breast girth to chest girth. Chest girth is
determined first and equals the circumference of the
chest measured under the arms. Breast girth is mea-
sured across the nipples and should encompass the
fullest part of the breasts. If breast girth exceeds chest
girth by 1 in., cup size is an A; 2 in., B; 3 in., C; 4 in.,
D; and 5 in., DD. He offers a rule-of-thumb for how
F.S. Fahmy and M.A.A. Saleh
b
Fig. 45.14 (a) Preoperative. (b) Twelve weeks after surgery
much tissue will have to be resected to attain the
desired breast size (Table 45.1).
These figures should be taken only as a rough esti-
mate when formulating the surgical plan. Surgical
experience and different techniques will have much
more influence on final breast size than the resection
guidelines.
45.9 Complications of Breast Reduction
General complications of reduction mammaplasty
include hematoma, fat necrosis, infection, poor wound
healing particularly at the T-junction with partial or
complete disruption of the suture line, hypertrophic
scarring, breast asymmetry, under or over reduction,
persistent pain, and change in breast shape over time.
Reduction mammaplasty might affect:
45 Reduction Mammoplasty: The Piece of Art
a resected to attain the desired breast size
b nipple perfusion before and after reduction mamma-
Fig. 45.15 (a) Preoperative patient with enlarged ptotic right
breast. (b) After surgery
45.9.1 Vascularity of the Nipple and Areola
The complications of reduction mammaplasty are
related primarily to insufficient vascularity of either
the skin flaps or the pedicle on which the nipple-areola
complex is based. Confirmation of adequate nipple
perfusion is usually based on clinical exam and can be
ascertained by laser Doppler flowmetry (LDF) and
fluorescein flowmetry.
Hallock [61] evaluated patients undergoing breast
reduction and compared the quantitative laser Doppler
769
Table 45.1 Rule-of-thumb for how much tissue will have to be
Chest circumference For each cup
in inches reduction size remove (g)
3234 100
3638 200
4244 300
4446 400
flowmetry with clinical examination. He measured
perfusion of identical spots on the areola preopera-
tively and immediately after inset of the nipple-areola
complex into its new position. He concluded that if the
post transfer blood flow was thought to be less than
50% of the preoperative value, the pedicle should be
explored. The author emphasizes that laser Doppler
flowmetry can be a helpful adjunct to clinical tests of
perfusion, particularly in darkly pigmented areolas.
Roth et al. [62] studied absolute Doppler values of
plasty. Nipple perfusion immediately postoperative
averaged 4.8 mL/min/100 g in patients who had
no complications of surgery. In patients who had
minor complications or gross necrosis, the nipple
perfusion value was 1.4 and 0.8, respectively. Values
in the range of 1.02.0 mL/100 g indicate marginal
perfusion. Values <1.0 signify inadequate perfusion
and warrant suture removal or consideration for
exploration or free nipple grafting. The author rec-
ommends the laser Doppler for monitoring nipple-
areolar perfusion in large reductions and particularly
in dark-skinned patients who are difficult to evaluate
clinically.
Perbeck et al. [63] used laser Doppler flowmetry
and fluorescein flowmetry (FF) to evaluate viability of
the nipple-areola complexes in undergoing reduction
mammaplasty. By LDF, there was a 2.5 increase in
circulation to the skin over preoperative levels after
deepithelialization. When epinephrine was injected,
the circulatory increase was only 1.5 the preoperative
level.
Tracy and associates [64] used laser Doppler flow-
metry to assess the blood supply of various types of
pedicles undergoing reduction mammaplasty. In the
immediate postoperative period, areolar perfusion
declined by 23% (Skoog technique), by 18% (central
pedicle technique), and by 21% (inferior pedicle
technique). Two weeks after breast reduction, LDF
values were 12% below baseline (Skoog technique),
2% above baseline (central pedicle), and 44% below
770
baseline (inferior pedicle). While this is an interesting
study, they are technique dependent with varying suc-
cess in different surgeons hands.
45.9.2 Nipple Sensation
Loss of sensation to the nipple is a well-known com-
plication of reduction mammaplasty. Townsend [65]
finds only eight of 46 breasts had no return of sensa-
tion following nipple grafting which varies from 2 to
12 months.
Slezak and Dellon [66] documented lower sensory
thresholds in the nipple, areola, and periareolar skin of
women who had gigantomastia (D-cup or greater)
compared with the same parameters in small-breasted
women. The authors postulate that this may be related
either to increased surface area of large breasts with a
constant number of nerve fibers, or the result of a
stretching intercostal nerves caused by the breast
enlargement. Patients underwent breast reduction by
McKissock technique and amputation with free nipple
graft. Thirteen patients were evaluated perioperatively
using vibrometers and SemmesWeinstein testing.
Nine patients available for follow-up, six had better
sensation, two were less sensitive, and nipple sensation
was unchanged in one. In the amputation group, some
sensory loss was noted early postoperatively, but it
improved with time.
Gonzalez et al. [67] quantified nipple-areolar sensa-
tion pre and postoperative using SemmesWeinstein
pressure threshold testing. They adopted the central
parenchymal pedicle technique or a laterally based
inferior pedicle technique. Overall, nipple sensitivity
was lost in 9.5% of breasts, and they correlated with
increasing breast size and corresponding amount of
resection, as when <440 g per breast was resected,
nipple sensation was retained 100% of the time.
Temple and Hurst [68] studied 45 women undergo-
ing inferior pedicle breast reduction. Pressure thresh-
old measurements were taken preoperatively and at 2
and 6 weeks, postoperatively. They noted significant
improvement at 26 weeks. Only 2% of breasts had
nipple numbness at 6 weeks.
Hamdi et al. [69, 70] looked at breast sensation after
superior pedicle versus inferior pedicle mammaplasty.
The cadaveric study was designed to quantify the nerve
branches preserved in the pedicles during reduction
surgery. They found slightly more branches in inferior
F.S. Fahmy and M.A.A. Saleh
pedicles compared with superior pedicles. Anterior
and lateral branches of the second through fourth inter-
costal nerves were found in both groups and became
more superficial near the areola. The authors conclude
that careful deepithelialization of the pedicle is a must
to keep the superficial nerves intact near the areolar
border.
Hamdi et al. [70] analyzed breast sensation after
superior versus inferior pedicle mammaplasty. They
showed decreased nipple sensibility in both groups
which was documented at 3 months. The breast skin
had better sensation after superior pedicle techniques,
while the areola had slightly better sensation after infe-
rior pedicle techniques. No patient had a completely
insensible NAC at 6 months.
Greuse [71] prospectively assessed breast sensitiv-
ity after Lejours vertical mammaplasty (with superior
pedicle). Assessments were done preoperatively and
3, 6, and 12 months postoperatively using Semmes
Weinstein monofilaments (constant pressure thresh-
old), heated and cooled metal probes (for hot and cold
perception), calipers (for static and moving two-point
discrimination tests), and a Biotensiometer (to mea-
sure the vibration threshold). Their study was divided
into two subgroups: Group I had sternal notch to nip-
ple less than 29 cm and less than 500 g of tissue
removed; group II had sternal notch to nipple greater
than 29 cm and more than 500 g of tissue resected.
In group I, there was an initial postoperative decline
in sensitivity, although eventually returned to their
normal level. In group II, although sensitivity to
temperature and vibration diminished on the nipple-
areola, patients did not complain of decrease in breast
sensation.
45.9.3 Breast-feeding
Aboudib [72] compared the late results of reduction
mammaplasty by the Pitanguy technique in 39 patients
who did not become pregnant after surgery (group A)
and 11 patients who did (group B). There were no
significant differences between the groups in terms
of weight gain, breast volume, or breast ptosis. Nine
women in group B (91%) reported normal lactation
and breast-feeding. The other two women reported
decreased milk secretion and did not nurse.
Marshall et al. [73] studied breast-feeding in
women after reduction mammaplasty. The patients
45 Reduction Mammoplasty: The Piece of Art
abilities to nurse were recorded for up to 3 months
after delivery, 93% wished to breast-feed, and on dis-
charge, 73% were doing so. After 3 months, the num-
ber had dropped to 27%. All babies except one born of
a mastopexy patient required complementary feeds. In
the control population of nonreduced patients, 82%
were breast-feeding on discharge from the hospital
and 54% were still breast-feeding after 3 months.
Seven percent of babies were able to feed entirely
from the breast without complementary feedings.
Although, no single operation was clearly superior in
avoiding transection of the lactiferous ducts, the
author recommends leaving all functional breast tis-
sue attached to the nipple in a physiologic manner
whenever possible.
Harris et al. [74] examined breast-feeding ability
and behavior in reduction mammaplasty patients using
inferior pedicle technique. The authors surveyed 68
women who had breast reduction, 29% (20) had
become pregnant after surgery. All of them lactated,
seven (35%) nursed their infants for at least 2 months,
nine (45%) nursed for up to 2 weeks, and the other four
did not attempt breast-feeding because of insufficient
milk production.
Brzozowski et al. [75] examined 78 women who
had children after their breast reduction using inferior
pedicle technique. He found that 41 (52.6%) did not
attempt to breast-feed, 14 (17.9%) were unsuccessful,
15 (19.2%) breast-fed exclusively, and eight (10.3%)
breast-fed with formula supplementation. Postpartum
breast engorgement and milk production was experi-
enced by 31 of the 41 patients who did not attempt to
breast-feed. The authors conclude that breast-feeding
is possible post-reduction mammaplasty, and that the
percentage of patients who successfully do so is com-
parable to the proportion in the general population. As
part of the informed consent process, these data should
be reviewed with patients of childbearing age before
reduction surgery.
45.9.4 Interference with Cancer Screening
Because of the extensive dissection in reduction mam-
maplasty, some authors have expressed concern about
the possibility that postoperative fibrosis and scarring
may interfere with breast cancer detection.
Beer et al. [76] retrospectively assessed their ability
to diagnose breast tumors after reduction. Ultrasound
771
was unreliable and they recommend mammograms
3 months postoperative to establish a baseline from
which to track postsurgical changes. They also men-
tioned that excisional biopsy should be done if there is
any doubt about the diagnosis suggested by the imag-
ing modalities.
Titley et al. [77] analyzed histologic findings in
reduction mammaplasty specimens. The retrospective
study included 295 reduced breasts. They noticed
25.6% were abnormal, although no premalignancy or
overt cancer was identified. By questionnaire, the
authors determined that 89% of British plastic sur-
geons routinely sent breast reduction specimens for
pathologic study [and] 42% had seen at least one case
of breast cancer reported from this tissue. They rec-
ommend routine histopathologic study of reduction
mammaplasty specimens in all patients over 40 and in
younger patients when risk factors for breast cancer
are present or the tissue appears grossly abnormal at
surgery. Mammography was also recommended for
patients 5064 years old.
zmen et al. [78] reviewed 274 breast specimens
revealing three breast carcinomas (1.1%). The authors
comment that this is higher than previously reported
rates for incidental carcinomas in breast reduction
specimens. Their recommendations are as follows:
1. Perform a thorough physical examination in all
patients preoperatively and mammography in those
over 35 years old.
2. Order intraoperative frozen sections of any suspi-
cious areas.
3. Send all reduction specimens for pathologic
examination.
4. Accurately mark specimen location.
5. Have the pathologist perform histologic examina-
tion as if it were a breast cancer specimen.
Mandrekas et al. [79] described the clinical and
radiologic features of fat necrosis after breast reduc-
tion surgery. They mentioned that the use of electro-
cautery during mammaplasty may trigger necrotic
changes in breast fat, which are difficult to differenti-
ate from breast carcinoma. Surgical resection with
scalpel may lessen this problem.
At the present time, most plastic surgeons continue
to send all reduction specimens for histopathologic
diagnosis. Specimens should be marked accurately
as to medial, central, and lateral quadrants to help
the pathologist localize the lesion, if found. Preopera-
tive mammography is to be performed according to the
772
recommendations for breast cancer screening issued by
the American Cancer Society in 1997. These include:
1. Breast self-exam every month for women age 20
and over.
2. Clinical breast exam every 3 years for women age
2040.
3. Clinical breast exam and mammography every year
for women 40 and older.
Analysis of the complications associated with dif-
ferent techniques may provide a clue to their relative
success. At the same time, it is very difficult to com-
pare the outcome of different techniques for reduction
mammaplasty, as the variables of patient age, weight,
body build, breast size, degree of reduction achieved,
skin elasticity, distance of transposition of the NAC,
and other patients variables.
Dabbah et al. [39] studied 185 women after reduc-
tion mammaplasty. Preoperatively, the most common
complaints were shoulder grooving, back pain, shoulder
pain, and neck pain. Average patient age was 40 years.
The average amount of breast tissue removed was 855 g
per breast. Postoperatively, 97% of their patients had
improvement of symptoms and 59% were asymptom-
atic. Infection and fat necrosis occurred in 22%, necro-
sis of the nipple-areola in 4%, and unsatisfactory scars
in 4%. Overall, 95% of patients were happy or very
happy with the results of surgery, and 98% would rec-
ommend reduction mammaplasty to a friend.
Maxwell Davis et al. [41] reviewed 406 women
who had bilateral reduction mammaplasty. Mean
patient age at surgery was 38 years and average reduc-
tion was 676 g per breast. The inferior pedicle tech-
nique was used in 85% and a Strombeck mammaplasty
was done in 15%. Postoperative complications occurred
in 53% (215 women). Altered nipple sensation was
reported in 25%, loss of nipple-areola complex in 6%,
wound healing problems in 19%, bleeding from inci-
sions in 18%, infection required antibiotics in 12%,
and additional surgery was required in 5% of patients.
Overall, 87% of patients were satisfied with their
results. Of the 13% who were not satisfied, 18% had
unacceptable scars, 9% felt their breasts were too large,
9% felt their breasts were too small, 8% had breast
asymmetry, and 9% had breast contour deformities.
Woods et al. [80] compared the Maliniac, Skoog,
Dufourmentel-Mouly, and McKissock mammaplasties.
They found that complication rate was higher with the
Maliniac and Skoog procedures, whereas McKissocks
technique had the fewest postoperative problems.
F.S. Fahmy and M.A.A. Saleh
Samdal et al. [81] documented the value of infiltrat-
ing dilute epinephrine for the control of intraoperative
bleeding. Blood loss was reduced by more than 50%
when compared with the non infiltrated side.
Epinephrine injection was associated with no instance
of flap compromise or postoperative bleeding.
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26(2):211215
 The Moufarrege Total Posterior
Pedicle Mammaplasty
Richard Moufarrege and Elia Botros
46.1 Introduction and Principles
The particular philosophy of the Total Pedicle consists
of the entire exposure of the breast on all its anterior,
superior, inferior, external and medial sides, preserv-
ing the integrity of its posterior aspect with its attaches
to the muscles of the thoracic wall [14]. The denuded
breast gland is then sculpted on an open sky basis and
acts itself as pedicle for the nipple areolar complex
(NAC) [15]. The gland and its NAC are so vascular-
ised by the vessels perforating the pectoralis major
muscle which constitutes 7080% of the vascular sup-
ply of the breast [25]. This explains the absolute vas-
cular security of that pedicle, compared to the security
of the traditional thin pedicles [13, 5].
46.2 Technique
46.2.1 Marking
Markings are done on the patient in a vertical position.
None of the traditional measures between point-marks,
such as the distance between the nipple and the
suprasternal notch, the one between the two nipples or
the distance between one nipple and the midsternal
line, are used. These measures could, in a certain
R. Moufarrege (*) E. Botros
Department of Plastic Surgery, Hcte-Diel Hospital,
Montreal University, Montreal, QC, Canada
e-mail: plasticsurg_moufar@hotmail.com;
botroselia10@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_46, Springer-Verlag Berlin Heidelberg 2013
46
number of women, be appropriate. However, they can
lead to vicious positioning errors such as offset nipples
positioned too centrally, too high, too outward or too
inward.
The authors landmarks are defined by the junction
of two lines.
I. The first one being the breast axis. This does not
correspond necessarily to the mid-clavicular line
nor passes absolutely by the present nipple. It is the
vertical axis of the breast that divides the frontal
aspect of the breast in two equal halves (Fig. 46.1).
Whichever is the preoperative position of the nip-
ple, the new nipple must be on that vertical axis. If
not, errors occur and we obtain an offset nipple.
II. The second landmark line is the one passing
through the submammary fold. The new nipple
should be placed on that line (Fig. 46.2). All in all,
the new nipple should be positioned at the junction
of these two lines (Fig. 46.3) [3, 5].
III. Practically the surgeon starts by drawing the breast
axis. This will be better defined by choosing two
median points, one upper and one lower, at equal
distance from the internal and lateral limits of
the breast and joining them by a vertical line
(Fig. 46.4).
With practice and repetition, the designation
of the axis will be done automatically and with
ease. Once the breast axis is established, the sur-
geon will place his hand, and mainly his index, in
the fold under the breast. He will draw on the new
breast axis the position of the new nipple, exactly
at the level of the inframammary fold. The upper
pole of the areola will then be situated 2 cm higher
(Fig. 46.5).
775
776 R. Moufarrege and E. Botros

Fig. 46.1 The breast axis

passes through the center of
the clavicle in the right breast
but not the left one

c a
a
c

d o b
o b

a b

Fig. 46.3 The new nipple is at the junction of the two vertical
b axises and the horizontal submammary line

For the drawing, Aufricht keyhole will be

Fig. 46.2 The submammary fold line passes simply horizon-
tally in the submammary fold of the breast
adopted but with important modifications. The
Aufricht keyhole was traditionally round. By clos-
ing it, chances are that it will turn into an ellipsoid
vertical shape. It is suggested to modify it by start-
ing with an ellipsoid Aufricht keyhole which,
when closed, will turn into a perfect round shape
(Fig. 46.6).
Logically, one cannot remove the same skin surface
on all breasts of all sizes at all ptosis degrees. The
author personally adapts the surface of removed skin
46 The Moufarrege Total Posterior Pedicle Mammaplasty
to the degree of ptosis, contrary to the traditional mam-
maplasties. Therefore, the author (RM) divides patients
into three categories [3, 5]:
Category I: There is no ptosis; the nipple is at the
level of the inframammary fold. In this case, the
a A
a
b B
o
b
Fig. 46.4 The design of the breast axis is made by the use of two
horizontal virtual lines at two different levels (a and b). The mid-
dle point of each line is defined and the breast axis is then obtained
by joining the two last points with a vertical straight line
Fig. 46.5 Designing the new
nipple position and the
Aufricht keyhole
777
keyhole arms opening will be at an angle of 90
(Fig. 46.7).
Category II: There is ptosis; the nipple is below
the inframammary fold. The breast at the level of the
fold is thick, full, and consistent. In this case, the
keyhole arms opening will be at an angle of 140
(Fig. 46.8).
Category III: The nipple is below the inframam-
mary fold but at the level of that fold, the breast is
empty, without any consistency. In this case, the
keyhole arms opening will be at an angle of 180
(Fig. 46.9).
The surgeon will thus place the center of the key-
hole on the vertical axis of the breast. The level of the
inframammary fold of the upper limit of the keyhole
will be 2 cm above this point. The keyhole arms will
adopt the orientation defined by the ptosis angles (90,
140, and 180) and are extended without any breaks,
like two meridians of the Earth globe, until their junc-
tion on the inframammary fold on the vertical axis of
the breast (Fig. 46.10) [3, 5].
46.2.2 Incision
The surgeon will start the periareolar incision leaving
a diameter of 4 cm in the NAC. He defines and pro-
ceeds to this deepithelialization of a dermal flap sur-
rounding the NAC and down to the inframammary
fold. This dermal surface, 46 cm large, will have a
vertical length depending on the ptosis and the breast
size, from 6 to 20, if not 30 cm in large hypertrophies
778
Fig. 46.6 (a) Round keyhole
gives an ellipse when closed.
(b) Ovaloid keyhole gives a
circle when closed
a b
I I
90
Fig. 46.7 Category I. No ptosis, angle 90
II II
140
Fig. 46.8 Category II. Ptosis with fullness at the inframam-
mary fold level, angle 140
(Fig. 46.11) [15]. This deepithelialization will be
made easier with the use of vertical striations which
will be removed easily in a very short time of 12 min
(Fig. 46.12) [5]. The surgeon will make the incision
around the dermis first and continues along the pre-
established drawings (Fig. 46.13).
46.2.3 Undermining or Denuding the Breast
All the skin of the breast is undermined making a divi-
sion between the glandular tissue and the subcutane-
ous fat. This is a real nonvascularised plan. This
operation is made easy with the use of skin rakes hold-
ing the tissue vertically while a ten scalpel blade makes
the separation, shaving the glandular tissue. This is
performed on the lateral flap, the medial flap and the
upper flap until the limit of the breast gland is reached
(Fig. 46.14) [2, 3, 5].
R. Moufarrege and E. Botros
III III
180
Fig. 46.9 Category III. Ptosis with emptiness at the inframam-
mary fold level, angle 180
The surgeon will respect laterally, at the level of the
medial axillary line, that areolar tissue covering the
lateral wall of the thorax on the serratus muscle, in
order to preserve the fourth, fifth, and sixth intercostal
nerves which are in charge of the erogenous sensation
of the nipple (Fig. 46.15) [2, 3, 5].
On the upper limit of the breast, opening the
Pectoralis Major fascia will help create a convex and
very attractive superior profile (Fig. 46.16) [5].
At this stage, the breast is entirely stripped from its
cutaneous cover and will be always attached by its
posterior aspect to the muscular plan of the thoracic
wall. However, in the center of the breast there will
remain a certain surface of the skin with roughly a
horseshoe shape covering the internal and the external
quadrants of the breast, meant to be removed and the
upper quadrant meant to remain (Fig. 46.17) [2, 3, 5].
46.2.4 Resection
The exposed breast will undergo an open sky basis
sculpture. The resection will start with the medial
quadrant and will be minimal. On the contrary, all the
external quadrant of the breast with the axillary exten-
sion will be removed. The entire gland consisting in
the upper and lower quadrants will be preserved and
conserved from the higher limit of the gland to the
inframammary fold (Figs. 46.18 and 46.19) [2, 3, 5].
46 The Moufarrege Total Posterior Pedicle Mammaplasty 779

90 180

A C
5
cm cm
5

B D

Fig. 46.10 Extending the keyhole arms in a meridian manner

Fig. 46.11 Periareolar incision with a 4 cm diameter. Desig-

nation and deepithelialization of the dermal inferior vault Fig. 46.12 Strip deepithelialization
780 R. Moufarrege and E. Botros

Fig. 46.15 The surgeons forceps shows the areola area on the
lateral thoracic wall where the fourth, fifth, and sixth intercostal
nerves pass

Fig. 46.13 Incisions first around the dermal vault, then along
the external pre-design

Fig. 46.16 Opening the pectoralis major fascia at the upper

limit of the breast

Fig. 46.14 Denuding the frontal aspect of the breast by sepa-

rating the gland from the subcutaneous fat

The resection will be performed with a long

movement of scalpel dividing the gland by a bevelling
movement from the superficial surrounding the deepi-
thelialized area, widening down to the base of the central
glandular pedicle, medially and laterally (Fig. 46.20).

46.2.5 Reconstitution

Reconstitution starts by positioning the areola in its Fig. 46.17 Aspect of the breast after undermining the sur-
new location with two diametrically opposed sutures rounding flaps and before resection
46 The Moufarrege Total Posterior Pedicle Mammaplasty 781

Fig. 46.19 The remaining gland after the reduction held in the
surgeons hand

Fig. 46.18 The surgically resected piece of the gland. On the

left side, one can see the internal quadrant resection. On the right
side is the large main piece consisting of the whole external
quadrant

Fig. 46.20 The beveled

movement of division
assuring conservation of the
main neurovascular elements
in the base of the gland close
to the muscle

at 12 oclock and 6 oclock, followed by the closing of
the vertical incision under the NAC. This will have,
depending on the case, a 620 cm length or even more
(Figs. 46.21 and 46.22) [2, 3, 5].
In the authors (RM) philosophy of the importance
of the breasts ratios respect (The Moufarrege Golden
Ratio of the Breast), the author conserves 6 cm of
length on that vertical scar under the nipple and
changes all the excess of the length into an inverted
T which will have, in most of cases, a rather short
horizontal section between 3 and 7 cm (Figs. 46.23
46.25) [6, 7].
Closing will continue by positioning sutures wher-
ever necessary, without any tension. This is very
important and real: Actually the division between the
skin and the underlying gland will provide the skin,
not only with the most harmonious and most attractive
shapes, but also with a closing capacity without any
tension, guaranteeing an increased security to the qual-
ity of the conserved skin (Figs. 46.2646.37).
782 R. Moufarrege and E. Botros

Fig. 46.21 Positioning the

nipple areolar complex (NAC)
in its new location

Fig. 46.22 Closing the

vertical line before
transformation into an
inverted T

R=12 R=6 R=4 R=3 R=2,4 R=2 R=1,7 R=1,5 R=1,3 R=1,2 R=1,1 R=1 R=0.002

Soin juvenile Soin acufte harmonious Rapports acceptables Rapports anonmaux

Juvenile Harmonious Acceptable Abnormal ratics

R R R R R R R R R R R R R
12 6 4 3 2.4 2 1.7 1.5 1.3 1.2 1.1 1 0.9

Soin juvenile Soin acufte harmonious Rapports acceptables

Juvenile Harmonious Acceptable Abnormal ratics

Rapports anonmaux

Fig. 46.23 The graph shows breast lengths and allows determi- most harmonious breasts the ratio of height over projection
nation of the ratios between the height and the projection and should be equal or higher than 2
their effect on the appearance of the breast. Thus to obtain the
46 The Moufarrege Total Posterior Pedicle Mammaplasty 783

> 6cm

Fig. 46.25 The three acceptable incisions in the Moufarrege

Total Posterior Pedicle. Simple purse incision is only applicable
in very small breast and ptosis

Fig. 46.24 Transformation of the too long vertical incision into

an inverted T

Fig. 46.26 Closing without

tension
784 R. Moufarrege and E. Botros

Fig. 46.27 (Upper)

Preoperative. (Lower) Six
months postoperative

Fig. 46.28 (Upper)

Preoperative patient with
symmastia. (Lower) Three
months postoperative after
correction with a simple
inverted T incision

46.3 Breast Lifting and Lifting 46.4 Advantages

with Augmentation
The same principles apply in breast lifting with the
same measures and the same angles and skin resection,
but without breast gland reduction. It is a very secure
technique to combine lifting and augmentation in the
same time [25].
The Total Pedicle is secure. The landmarks serving for
drawings ensure perfect breast positioning. The pedicle
quality represented by the entire remaining gland, the
preservation of the perforating vessels, the security of
glandless cutaneous flaps remodelling the whole remain-
ing breast, covering it with a compliant elastic envelope
46 The Moufarrege Total Posterior Pedicle Mammaplasty 785

Fig. 46.29 (Upper)

Preoperative. (Lower) Three
months postoperative after
lifting plus augmentation

Fig. 46.30 (Upper)

Preoperative 36-year-old
female. (Lower) Three years
postoperative

provides to this technique a wage of a high harmonious nerves assure functional properties of breast feeding and
shape. The preservation of the galactophoric ducts and erotogenic sensation of the nipple, hardly encountered
the continuity of the fourth, fifth and sixth intercostals in other traditional mammaplasties.
786 R. Moufarrege and E. Botros

Fig. 46.31 (Upper)

Preoperative 45-year-old
female. (Lower) Five years
postoperative

Fig. 46.32 (Upper)

Preoperative. (Lower) Six
months after breast lift
46 The Moufarrege Total Posterior Pedicle Mammaplasty 787

Fig. 46.33 (Upper)

Preoperative 21-year-old
female. (Lower) Three years
postoperative

Fig. 46.34 Best way to treat tuberous breast

788 R. Moufarrege and E. Botros

Fig. 46.35 A 37-year-old

female, pre-operative and
30 months post-operative
face and profile

Fig. 46.36 (Upper)

Preoperative. (Lower) Six
months postoperative
46 The Moufarrege Total Posterior Pedicle Mammaplasty 789

Fig. 46.37 (Upper)

Preoperative. (Lower)
Postoperative

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vertical posterior pedicle. Quebec Society of Plastic Surgery
Convention
1. Moufarrge R, Muller GH, Beauregard G, Papillion J, Boss
5. Moufarrge R. The Moufarrege total posterior pedicle mam-
JP (1982) Mammoplastie avec pdicule dermoglandulaire
maplasty. http://www.emedicine.com/plastic/topic488.htm
infrieur. Ann Chir Plast 27(3):249254
6. Moufarrge R (2005) Anatomical and artistic breast consid-
2. Moufarrge R, Beauregard G, Boss JP, Papillion J (1985)
erations. Ann Chir Plast Esthet 50(5):365370
Reduction mammaplasty by the total dermoglandular pedicle.
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Aesthetic Plast Surg 9(3):227232
(2010) Existe-t-il un rapport entre les incisions et la forme
3. Moufarrege R (1990) The total dermoglandular pedicle
finale d un sein? Ann Chir Plast Esthet 55(2):111134
mammaplasty. In: Georgiade GS, Riefkohl R (eds) Aesthetic
surgery of the breast. Saunders, Philadelphia, pp 371386
 Mastopexy with Chest-Wall-Based
Flap and Pectoralis Muscle Loop
Ruth Maria Graf, Andr Ricardo DallOglio Tolazzi,
and Maria Ceclia Closs Ono
47.1 Introduction
The evolution of all surgery, including breast surgery,
is persistent and ongoing [114]. The great advances
by Wise [15], Pitanguy [16], Lassus [1719], Lejour
[2023], Benelli [24], and others have brought us to
the close of the twentieth century. These techniques
have not only simplified the operative plan but have
also contributed to a shorter scar and a more aesthetic
breast.
This chapter describes a maneuver designed to
give a better shape to the breast. This maneuver
involves the use of a chest-wall-based flap of breast
tissue that is moved into the upper pole of the breast
and held in place by a loop of pectoral muscle under
which it is passed. The technique can be used with
different kinds of incisions: standard inverted T,
short T, L-shaped incisions, or periareolar vertical
incisions. Our choice, and the technique described in
R.M. Graf, M.D., Ph.D. (*)
Division of Plastic and Reconstructive Surgery,
Hospital de Clinicas da Universidade Federal do Parana,
Rua Solimes, 1175, Curitiba, PR, Brazil
e-mail: ruthgraf@uol.com.br
A.R.D. Tolazzi, M.D.
Plastic Surgery Unit, Federal University of Paran,
Curitiba, PR, Brazil
e-mail: artolazzi@yahoo.com.br
M.C.C. Ono, M.D.
Plastic Surgeon, Member of the Brazilian
Society of Plastic Surgery, Curitiba, PR, Brazil
e-mail: mccono@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_47, Springer-Verlag Berlin Heidelberg 2013
47
this chapter, consists in a predefined vertical incision
with whatever redundant skin that remains after
excising the vertical ellipse, associated with a vari-
able periareolar skin resection closed with a round-
block suture. This is best described as circumvertical
excision. If reduction is necessary, it can easily be
carried out in this technique by removing the desired
amount either vertically under the breast or from its
base. There is no limit to the amount of breast tissue
that can be removed.
47.2 Technique
Marking is done with the patient in the upright posi-
tion. Lines are drawn first straight down the midline
from the suprasternal notch to the xyphoid process and
second, from a point 5 cm from the suprasternal notch
at the clavicle to the nipple-areola complex (NAC) and
then straight down to the inframammary fold. A point
at 1720 cm on the suprasternal-NAC line is marked
(point A) which will be the top of the areola. On the
breast line, 24 cm above the inframammary fold point
D is marked. This distance varies between 2 and 4 cm
depending on the size of the breast (Fig. 47.1). The
breast is then gently displaced laterally (a technique
described by Lejour), and a line is drawn parallel to the
midline, connecting point A and D. A similar line is
drawn with the breast displaced medially. A distance
of 58 cm is measured from point D upward on the
medial and lateral lines (points B and C). It should be
pointed out that the tension resulting from this dis-
placement should be firm enough to allow adequate
skin resection but not so tense as to create difficulty
with closure. This distance varies also in accordance
791
792
Fig. 47.1 Basic markings of vertical technique. Lines are
drawn straight down the midline from the suprasternal notch to
the N-A complex. Point A, 20 cm from the clavicle, which will
be the top of the areola (superior left), from a point 5 cm from
the suprasternal notch at the clavicle to the N-A complex and
then straight down parallel to the midline line, crossing the infra-
with the size and laxity of the breast. Gently curved
lines are drawn from point A to point B and C. Line
A-B should never be closer than 9 cm to the midline
and line A-C, never <10 cm from the anterior axillary
line.
The variation in distances of point D to the infra-
mammary fold and of lines B-D and C-D allows
the surgeon the latitude of adjustments, depending on
the size of the breast. The larger the breast is planned
to be, the greater these distances are marked. These
distances, however, should never exceed 4 and 8 cm,
respectively.
An additional detail is that points B and C should be
marked slightly closer to each other, so when they are
closed there will be no significant tension.
R.M. Graf et al.
mammary crease not <11 cm (superior right). The breast is gen-
tly, with the Lejour maneuver, displaced laterally (inferior left)
and medially (inferior right) to obtain the vertical lines. The
suprasternal notch is noted to be at the cephalad edge of the
bone, not down into the notch
47.3 Operative Procedure
The patient is placed supine on the operating table and,
after induction with general or epidural anesthesia
(local is possible) and prepped and draped, the incision
markings are infiltrated subdermally (except superior
to the areola), with diluted epinephrine-saline solution
(1:100,000). The area of the skin demarcated by lines
A-B, A-C, B-D, and C-D is deepithelialized (Fig. 47.2),
leaving the NAC (4.55 cm in diameter) in place. An
incision is made in the dermis transversely along lines
B-D and C-D, passing 1 cm below NAC. This is the
beginning of the creation of the chest-wall-based flap
(Fig. 47.3). Along the vertical lines, this incision is
beveled inward for 12 cm to preserve tissue on the
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop 793

Fig. 47.2 The vertical lines cross at the midbreast line, 24 cm a gently curved line is drawn from point A to point B (inferior
above the inframammary fold, and point D is made (superior left) and again from point A to point C (inferior right). Line A-B
left); a distance of 58 cm is measured on the medial and lateral should never be closer than 9 cm to the midline and line A-C,
lines and point B and C are placed, respectively (superior right); never <10 cm from the anterior axillary fold

Fig. 47.3 Patient at the operating table with skin demarcation with the vertical lines and the chest-wall-based flap
794
Fig. 47.4 Deepithelization and dermis incision following
demarcation, 2 cm above points B and C (superior left); along
the vertical lines, this incision is beveled inward for 12 cm so
as to preserve tissue on the medial (superior right) and lateral
medial and lateral pillars. After preserving this tissue,
the incisions continue inward and away from the flap
so creating a broad base for the mammary flap. This
dissection is carried to the chest wall with minimal
amount of subcutaneous tissue being left on the skin as
dissection is carried to the inframammary fold.
After this dissection has been performed laterally
and medially, a large hook is placed in the NAC and
the breast is lifted straight up. Then, and incision is
made in the breast tissue from points B to C, proceed-
ing to the pectoral fascia. Great care must be taken at
this point not to undercut the flap (chest wall pedicle).
The flap is now freely mobile and is based on vessels
from the fifth and sixth intercostal spaces as a perfora-
tor flap (Figs. 47.4 and 47.5). The flap is free from all
of the four sides: superior, lateral, inferior, and medial.
Its very important that the flap not be restrained; if it
is, continuous dissection should be extended to the
R.M. Graf et al.
(inferior left) pillars for closure later; a large hook is placed in
the N-A complex and the breast is lifted straight up, and dissec-
tion of the breast tissue from point B-C is carried out 1 cm below
the areola, proceeding to the pectoral fascia (inferior right)
pectoral fascia. This freely mobile, totally chest-wall-
based flap is comprised of breast tissue that in other
procedures bottoms out but in this procedure is being
transposed into the upper pole where it will be fixed.
The breast tissue is retracted upward and cephali-
cally and dissected off the pectoral fascia up to the
second intercostal space, creating a space in the upper
pole of the breast into which the flap will be fixed.
Before this, however, a strip of pectoral muscle approx-
imately 810 cm long and 1.52 cm wide is marked
with methylene blue. Its caudal or inferior line is at the
cephalic end of the flap base (Fig. 47.6).
This muscle strip is elevated incorporating no more
than one half of the muscle (the posterior fascia of the
muscle is not violated), and the donor site is closed
with 2-0 nylon. This muscle loop will be used to hold
the flap in position in the upper pole. The flap is then
passed under the pectoral loop into the space of the
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop
Fig. 47.5 The incisions continue inward and away from the
flap so the base is broad. This dissection is carried to the chest
wall with a minimal amount of subcutaneous tissue being left on
upper pole of the breast. It is very important that all
dermal elements on the flap be completely passed
under this loop. The dermis of the flap is then sutured
to the pectoral fascia with a running 2-0 nylon suture,
starting laterally and finishing medially. If after pass-
ing the flap under the loop there seems to be excessive
tension on the loop causing pressure on the flap, the
loop can be released by additional dissection laterally
(medial dissection could disrupt the origin of the
muscle) (Fig. 47.6).
With the flap in the correct position and the breast
suspended by the hook in the NAC, breast tissue excess
is removed. At this step of the surgery the reduction is
made in accordance with the breast size and the desire
of the patient. The main block of tissue is removed as an
inverted central kill, from the base of the breast laterally
and less amount centrally to reduce the base and the
excessive projection of the breast. The largest reduction
with this technique (vertical incision and circumvertical
795
the skin as dissection is carried to the inframammary fold
(superior); undermining of chest-wall-based flap maintaining
the large base (inferior)
closure) was 8001,000 g, including the liposuction in
the lateral aspect of the breast. The chest-wall-based
flap, however, can be used in any breast size.
After reducing the excessive breast tissue (Fig. 47.7),
one interrupted suture of 2-0 nylon is placed in the
superior breast tissue and the pectoral fascia just
cephalic to the flap (at the second intercostal space) in
order to lift the undermined breast tissue and improve
upper pole projection.
Closure starts with suturing the pillars with 2-0 nylon
in several layers. Its preferable to place the needle later-
ally deeper than medially to preserve more fullness
medially. Deep dermis of the superior vertical wound is
sutured placing together the subareolar points B and C.
A round-block suture is done around the NAC to
homogeneously distribute the periareolar skin and to
reduce tension on the NAC (Fig. 47.8). Eight cardinal
points are marked in the periareolar skin and in the
areola. The running suture is done using a 3-0 colorless
796
Fig. 47.6 A strip of pectoral muscle approximately 810 cm
long and 1.52 cm wide is marked with methylene blue just
superior to the base of the chest-wall-based flap (superior left)
and elevated leaving the deep half of the muscle intact (superior
nylon. Passing through the deep dermis of the outer
skin and the areolar deep tissue, the suture takes small
amount of tissue between the markings in the areola
and large bites right on the markings of the periareolar
skin. Tensioning the suture reduces the periareolar
circumference up to the desired diameter for NAC
(about 4.5 cm).
Starting from point D, vertical skin is closed with
interrupted sutures of 3-0 Monocryl. Anchoring the
deep dermis to the underneath pillars, these sutures
elevate the whole vertical component, placing the point
D at the level of the new inframammary fold. So, the
final vertical scar will end up at the level or slightly
above the new inframammary crease. Final skin clo-
sure is done with a running intradermal suture of 4.0
Monocryl (Fig. 47.9). No drains are routinely used.
R.M. Graf et al.
right); passage of chest-wall-based flap under the bipedicled
muscular flap and closure of the donor site (inferior left); suture
of the flap to the second intercostal space (inferior right)
47.4 Discussion
Although the classic inverted T incision mamma-
plasties are easy-learning techniques for young plastic
surgeons and give more reproducible results on the
operating table, they have several drawbacks that
should be reassessed [25, 26]. The short vertical inci-
sion dogma (near 5 cm) associated with an inferior
horizontal resection pattern of the skin and paren-
chyma leads the breast to a broad and flat cone shape,
with poor projection, which tends to worsen with time
[25, 27, 28]. All this issues and the concern of scar
length promoted the development of new techniques
for breast surgery.
Although the history of vertical mastopexy dates
back to Lotsch [29] and Dartigues [30], and later
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop
Fig. 47.7 Resection of the excessive breast tissue (superior
left); suture of the upper breast tissue to the pectoral muscle
superior to the flap (superior right); suture of the medial and
extended to breast reduction by Ari [4], it was other-
wise lost to surgical history until Lassus [1719]
resumed interest in the decade of the 1960s. Using
adjustable markings, an upper pedicle for the areola
and central breast reduction, Lassus has employed ver-
tical reduction mammaplasty in a wide range of breast
hypertrophies. It was then modified and popularized by
Lejour [2023] and several other authors [27, 3138].
In 1990, Levet [39] described a pure posterior pedicle
flap for breast reduction. During all this time, innumer-
ous authors observed that breast descent and loss of
upper pole fullness (bottoming out) was often seen in
their own work and the work of others. Ribeiros tech-
nique [40, 41], which uses an inferior pedicle flap trans-
posed into the upper pole, provided improvement of
797
lateral breast columns (inferior left) and closure of points B and
C (inferior right)
this problem. Daniel [42] associated a bipedicled flap
of major pectoralis muscle to keep Ribeiros flap in a
higher position, further minimizing the bottoming out
phenomenon. The authors have proposed some modifi-
cations to the mammary flap, describing it as totally
based on the chest wall and held in place by the pectoral
loop [3336]. There are also other flaps described in the
literature [43].
Since 1994, these flaps have been performed in
inverted T, oblique or L scar, and, more recently, in
vertical scar mammaplasties. The approach was
switched from inferior pedicle flaps to flaps based
only in the thoracic wall vasculature, completely
detached from the dermis and structures around, main-
taining the overlying dermis in order to give better
798
Fig. 47.8 The round block is done around the N-A complex.
Eight cardinal points are marked at the skin and at the areola to
spread regularly the areola. To close the skin and reduce wound
tension around the areola, a round-block suture is made all the
way around the periareolar skin with 3-0 colorless nylon. This is
a running suture passing through the deep dermis of the outer
skin and the areolar deep tissue. In the external skin, the suture
is passed on the markings, taking a big amount of tissue, and at
the areola, the suture is passed between the markings, taking
Fig. 47.9 Final skin closure with shortening of vertical incision and round-block suture around the areola
R.M. Graf et al.
small amount of tissue. Tensioning the suture reduces the cir-
cumference up to the desired diameter accommodating a 4.5-cm
nipple-areolar complex (superior). Starting from point D, skin is
closed with 3-0 Monocryl in the deep dermal tissues with inter-
rupted sutures anchoring the vertical wound to the tissue of the
deep pillars, continuing suturing until reaching the subareolar
skin, so the vertical scar is kept at the same level as the new
inframammary crease (inferior)
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop
Fig. 47.10 Skin markings of the vertical technique (left); comparison of skin resection between vertical scar technique (red ink) and
inverted T or Wise pattern (blue ink) (right)
support and shape to the flap after fixation to the
underlying pectoral fascia. Figure 47.10 demonstrates
minimizing of the scar in the vertical technique when
compared with a technique using a Wise pattern [15].
The upper pole of the breast maintains more volume,
and the vertical scar is placed above or at the level of
the new inframammary crease with minimal breast
descent.
The length of the chest-wall-based flap changes
according to the distance between the areola and infra-
mammary crease. Its upper limit is located 1 cm below
the inferior edge of the areola, and the lateral borders
extend to the medial and lateral breast contours. Its
base extends to the inframammary crease with 68 cm
of width and 4 cm of thickness, with its vascular pedi-
cle based on intercostal vessels of the fifth and sixth
intercostal spaces. The bipedicled muscle flap (pecto-
ralis loop) is situated immediately above the base of
the breast tissue flap, with 1.52 cm of width and
810 cm of length. It should be dissected in the same
direction of the muscle fibers, with the caution to
elevate no more than one half of the muscle thickness,
superficially. The posterior fascia of the muscle is not
violated, leaving intact the ganglionar chain between
the minor and the major pectoralis muscles, which is
responsible for part of the lymphatic drainage of the
breast.
It is possible to use this combination of techniques
for mastopexy only, when there is no breast tissue in
excess to be removed, or for breast reduction, when the
resection of excessive breast tissue is done in the col-
umns or base of the breast, after the thoracic wall flap
799
is fixed. With this technique, we observed that we
remove less breast tissue compared with other tech-
niques that do not use the chest-wall-based flap and
that the breasts have a narrower base. In our experi-
ence, the average amount of breast tissue resected was
250 g, which is less than in other techniques we have
used without the thoracic flap. In great hypertrophies
or severe ptosis, the point D should be marked higher
above the inframammary fold, up to 4 cm. This maneu-
ver is done to leave the skin and subcutaneous tissue of
the lower breast pole as part of the thoracic wall, with
a higher new inframammary crease. Redundant skin is
removed in the vertical excision and the circumareolar
round-block excision.
The exceeding skin in the vertical branch observed
during surgery can be closed with a subcuticular suture
that shortens this scar. During the first 2 months of the
postoperative period, there is an accommodation with
no need to remove skin horizontally in the inferior
portion of this scar, as suggested by Marchac [44]. A
round-block suture is done around the areola with the
purpose to reduce even more the length of the vertical
scar by compensating skin excess around the areola.
Some advantages of this technique are as follows
(Figs. 47.1147.14):
1. Long lasting breast projection and upper pole full-
ness with the patient in both supine position and
decubitus. The areola remains in a good location
and very little breast descent occurs (minimal bot-
toming out).
2. A vertical scar that does not cross the new infra-
mammary crease, and with better quality due to less
800
Fig. 47.11 Preoperative 30-year-old patient with breast ptosis (superior); 6 months postoperative mastopexy with vertical scar and
the use of the chest-wall-based flap (inferior)
skin tension, which was achieved through internal
sutures of breast tissue.
3. A narrower breast base due to the vertical principle
of parenchyma resection and approximation of
breast pillars.
47.5 Conclusions
The achievement of a good aesthetic result in mamma-
plasty requires an adequate shape, minimal scar, NAC
complex on the top of breast projection, and a relatively
narrow base. With the traditional techniques, breast
shape has been accomplished with dermal sutures that
would relax along the years, resulting in a descent of all
breast tissues (skin stretches with time).
By performing the vertical scar technique associated
with a chest-wall-based flap and holding it in position
R.M. Graf et al.
in the upper pole with a bipedicled major pectoralis
muscle flap, it is observed in long-term follow-up that
a minimal scar resulted, the shape was better, and that
there was maintenance of upper pole fullness and mini-
mal bottoming out, thus keeping NAC in the optimal
position of breast projection (Fig. 47.15).
This technique accomplishes this with a vertical
scar that does not extend bellow the inframammary
fold. In older techniques, breast shape was determined
by skin tightening, and as the skin stretched, the shape
was lost. By this technique, breast tissue is divided,
moved into its desired position, and fixed by the pecto-
ral loop, thus maintaining a youthful appearance for
the breast. Therefore, its shape does not depend on
skin closure for contour, but the specific tissue that
usually bottoms out is transposed and stably held into
in the upper pole. This is another step in the evolution
of breast surgery.
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop 801

Fig. 47.12 Preoperative 25-year-old patient with mild breast ptosis (superior); 2 years after vertical mastopexy (inferior)

Fig. 47.13 Preoperative 35-year-old patient with breast hyper- inferior) and 2 years after touch up with horizontal scar at the
trophy and ptosis (left superior and left inferior); 1 year after lower (right superior and inferior)
vertical mastopexy (middle and right superior; middle and right
802 R.M. Graf et al.

Fig.47.14 Preoperative (left superior and inferior); 10 years postoperative (right superior and inferior)

Fig. 47.15 Skin markings of the vertical technique (left); passing the chest-wall-based flap under the pectoral loop (middle) and
schematic lateral view of the flaps (right)
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop 803

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 Hypertrophic Tubular Breast
Reduction: Surgical Technique
with New Inframammary Fold Level
Toma T. Mugea
48.1 Introduction
The mammary glands, a distinguishing feature of
mammals and a primary symbol of femininity, begin
development early in embryologic life and only culmi-
nate in the postpartum lactation of the adult female.
Congenital breast malformations occur in 26% [1]
with its range in severity from the relatively minor to
major chest wall deformities. Minor malformations
may not even be recognized, while major deformities
may cause significant functional, psychological, and
aesthetic concerns.
These malformations generally fall into one of two
categories, the presence of supernumerary breast tissue
or the absence or underdevelopment of breast tissue.
The absence or underdevelopment or underdevelop-
ment of breast tissue is less common than the presence
of supernumerary tissue. These conditions may be uni-
lateral or bilateral and result from partial or complete
underdevelopment of the mammary bud.
The condition can affect the ability of women to
breast-feed, but other physical aspects of fertility and
pregnancy are not affected by the condition.
T.T. Mugea, M.D, Ph.D.
Professor of Plastic and Aesthetic Surgery, Plastic and
Aesthetic Surgery, Oradea Medical University, Oradea,
Romania
Medestet Clinic, Cluj-Napoca, Romania
e-mail: drmugea@medestet.ro
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_48, Springer-Verlag Berlin Heidelberg 2013
48
48.2 Breast Shape and Contour:
Surgical Anatomy
Breast shape and contour are influenced by:
1. The volume of breast parenchyma in each quadrant,
2. The amount and location of the subcutaneous and
intraparenchymal fat,
3. The body contour of the chest wall,
4. Its muscular covering and thickness, and
5. The tightness and elastic quality of the skin.
The fascial attachments of the breast to the under-
lying chest wall also influence breast appearance.
The breast develops and is contained within support-
ing layers of superficial fascia. The superficial layer
of this superficial fascia is the outer layer covering
the breast parenchyma, located near the dermis and is
not always distinct from it. The more distinct is the
superficial fascias deep layer on the deep posterior
surface of the breast. A loose areolar area is inter-
posed between the deep layer of the superficial fascia
and the superficial layer of the deep fascia that covers
the outer layer of musculature chest wall.
The retromammary space will allow the breast
tissue to have a natural gliding over the chest. The
superficial layer of the deep fascia overlays the
outer surface of the pectoralis major, the upper
portion of the rectus abdominis, the medial serratus
anterior, and the external oblique muscle in the
lower central breast. This fascia is thinner over the
muscular portions of the pectorals major and serra-
tus anterior [2].
The connective tissue that supports the structures of
the breast (Coopers ligaments) runs from the deep
805
806 T.T. Mugea

muscle fascia, through the breast parenchyma, to the

dermis of the overlying skin (Fig. 48.1).
The attachments of these suspensor ligaments
between the deep layer of the superficial fascia and the
deep muscular fascia are not tight and allow the breast
mobility. These attachments can be stretched and
attenuated by weight changes, pregnancy, and aging,
which can result in excess breast mobility over the
chest and ptosis. This is the main problem in perform-
ing mastopexy for women who lose weight more than
20 kg in short time. Breast mould is gliding all over the
chest, borrowing skin also from the epigastric and
hypochondrial areas, making the preoperative plan
and drawing more difficult.
At the upper pole of the breast, near the second rib
space, the pectoral fascia tightly connects with the
superficial fascia of the breast, and it is difficult to
dissect bluntly [3]. Here is the meeting point of three
fascias, hanging to the clavicle. The superficial layer
of the superficial fascia joins the deep layer of super-
Natural milk lines ficial fascia (including between them the breast

Subclavius muscle

First rib

Superficial layer Clavipectoral

of superficial fascia fascia
Second rib
Deep layer
of superficial fascia Pectoralis major
muscle
Superficial layer Pectoralis minor
of deed fascia muscle
Retromammary space
with suspensors ligaments Deep layer
of deep fascia
Coopers ligaments

Breast mould

Sixth and seventh ribs

Rectus abdomins muscle

Fig. 48.1 Breast and pectoral
fascias (After Nahai [2], Inframammary crease ligaments
modified)
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
Fig. 48.2 Breast mound development and natural gliding on
the chest wall. The blue lines represent the breast mould limits,
and the red one the initial nipple level. Breast central and
mould) and the superficial pectoralis fascia. At the
upper and middle pectoral fascia, many thin fibers are
found between the pectoral fascia and the deep layer
of the superficial fascia of the breast [4].
In the normal growing phase, the breast can be
considered to have a hemispheric shape, with the
nipple in the middle, in the most prominent point
(Fig. 48.2). As the breast will gain weight, because of
the gravity and ligament tightening, the breast mould
will translate in the lower two thirds of the breast
vertical meridian, together with the nipple areola
complex.
Age, gravity, breast volume, and decreased elasticity
contribute to a gradual lowering of the breast landmarks
over time, as a woman gets older and experiences
normal physiologic changes. The extent of this descent
depends primarily on the volume of the breast and the
elasticity of the tissues. The breast mould and central
pedicle will change the position according to the
gravity.
In breast pseudoptosis, only the breast mould is
hanging. The nipple and the inframammary fold are at
the same level like in the normal situation. In the glan-
dular ptosis, the breast and inframammary fold glide
over the chest. In the true breast ptosis, the breast and
807
inferior pedicles follow the breast mould in its descending move-
ment. (Left) Teenager. (Middle) Young female. (Right) Adult
female
nipple glide over the chest, but the inframammary fold
is at the same level [6, 7].
48.3 Breast Embryology
Normal breast embryologic development follows
several stages, with three main participants:
1. Number of breast cells (glandular and stromal)
2. Superficial fascia of the thorax
3. Signaling elements (endocrine, paracrine, and auto-
crine signals).
During the fourth week of gestation, paired ectoder-
mal thickenings termed mammary ridges or milk lines
develop on the ventral surface of the embryo from the
axillae to the medial thigh [8, 9]. In normal human
development, these ridges disappear except at the level
of the fourth intercostal space, where the mammary
gland subsequently develops [9].
During the fifth week of gestation, the remnant of
the mammary ridge ectoderm begins to proliferate (the
primary mammary bud), and during the seventh week,
grow downward as a solid diverticulum into the under-
lying dermis. Progressively, superficial fascia is reverted
as a finger glove and becomes double by folding
808 T.T. Mugea

in front of the breast, with a strong round ring in the
middle, and a single layer sheet covering the deep sur-
face of the breast (Fig. 48.3).
Between dermis, superficial fascia, and deep fascia
over the trunk, there are fibrous structures which hold
the tissues in a tight way during the growing phase.
During the breast development, these fibrous structures
became more tight and evident as suspensors ligaments
of Cooper, which join the two layers of the superficial
fascia and extend to the dermis of the overlying skin

a b
Suspensor
Ligaments

Skin Superficial
Fascia Central Superficial
Primary Mammary Fascia
Mammary Deep Bud Deep Layer
Bud Fascia

Superficial Mammary
Fascia Bud
Ring Branches

c d
Superficial
Fascia

Central
Mammary Superficial
Central
Bud Fascia
Mammary Superficial
Deep Layer
Bud Fascia
Deep Layer
Mammary
Superficial
Bud
Fascia
Branches Superficial
Ring Mammary
Fascia Bud
Ring Branches

Fig. 48.3 Normal breast and its embryologic development

48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
e
Susperficial
Fascia Suspensor
Ligaments
Central
Mammary Superficial
Bud Fascia
Deep Layer
Mammary
Superficial Bud
Fascia
Branches
Ring
Fig. 48.3 (continued)
and the deep pectoral fascia [810]. The superficial
layer of the superficial fascia is absent under the areola,
because here is the place of mammary bud invagination
into the mesenchyme [11].
During the remainder of gestation, this bud contin-
ues lengthening and branching to form the lactiferous
ducts, corresponding to five directions: one central
and four to the corners generating a pyramid like
image. This is a very special moment, when each bud
branch can develop normally, generating a proper
number of future breast lobules or can be stopped. All
these events are under strong regulation of local
growth factors.
The breast is ready as future projection, and only
the hormonal influence at puberty will allow the full
reading of this program. It seems that if some breast seg-
ments will have less glandular tissue and less hormonal
receptors, the pyramid will not be symmetric. Wuringer
[12] describes the division of the mammary parenchyma
into two parts by the horizontal fibrous septum includ-
ing the vascular and nervous membranes attached to it.
The bipartition of the parenchyma may be explicable as
an invagination of the ectoderm cranially and caudally
from the inductive mesenchyme, and it may be seen as a
fusion of two mammary glands. According to Wuringer
[13], the reason for volume differences in breast
809
f Superficial Fascia
Suspensor
Superficial Layer Ligaments
Cooper Deep Layer
Ligaments
Areola
Deep
Fascia
Superficial
Fascia
Ring
Inframammary
Crease
Glandular Lobes Ligament
hypertrophies or asymmetries is always the variable
thickness of the parenchymal layer.
At term, approximately 1520 lobes of glandular
tissue have formed, each containing a lactiferous duct.
The lactiferous ducts drain into retroareolar ampullas
that converge into a depressed pit in the overlying skin.
Stimulated by the inward growth of the ectoderm, the
mesoderm surrounding this area proliferates, creating
the nipple. The surrounding areola is formed by the
ectoderm during the fifth month of gestation. The
areola also contains other epidermal glands, including
glands of Montgomery (sebaceous glands that serve to
lubricate the areola).
At birth, the breast is composed of radially arranged
mammary lobes, like a cone, draining via lactifer-
ous ducts into ampullas that empty onto the nipple
(Fig. 48.3). The nipple appears as a small pit in the
center of a thickened areola containing a few glands of
Montgomery.
Shortly after birth, the nipples become everted from
proliferation of the surrounding mesoderm, and the
areolas develop a slight increase in pigmentation.
The initial phase occurs between birth and puberty,
during which time the supporting stromal structures and
ducts enlarge in proportion to the increase in body size
of the individual, but no lobular development occurs.
810 T.T. Mugea

Stages of breast development.
At puberty, elongation and thickening of the
ductal system occur, and the breast volume increases
primarily from deposition of fat and deve-
lopment of periductal connective tissue. This
development is generally complete by age 20 years
(Fig. 48.2).
If pregnancy occurs, the glands complete their dif-
ferentiation and reach functional maturity with the
intralobular-branched ducts forming buds that become
secretory alveoli. The epithelial cells of the alveoli
begin to accumulate the cytoplasmic organelles nec-
essary to sustain lactation in the postpartum period.
Breast changes during pregnancy.

Gestational Age:

19 Weeks 31 Weeks
7 Weeks

Breast Volume:
293ml 381ml 398ml
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 811

By age 40 years, the mammary glands begin to atro-
phy. During and after menopause, the altered hormonal
environment leads to a senescent state, with involution
of the glandular component and replacement with con-
nective tissue and fat.
48.4 Tubular Breast Etiology
A tuberous breast is basically caused by incom-
plete development of the mammary gland, usually
in the two inferior quadrants, and probably as a
result of adhesion of the two layers of breast fascia
followed by formation of a constrictive ring around
the areola [14].
Many authors have referred to the embryology of
breast development, but the theories put forward are
far from satisfactory. Pers (1968) [15] postulated that
there is failure of tissue differentiation in a limited
zone of the fetal thorax. Mandrekas [16] considers
that the absence of the superficial layer of the super-
ficial fascia underneath the areola [8, 11], coupled
with the constricting ring[17] formed by the thick-
ening of the superficial fascia [18] especially in the
lower pole of the breast, inhibits the expansion of
the developing breast and leads to a herniation of the
breast parenchyma toward the nippleareola
complex.
The author postulates that the embryological origin
of tuberous breast deformity could be related to a simul-
taneous coexistence of several pathogenic factors:
1. Tight superficial fascia, which does not allow the
primary mammary bud to penetrate inside and
advance into the mesoderm. As a result, the mam-
mary bud cannot develop as normal in the superfi-
cial fascia glove and, without local paracrine
signals (growth factors), will stop the development
at one stage, in one or more direction.
2. Local signaling defect for bud branches to develop.
3. Lack of bud development by a self-defect, partially
or complete.
The author considers this situation as credible for
tuberous breast etiology because:
1. There is a silent congenital disease.
2. There is a growing process starting at puberty.
In tubular breast, it seems that the quality and quan-
tity of the hormonal stimulus is not different from
normal, but the lower quadrants (Fig. 48.4), which
are the most affected, have less glandular tissue and
less hormonal receptors. This corresponds to caudal
parenchymal layer described by Wuringer [13].
3. In type III, the breast tissue grows in front of one
fibrotic ring level (Fig. 48.5), corresponding to the
superficial fascia reverse haul for invagination,
where the central buds stop to advance and branch
into the mesoderm.

a b

Superficial Susperficial
Fascia Fascia Suspensor
Suspensor Ligaments
Ligaments

Central Superficial
Mammary Fascia
Deep Layer Areola
Bud
Cranial & Central
Glandular Lobes
Superficial Mammary
Fascia Bud
Ring Branches Superficial
Fascia Inframammary
Ring Crease
Ligament

Fig. 48.4 Tubular breast missing inferior glandular lobes development. This corresponds to type II tubular breast
812
a b
Superficial
Fascia
Suspensor
Ligaments
Central
Mammary
Bud
Mammary
Bud
Branches
Inframammary
Crease
Superficial Ligament
Fascia
Ring
Fig. 48.5 Tubular breast missing all peripheral quadrants from the pyramid. Only central part of the mammary gland developed.
This corresponds to type III tubular breast
4. In type I or type II, the breast tissue can expand and
develop normally in the unaffected segments.
5. Breast hypertrophy can occur even in this congeni-
tal malformation for type I or type II.
6. The high level of inframammary fold is always
present, corresponding to the horizontal septum
described by Wuringer [12, 13] with central neuro-
vascular pedicle (Fig. 48.2).
7. Areola is enlarged as a normal expanded tissue.
Superficial fascia and apparent constricting ring are
not the cause but the result of the growth defect,
because this ring is close to the deep fascia, and there
is no breast tissue behind this level. Otherwise, a
clepsydra shape of the breast supposes to be present,
and its not the case in clinical cases.
48.5 Aesthetic Breast Analysis
Some women are born missing one or both breasts
and/or nipples. There are many reasons for this to
occur, but the effect is devastating. Alternately, all
tissues might be present, but simply do not develop
properly. This is called breast hypoplasia or sometimes
breast hypotrophy. Typical breasts can also be affected
by size and proportion issues. Most breasts are not
symmetrical, and it is common for women to have
up to a 30% size discrepancy from one side to the
other. However, sometimes, this difference in size is
extremely pronounced, making the body appear unbal-
T.T. Mugea
Superficial
Fascia Suspensor
Ligaments
Central
Mammary
Gland Undeveloped
Mammary
Gland
Areola Inframammary
Crease
Ligament
Superficial
Fascia
Ring
anced and making a proper bra fit impossible without
custom tailoring.
Additionally, nipples and areolas may be consid-
ered too large or too small for the breasts they occupy.
While this is a very subjective topic, it can still be trou-
bling to any woman who views her body as
abnormal.
Throughout the breasts development and evolution
alterations often appear due to volume excess (hyper-
trophies) or absence of volume (atrophy, hypotrophy)
and unequal development (asymmetries) or malforma-
tions (tuberous breasts).
It is impossible to impose a single standard of breast
beauty to women who are so entirely different in
height, weight, and constitutional type. Therefore, we
need to discover the sizes that are aesthetically right
for each particular woman, starting from her main
parameters: height, weight, trunk height (the distance
between manubrium notch and the pubis), width
across the shoulders, and pelvic width at the level of
the anterior superior iliac spines. These parameters
will be included into a computer program (TTM
patent) and will give the Breast Golden Number,
representing the breast dimensions which correspond
to the aesthetical proportion between the breast and
the body. This computer program came after a com-
plex assessment of the breast and body in 50 cases of
Caucasian females with aesthetic breasts, in harmony
with their body, which looks also aesthetically pleas-
ant [19].
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
Table 48.1 TTM chart
with breast and trunk
measurements
In order to achieve the best aesthetic results in
breast augmentation, the surgeon must evaluate each
breast before the surgery, in terms of position, propor-
tion, symmetry, volume, soft tissue elasticity, skin
excess, and ptosis degree (if exists). TTM chart
includes the breast and body parameters [19] needed
for an objective aesthetic evaluation of the breast
(Table 48.1).
813
48.6 Breast Score for Soft Tissue Elasticity
To estimate skin tightening and soft tissue elasticity,
we use the Pinch Test in the upper pole of the breast.
We grasp the biggest amount of skin and soft tissue that
can be moved over the pectoralis fascia. If two dots are
marked on the skin in the pinched situation, we can do
the measurements also for relaxed one (Fig. 48.6).
814
a Soft Tissue Elasticity Assessment
Relaxed (R) : Pinch Test (P)
8 cm
b
Soft Tissue Elasticity Score
R:P<2 Tight = Score 1
R:P=23 Normal = Score 2
R:P>3 Loose = Score 3
Fig. 48.6 Pinch test for soft tissue elasticity assessment
If the Deep Pinch Test shows an R:P ratio <2, this
corresponds to a tight situation, and the Breast Score
for Elasticity is 1.
If the Deep Pinch Test shows the R:P ratio to be between
2 and 3, this corresponds to a normal soft tissue elasticity
situation, and the Breast Score for Elasticity is 2.
If the Deep Pinch Test shows the R:P ratio >3, this
corresponds to a loose soft tissue or skin excess, and
the Breast Score for Elasticity is 3.
Getting experience, the plastic surgeon can appreci-
ate directly after the Pinched Test, the tight, normal, or
relaxed situation, corresponding to the Breast Score
for Soft Tissue Elasticity 1, or 2, or 3.
48.7 Breast Score for Skin
Excess
Because in breast augmentation, the lower third of the
breast will be expanded to get maximum nipple projection,
we should know the amount of extra skin that can be
available. For these, we do the inferior meridian measure-
ments in relaxed and in stretched situation (Fig. 48.7).
T.T. Mugea
: 3 cm = 2,5 cm
The difference between stretched and relaxed infe-
rior meridian, in cm, will give the Skin Excess Score
that will be 1 for 1 cm excess, 2 for 2 cm excess, and 3
for 3 cm excess.
48.8 Breast Score for
Volume
Especially in terms of volumes, implant selection in
breast augmentation depends on the actual existing
breast volume, evaluated by the difference between the
Breast Golden Number (BGN) and the Breast Vertical
Meridian (BVM) (Fig. 48.8).
In cases with severe breast hypotrophy or amastia,
BVM will be close or similar with Breast Vertical
Diameter. As the breast mould is growing, the BVM
will increase in dimensions, and the aesthetic breast
will be similar with the BGN. If the difference in cm
between BGN and BVM is 1, or 2, or 3, or more, the
corresponding Breast Volume Score will be 1 (mild
hypotrophy), 2 (moderate hypotrophy), or 3 (severe
hypotrophy).
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 815

a Skin Excess Score

Stretched - Relaxed Inferior Meridian

8,5 cm 6 cm = 2,5 cm

b Skin Excess Score

Stretched (S) - Relaxed (R)
1 cm = No Extra Skin = Score 1
2 cm = Moderate Excess = Score 2
3 cm = Good Skin Excess = Score 3

Fig. 48.7 (a) Relaxed and stretched inferior meridian measurements. (b) Soft tissue elasticity assessment

48.9 Breast Score for Ptosis
To evaluate the ptosis degree (Fig. 48.9), we take the
Inframammary Fold Length from Breast Circumference
(BC). If the difference in cm between BC and IMF is
1, or 2, or 3, the corresponding Breast Ptosis Score will
be 1 (mild ptosis), 2 (moderate ptosis), or 3 (severe
ptosis).
48.10 Breast General Score
The final breast assessment, named Breast General Score
(BGS), will include in order the first number for Soft
Tissue Elasticity, the second number for Skin Excess,
and the third number for Breast Volume. In cases with
ptosis, the fourth number will be added (Fig. 48.10).
48.11 Tubular Breast: Short Denition
and Classication
Even if in the literature there are many terms for tubular
breast definition, tuberous breasts, tubular breasts,
snoopy breasts, herniated areolar complex, domed
nipple, nipple breast, constricted breast, lower-pole
hypoplasia, and narrow-based breast are some of the
names used to describe this deformity or the so-called
new deformities that, under careful inspection, are no
different from the original one described by Rees and
816 T.T. Mugea

Fig. 48.8 Breast Volume

Score evaluated by the a Glandular Volume Score
difference between Breast
Golden Number (BGN) and
Breast Vertical
Meridian (BVM)

BGN BVM
BGN = Breast Golden Number
BVM = Breast Vertical Meridian

b Glandular Volume Score

BGN BVM = 0 Normal Volume
1 cm = Small Hypotrophy = Score 1
2 cm = Moderate Hypotrophy = Score 2
3 cm = Severe Hypotrophy = Score 3

a Breast Ptosis Score

BC IMF

BC = Breast Circumference

IMF = Inframammary Fold

b Breast Ptosis Score

0 = No Ptosis

Fig. 48.9 Breast Ptosis Score

1 cm = Small Ptosis = Score 1
is 0 for the right breast and 3 2 cm = Moderate = Score 2
for the left breast. Left Breast
Circumference is 26 cm, and 3 cm = Moderate Plus = Score 3
the BGN is 19 cm
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 817

a
Score 113 Score 213

b
Score 222 Score 232

Fig. 48.10 Clinical cases with different Breast General Scores (BGS)
818 T.T. Mugea

c
Score 323 Score 333 + ptosis 2

d Asymmetry & Breast Hypotrophy

BGS = 333 + 2 BGN = 19 cm BGS = 323

Areola Size = Normal Areola Size = Normal

IMF = Normal IMF = Shrot & High Situated
All Meridians = Normal All Meridians = Smaller then BGN

Fig. 48.10 (continued)

48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 819

e Score 211 Score 210

f Severe Breast Hypotrophy

BGS = 223 BGN = 19 cm IMF = 14 cm

Areola Size = Normal

IMF = Short & High Situated
All Meridians = Smaller then BGN

Fig. 48.10 (continued)

820
Aston [17]. In its full expression [2022], the deformity
is characterized by:
1. A small breast, minimal breast tissue, sagging
2. A breast parenchyma volume reduction
3. A cylindrical rather than a conic shape
4. A relatively reduced base circumference both on
the vertical and horizontal axes
5. Unusually wide spacing between the breasts
6. A constricting ring that herniates the nippleareola
complex
7. Areolar hypertrophy (enlarged, puffy areola)
8. Hypoplasia of the lower mammary quadrants
9. A submammary fold situated too high
Fig. 48.11 (a) Teenager patient with apparently normal shape
but with hypotrophy of right breast and left breast with tubular
disease type I B. (b) Five years later with tubular breast type
T.T. Mugea
To conclude and make a simple definition, the
author considers that tubular breast represents a con-
genital breast deformity with:
1. Asymmetric breast meridians
2. Short inframammary fold length
3. High situated inframammary fold level (short breast
vertical diameter)
Tubular breast classification is similar to Grolleau
[18], but with a precise definition:
Type I (inferior and medial meridians shorter
inferomedial quadrant hypoplasia)
Type II (inferior, medial, and lateral meridians
shorter inferior quadrant hypoplasia)
I B on the right side and tubular breast type I C on the left side.
No areola widening
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 821

Type III (all meridians shorter than normal all
quadrant hypoplasia except central segment)
According to the glandular volume correction, each
type of tubular breast can be with:
1. Severe breast hypoplasia
2. Moderate hypotrophy or normal breast volume
3. Hypertrophic breast.
Because all tubular breasts have a high situated
and short inframammary fold length, as soon as they
got some volume, they would have a certain degree of
ptosis (Fig. 48.11). Wide areola is not included in the
definition because it is present only in some cases
(Fig. 48.12), usually after breast enlargement. The
inframammary fold stays at the same level, in a higher
position than normal, and the breast development in
the other quadrants, except the inner inferior one,
generates the breast asymmetry and ptosis. The breast
mould is hanging over the inframammary fold.

a Tubular Breast Type I B & I C

Right Breast = Type I B Left Breast = Type I C

b Tubular Breast Type III A & I B

Right Breast = Type III A Left Breast = Type I B

Fig. 48.12 Different types of tubular breast according to the new proposed classification
822 T.T. Mugea

c Tubular Breast Type II A

d Tubular Breast Type II A

Right breast with severe hypoplasia

e Tubular Breast Type II B

Fig. 48.12 (continued)

48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 823

f Tubular Breast Type II B

g Tubular Breast Type II C

h Tubular Breast Type III A

Fig. 48.12 (continued)

824
48.12 Tubular Breast: Congenital
Disease in Twin Sisters Case
The author found a rare and interesting case of twin
sisters, both with tubular breasts, moderate thoracic
scoliosis, and sternal depression in the upper part.
Their mother has normal breasts (Fig. 48.13), with
normal development and ptosis according to her age
and three pregnancies in the past. Both sisters have a
Type II tubular breast.
First twin sister (Fig. 48.14) has tubular breast Type
II B with short and high situated inframammary fold,
wide areola, and inferior quadrant hypotrophy. She has
a b
Fig. 48.13 Mothers twin sister breasts
a b
Fig. 48.14 Twin sister A with tubular breast type II B
T.T. Mugea
a moderate breast hypotrophy, so she got a Type II B
tubular breast according to our classification.
Second twin sister (Fig. 48.15) has tubular breast
Type II C with short and high situated inframammary
fold, wide areola, and inferior quadrant hypotrophy.
Because she has breast hypertrophy (breast volume
bigger than normal), according to our classification,
she got a Type II C tubular breast.
The lifting effect on the breast created by rising the
arms (Fig. 48.16) demonstrates the strong connection
between breast suspensory ligaments, breast mould,
and the superficial fascia ring showed at the areola
margin (red arrow) for twin sister A.
c
c
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 825

a b c

Fig. 48.15 Twin sister B with tubular breast type II C

Fig. 48.16 (a) Mother.

(b) Sister A. (c) Sister B
826 T.T. Mugea

Fig. 48.16 (continued)

b
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
Fig. 48.16 (continued)
c
Comparing the picture from the mother and twin
sisters in this position, we can see how the suspensory
ligaments lift almost all the volume in tubular breasts,
like a hammock, demonstrating in this way that the
lower glandular quadrants are hypotrophic.
To explain how this complex congenital disease
affects in the same way the twin sisters is a real
challenge, allowing speculation about genetic program,
signals, and growing factors involved.
827
48.13 Treatment Goals and Surgical
Options
The main goal of tubular breast treatment is to restore
a normal breast shape. To achieve this, it has to:
1. Expand breast circumference
2. Expand skin envelope in lower pole
3. Release fibrotic constriction at the superficial fascia
ring
828
4. Lower the inframammary fold level
5. Increase breast volume (when appropriate)
6. Reduce areola size and correct herniation (when
appropriate)
7. Correct nipple location and breast ptosis (when
appropriate).
Every attempt is made to correct the deformity in a
single stage operation. Many techniques have been
described, reflecting the reconstructive challenge of
this deformity. The main concepts in reshaping the
deformed breasts are:
1. Periareolar mastopexy techniques to reduce areola
and reposition the nipple areola complex [17,
2031]
2. Breast parenchyma redraping by inferior pole radial
scoring, mobilization, or division [1618, 30, 3234]
3. Augmentation with permanent implant or expand-
able permanent implants [29, 35, 36]
4. Reconstruction by autogenous tissue [15, 37, 38]
5. Breast reduction when appropriate [15, 39]
48.14 Tubular Hypertrophic Breast Type
II C Correction
The majority of surgical techniques for tubular breast
correction are focusing on the hypoplastic breast, con-
stricting ring with wide areola and high position, and
the inframammary fold.
The problem of hypertrophic tubular breast has a
relatively low incidence, and the surgical techniques
described represent either a reduction mammaplasty
with a superiorly based dermal pedicle and resection
of the inferior portion of the breast, resulting in an
inverted T scar [15, 40], or a modification of Maillard
Z-plasty technique [15, 41].
Also, type I B or type I C deformities were treated
so far by circumareolar mastopexy and reduction
mammaplasty with a superiorly based glandular
pedicle (Lejour-type reduction/mastopexy) in hyper-
trophic or adequately sized breasts [15, 18] and a
lateral dermoglandular flap to fill the lower medial
quadrant [18].
For type II C tubular breast (Fig. 48.13), the clinical
appearance corresponds to hypertrophic breasts, with
wide areola and short inframammary fold, highly
situated.
Based on the anatomical data, the author suggests a
new technique for lowering the inframammary fold
level (Fig. 48.17), without disturbing the local anatomy
T.T. Mugea
(inferior NAC pedicle and inframammary crease liga-
ment) (Fig. 48.18).
Actually, deepithelialization is being done on the
thoracic skin up to the level we want to be the new
inframammary fold level, and we glide into caudal
direction the lateral flaps and suture to it in an inverted
T scar. Wechselberger [39] presents also a deepitheli-
alized skin flap, but that is anchored to the periosteum
of the fifth or sixth ribs to reconstruct the inframam-
mary fold in double-bubble postoperative deformity.
This technique is simple, easy to learn, and allows
breast reduction with inferior based pedicle for nipple
areola complex in the same time with lowering of the
inframammary fold at the desired level, without fear of
jeopardizing the NAC vascularity. Also the lowering of
the inframammary fold level by deepithelialized skin
ellipse can be associated with a round block mastopexy
for tubular breast Type II B.
In this way, the fullness of the inferior breast quad-
rants is restored, when the medial and lateral breast
limits (breast horizontal diameter) are close to the
normal situation, as in Type II tubular breast.
48.14.1 Advantages
1. Precise planning of the surgery with predictable
breast shape.
2. Patient satisfaction with good aesthetic result visible
next day after the surgery.
3. Areola reshaping with a natural appearance.
4. Inverted T scar is better accepted than a Z-plasty,
which is more visible on the lower part of the breast.
This technique provides a stable and long lasting
suspension along an exactly defined line, using the
glandular and fascial structures of the breast, as one
unit. Nipple sensibility and vascularization are preserved
by the inferior pedicle.
48.14.2 Disadvantages
1. A strong limitation of this technique came from the
condition that the available length of lateral flaps
must have together, at least, the same dimension
like the new inframammary fold length.
2. Operation time required: average 2 h and 30 min,
no longer than a routine breast reduction.
3. Hospital stay for 24 h.
4. Drains usually for 12 h.
5. Recovery usually in 7 days.
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 829

Fig. 48.17 Breast reduction

technique for type II C tubular
breast, telescoping the inferior a
pedicle and caudal gliding of
inframammary fold
Deepithelialised
Skin Flap

Old
Inframammary
Fold Level

Old Tubular Areola

New
Inframammary
Fold Level
Deepithelialised
Periareolar Skin

Inferior
Dermoglandular
Flap Pedicle

b
NAC

Deepithelialised
Skin Flap
Old
Inframammary
Fold Level Pectoralis
Fascia
New
Inframammary
Fold Level

Deepithelialised
Thoracic Skin Inferior Dermoglandular
Flap Pedicle

48.15 Patient Consultation
Patient appointment, waiting, consultation, clinical
examination with breast measurements, informed
consent, and preoperative preparations are done in the
same way as has been presented in details in our chap-
ter about breast reduction/mastopexy in this book.
Standard breast pictures are taken after examination
and loaded in the patient electronic file version. These
include standing front, profile and oblique exposition,
with arms relaxed and lifted. In order to demonstrate
the inframammary fold level and the neck of the
breast (the attachment base to the trunk) useful for
tubular breast examination, special pictures are taken
830 T.T. Mugea

Superficial Layer
Superficial Fascia

Pectoralis
Deep Layer Fascia
Superficial Fascia

Central
Pedicle

Old
Inframammary
Fold Level

Inframammary
Inferior Crease Ligament
Dermoglandular
Flap Pedicle
New
Inframammary
Fold Level

Fig. 48.18 Postoperative position of old inframammary fold level, inferior pedicle, and inframammary crease ligament location
inside the breast mould (left) and the normal breast anatomy (right)

with breast sustained and gently pulled out by the
assistant (Fig. 48.19).
According to the TTM chart (Table 48.2), the sur-
geon can document and show to the patient the breast
problems, even small asymmetries. Body height, weight,
trunk measurements, and standard breast measurements
are very important elements for defining Breast Golden
Number (BGN) and Breast General Score (BGS).
After collecting the data in the chart, we fill the
boxes nominated in the TTM program for breast reduc-
tion (Fig. 48.20), organized in similar sections as the
chart. The surgeon has to select the calculate named
icon situated in the right upper corner of the table, and
automatically, the computer will list, in red color, what
are the ideal breast dimensions for the patient.
Because in this case we have a patient with a tubu-
lar breast type II C, the inframammary fold length
(16 cm) is significant shorter that supposed to be in a
normal case (2023 cm).
Till now, this is the only program available for
breast assessment, allowing precise preoperative plan-
ning for breast reduction or mastopexy, in order to
achieve aesthetic results. We create and use it for every
case, demonstrating its accuracy in the last 10 years.
At the follow-up, we can also document the present
situation of the breast and how it was the evolution in
time.
After the first consultation and examination,
according to the patient desires, based on pictures and
computer program, and sometimes using free drawing
on the consultation file, the surgeon will explain in
details what the problems are and what can be done to
solve it.
If the patient understands the procedure, including
the risks of incidents and accidents and complications
related to the anesthesia also, she will receive a printed
document containing these things and the lab tests and
other medical examination necessary.
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 831

a b c

d e f

g h i

Fig. 48.19 Patient with hypertrophic tubular breast type II C. Note the short (16 cm) and high situated inframammary fold, wide
areola (14/10 cm diameters), and small breast vertical diameter (8 cm) with a big Breast Vertical Meridian (43 cm)
832
j k
m n
Fig. 48.19 (continued)
48.16 Final Preoperative Consultation
After first consultation, the patient goes home and
digests the information and experience acquired
during the first visit to the surgeon. If she takes the
decision to have the surgery, she will undergo the
medical investigations recommended, and she will be
scheduled for a second appointment.
At the second consultation, the surgeon will check
the results from the recommended investigation and
will discuss in more detail the procedure, including
risks, and unfavorable possible events. Special atten-
tion will be paid for scars and wound healing.
T.T. Mugea
l
In front of the assistant, the patient will read and
sign the consent for the surgery and anesthetic proce-
dure (Consent Form).
According to the clinic policy, the patient has to pay
the full price of the procedure at least two weeks before
admission. No discount, partial payment, or bank guar-
anty will be admitted. For all the services paid, the
patient will receive a receipt. Patients begging for
financial favors, promising that they will be advertis-
ing our clinic and bring new patients among their
friends, will be erased from the list. Accepting patients
with this kind of behavior in private practice is equiva-
lent to an opened gate for problems after the surgery.
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 833

TTM program for Breast Reduction / Mastopexy

Fig. 48.20 TTM Junior program for breast reduction/mastopexy, with actual and ideal dimensions

They will become demanding, unhappy with the
results, whatever will be, and will turn out into an
enemy and bad advertising person.
According to the patient desire, and waiting list, the
surgeon will schedule the date of the operation.
48.16.1 Surgical Plan
The entire procedure is designed before surgery,
with the patient sitting and arms placed to the sides.
The following clue points and lines are marked: manu-
brium, acromion, supero-anterior iliac spine, and
pubis.
The inframammary fold with its medial and lateral
end point is marked. The new inframammary fold mid-
point level should correspond to the six ribs, on medio-
clavicular descending line, and is situated 2 cm below
the old inframammary fold level (Fig. 48.21). After
marking these reference points, we draw the line
representing the new inframammary fold and mark the
midpoint of it (Fig. 48.22). The new inframammary
fold length to be surgically created is 19 cm, shorter
than the end result, which will be 21 cm, according to
the Breast Golden Number.
Because the upper pole of the breast is flat at the
marking time, when the breast cone is filled, the nipples
new position with breast tissue behind it will be pushed
forward, like a pendulum, and the manubriumnipple
distance will become shorter (form aesthetic point of
view), with the nipple situated in a higher position than
desired. To correct this, we add 10% extra length to the
calculated manubriumnipple distance for the new nip-
ple position. To define the new nipple location, the ruler
passed behind the neck to the nipples, and a dotted line
marked the inner side of the ruler. The meeting point
between this line and Mn-Ni distance, located accord-
ing to the 10% correction rule, will be the new nipple
position, in this case, 21 cm from the manubrium notch
(19 + 2 cm, representing 10%, = 21 cm).
834 T.T. Mugea

Table 48.2 TTM chart with

breast and trunk
measurements for patient with
short inframammary folds
(16 cm) and wide areola
diameters, right 14/10 cm and
left 12/8 cm. Breast vertical
diameter is 8 cm shorter than
horizontal one. Normal is
11 cm

In order to avoid all this calculations, sometimes
boring for a surgeon, we created a new version of TTM
program for breast reduction and mastopexy, able to
show instantly all the measurement to do the preopera-
tive marking of the breast based on Breast Golden
Number. This is TTM Advance version (Fig. 48.23).
All the marking steps are similar with our demonstration
presented in this book at mastopexy with short inverted
T scar chapter.
Using a ruler, we mark step by step the points situ-
ated at 9 cm distance from the medial and from the
lateral edges of the inframammary fold. This will
define the level of vertical T branch and represent
half of the inframammary fold length (9 cm).
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 835

Fig. 48.21 Surgical plan for

breast reduction and
inframamary fold caudal 8 cm
21 cm Mn New Ni Breast
gliding
Vertical Diameter

9 cm
IMF

5 cm

2 cm

27 cm Mn Ni
14 cm
Areola
Vertical Diameter

15 cm Ni - IMF

Deepithelialised
Periareolar Skin

New Areola Margin

Deepithelialised
Skin Flap

Pectoralis
Fascia

Old
Inframammary
Inferior Fold Level
Dermoglandular
Fig. 48.22 Intraoperative Flap Pedicle New
view with inferior Inframammary
dermoglandular pedicle and Fold Level
new inframammary fold level
836
Fig. 48.23 TTM Advanced program for breast reduction/mastopexy, with suggested marking dimensions
We select the Wise pattern keyhole, corresponding
to the 5 cm diameter areola, and holding the upper pole
of the key at 2.5 cm superior to the marked nipple
point, we enlarge the keyhole branches until these meet
the doted lines corresponding to the vertical branches
of inverted T.
According to TTM chart, NiInfra distance should
be 7 cm (1:3 from Inframammary Fold Length), and
the length of each vertical T branch will have in this
case 5 cm, because 2 cm came from areola diameter.
With full marking done, a picture will be taken for the
files (Fig. 48.24).
48.16.2 Surgical Technique
The patient comes into the operating theater with a dis-
posable cap and dressed with a large gown that will be
removed by the nurse before sitting on the table. In
T.T. Mugea
tranquility, the anesthetic team will proceed to put an
IV line and connect the patient to the monitors. The
anesthesia will be with oral intubation.
When the patient is asleep, the radiofrequency bipo-
lar electrocautery will be connected, and the scrub
nurse will prepare the table with instruments. The
operation field is prepared with Betadine solution, and
after the patient is covered with sterile drapes, the key
points are marked by small intradermal injections with
Methylene Blue on both breasts. This is necessary to
avoid the dissipation of the drawings during the opera-
tion. A special cutting ring, with a hole centered on the
nipple position, will mark the new areola diameter.
According to the drawings, the intradermal incisions
on both breasts are made with No. 15 blade scalpel,
and deepithelialization started carefully from the
new inframammary fold level using a sharp scissor
(Fig. 48.25). When the deepithelialization is com-
pleted, using the electrocautery, the transdermal
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
a b
Fig. 48.24 Final preoperative marking of the patient
incisions are started, saving a 5-mm margin from the
skin, which will be used at the closing sutures. This
marginal dermis will hold the skin in the suture with-
out tension and will prevent the bad scars during the
healing process.
The glandular incision is made using No. 21 cold
blades. In this way, the margins are kept clean, with-
out thermal damage, and allow normal wound healing.
To help in this maneuver, the assistant holds the key
points of the incisions with skin hooks, and with the
left hand, the lateral side of the gland that is hanging
is gently pushed to medially. This incision should be
done through the gland mould, if possible, at once,
down to the retroglandular space, carefully not to open
the muscular pectoralis major fascia. This point is
very important, because along this retroglandular
space, the breast central neurovascular pedicle runs
to the nippleareola complex. The dermoglandular
excess from lateral and medial flaps will be carefully
excised, according to the plan. Incisions are completed
superiorly, and the inferior pedicle is well mobilized
(Fig. 48.26).
837
Key dermal stitch with 2/0 Vicryl holds together
areola with lateral and medial cutaneous flaps, at the
superior end of the vertical T branch and bought
breast pillars, lateral and medial, are sutured with 2/0
Vicryl, in front of the inferior pedicle, holding the
breast mould. Second layer is a reverse dermohypo-
dermic stitch, with 2/0 Vicryl, and includes the ante-
rior layer of the superficial fascia of the breast. Suction
drain is placed in the retroglandular space and attached
to the sterile bag, with a mild negative pressure.
The skin suture (Fig. 48.27) is performed with
intracuticular running suture with 5/0 PDS.
The whole incision length is taped with SteriStrips
changed every 7 days, for 36 weeks. Patients are
asked to wear brassiere for 6 weeks.
48.16.3 Postoperative Result
At the end of the operation, even the NAC is centering
the breast mould on both sides (Fig. 48.28) and they look
divergent because of lateral position on the chest wall,
838 T.T. Mugea

a b

Fig. 48.25 Deepithelialization completed at the new level of at the closing sutures. The dermoglandular excess from lateral
the inframammary fold, inferior NAC pedicle, and a 5-mm and medial flaps (red arrows) will be excised
margin from the skin flaps (yellow arrows), which will be used

a b

15 cm
Dermoglandular
Pedicle Length
5 cm

9 cm

16 cm

19 cm

Fig. 48.26 Glandular excision completed and NAC inferior pedicle released and still attached to the thoracic wall at the old
inframammary fold level
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 839

a b

Fig. 48.27 Breast reduction completed. Patient lying on the operating table

a b

c d

Fig. 48.28 NAC normal position centring the breast mould after the surgery
840 T.T. Mugea

Fig. 48.29 (a) Preoperative. (b) One month postoperative after breast reduction and lowering of the inframammary fold level for
tubular breast type II C

which is round. At 1 month after the surgery (Fig. 48.29),
comparative photos show a good result, with breast
reduction and lowering of the inframammary fold level.
Postoperative breast measurements (Fig. 48.30) show
the breast golden number achieved by horizontal meridian,
vertical meridian, and inframammary fold length, except
the distance between the nipples, which is bigger. Another
example for this surgical technique applied on tubular
breast Type IIC (twin sister B from Fig. 48.17) is repre-
sented in Fig. 48.31 (preoperative pictures) and 48.32
(postoperative pictures).
48.17 Tubular Breast Type II B Correction
with Round Block Mastopexy
and New Inframammary Fold Level
by Skin Deepithelialization
48.17.1 Case Presentation
When tubular breast is Type II B (Fig. 48.33), there is
no need for glandular excision, and the shape of the
breast can be modified by Benelli periareolar mastopexy
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 841

TTM program for Breast Reduction / Mastopexy

Fig. 48.30 Postoperative breast measurements show the breast golden number achieved by horizontal meridian, vertical meridian,
and inframammary fold length, excepting the distance between the nipples

associated with inframammary fold lowering using the
deepithelialization technique.
Patient breast measurements (Table 48.3) demon-
strate breast ptosis (nipple located at 2 cm outside
acromio-pubian line on the inverted triangles), short
inframammary fold (17 cm), small breast vertical
diameter (7 cm), and wide areola (12/11 and
11/10 cm).
The TTM program shows the ideal breast dimen-
sion (Fig. 48.34) with Breast Golden Number as 20.66
(almost 21 cm).
48.17.2 Preoperative Plan
Surgical objectives (Fig. 48.35) for this case are to
reduce the areola diameters according to the desired
dimensions and correct NAC position using Benelli
technique, and lowering the inframammary fold with
2 cm by deepithelialization. Breast volume does not
change. The fullness of the tissues in the new skin
surface will enhance also the breast vertical diameter
apart of the 2 cm achieved by the lowering of the
inframammary fold level.
842 T.T. Mugea

Fig. 48.31 Tubular Breast Type IIC (twin sister B from Fig. 48.17). Preoperative pictures with marking plan
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
Fig. 48.32 Postoperative picture at 24 hours (superior raw) and
one month after the surgery (inferior raw). This patient with
tubular breast Type IIC and severe chest malformation (twin sis-
ter B from fig. 48.17) had a similar operation technique.
For these purposes, the areola will be reduced up to
5 cm using a deepithelialized flap technique and the
skin excess of the superior meridian up to achieve
21 cm distance from sternal notch to nipple.
For inferior meridian (Fig. 48.36), skin excision
will reduce NiInfra to 7 cm, and the elliptical exci-
sion in the inframammary fold (4 17 cm) will allow
its caudal gliding with 2 cm. Benelli round block
technique and areola ring partially released from the
central pedicle (Fig. 48.37) allow obtaining a better
shape of the areola, without too much flattening, but
843
Preoperative pictures with marking plan (Fig.48.33) and postop-
erative results (Fig.48.34) show the achievement of a quite nor-
mal shape and position of the breasts
with the risk of jeopardizing the vascularization.
Finally, we may obtain a new shape of the breast, close
to the normal one (Fig. 48.38).
48.17.3 Surgical Technique
After preoperative preparation of the patient, early
described in this book in breast reduction chapter,
according with the drawings, we start the surgery with
dermal incision to define the deepithelialized areas on
844 T.T. Mugea

Table 48.3 Patient breast

measurements demonstrate
breast ptosis (nipple located at
2 cm outside acromio-pubian
line on the inverted triangles),
short inframammary fold
(17 cm), small breast vertical
diameter (7 cm), and wide
areola (12/11 and 11/10 cm)
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level
Fig. 48.33 Preoperative patient with tubular breast type II B
areola and inframammary fold (Fig. 48.39). The infra-
mammary fold ellipse is deepithelialization (Fig. 48.40)
and the wound sutured with reverse dermohypodermal
sutures with 2/0 Vicryl from the middle. The final
wound closure is done with 5/0 PDS resorbable running
intradermal suture, and then the distance between the
new inframammary fold and the level of periareolar
excision (Fig. 48.41) which is supposed to be 5 cm is
checked.
845
Second step of the procedure starts with areola
deepithelialization and marginal dermohypodermal
incision of the central flap with electrocautery, saving
a 5-mm margin from the skin, which will be used at
the closing sutures. This marginal dermis will hold the
skin in the suture without tension and will prevent the
bed scars during the healing process. The wound diam-
eter is decreased to the desired diameter of 5 cm, using
a purse string suture with 2/0 Vicryl (Fig. 48.42).
846
TTM program for Breast Reduction / Mastopexy
Fig. 48.34 TTM Junior program for patient
Areola is released and undermined like a mush-
room about 0.5 cm around the dermal edges of cen-
tral pedicle (Fig. 48.43) and then sutured to the
dermohypodermic layer of the new skin margin with
reverse separate 2/0 Vicryl sutures and running intrad-
ermal suture with 5/0 PDS.
The whole incision length is taped with SteriStrip
changed every 7 days, for 36 weeks. Patients are
asked to wear brassiere for 6 weeks.
T.T. Mugea
48.17.4 Postoperative Result
Even postoperatively the patient has a small conges-
tion areas on the areolas (Fig. 48.44), the wound
healed without other problems, and the inframammary
fold looks fine at 1 month. New breast measurements
introduced into the computer program show the
achieving of Breast Golden Number, 21 cm in her
case.
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 847

a b
7 cm 11 cm - Breast
21 cm Mn - New Ni Breast Vertical Diameter
21 cm Mn - Ni
Vertical Diameter

IMF

24 cm Mn - Ni 5 cm 2 cm

7 cm Ni - IMF

11 cm Ni - IMF

c d
Superficial Layer
Deepithelielised Superficial Fascia
Areola
Areola Ring
Deep Layer
Areola Superficial Fascia
Deepithelielised central pedicle
Skin Pectoralis
Benelli Round Block Fascia
Central
Pedicle
New
Inferior
Inframammary Fold
Pedicle
Inframammary
Crease Ligament

New
Inframammary
Fold Level

Fig. 48.35 (a) Preoperative plan for tubular breast type II B. released from the central pedicle. New inframammary fold done.
(b) Surgical plan for skin excision in the inferior meridian. (d) Postoperative schema of anatomic elements
(c) Benelli round block and deepithelialized areola ring partially
848 T.T. Mugea

Fig. 48.36 Surgical plan for New Areola Deepithelielised

skin excision in the inferior Diameter Old Areola Ring
meridian

5 cm

5 cm
Old Inframammary
Fold Level

2 cm
New Inframammary
Fold Level

Deepithelielised
Areola
Areola Ring

Areola
Deepithelielised Central Pedicle
Skin

Benelli Round Block

New
Inframammary Fold

Fig. 48.37 Benelli round

block and deepithelialized
areola ring partially released
from the central pedicle
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 849

Superficial Layer
Superficial Fascia

Deep Layer
Superficial Fascia Pectoralis
Fascia

Central
Pedicle

Inferior
Pedicle
b
Inframammary
Crease Ligament

New
Inframammary
Fold Level

Fig. 48.38 Postoperative anatomic elements

Fig. 48.39 Dermal incision to delimitate the deepithelialized

areas on areola and inframammary fold

a b

Fig. 48.40 Suturing the deepithelialized inframammary fold

850 T.T. Mugea

c d

Fig. 48.40 (continued)

a a

Fig. 48.41 Areola to inframammary fold distance is now 5 cm,

according to the plan

Fig. 48.42 (a) Marginal dermohypodermal incision of the cen-

tral flap with electrocautery, saving a 5-mm margin from the
skin. (b) Purse-string suture with 2/0 Vicryl (right picture)
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 851

a b

Fig. 48.43 Areola released about 0.5 cm around the dermal edges of central pedicle and sutured to the dermohypodermic layer of
the new skin margin with reverse separate 2/0 Vicryl sutures and running intradermal suture with 5/0 PDS

Fig. 48.44 (a) Seven days postoperative. (b) One month postoperative. (c) One month postoperative new inframammary fold.
(d) Postoperative dimensions of the breast
852
d TTM program for Breast Reduction / Mastopexy
Fig. 48.44 (continued)
Comparative pictures before and after the proce-
dure (Fig. 48.45) show tubular breast type II B correc-
tion, with minimal scaring, placed in easy hidden
areas like periareolar and inframammary fold.
48.18 Conclusions
Tubular breasts represent a real challenge for plas-
tic surgery, and there is no single procedure to cor-
rect it. Still there are anatomical details and
T.T. Mugea
embryological evolution steps to be understood and
clarified. The new tubular breast type classification
we use is a tool which allows a better definition of
surgical objectives and surgical techniques to be
applied.
To obtain good postoperative results, a proper
preoperative evaluation is needed including breast
general score, with data filled into the chart and
computer program for breast reduction/mastopexy
(Fig. 48.11).
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 853

Fig. 48.45 (a) Preoperative.

(b) Postoperative a

c
854
Fig. 48.45 (continued)
d
References
1. Hammond DC (2008) In: Atlas of aesthetic breast surgery,
Elsevier Health Sciences, Saunders Elsevier Inc., p 187
2. Nahai F (2005) The art of aesthetic surgery: principles
and techniques. Quality Medical Publishing, Inc., St Louis,
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3. Graf RM, Bernades A, Auerswald A, Damasio RC (2000)
Subfascial endoscopic transaxillary augmentation mamma-
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Bo L (2006) Anatomy and clinical significance of pectoral fas-
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reduction by application of the ligamentous suspension.
Plast Reconstr Surg 103(5):14001410
14. Gabka JK, Bohmert H, Blondeel PN (2008) Tuberous (tubu-
lar) breast deformity, plastic and reconstructive surgery of
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tuberous breast deformity: classification and treatment. Br J
Plast Surg 49(6):339345
16. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D,
Lambrinaki N, Ioannidou-Mouzaka L (2003) Aesthetic recon-
struction of the tuberous breast deformity. Plast Reconstr Surg
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17. Rees TD, Aston SJ (1976) The tuberous breast. Clin Plast
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(1999) Breast base anomalies: treatment strategy for tuberous
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1(4):402406
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(1990) Tuberous breast: clinical and therapeutic consider-
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453458
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(2009) Aesthetic correction of tuberous deformity: lessons
learned with a single-stage procedure. Breast J 15(3):
279286
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the extremely hypoplastic tuberous breast. Aesthetic Plast
Surg 20(5):385390
33. Ribeiro L, Canzi W, Buss A Jr, Accorsi A Jr (1998) Tuberous
breast: a new approach. Plast Reconstr Surg 101(1):4250
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34. Hodgkinson DJ (2001) Tuberous breast deformity: princi-
ples and practice. Ann Plast Surg 47(1):9798
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breasts utilizing tissue expansion. Aesthetic Plast Surg 15(4):
307312
36. Scheepers JH, Quaba AA (1992) Tissue expansion in the
treatment of tubular breast deformity. Br J Plast Surg 45(7):
529532
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syndrome. Ann Plast Surg 19(5):414420
38. Elliott MP (1988) A musculocutaneous transposition flap
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Inframammary fold reconstruction with a deepithelialized
skin flap. Ann Plast Surg 50(4):433436
40. Lemperle G, Nievergelt J (1991) Plastic and reconstructive
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ing. Plast Reconstr Surg 77(1):6676
 Breast Reduction with Vaser
49
Alberto Di Giuseppe, Michael Nagy,
Mario Scaglioni, and Elisabetta Petrucci

49.1 Breast Reduction Protocol

(Figs. 49.149.34)

Vaser-assisted breast reduction and lift should only be

performed by surgeons experienced with the Vaser
system for fatty tissue emulsification. At least ten cases
of standard Vaser-assisted lipoplasty are recommended
before moving to application to the breast.

49.1.1 Patient Indications

Patients seeking a reduction in breast volume with

minimal or no scarring and minimal postoperative
pain. A breast lift procedure may be needed (simulta-
neously or secondarily) to adjust nipple location and
breast shape. The procedures and methods discussed
below are applicable only to patients with breasts hav-
ing a good amount of fatty tissue as determined by
mammography, physical exam, and history. These

A. Di Giuseppe (*)
Institute of Plastic and Reconstructive Surgery, Fig. 49.1 In a woman, decreasing the weight of the breast by
School of Medicine, University of Ancona, gently elevating the gland will cause the nipple-areola complex to rise
Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
M. Nagy
procedures will not work well on patients with breasts
Division Plastic and Reconstructive Surgeon, Personal having a very high percentage of glandular/breast tis-
Enhancement Center, Organization Toms River, New Jersey, sue. Patients with breast nodules or other suspicious
Toms River, NJ, USA tissues are not indicated.
e-mail: mikenagy11@gmail.com
M. Scaglioni E. Petrucci
Department of Plastic and Reconstructive Surgery,
University of Ancona,
49.1.2 Informed Consent
Ancona, Italy
e-mail: mario.scaglioni@gmail.com; bettysca@gmail.com Include use of photos for educational purposes.

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 857

DOI 10.1007/978-3-642-21837-8_49, Springer-Verlag Berlin Heidelberg 2013
858
Fig. 49.2 Breast reduction with liposuction (by Courtiss)
Fig. 49.3 Fibrofatty breast tissue. This is the ideal candidate
for this type of operation. Breast must be essentially fatty to
allow ultrasound energy to emulsify this component. Skin must
not be lax and ptosis must be minimal
A. Di Giuseppe et al.
Fig. 49.4 Preoperative mammograms. Note the retromammary
space which contains plenty of fat to be addressed. The breast
parenchyma is preserved
49.1.3 Preoperative Screening
and Mammograms
Determination of approximate percentages and locations
of fatty tissue, mixed fatty/glandular tissues, and glandu-
lar/breast tissues by mammography and physical exam.
49.1.4 Preoperative Marking and Planning
Estimate volume to be removed from each breast.
Strategic plan for volume removal. Controlling the
final shape and contour requires careful selection of vol-
umes to be removed, similar in concept to standard open
breast reduction. The mammogram will provide guidance
as to the location and amounts of fatty tissues and mixed
fatty/glandular tissues. In general, the central cone, a
6-cm-diameter circle around the nipple and 23 cm deep
is not to be treated with the Vaser. This area is often
49 Breast Reduction with Vaser 859

a b

Fig. 49.5 (a) Preoperative planning as in standard breast reduction. (b) Skin incisions are marked at the inframammary, periareolar,
and axillary areas

Fig. 49.6 (a) Superwet infusion: deep, intermediate, and super- ultrasound. Tumescent solution is made by 1,000 mL of saline
ficial. (b) It is essential to have a meticulous infiltration of the solution plus 1 mL of adrenaline
superficial layers and wait for 10 min minimum before starting
860 A. Di Giuseppe et al.

Fig. 49.7 Superficial undermining of breast skin envelope with Fig. 49.9 Probe in action from axillary incision and periareolar
3.7-mm probe. Deep emulsification with 2.9-mm probe incision for undermining of the superficial skin envelope. Deep
emulsification with probe through inframammary skin incision

Fig. 49.8 Vaser probes: 1, 2, and 3 rings in 2.9- or 3.7-mm Fig. 49.10 Deep layers treated with 2.9-mm probe. Superficial
probes layers with 3.7-mm probe
49 Breast Reduction with Vaser 861

Fig. 49.11 Skin incision

Fig. 49.14 Other skin protector at the periareolar incision

Fig. 49.12 Tumescent infiltration

Fig. 49.15 Skin protectors at periareolar, inframammary, and

axillary incisions

Fig. 49.16 Breast tissue with markings and skin protector on

site. Note the red area surrounding the areola, where most of the
Fig. 49.13 Skin protector sutured on site breast parenchyma is located, has to be avoided
862 A. Di Giuseppe et al.

Fig. 49.19 Undermining continues through axillary incision

Fig. 49.17 Vaser in action through periareolar incision, on
superficial layers

Fig. 49.18 Undermining continues under the breast skin Fig. 49.20 Lateral part of breast treated with Vaser
envelope

constituted by mainly glandular tissue. The recommended 49.1.6 Patient Positioning

approach is to remove the fatty tissues in the deeper planes
first and observe the changes in the shape and volume of
the breast. Then move to the lateral and medial quadrants
for additional volume removal and shaping.
49.1.5 Anesthesia
Breast reduction with Vaser is generally performed
under general anesthesia or with local tumescent anes-
thesia and intravenous sedation.
The patient is kept in supine position with arms at 90.
49.1.7 Incisions
Inframammary crease (central) and axillary incisions
are used. Incisions may be placed in locations that will
be excised if a subsequent breast-lifting operation is to
be performed.
49 Breast Reduction with Vaser
Fig. 49.21 VentX cannula starts aspiration of the emulsified
tissue
Fig. 49.22 Emulsified fat coming out from breast
Fig. 49.23 Aspiration continues from inframammary approach
863
Fig. 49.24 Verifying skin thickness after aspiration
Fig. 49.25 Aspiration on the lateral side
49.1.8 Infusion
Epinephrine at 1:500,000. Wait for 10 min. Infuse with
blunt infusion cannula, not a needle. Infuse uniformly
and evenly into any and all locations where the Vaser
or the suction cannula may be used, not a needle.
Infuse uniformly and evenly into any and all locations
where the Vaser or the suction cannula may be used.
Infuse at least 2 times the estimated total aspirate vol-
ume to be removed. Additional fluid may be used in
864 A. Di Giuseppe et al.

Fig. 49.29 Aspiration from axillary incision

Fig. 49.26 Aspirate from one breast

Fig. 49.30 Contralateral side

Fig. 49.27 Aspiration from deep layers

Fig. 49.28 Aspiration from periareolar incision Fig. 49.31 Breast massaging for emulsion cleaning
49 Breast Reduction with Vaser
Fig. 49.32 Immediate result
Fig. 49.33 Postoperative. Note early correction of breast
ptosis
areas that will be dissected to decrease bleeding.
The breast will easily accommodate extra fluid.
49.1.9 Skin Protection
Skin protection is used at each incision site. Skin pro-
tection is not needed if skin is to be excised.
49.1.10 Emulsication
For smaller volumes (100500 mL), use 2.9-mm diam-
eter, 24-cm probe, 70%80%90%, Vaser mode.
Seventy percent of the breast is very soft. Move to 80%
or 90% if breast is more fibrous. Apply Vaser until fat
is thoroughly emulsified, at least 1 min per 100 cc
infused.
865
Fig. 49.34 Special dressing with Epi-foam
For larger volumes (5001,500 mL), use 3.7-mm
diameter, 24-cm VASER probes, either one or two
grooves, depending on how fibrous. Two grooves for
softer breast. One groove for more fibrous breast. 70%
80%90%, Vaser mode. Apply Vaser until fat is thor-
oughly emulsified, at least 1 min per 100 mL infused.
49.2 Aspiration
Use 3.7-mm-diameter SST-6 style VentX cannula for
initial debulking and shaping and 3.0-mm SST-6 for
final shaping and contouring. Massage the breast and
push any remaining free fluids out of incisions.
49.2.1 Breast Lift
A mastopexy procedure may be combined with the
Vaser volume reduction to remove excess skin and/or
provide additional lift to the breast (Figs. 49.3549.38).
The different levels of desired lift and volume removal
will guide the choice of the mastopexy selected.
Several different approaches are discussed below, each
based on volume removed and the desired amount of
lift. Other types of mastopexy may be considered.
For grade I to low grade II ptosis, expected volume
is from 300 to 700 mL per breast. Vaser volume reduc-
tion is without mastopexy. No scars. The expected lift
is 24 cm. For low grade II to high grade II ptosis,
expected volume is from 400 to 1,000 mL per breast.
Vaser volume reduction is with periareolar mastopexy.
Expected lift is 46 cm. Periareolar incision only. Note
that the tension in the periareolar scar will be signifi-
cantly reduced by the reduction in breast volume. Grade
II to grade III ptosis, expected volume is from 500 to
1,500 mL per breast. Vaser volume reduction is with
866 A. Di Giuseppe et al.

vertical mastopexy. Expected lift is 68 cm. Periareolar 49.3 Vaser in Breast-Shaping

and short vertical incisions. Note that the tension in the
periareolar scar will be significantly reduced by the
reduction in breast volume. Grade II to grade III ptosis,
very large volumes. Vaser volume reduction with Passot
reduction. Inframammary scar and periareolar scar.
Drain each breast with a Jackson Pratt flat 710-mm
drain for 12 days. Antibiotics and anti-inflammatory
drugs are used for 35 days postoperative. Postoperative
taping/dressing/support using Epi-foam and support bra.
Follow-up mammograms are at 6 months and 2 years.
Procedures Associated
with Passot Reduction Technique
The so-called button mammaplasty was the most
famous breast reduction technique of the nineteenth
century. This was introduced by Passot, in 1925, and
was also known as the no-vertical scar reduction
(Fig. 49.39). The technique is a horizontal flap
inferiorly based to vascularize the breast tissue. Vaser
is utilized to emulsify the upper breast quadrants.

Fig. 49.35 (Left) Preoperative 32-year-old patient with medium breast hypertrophy (Right) Postoperative after 550 mL of aspirate
for size. Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
49 Breast Reduction with Vaser 867

Fig. 49.36 (Left) Preoperative 29-year-old patient with middle breast ptosis. (Right) Postoperative after 450 mL of aspirate for size.
Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
868 A. Di Giuseppe et al.

Fig. 49.37 (Left) Preoperative 26-year-old patient with breast ptosis and inverted nipple-areola complex. (Right) Postoperative fol-
lowing 550 mL of aspirate for size. Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
49 Breast Reduction with Vaser 869

Fig. 49.38 (Left) Preoperative 24-year-old patient. (Right) One week postoperative after 450 mL of aspirate for size. Numbers
explains new midclavicular notch to nipple position (a) front view, (b) oblique view
870 A. Di Giuseppe et al.

Fig. 49.39 Passot breast reduction

General References
Shiffman MA, Di Giuseppe A (2006) Liposuction, principles
and practice. Springer, Berlin
Shiffman MA, Di Giuseppe A (2010) Body contouring, art,
science, and clinical practice. Springer, Berlin
 Gynecomastia: Scarless Male Breast
Reduction with Vaser
Alberto Di Giuseppe, Antonella Belligolli,
Marina Pierangeli, Davide Talevi,
and Luca Grassetti
50.1 Introduction
Gynecomastia can be present in men in three different
forms (Fig. 50.1):
1. Pure the majority of breast parenchyma is
affected.
2. Fatty the majority of breast tissue is formed
by fat.
3. Mixed a combination of both previous situations.
50.2 Treatment
In the past, [2] SAL (Suction Assisted Lipoplasty) has
been proposed as priority treatment for standard gyne-
comastia (Fig. 50.2). The technique presents the
following limits:
A. Di Giuseppe (*)
Department of Plastic and Reconstructive Surgery,
Ancona University, Ancona, Italy
Institute of Plastic and Reconstructive Surgery, School
of Medicine, University of Ancona, Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
A. Belligolli M. Pierangeli D. Talevi
Department of Plastic and Reconstructive Surgery,
Ancona University, Ancona, Italy
e-mail: a.belligolli@alice.it; marinapierangeli@libero.it;
davidetalevi@yahoo.it, tlvdvd@yahoo.it
L. Grassetti
Department of Plastic and Reconstructive Surgery,
Ancona University, Ancona, Italy
Department of Plastic and Reconstructive Surgery,
Ancona University School of Medicine, Ancona, Italy
e-mail: lucagrassetti2000@yahoo.it
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_50, Springer-Verlag Berlin Heidelberg 2013
50
1. It is not selective, thus implies mechanical destruction
of all breast tissue components.
2. It is often a bloody procedure, because of the rich
vascularization of the area.
It is ineffective to treat pure gynecomastia, as male
breast tissue is resistant to mechanical destruction with
cannula, due to his fibrotic component.
In order to improve results of SAL to gynecomastia,
the author has introduced Vaser over the past 10 years.
50.3 Procedure
Ultrasound study or mammography can be done to
assess composition of breast parenchyma, though clin-
ical evaluation offers an easy diagnosis.
Vaser in gynecomastia utilizes three different
probes:
1. 3.7 mm 1 or 2 rings for superficial undermining.
2. 2.9 mm, 1 ring for deep tissue emulsification.
3. 2.9 mm arrow tip for hard fibrotic glandular
destruction.
The operation is performed under local anesthesia
plus intravenous sedation. In the alternative, general
anesthesia can be considered in big cases or when is
part of a body contouring procedure.
50.3.1 Technique (Fig. 50.3)
Skin incisions are performed at the inframammary
crease and axilla [1]. Tumescent fluid is infiltrated with
a blunt cannula into the superficial and deep layers.
After tumescent infiltration, wait for 15 min. A skin
dilator is used to allow skin-protector positioning. The skin
871
872 A. Di Giuseppe et al.

Fig. 50.1 (a) Different types

a b
of gynecomastia. (b) Pure
gynecomastia. (c) Mixed
gynecomastia. (d)
Gynecomastia associated with
breast ptosis

protector is placed in the incision. Superficial under-
mining is performed with a 3.7-mm solid probe 1
ring.
After Vaser emulsification suction is applied to
remove the emulsified fat. After completing removal
of emulsified tissue, the flap is checked for thinning.
No zones of adhesion remained should remain. Suction
drainage is placed and used for 24 h. Epifoam is used
for dressing and a garment is applied.
The result of the treatment of mixed gynecomastia
is shown in Fig. 50.4. Pure gynecomastia treatment is
described in Fig. 50.5, and the results of treatment are
shown in Fig. 50.6. The results of clinical cases are
shown in Figs. 50.750.9.
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 873

b
Skin

Pectoralis muscle

Muscle fascia

Rectus muscle

Fig. 50.2 (a) Gynecomastia with SAL (suction-assisted lipoplasty). (b) Gynecomastia with SAL, by periareolar incision
874 A. Di Giuseppe et al.

b c

d e

f g
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 875

h i

l m

Fig. 50.3 (continued)

Fig. 50.3 (a) Preoperative markings. (1) Skin incisions at infra-
mammary crease and axilla. (2) Green marks pure breast tissue.
(b) Set of instrumentation for Vaser. (c) Tumescent infiltra-
tion with blunt cannula. (d) Superficial and deep layers infiltra-
tion. (e) Tissue expanding. (f) After tumescent infiltration,
wait 15 min. (g) Skin dilator to allow skin protector positioning.
(h) Skin protector in place. (i) Superficial undermining with
3.7 mm solid probe 1 ring. (j) Superficial undermining with
probe. (k) Emulsion flowing out. (l) After completing removal
of emulsified tissue, check flap thinning. (m) Verifying full
undermining, no zones of adhesion remaining. (n) Aspirate from
one site. (o) Suction drainage for 24 h. (p) End of surgery
Symmetry. (q) Epifoam Dressing. (r) Garment
876 A. Di Giuseppe et al.

n o

p q

Fig. 50.3 (continued)

50 Gynecomastia: Scarless Male Breast Reduction with Vaser 877

a b

Fig. 50.4 Mixed gynecomastia. (a) Preoperative. (b) Postoperative following Vaser liposuction
878 A. Di Giuseppe et al.

a b

c d

f
e

g
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 879

h i

Fig. 50.5 (continued)

Fig. 50.5 (a) Pure gynecomastia. (b) Markings. (c) Tumescent
infiltration, superwet. (d) Vaser continuous mode. (e) Vaser set
at 80% of total power. (f) Skin protector on site. (g) The new
arrow probe. Note the shape of the tip which radiates energy to
destroy fibrotic male breast, working as a scalpel. The side still
emulsify as a standard probe. The combined action doubles the
effect in selective fibrotic tissue. Vaser mode, at this stage, may
be useful to progress in fibrotic tissue. (h) The new Vaser probe
in action. (i) Result after emulsification of mammary region,
thorax, and selective destruction of breast male fibrotic tissue.
(j) Suction drainage on site
880 A. Di Giuseppe et al.

a b

Fig. 50.6 (a) Preoperative patient with pure gynecomastia. (b) Postoperative
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 881

Fig. 50.7 (a) Preoperative 37 year-old patient with from previous treatment with SAL. (b) Postoperative
882 A. Di Giuseppe et al.

Fig. 50.7 (continued)

a b

Fig. 50.8 (a) Preoperative 50 year-old patient with pure gynecomastia. (b) Postoperative
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 883

Fig. 50.9 (a) Preoperative 29 year-old patient with pure gynecomastia. (b) Postoperative
884 A. Di Giuseppe et al.

Fig. 50.9 (continued)

References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science and clinical practice. Springer, Berlin
1. Shiffman MA, Di Giuseppe A (2006) Liposuction: principles
and practice. Springer, Berlin
 Part V
Abdomen
 Abdominoplasty: Aesthetics
of the Anterior Abdominal Wall
Fahmy S. Fahmy and Mohamed Ahmed
Amin Saleh
51.1 Introduction
Beauty and body aesthetics has its roots as far as
30,000 BC. Body contouring had been made by such
external methods as tattooing or scarification and the
wearing of girdles [1].
The concepts of beauty and ideal weight may have
varied over time and among cultures; a firm, toned
abdomen, and a narrow waistline have been univer-
sally admired since antiquity. The appeal of full hips
and a slender waistline is rooted in the Darwinian phi-
losophy known as evolutionary psychology which
states that women must be desirable and attractive so
that they are more sought after for reproduction [2].
Numerous articles have been written about the dif-
ferent techniques of the abdominoplasty procedure and
date back from over a century ago. Abdominoplasty
not only deals with the excess redundant skin of the
anterior abdominal wall but also corrects diastasis of
the rectus as well as the external oblique muscle.
The abdominoplasty procedure needs to be tailored to
the trunk anatomy and to the aesthetic goals. It is a proce-
dure that also requires sculpting ability and the knowledge
to place the incision to suit the particular body type.
F.S. Fahmy (*)
Department of Plastic Surgery,
Countess of Chester Hospital, Cheshire, UK
e-mail: plasticsurgfahmy@aol.com
M.A.A. Saleh
Plastic Surgery Department, Ain Shams University,
Cairo, Egypt
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_51, Springer-Verlag Berlin Heidelberg 2013
51
51.2 History
The modern surgical era dates back to 1870, when
body contouring and different abdominoplasty proce-
dures were described to achieve better aesthetic out-
come or to hide abdominal scar. Surgeons who were
repairing umbilical hernias did the first dermolipec-
tomy, having the advantage of technically facilitating
the hernia repair and relieving the patient from the
hanging skin.
Abdominoplasty was described in different coun-
tries and popularized. Kelly, in 1899 [3], was the first
to report the procedure in the United States, calling
it transverse abdominal lipectomy. He underwent
herniorrhaphy through a transverse incision across
both flanks, without undermining, and the umbilicus
was sacrificed.
Preservation of the umbilicus was first reported by
Gaudet and Morestin 1905 [4] while repairing large
hernias along with the resection of the excess abdominal
skin and fat. In Germany Weinhold 1909 [5] reported
the cloverleaf incision, a combination of vertical and
oblique incisions to improve the contour of the abdom-
inal wall. Desjardin, in 1911 [6], reported the excision
of excess skin and fat weighing over 22.4 kg through
vertical abdominal incision. This was followed by
Babcock in 1916 [7] who was the first to report vertical
elliptical resection with wide undermining of the
abdominal wall. In 1918, Schepelmann [8] modified
the Babcock elliptical incision into a transverse tear-
drop incision extending from the xyphoid to the pubis
(Fig. 51.1).
887
888
a b
Fig. 51.1 Vertical techniques of abdominoplasty. (a) Babcock
(b) Schhepelmann
Low transverse elliptical abdominal lipectomy was
described by Jolly in 1911 [9]. This was followed by
Thorek in 1924 [10] as he removed the excess skin and
fat down to the fascia in a wedge-shaped form. He
called the technique plastic adipectomy. He described
the removal of the umbilicus if required in a crescent
excision, and transplanting it as a composite graft. In
1931, Flesch-Thebesius and Wheisheimer [11] modi-
fied the Thorek incision and included the umbilicus. In
1949, Pick [12] reported his technique, followed by
Barsky in 1950 [13] which was a modification of the
Thorek transverse incision with the addition of the
vertical incision at its ends.
Belt-like fashion incision was first introduced by
Somalo in 1940 [14]. Gonzalez-Ulloa [15], Vilain, and
Dubouset [16] reported circular abdominoplasty simi-
lar to that described by Pick and Barsky technique.
The four quadrants resection technique was described
by Galtier in 1955 [17].
Modern concepts of abdominoplasty through low
transverse abdominal incision with wide undermining
and transposition of the umbilicus described by Vernon
in 1957 [18]. This was followed by Dufourmental and
Mouly in 1959 [19], including the Vernon technique
and a small vertical incision at the midline. Spadafora
1965 [20] described a similar technique to Vernons,
but he lowered the incision to a less conspicuous site.
In 1967, Callia [21] reported a similar incision to that
of Spadaforas with a lower incision below the ingui-
nal crease not only to get a less conspicuous scar, but
also had added advantage of lateral thigh lift. To sum-
marize the evolution of the techniques up to 1967, the
abdominoplasty procedure can be categorized into: (1)
F.S. Fahmy and M.A.A. Saleh
surgeons that favored the transverse incision, (2) those
that favored the vertical incision (3) and a combination
of vertical and transverse incisions (Fig. 51.2).
Grazer 1973 [22], Pitanguy 1975 [23] (extensive
undermining, muscle tightening and compression dress-
ing), Regnault 1972 [24] (W shaped incision), Baroudi
1975 [25], Baker et al. 1977 [26] (the template method)
and Planas 1978 [27] (the vest over pants technique).
This period between 1970s and the 1980s emphasized on
contour refinements, the low transverse incision, small
umbilicus and long term contour results (Fig. 51.3).
Lockwood 1995 [28] assumed that discontinuous
undermining allows effective loosening of the abdomi-
nal flap while preserving vascular perforators, and with
aging and weight fluctuations (including pregnancy),
abdominal skin relaxation occurs primarily in the ver-
tical direction from the xyphoid to the pubis in the
lower abdomen, but the opposite occurs in the epigas-
tric region. He concluded that the ideal abdominoplasty
pattern would resect as much or more laterally than
centrally, leading to more natural abdominal contours.
The introduction of suction-assisted lipectomy
which was popularized by Kesselring and Meyer 1978
[29] and Illouz 1983 [30], emphasized the concept of
sculpturing and body contouring to get the best results
when combined with abdominoplasty procedure.
Liposuction not only popularized mini-
abdominoplasty procedure, but also led to the devel-
opment of minimally invasive surgery endoscopic
abdominoplasty that would provide aesthetic improve-
ment of the abdominal wall laxity, rectus muscle dia-
stasis, and would minimize the resultant scar.
Mini-abdominoplasty was of limited use and it was
first introduced by Elbaz and Flageul in 1971 [31], and
was modified by Glicenstein in 1975 [32]. After the
introduction of liposuction, Wilkinson and Swartz in
1986 [33], and Greminger 1987 [34] reported their
series of patients.
Endoscopically assisted techniques, such as plica-
tion of the rectus fascia through an umbilical incision
by using an endoscopic retractor, were described by
Marques et al. 1990 [35]. These approaches were
described as prefascial endoscopic abdominoplasty
[36, 37]. Nahas, in 1993 [38], underwent a cadav-
eric study using the laparoscopic approach to poste-
rior rectus diastasis repair. Scheflan (International
Endoscopic Symposium, Hannover, October 1994,
personal communication) performed laparoscopic
plication of the rectus muscle in a single patient.
Zukowski et al. 1998 [39] introduced endoscopic
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall 889

a b c d

Fig. 51.2 A combination of vertical and transverse incisions. (a) Pick, Barsky (b) Galtier (c) Weinhold (d) Flesch-Thebesius and
Wheisheimer

a b c

d e f g

Fig. 51.3 Horizontal techniques of abdominoplasty. (a) Kelly (b) Thorek (c) Gonzalez-Ulloa (d) Baroudi (e) Pitanguy (f) Grazer
(g) Regnault

intracorporal abdominoplasty in 85 patients com- and effectively plicates the rectus fascia, thereby
paring their technique with the traditional open reducing abdominal wall laxity. It also has a rate of
abdominoplasty. They concluded that the endoscopic morbidity in a skilled laparoscopists hands no greater
intracorporal abdominoplasty reduces operative scars than with traditional open abdominoplasty.
890
51.3 Pathology
Heredity and environmental factors play an important
role in a persons body shape. The pathophysiology of
the abdominal contour deformities includes few ele-
ments with variable degrees. These could be: redun-
dant, flaccid skin, excessive adipose tissue, muscular
diastasis, musculoaponeurotic laxity, and scar defor-
mities, including striae.
Heredity is the primary determinant of our basic
body habitus. It is hereditary that causes the unsightly,
diet-resistant fat bulges in many individuals of aver-
age weight. In the female, these inherited accumula-
tions usually occur in a gynecoid distribution in the
lower abdomen, hips, saddlebags, and inner thighs. In
males, accumulations of diet-resistant fat occur in an
android distribution in the flanks, abdomen, and chest.
Heredity may also be responsible for weak lower-
abdominal muscles, which results in a round, pro-
tuberant abdomen. Tall individuals with a marked
lordotic posture may have a protruding abdomen.
Environment plays an important role, as in very
obese patient with a lifestyle of little exercise and a
high caloric intake. Abdominal surgery, and some
neurologic lesions, may result in a bulging abdomen
from weakened or denervated muscles. Time, repeated
weight loss, and weight gain (weight fluctuation) have
additional deleterious effects on skin tone. This may
vary from a hanging abdominal panniculus to severely
dimpled cellulite-type skin. Aging as a natural process
plays an important role in increasing or decreasing and
redistribution of fat, loss of body muscles mass, and
loss of tissue elasticity [40].
Lower abdominal bulges can result from the ten-
dency for fat accumulation in the lower abdomen as
well as from an absence of the posterior rectus sheath
below the arcuate line of Douglas. Intraperitoneal fat
(visceral adipose tissue) is not treated by any abdomi-
nal contour procedure; it accumulates with age and is
more likely to be found in men. Women also accumu-
late this type of fat as they approach menopause.
Greminger [34] has illustrated that the bony structure
of the torso and pelvis determines the basic dimensions
(short or long waist) of the abdomen. This leads
to a general impression of the patients overall body
habitus.
Pregnancy is one of the major causes of stretched
abdominal musculoaponeurotic systems and loose
skin. The deformity may vary from merely a rounded
protruding lower abdomen to one with severe diastasis
F.S. Fahmy and M.A.A. Saleh
of the rectus abdominis muscles and extensive striae.
Weight gain during pregnancy is an important concern
of patients, and consists of three major components:
muscle, fat, and water. The volumetric increase of the
abdominal contents during pregnancy causes laxity of
the musculoaponeurotic system and diastasis of the
rectus muscle plus stretching of the skin [41].
It is generally believed that separation of the rectus
muscles occurs in all pregnancies and can never be
restored by exercise alone. Post partum, most patients
will experience a gradual tightening of skin over sev-
eral months. If redundancy remains after 6 months, the
condition is probably permanent. Stretch marks occur
in 90% of pregnant white women and are believed
to be caused by increased estrogen levels, additional
stress on tissues, and an increase in the relaxin hor-
mone. Striae are considered to be a form of dermal
scarring that follows rupture and separation of dermal
collagen with subsequent filling in of the gap. Other
important factor of pregnancy is the scar associated
with cesarean section [41].
51.4 Classication
Despite the recent changes in abdominal contour oper-
ations, the objectives continue to be (1) maximum
resection of excess skin, (2) reduction of subcutane-
ous adipose tissue volume, and (3) elimination of mus-
culoaponeurotic laxity to produce a slimmer, flatter
abdomen.
The aims of the ideal surgical procedure should
be to:
1. Accomplish the goals through the least conspicuous
incision, conforming to preferred clothing styles.
2. Address specific anatomical deformities.
3. Suit a wide range of patients.
4. Treat adjacent aesthetic units while respecting the
integrity of contributing skin vascular territories.
5. Require the least amount of operative, hospitaliza-
tion, and recovery time.
6. Produce minimal morbidity and postoperative dis-
ability [42].
Flexible systems of treatment have been devised
and developed by numerous authors for this purpose.
Matarasso, in 1989 [43], classified abdominal defor-
mities based on severity of the skin, fat, and muscular
flaccidity, and selects the most appropriate surgical tech-
nique for abdominal contouring according to the degree
of deformity (Table 51.1). Later in 1995, Matarasso [44]
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall 891

Table 51.1 Matarassuo abdominoplasty classification system

Category Skin Fat Musculofascial system Treatment
Type I Minimal laxity Variable Minimal flaccidity Suction-assisted lipectomy
Type II Mild laxity Variable Mild lower abdominal flaccidity Mini-abdominoplasty
Type III Moderate laxity Variable Moderate lower and/or upper abdominal flaccidity Modified abdominoplasty
Type IV Severe laxity Variable Significant lower and/or upper abdominal flaccidity Standard abdominoplasty
with suction lipectomy

Table 51.2 Minimal access subtypes of the abdominoplasty system

Category Skin Fat Musculofascial system Treatment
Type 1a Minimum laxity Minimum flaccidity Extended SAL
Type 2a Mild laxity (vertical scar) V Mild lower abdominal flaccidity Open mini
Type 3a Minimum laxity V Lower/upper abdominal flaccidity Endoscopic muscle access

Table 51.3 Pitanguy classification of aesthetic abdominal deformities

Type Clinical presentation Suggested technique
I Abdominal lipodystrophy without skin flaccidity; absence Liposuction
of diastasis or hernia
II Moderate abdominal lipodystrophy with diastasis Mini-abdominoplasty or endoscopic abdominoplasty
III Accentuated abdominal lipodystrophy with cutaneous Standard abdominoplasty
flaccidity and excess; presence of diastasis; with or
without associated scar
IV Skin flaccidity and/or lipodystrophy, with diastasis or Atypical approach
eventration; associated scar
O Marked generalized abdominal lipodystrophy with These patients are not ideal candidates for abdominoplasty,
absence of excess skin and should be prepared for surgery by strict clinical
treatment to lose weight

subsequently updated his classification treatment scheme
to incorporate subtypes (Table 51.2).
Pitanguy, in 1995 [45], presented his classification
(Table 51.3).
Rohrich et al. [46] used a modified Matarasso clas-
sification that is based on clinical assessment of the
degree of skin redundancy, amount of abdominal fat,
skin thickness and tone, and status of the abdominal
musculature. Abdominal deformities were classified
into IV types, each is subdivided into an or b, accord-
ing to the presence or absence of muscle diastasis.
Type I: (A) no skin and fat excess, and no diastasis
of the recti muscle treated with Ultrasound assisted
liposuction (UAL)or suction assisted liposuction
(SAL) alone, type (B) treated as before with or without
endoscopic diastasis repair. Type II: (A) mild skin and
fat excess, no diastasis of the recti muscle treated with
(UAL) or (SAL) alone, type (B) treated with UAL or
SAL with or without endoscopic diastasis repair. Type
III: (A) moderate skin and fat excess, no diastasis of
the recti muscle treated with UAL, type (B) treated
with infraumbilical-Mini abdominoplasty and UAL of
epigastrium. Type IV: (A) significant skin and fat
excess, no diastasis of the recti muscle treated with tra-
ditional abdominoplasty and UAL of flank, type (B)
treated with traditional abdominoplasty, diastasis
repair and UAL of flank.
Regnault [46] performed anterior sheath plication
in 90% of patients requesting abdominoplasty, as he
believes that most women who have had multiple preg-
nancies have some laxity of the musculoaponeurotic
fascia, if not true diastasis recti. Although Pitanguy
[47] documented only 3% of patients with diastasis
recti in his series of 539 patients, he routinely rein-
forces the musculoaponeurotic wall as part of the
abdominoplasty procedure.
Nahas [48] developed an objective classification for
abdominoplasty based on the musculoaponeurotic
deformity (Table 51.4) (Fig. 51.4).
Jackson and Downie [49] recommend additional
horizontal plication when laxity is still noted after
vertical rectus plication, as reported by Grazer and
Goldwyn [50]. Abramo, Viola, and Marques [51]
perform transverse epigastric and suprapubic plication
892 F.S. Fahmy and M.A.A. Saleh

Table 51.4 Classification and treatment of abdominal wall deformities based on muscloaponeurotic deformity
Myofascial
deformity
type Clinical finding Treatment
A RD Secondary to pregnancy PRS
B RD and laxity of the lateral and PRS and L-shaped plication of the external oblique aponeurosis
infraumbilical aponeurotic layer
C Congenital lateral insertion of the Release and undermining of the recti muscles from their posterior recti
recti muscle sheaths and advancement of these muscles to the midline
D RD and poor waistline RD and poor waistline PRS and advancement of the external oblique muscles

Types of Abdominal Deformity and Their Correction

Type A Type B

156.972

RD
L R L R

Rectus diastasis secondary to pregnancy Rectus diastasis with laxity of the musculoaponeurotic layer

Type C Type D

EOM

RM
CRD PS
L R L R
Congenital lateral insertion of the rectus muscles at the
costal margins and probable herniae

Fig. 51.4 Types of abdominal deformity and their correction. congenital lateral insertion of the rectus muscles at the costal
Type A: rectus diastasis secondary to pregnancy. Type B: rectus margins and probable hernia. Type D: rectus diastasis and poor
diastasis with laxity of the musculoaponeurotic layer. Type C: waistline definition. (Reprinted from Nahas [48])

in addition to longitudinal pleating for the entire length
of the rectus muscles, in what they call a lying H
pattern. Alternative techniques consisting of vertical
and lateral plication may improve the waistline and
prevent epigastric bulging. Crdenas Restrepo and
Munoz Ahmed [52] reported that their technique
involves transverse plication as opposed to the more
traditional vertical closure.
De Pina [53] resects the medial margins of the rectus
muscles and plicates the posterior sheath to improve
abdominal wall contour. Psillakis [54] advocates suturing
the aponeurosis of the external oblique muscles to the
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall
rectus fascia. He also excised the 7th and 8th rib carti-
lage, to narrow the waist and decrease the diameter of the
upper abdomen [55].
Van Uchelen et al. [56] assessed the long-term dura-
bility of vertical plication of the anterior rectus sheath
with an absorbable material. Questionnaires and ultra-
sound investigation of the competence of the fascia was
done at a mean of 64 months. The authors recommend
against the use of absorbable material for musculofas-
cial plication as 40% of his patients had residual or
recurrent diastasis.
51.5 Aesthetics of the Anterior
Abdominal Wall
The abdominal wall is formed by the relationship
between the osteomuscular system, the subcutaneous
fibro adipose tissue, and the skin. This relationship
gives the appearance of an aesthetic contour with light
reflection produced by prominences and shadows
resulting from depressions. In the midline from the
xyphoid to the navel a shadow is formed by the depres-
sion of the medial sulcus. Lateral to this sulcus, there
are two vertical wide strip reflections produced by
the prominence of the rectus muscle that joint under
the umbilicus, forming a mound.
More lateral and slightly more posterior to these
prominences, there are two wide strips of shadows
called semilunar sulcus, in a lyre form, produced by
the depressions formed by the insertion of the skin at
the fascia of the oblique muscles, which are inserted
into the external margin of the rectus muscles and into
the inguinal ligaments and pubis. More laterally, the
profile of the abdomen is formed by the thoracic cage
superiorly, the pelvis inferiorly, and the waist in
the middle (Fig. 51.10). The waist extends 710 cm
between the inferior costal ribs and the iliac crest. The
shape of the waist is also dependent on the superior
aperture of the pelvis. The larger the pelvis, the more
accentuated the waist. The waist can be absent when
the pelvis is small, when the distance between the pel-
vis and the ribs is reduced, or when muscular atony or
fat deposits are present.
In the inferior extremity of the shadow of the medial
sulcus, a more accentuated shadow is formed by the
triangular depression of the navel. Spatially, it is situ-
ated 1 or 2 cm over a transverse plane that corresponds
to the third or fourth lumbar vertebra. The shape of the
navel varies from person to person and also varies at
893
different ages. Modifications of position and thickness
of the tissues will alter the aesthetic appearance of the
abdomen due to the changes of the light reflections
and shadows. Therefore, the basic surgical principle
today in abdominoplasty is to sculpture the tissues,
reshaping the light reflections and shadows by giving a
new tension in the musculoaponeurotic layer, by sculp-
turing the overlaying fat on the cutaneous envelope,
and by resecting excess skin when it is present [55].
51.6 Preoperative Assessment
and Patient Selection
51.6.1 Medical History
An accurate assessment of the patients deformities and
their medical history are essential for a successful
abdominoplasty procedure. Surgeons must take into con-
sideration all aspects of the patients medical history.
Most patients requesting body contour improve-
ment will be women, so detailed history of previous
pregnancies should be asked for: number of pregnan-
cies and miscarriage, the number of children, and
whether the woman has a history of cesarean section is
important. A female patient who has had more than
one pregnancy is certainly more likely to have devel-
oped rectus muscle diastasis. They should be ques-
tioned regarding her desire for future pregnancies, and
surgeons should advise their patients to wait until their
families have been completed before proceeding with
definitive abdominal body contour improvement.
Significant medical problems that may affect the
outcome of surgery include a history of hypertension,
coronary artery disease, chronic obstructive pulmo-
nary disease, diabetes mellitus, hepatitis C, and human
immunodeficiency virus. Knowledge of the possible
allergies and intake of medications, whether prescribed
or over-the-counter herbs, Aspirin, nonsteroidal anti-
inflammatory drugs, warfarin, and other products that
may adversely affect the coagulation mechanism is
important so that the patient may be instructed to dis-
continue them for an appropriate period before under-
going surgery.
The effects of smoking on delayed wound healing
are well known, that is why Patients should be asked
about smoking history (active or passive, number and
type of smoking, and duration), and they should be
asked to abstain from smoking for a significant period
before and after surgery.
894
Prevention is the key to reduce the incidence of
deep venous thrombosis and pulmonary embolism.
Surgeons should ask for: a previous history of deep
venous thrombosis or pulmonary embolism, history of
malignancy, inherited or acquired thrombophilia, obe-
sity, heart failure, use of oral contraceptives, history of
spontaneous miscarriages, pregnancy within the past
3 months, age older than 40 years, presence of varicose
veins in the lower extremities, and recent surgery with
the use of general anesthesia [57, 58].
An additional factor that is of significance is a his-
tory of intra-abdominal operations. The location of
scars is important in determining the plan of correc-
tion. Patient height and weight should be asked about
and measured. Tall, lean individuals will have an
easier postoperative course and a different appear-
ance than an obese, short individual, who may require
more procedures for body contouring. The patients
weight should be stable for at least 3 months, and if
he or she is overweight, it is advisable that they lose
weight down to a desired goal before proceeding
with surgery. A history of abdominal hernia and a
thorough gastrointestinal history, such as irritable
bowel syndrome or inflammatory bowel disease,
should be covered as well.
51.6.2 Physical Examination
The physical examination should be detailed. The sys-
tems examined should include the heart and lungs as
well as other areas of the body involved in the patients
complaint. Examination of the patient is performed in
the standing, sitting, supine, lateral, and lateral hip-
flexed (divers) positions to evaluate skin, subcutane-
ous fat, and muscle layers.
The patients general appearance including the
abdomen, location of scars should be documented and
photographed. Supra-umbilical scars can present cer-
tain problems, such as impaired blood supply of the
superior flap, difficult dissection in the scar area, or
patient dissatisfaction with the scar still visible postop-
eratively. Most infraumbilical scars are removed dur-
ing abdominoplasty [59]. Adhesions of the skin at the
level of the waist are not uncommon, and these bands
can essentially divide the abdominal excess skin into
superior and inferior segments. There is a significant
risk of ischemia of the abdominal flap if extensive
release of these adhesions is attempted; discontinuous
undermining is preferable [60].
F.S. Fahmy and M.A.A. Saleh
Most stretch marks are located in the lower half of
the abdomen, extending laterally to the flanks. Many
of these will be removed along with the skin and sub-
cutaneous tissue flap. If a hernia is present, its repair is
essential for aesthetic improvement. However, a large
hernia may require complex repair before the perfor-
mance of an abdominoplasty for aesthetic improve-
ment, which would then subsequently be performed at
a later date. Diastasis of the rectus abdominis muscles,
whether mild, moderate, or severe, is usually corrected
at the time of the abdominoplasty.
The flaccidity and laxity of skin of the abdomen
below the umbilicus, is treated by redraping with exci-
sion of the excess skin and soft tissue along the inferior
margin. Flaccid skin above the umbilicus is treated by
redraping of the abdominal flap and liposuction, and in
severe cases, it may require a staged reverse abdomi-
noplasty. Laxity of the adjacent areas of the flanks and
thighs can be treated with liposuction, but in more
severe cases, high-lateral-tension abdominoplasty pro-
cedures along with extension of the incision laterally
should be considered.
After all these issues are considered, patients are then
staged according to the abdominoplasty system of clas-
sification, and patients concerns regarding the extent of
surgery, tolerance of possible complications, recovery,
and incisions all play a role in the decision making.
51.7 Authors Preferred Method
Abdominoplasty is certainly a very common proce-
dure in cosmetic surgery. Initial impression and maybe
experience would suggest it is an easy operation to
perform. The more I did over the last 20 years, the
more I understood and appreciated its challenges. It
might appear easy on the surface but undoubtedly task-
ing to overcome its challenges and to achieve our ulti-
mate goal of perfection. Is the incision design; straight
or curved, high or low, short or long? Is the recti, divar-
icated or not, plicate or not? If we plicate, is it before
or after flexing the operating table, absorbable or non-
absorbable, 1 or 2 stitches, and interrupted or continu-
ous? The umbilicus relocation, is it high or low or just
right? Is the umbilicus central or off-center? Even
more, is the umbilical incision for relocation trans-
verse, longitudinal, circular, semicircular, or facing up
or down? Is the incision large enough or too small with
the pending umbilical phimosis? What a dilemma,
even this little structure creates such a controversy! In
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall
Fig. 51.5 Midline and transverse suprapubic marking
fact the shape, size, and orientation of the umbilicus
could be a reflection of youth, hence its significance!
Planes of dissection, planes of excision of abdominal
apron, do they exist, can they be identified? Excision
of abdominal apron, is it conservative or as tight as
possible closure? How can I achieve symmetry? How
can I avoid the potential complications with particular
reference to seromas? I will aim to address the above
in the following step-by-step approach:
1. Incision
Preoperatively, the patient is marked in the standing
position (Fig. 51.5):
(a) A straight line extending from the xiphisternum
to the center of the vulval region marks the mid-
line of the abdomen. This helps in the future
planning of transposing the umbilicus.
(b) Right and left longitudinal lines (often cross-
ing the ASIS) on either side, demarcating the
extent of the folding of abdominal apron (usu-
ally the lateral extent of my incision is short of
those two lines). This may in cases extend
beyond the ASIS. In slim patients with little
folding, the ASIS is my most lateral extent of
the incision.
(c) A transverse marking along the fold created by
the abdominal apron.
Intraoperatively, you must make sure that the oper-
ating table allocated, can be flexed to the required posi-
tion. Under a general anesthetic, the patient is in the
supine position. Now mark your incision. The incision
is usually designed just above the pubic area (hairy
part) in the middle then extending slightly up and lat-
eral towards the ASIS. This incision can stop short of
the ASIS or extend further, just short of the lateral
895
Fig. 51.6 Umbilical stay suture and marking for plication
extent of the abdominal apron fold, as marked by the
two lines (pre-operatively). Two sutures along my pre-
vious midline marking, one supra umbilical and one in
the pubic area, are used to further demarcate the
midline.
A 10-blade is used for the transverse abdomino-
plasty incision along the markings indicated before.
This incision is shelved cephalad for 23 cm, leaving
more fat on the abdominal/pubic area along the full
length of the incision. This helps to avoid future tether-
ing of the abdominoplasty scar. It provides a padding
to support the final scar.
2. Surgical Dissection and Planes
As the dissection proceeds cephalad, this should be
in a plane superficial to the Scarpas fascia (thin, glis-
tening, transparent, mobile layer of fascia). This layer
harbors a number of lymphatics and may help to reduce
future seromas. I continue my dissection with a no. 10
blade locating and cauterizing any perforators, prefer-
ably before dividing them. It can be more time-con-
suming to cauterize the blood vessels after they have
been divided and retracted in the abdominal wall. Its a
false economy to try and rush the dissection of the
abdominal apron; more time will be needed to achieve
adequate hemostasis.
A circle is then marked around the existing umbili-
cus. Two skin hooks are used on either end of the circle
to lift the umbilicus. A no. 15 blade is then used full
thickness incision around the market circle. This will
help to skeletonize the umbilicus from its attachment
to the abdominal skin. A marker stitch is then placed at
the 12 oclock of the umbilicus. This helps in alloca-
tion and future orientation of the umbilicus, at the time
of its transposition (Fig. 51.6).
896
Fig. 51.7 Flexed portion
of the table
The dissection of the abdominal apron then con-
tinues approaching the umbilical stalk, I divide the
infraumbilical apron along the infraumbilical preopera-
tive midline marking. The umbilical stalk is then totally
skeletonized from the surround abdominal apron. The
dissection then proceeds cephalic as far as the xiphister-
num in the midline and costal margins laterally, preserv-
ing the Scarpas fascia layer on the abdominal wall.
3. Plication of Recti (Fig. 51.651.8)
Once the extents of my dissection are reached, the
operating table is then flexed. The abdomen /patient
should be paralyzed at this stage. The authors have not
been able to adhere to fixed degree of flexion. It
depends on the patient, the abdominal apron, abdomi-
nal wall, etc. Generally speaking with the flexion can
range from 30 to 70 at the hip region. Hemostasis is
further achieved. Two longitudinal lines are marked
extending from the costal margin down to the pubic
margin lateral to the divaricated/weak area of the
abdominal wall. There are no clear indicators or land-
marks for the width between those three lines. It can
range from 3 to 7 cm depending on the extent of the
divarication. Two looped-nylon zero sutures are used.
The first suture starts just above the umbilicus in a con-
tinuous fashion towards the xiphisternum. The suture
bites in the anterior rectus sheath tend to be in an
oblique fashion to avoid cheese-wiring the sheath. At
the xiphisternum level, an Aberdeen knot is done to
finish the stitch. The second looped continuous nylon
suture starts just below, but very close to the umbilical
stalk and proceeds to finish in an Aberdeen knot at the
level of symphysis pubis. Note that the two Aberdeen
F.S. Fahmy and M.A.A. Saleh
knots are at the xiphisternum and pubic area, away
from the umbilicus, therefore avoiding palpable knots
in slim patients.
Hemostasis is checked again and two low-suction
vacuum drains are inserted, one on either side of the
abdominal wall. The drains puncture wounds are in
the hairy pubic area on either side of the midline. I tend
to suture my drains.
4. Excision of Abdominal Apron (Fig. 51.9)
A midline 3/0 Monocryl subcutaneous suture is
inserted in the middle line between the pubic area and
the advanced supra-umbilical skin. This suture should
be under very little tension. The abdominal apron on
either side of this suture is held with two lanes on either
side. With a gentle inferior and slightly medial traction
on the aprons, a transverse line with slight convexity
facing inferior is drawn extending laterally from
the midline Monocryl suture to adjoin the lateral end
of the transverse suprapubic abdominal incision. The
triangular flap inferior to this line on each side presents
the apron to be excised. You must look and check,
there is enough laxity there to close the abdominal
wound following excision of the apron.
With a no. 10 blade a perpendicular is incision
along the marked line is undertaken (Fig. 51.10). This
continues deeper until approximately half way through
the flap; we will notice a white shiny layer. This is
the Scarpas fascia (Fig. 51.11). This is the level that
dictates the thickness of your abdominal flaps to be
sutured at the end of the surgery. It is at the Campers
fascia level that you need to shelve your dissection
plane from a perpendicular to a cephalad direction.
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall
a a
Fig. 51.8 (a) Upper part of the rectus plicated. (b) Upper part
of rectus plicated (umbilicus to xyphosternum). (c) Plication of
lower part completed (umbilicus to symphysis pubis)
This is even more so at the lateral extent of the excised
abdominal apron to reduce any potential of a dog ear.
Adhering to the Campers fascia plane would ensure
that the remaining abdominal flaps are uniform. In
897
Fig. 51.9 (a) Marking of the apron to be excised. (b) Marking
of the apron to be excised. (c) Final marking of the two sides of
the apron to be excised
summary, the excised abdominal apron should have
more fat than skin, excised superiorly (Fig. 51.12).
5. Skin Closure
The abdominal wound is closed in two layers
starting from lateral to medial. The first lateral suture
should be aimed to eliminate any dog ears. The sub-
cutaneous stitch is usually inserted more lateral in
898 F.S. Fahmy and M.A.A. Saleh

b
Fig. 51.10 Incision of apro

the upper abdominal flap compared to the lower flap

of the abdominal incision. This helps to eliminate
any dog ears. For subcutaneous suturing, 3/0
monocryl is used, while 4/0 Monocryl is used as a
subcuticular suture. Before complete subcutaneous
closure (Fig. 51.13), the umbilicus is transposed/
relocated.
6. Umbilical Relocation
The neo-umbilicus is repositioned before com-
plete closure of the transverse wound. I introduce my
hand (Fig. 51.14) through this wound holding the
umbilical stalk, between my index and middle fin-
gers. The two fingers point directly up towards the c
abdominal apron. This point is marked and presents
the future umbilical site. A number of incisions have
been advocated in the literature all aiming to achieve
an umbilicus as near natural appearance as possible. I
tend to use a V-shaped incision with the two vertical
limbs widely separated and symmetrical on either
side of the midline. This incision is extended deeply
to be of full thickness. The incision has to be large
rather than small to avoid umbilical phimosis
(Fig. 51.15). The umbilical stay suture is then deliv-
ered through this incision. For skin closure, 4/0
Monocryl subcutaneous suture and 6/0 Prolene inter-
rupted suture is used.
The transverse abdominoplasty incision is then com-
pletely sutured using the 3/0 subcutaneous Monocryl
and the 4/0 subcuticular Monocryl (Fig. 51.1651.19). Fig. 51.11 Identification of Campers fascia layer
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall 899

Fig. 51.12 Excised apron

Fig. 51.15 Neoumbiilicus

Fig. 51.13 Partial wound closure

Fig. 51.16 Wound closure complete

7. Dressings
Suture strips (half inch) and Mepore dressings are
used to cover all the wounds. Microfoam is then
directly applied to achieve some pressure on the abdo-
men as a whole. An abdominal pressure garment is
then applied after rolling the patient from side to side
to apply it. The patient is then transferred to the bed,
maintaining the flexed position.

51.8 Postoperative Care

The patient is nursed on the ward, maintaining the

intraoperative flexed position. They are encouraged to
Fig. 51.14 Hand introduced for umbilical repositioning start mobilization within the first 24 h, with the back
900
a b
Fig. 51.17 (a) Preoperative patient. (b) Six weeks postoperative following abdominoplasty
somewhat flexed to alleviate any tension on the suture
line. The drains are removed within 2448 h, and the
patient is advised to wear their own pressure garment,
cycling-short style, once the drains are removed and
before leaving the hospital. The pressure garment is
worn day and night for 6 weeks after the surgery.
I found that this approach reduces dramatically any
chance of seroma formation. This is minimal in my
practice.
The patient is seen 1 week post-surgery for removal
of umbilical sutures, and 2 weeks later for full inspec-
tion of all the wounds.
The author (FSF) has conducted an ultrasound study
to assess the longevity and durability of plication of
the recti. This was a prospective study with a 1 year
follow-up period. All the corrected diastasis was main-
tained within 1 year with the use of the looped non-
absorbable Nylon suture.
F.S. Fahmy and M.A.A. Saleh
Abdominoplasty is certainly one of the most gratifying
operations with high satisfaction rate. Equally, it has its
challenges and potential risks that can be avoided in a
large number of cases.
51.9 Complications
Complications following abdominoplasty might occur
at any time despite adequate surgical technique and
patient care. These might range from patient discom-
fort, pain, further surgical intervention, or up to a life
threatening condition. Patients should be informed
about these possible complications prior to surgery,
and surgeons should be aware of their prevention and
management.
In 1977, Grazer and Goldwyn [50] published their
results of a survey of the members of the American
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall
a b
Fig. 51.18 (a) Preoperative patient. (b) Six weeks postoperative following abdominoplasty
Society of Plastic Surgeons. The report represented a
minimum 10,490 abdominoplasties. The presence of
wound infection, dehiscence, hematoma, and skin loss
were manifested in decreasing order of occurrence.
Hematomas developed in more than 600 cases. Almost
half of all had to drain serum or blood from at least one
patient, and 39% of surgeons reported skin loss in at
least one patient. In addition, 47% of surgeons reported
frequent contracture of the umbilicus. They noted that
the frequencies of complications were inversely related
to the surgeons experience.
Hensel et al. [61] retrospectively reviewed abdomi-
noplasty patients over a 15-year period in an attempt to
identify factors that affected the outcome. The overall
complication rate was 32%; 1.4% was major compli-
cations. The revision rate was 43%, and complications
were significantly higher in smokers and in patients
with diabetes or hypertension, and they were magni-
fied in obese patients (86%). Similarly, Vastine et al.
[62] noted 80% complications of abdominoplasty in
obese patients.
Chaouat et al. [63] reviewed the records of 258
women who had abdominoplasty. They showed sig-
nificantly a higher rate of skin necrosis for patients
who had T-type abdominoplasty (35.5%) than for
901
those with infraumbilical plasties (1.43%) or full
abdominoplasties with horizontal scars (4.60%).
Complications could be classified into: imme-
diate, early and late ones. Immediate complications
of surgery can be life threatening and include deep
venous thrombosis, pulmonary emboli, fat emboli, and
hematoma. Fat embolism is a rare syndrome that is
manifested by the clinical triad of respiratory distress,
cerebral dysfunction, and petechial rash. It manifests
within the first 2 postoperative days and is treated sup-
portively with corticosteroids [64]. Grazer and Goldwyn
[50] reported a 1.1% incidence of deep venous throm-
bosis and 0.8% incidence of pulmonary embolism.
The exact cause of venous thrombosis in the setting
of abdominoplasty remains unknown. It is thought to
result from interference of superficial venous drainage
from the legs and pelvis caused by increased abdominal
pressure [65]. Matarasso recognized this tight under-
wear syndrome in an abdominoplasty patient caused
by the postoperative use of an abdominal binder [66].
Losken et al. [67, 68] showed that intra-abdominal
pressure was significantly increased following trans-
verse rectus abdominis musculocutaneous flap harvest,
particularly in bipedicled transverse rectus abdominis
musculocutaneous flaps closed primarily without mesh
902
Fig. 51.19 (a) Preoperative patient. (b) Six weeks postoperative following abdominoplasty
and the serious complications of thromboembolism
were realized in these patients. In contrast, Al-Basti
et al. [69] studied obese (body mass index more than
34), multiparous patients, measuring intra-abdominal
pressure before and after plication, finding a statisti-
cally significant increase in intra-abdominal pressure
that was not related to the clinically complications.
Controversy regarding the increased incidence of
complication rate if abdominoplasty combined with
F.S. Fahmy and M.A.A. Saleh
other procedures. Voss et al. [70] showed higher
morbidity, longer operative times, and hospital stay
when abdominoplasty was combined with other com-
mon gynecologic operations, with increased incidence
of pulmonary embolus (6.6%), whereas no pulmonary
emboli occurred in patients having only single pro-
cedures. Hunter et al. [71] confirmed the high risk of
pulmonary emboli in patients with combined abdomi-
nal lipectomy and gynecological procedures. On the
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall 903

Fig. 51.19 (continued)

other hand, Hesteler [72], Cardoso De Castro and
Cupello [73], and Gemperli et al. [74] found similar
morbidity and complication rates among patients who
had abdominoplasty combined with other procedures.
Finally, other than a significant risk of blood transfu-
sion, Shull and Verheyden [75] found no increased
morbidity and the hospital length of stay was reduced
by an average of 2 days when the surgeries were
combined.
Early complications include infection, skin necro-
sis, umbilical necrosis, seroma, and hematoma. Their
order varies in the literature, but the most commonly
reported are wound infection, dehiscence, hematoma/
seroma, and skin loss [76]. Van Uchelen et al. [77]
904
reported that the most alarming complication was 10%
incidence of injury to the lateral femoral cutaneous
nerve. This can result in permanent sensory loss along
the anterior, lateral, and posterior thigh that is usually
not interfering with the patients daily activities and
they become used to it over a long period of time.
Wound infection in any clean surgery, occurs in 1% of
patients in an outpatient and 3% in a hospital. It is not
unusual for slight erythema to occur around the sutures
without actual significant infection, and the wound
should be watched very carefully for progression of the
infection that may require intravenous antibiotics [77].
Most surgeons place patients on prophylactic antibiotics,
administered intravenously before and during the surgical
procedure, and oral supplements during the immediate
postoperative period [78].
Infections not responding to antibiotics may require
consultation with an infectious disease specialist and
may indicate early necrotizing fasciitis, sepsis or toxic
shock syndrome that can be fatal. This may be indi-
cated by lethargy, fever, and elevated white count.
Wound debridement, followed by prompt treatment
with appropriate intravenous antibiotics according to
tissue and blood cultures is essential in these serious
complications [77].
The large surface area of dissection extending from
the Mons pubis to the xiphoid process together with
the patients movement, results in the formation of
excessive serous fluid and development of seroma.
Saldanha et al. [79] noted that Seroma can best be
prevented by the placement of postoperative drains.
Pollock and Pollock [80] placed quilting sutures,
attaching the undersurface of the adipose tissue of the
abdominal flap to the anterior surface of the underly-
ing muscular fascia in an attempt to decrease the empty
space. They reviewed 65 abdominoplasty procedures
that were not drained, and found no hematoma, seroma,
or skin flap necrosis.
Pitanguy [76] stressed on preventing seroma by
avoiding desiccation of the dissected tissues, maintain-
ing rigorous hemostasis, and appropriate placement of
drains. He also routinely used a 2-kg custom-designed
anterior abdominal wall plaster shield for the first
2 days postoperatively to assure even and firm pressure
over the dissected abdominal flap.
Zecha and Missotten [81] mentioned different ways
of treating seromas, such as aspiration and compres-
sion to allow the tissues to seal, and injection of room
air to fill the cavity mentioning that it might be repeated,
recommending this method as it is less traumatic than
surgical excision of the pseudocyst.
F.S. Fahmy and M.A.A. Saleh
Wound dehiscence and skin necrosis occur with
attempts of surgeons to close the skin as tightly as pos-
sible. Intraoperative flexion of the trunk adds to this
tension and usually this position is not tolerated by
most of patients in the postoperative period, especially
if the patient has a chronic back problem. Very tight
skin closure might lead to vessel stretching, spasm,
and then clotting, causing flap necrosis which is usu-
ally in its central midportion.
Other contributing factors include: smoking, poorly
controlled diabetes mellitus, hematoma, seroma, infec-
tion, prior abdominal scar, and concomitant abdominal
liposuction [77].
Shiffman [82] mentioned that a subcostal scar from
previous surgeries disrupts the vascular supply to the
skin flap medial to the scar, and may result in flap
necrosis. This could be prevented by minimizing the
amount of flap resected, and leaving at least a 46-cm
space between the inferior point of the scar and the cut
edge of the skin flap, or by resecting the central portion
of the abdominal flap leaving a midline scar.
When liposuction is performed, it is recommended
that the superficial fat compartment be avoided, and that
liposuction performed below Scarpas fascia to limit
vascular compromise and contour irregularities [43, 83,
84]. Matarasso [85] described the critical areas of the
abdominal wall to liposuction at the time of abdomino-
plasty. He also concluded that abdominoplasty may be
combined with liposuction if the central upper abdomi-
nal area has cautious liposuction, and the areas lateral to
this central area have limited liposuction.
Late complications may be unavoidable or may be
caused by a technical error made at the time of surgery.
These include asymmetry of the abdominal contour,
recurrent diastasis of the rectus abdominis muscles,
hypertrophy, and keloid formation (usually attribut-
able to the patients genetic propensity). Occasionally,
reoperation to correct hypertrophic scarring, umbilical
stenosis, excision of excess residual abdominal skin or
subcutaneous adipose tissue, secondary correction of
rectus diastasis, or additional lipoplasty to improve a
contour irregularity of the abdominal wall may be
necessary [78].
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abdominoplasty extravasation of morel-lavalee. Br J Plast
Surg 52(6):500502
82. Shiffman MA (1994) The complicated abdominoplasty:
upper abdominal scars. Am J Cosm Surg 11:4346
83. Ousterhout DK (1990) Combined suction-assisted lipec-
tomy, surgical lipectomy, and surgical abdominoplasty. Ann
Plast Surg 24(2):126132
84. Lewis CM (1990) Combined suction-assisted lipectomy,
surgical lipectomy, and surgical abdominoplasty (discus-
sion). Ann Plast Surg 24(2):126132, discussion 132133
85. Matarasso A (1996) Classification and patient selection in
abdominoplasty. Oper Tech Plast Reconstr Surg 3(1):714
 Circular Lipectomy with Lateral
ThighButtock Lift
Hctor J. Morales Gracia
52.1 Introduction
Patients with body contour deformities are amongst
the challenges that plastic surgeons most frequently
face. These body contour deformities vary from patient
to patient in number, intensity, and anatomical location
depending on racial and genetic factors, and these are
worsened with overweight and even more with obesity.
These patients usually have tried different weight-
reduction methods including diets, reductive massages,
amphetamines, exercise, etc. Nevertheless, the major-
ity do not succeed, and they fall in to a vicious cycle
that only increases the problem.
Those who succeed in losing weight end up with
skin and soft tissue laxity problems. Some of these
patients have magical beliefs about liposuction, think-
ing that these will solve all their contour deformities.
Therefore, it is vital that plastic surgeons inform their
patients about the limitations of liposuction, the risks
of a radical liposuction, and the need for an appropri-
ate surgery. Most patients present a number of body
contour deformities that cannot be corrected in one
single surgical stage. Some will require three or more
surgical stages. For these reasons, I decided to create a
treatment program that combines several body contour
techniques without increasing the surgical risk. With
this program, its possible to change the patients sil-
houette (body contour), helping them to recover their
self-esteem and break the vicious obesity cycle [1].
H.J. Morales Gracia
CER Ciruga Plstica Esttica y Reconstructiva,
Monterrey, Nuevo Len, Mexico
e-mail: drhectormorales@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_52, Springer-Verlag Berlin Heidelberg 2013
52
Obesity and morbid obesity rates have increased in
the last decade all over the world and so the bariatric
surgery and consequently the number of post-bariatric
or massive weight loss patients that successfully have
lost weight and recurred (needed, asked for) to plastic
surgery. Initially, in post-bariatric plastic surgery, the
procedures were merely paniculectomies, cutting out
the skin excess, careless of the resultant scar placing,
and ignoring the body aesthetic units and symmetry,
without improving body contouring and shaping, and
yet the patients were satisfied. There was no experi-
ence in this kind of patients, but later, different plastic
surgeons started to create new procedures and some-
times modified pre-existent procedures to improve
them, observing all the principles of the aesthetic plas-
tic surgery, placing the scars following the aesthetic
units of the body, getting the best possible symmetry,
shape, and volume to obtain a nice silhouette.
The post-bariatric surgery patient is a much more
difficult patient than the moderately overweight patient
in getting an aesthetic result. To perform the surgery,
they must be weight stable; that can be achieved in
approximately 18 months after bariatric surgery. They
must also be in good nutritional shape. When they
come to the plastic surgeon, some of them have lost a
lot of the fat tissue; in these cases, the skin and subcu-
taneous tissue are very thin, and the fixation mecha-
nisms of the connective tissues to the muscular fascia
have excessive laxity which makes it easy to evaluate
the amount of skin resection using the pinch maneuver
and easy to control bleeding. But without fat, its
almost impossible to get a nice female body shape, and
in a couple of months, the tissues that were tightened
get loose; the tissues lost elasticity and due to elasticity
loss have excessive laxity. That is why we often see
907
908 H.J.M. Gracia

LATERAL SUPRA
UPPER ANTERIOR
GLUTEAL RESULTANT IDEAL
AND POSTERIOR
AREA OR FLANK SCAR SILHOUETTE
MARKING LINES
(LOVE HANDLES) LINE

UPPER
MARKING LINE
LOWER
ANTERIOR AND LOWER
POSTERIOR MARKING
MARKING LINES LINE

INTER
GLUTEAL GLUTEAL
TROCHANTERIC CREASE MIDLINE
HORIZONTAL AREA LATERAL
SUPRA PUBIC (SADDLE BAGS) GLUTEAL
MARKING LINE RECESS

OBLIQUE
PARANGUINAL
ASCENDING TROCHANTERIC
MARKING LINE LIPOSUCTION
INCISION

Fig. 52.1 The lift corrects the ptosis and improves the shape, size, and skin texture of the gluteus, making them appear round and
youthful

cases of circular lipectomies in post-bariatric patients
with badly located asymmetrical scars with a complete
lack of female silhouette, no volume at the gluteal area,
and residual skin excess in the abdomen for some
patients. The asymmetrical and/or misplaced scars
could be due to either bad planning or displacement of
the scar because the fixation sutures did not hold the
tissues that were extremely lax and weak and could be
even worse if there is still residual weight on the legs
or buttocks. That is why in this case, we must plan
properly following the aesthetic units of the body and
place as many fixation sutures as possible, and we
must team up with the bariatric surgeons and nutri-
tional assistance staff to assure patients weight and
nutritional stability prior to cosmetic surgery in order
to succeed. One of the advantages of the stable post-
bariatric patient is that the skin becomes very thin so
they usually tend to form less-conspicuous, almost
invisible scars.
52.2 Objectives with Circular Lipectomy
There are several objectives that we seek to achieve
with this circular lipectomy:
1. To lift and to improve the shape, size, and skin tex-
ture of the gluteus, making them look round and
youthful (Fig. 52.1)
2. To lift the lateral thigh, eliminating cellulite by
tightening the skin (Fig. 52.2)
3. To eliminate redundant flank tissue (Fig. 52.3)
4. To lessen the amount and size of (and sometimes
eliminate) the middle and lower back adipose cutane-
ous folds, therefore reducing waist size (Fig. 52.4)
5. To reduce the redundant skin and fat of the abdo-
men and to tighten the rectus abdominis and exter-
nal oblique muscles when needed, thus improving
the abdomen and waist shape (Fig. 52.5)
6. To break the vicious cycle of obesity
7. To leave a single circular scar that can be hidden with
a thong and that may be planned and placed according
to the patients dressing habits and of course respect-
ing the aesthetic units of the body (Fig. 52.6)
52.3 Indications
This surgery is indicated in thin, normal, and a little
overweight patients with loose and redundant skin and
subcutaneous tissue and even in patients with moderate
obesity and obesity (Fig. 52.7). It can also be indicated
only to lift the buttocks to improve the size and shape
and eliminate cellulite (Figs. 52.8 and 52.9). The
author frequently combine the Circular Lipectomy
-Lateral Thigh-Buttock Lift with breast surgery, either
mastopexy or breast augmentation, but it can also be
52 Circular Lipectomy with Lateral ThighButtock Lift
PTOSIS
Fig. 52.2 The lift improves the silhouette and eliminates cellulite by tightening the skin of the lateral thigh
combined with brachioplasty if needed in post-bariat-
ric patients, numbering the areas to be corrected and
making a surgical plan in order to reduce the number
of surgical stages within safety limits.
52.4 Preoperative Markings
For preoperative markings, the patient stands while the
trochanteric area that needs liposuction is outlined.
The supragluteal and lateral supragluteal areas (flanks)
that will be resected are marked starting with the lower
909
marking line at the posterior midline, 35 cm above
the intergluteal crease. A convex line lightly ascendant
is traced until it reaches the gluteal midline and then
extends caudally following the line of the inferior edge
of the lateral supragluteal fat pad (love handles) until it
reaches the upper edge of the lateral gluteal recess.
The contralateral side is marked in the same way,
forming a seagull-wing-shaped line (Fig. 52.9). The
upper marking line is marked at the midline, 2 or 3 cm
above the expected or desired suture line. It starts at
the midline usually 57 cm above the inferior edge of
the resection with lightly ascending curved line
910
Fig. 52.3 Circular lipectomy eliminates redundant flank tissue
extended laterally just over the lateral supragluteal fat
deposit (flanks). It is important to consider that the fur-
ther an incision is from the midline, the more lax the
subcutaneous tissue and its superficial fascial system
are [2]. The expected suture line at the lateral aspect of
the flanks will be located 57 cm below the upper limit
of resection. Once both lines are marked, the vertical
distance of midline is 57 cm and of the lateral aspect
of the flanks is 1425 cm (Fig. 52.9). The pinching
maneuver on the flank facilitates marking on thin
patients [3]. The abdominoplasty is then marked con-
ventionally. A horizontal line of 1012 cm, located just
above the pubic hair line, is traced, extended laterally
and following an ascending line parallel to the inguinal
H.J.M. Gracia
crease. The upper margin is a curved line with its upper
end located above the umbilicus (at the lowest),
depending on the case, and extended laterally until it
meets the inferior margin line. The posterior and ante-
rior marking lines are then joined in the most conve-
nient way for each case.
52.5 Surgical Technique
An intravenous line is set, and the anesthesiologist
administers light intravenous sedation with 50 mcg/kg
of mydazolam, 1mcg/kg of fentanest, 1 g of cephalot-
ine every 6 h, 50 mgs of ranitidine every 12 h, and
52 Circular Lipectomy with Lateral ThighButtock Lift
Fig. 52.4 Circular lipectomy lessens the amount and size (sometimes eliminates) of the middle and lower back adipose cutaneous
folds
5,000 U of subcutaneous heparin. Wlth the patient in a
lateral decubitus position the epidural catheter is intro-
duced at the L2-L3 level and in cases in which breast
surgery will also be performed, a second epidural cath-
eter is introduced at T6T7. A Foley catheter is set,
and the patient is changed to a prone decubitus
position.
The surgery starts with the trochanteric dry liposuc-
tion of the deep fat. If liposuction is not needed, the
cannula is used to undermine and free the trochanteric
area to facilitate the lift using a 4-mm cannula through
a small, oblique 7-mm incision located at the inferior
posterior edge of the trochanteric markings, being
careful not to damage or compromise the integrity of
911
the superficial fascial system and subcutaneous tissue
of the upper edge of the lateral thigh flap because
they are going to be used for closure. The resection of
the supragluteal and lateral supragluteal tissue starts
dividing (cut the flap in two) (Fig. 52.10) the flap at
the posterior midline to facilitate the undermining
and the resection; then, the incision is made on or fol-
lowing the superior or upper marking line, and then
the incision of the lower or on the lower or inferior
marking line is made both starting from medial to lat-
eral. The whole thickness of the subcutaneous tissue
is resected, exposing the fascia thoracolumbalis in
the mid-lower back area and laterally the aponeurosis
of the latissimus dorsi and external oblique muscles
912 H.J.M. Gracia

Fig. 52.5 The abdomen and waist shape are nicely improved

Fig. 52.6 The scar is placed at the limits of the bodys aesthetic units and can be hidden by a thong
52 Circular Lipectomy with Lateral ThighButtock Lift 913

Fig. 52.6 (continued)

Fig. 52.7 Circular lipectomy in a 35-year-old obese patient who refused bariatric surgery has significantly improved buttocks and
abdomen
914 H.J.M. Gracia

Fig. 52.8 The size, shape, uneven aspects, and cellulite of the buttocks are totally corrected by the lift
52 Circular Lipectomy with Lateral ThighButtock Lift 915

Fig. 52.9 Preoperative markings are done immediately before surgery with the patient standing
916 H.J.M. Gracia

Fig. 52.10 Cutting the supragluteal flap in two at the midline

facilitates the undermining and resection

[4]. The caudal limit of the undermining is just to the

level of the inferior line of the markings. Once the
undermining and resection are completed, the lower
flap is manually pulled up to confirm that the resec-
tion has been adequate and to establish the vector of
the lifting at several points and marking them the way
we like it (Fig. 52.11). In moderately obese patients,
it is difficult to establish by using the pinch maneuver
the amount of tissue to be resected; a partial resection
is made to facilitate the undermining and also to
establish the definitive level of the resection. In most
Fig. 52.11 Overlapping maneuver allows a more precise com-
patients, the tissue resection is greater than the initial plementary resection
marking because the flap displacement increases
once the tissue is resected, facilitating an overlapping
maneuver of the upper over the lower flap and allow- contour deformities. When the resection is excessive,
ing a more precise, complementary resection. This is the wound closure will be difficult, and the tension
especially important at the flanks because an insuffi- on the suture may result in dehiscence or widening
cient resection will not correct the cellulite or the of the scar.
52 Circular Lipectomy with Lateral ThighButtock Lift
Fig. 52.12 Gluteal flap pull up maneuver over the fascia thora-
columbalis and muscles to mark traction and fixation suture
line
Once the resection is completed, a combined maneu-
ver is performed that shifts the upper and lower flaps to
define and mark the traction axis of the lateral thigh
and gluteal lift (Fig. 52.11). The gluteal flap is pulled
up over the fascia thoracolumbalis, the aponeurosis of
the latissimus dorsi, and external oblique muscles to
mark traction and fixation suture line (Fig. 52.12).
The wound closure starts with zero monofilament
Prolene sutures, to fix midline, taking enough subcuta-
neous tissue, with its superficial fascial system, at mid-
line on the inferior flap and then enough tissue of the
aponeurosis of the fascia thoracolumbalis at the mid-
line. As many of these sutures (every centimeter) as
917
Fig. 52.13 Posterior suture ends laterally, leaving dog ears
necessary are placed on each side following the trac-
tionfixation suture line in order to pull up the flap and
reduce tension on the subcutaneous and subdermal
sutures, favoring better scar quality. A 2.5-mm-exter-
nal-diameter perforated tube is placed as suction
drainage. The subcutaneous tissue is sutured with zero
Prolene, taking enough subcutaneous tissue, with its
superficial fascial system, on both flaps and then tak-
ing some of the aponeurosis of the underlying muscles.
Ten to twelve of these sutures are placed on each side.
The subdermal layer is then closed with 3-0 Monocryl
inverted sutures, and there is no need for intradermal
suture. The posterior suturing is finished, leaving a dog
ear on each side before moving the patient to the supine
position (Fig. 52.13). The abdominoplasty begins with
the skin resection as marked. The rectus abdominis
muscle is plicated (Fig. 52.14) as is the external oblique
muscle when needed. The wound is closed in two lay-
ers, and suction drainages are left. At the end of the
918
Fig. 52.14 Rectus abdominis muscle plication significantly improves the abdominal silhouette
surgery, the patients wear a compressive girdle with
shoulder straps to suspend the buttocks during ambula-
tion. The patients spend one night at the clinic and
receive autologous blood if needed [5, 6]. They start
walking the next morning and are discharged at noon.
They are examined on the sixth postoperative day
when the drains and umbilicus stitches are removed.
Examination is continued weekly for the first month
and then monthly for a year [1].
52.6 Complications
Over the past 10 years, circular lipectomy has been
performed with lateral thigh and buttock lift in over
100 patients. No major complications have occurred.
All the patients had a fast recovery, beginning ambula-
tion the morning after the surgery and wearing the
compressive girdle with gluteal suspension. Some
patients indicated pain in the lumbar area, but it did not
prevent them from walking. It was easier for the most
obese patients to walk because of their decrease in
weight and reduced circumference due to the elimina-
tion of excess skin and fat folds. Their heart rate and
blood pressure decreased after surgery. The body con-
tour deformities involved were corrected in all the
patients, with very good aesthetic results. The average
fat volume obtained by liposuction was 400 g.
H.J.M. Gracia
The resected tissue weight varied from 1.3 to 1.5 kg
with an average of 3.6 kg.
Twenty-nine patients had abdominal seroma. In ten
patients, the seroma extended to the flank (or it was iso-
late formed at the flank and back), and six patients pre-
sented seroma leakage through the wound at the
posterior midline. This problem was spontaneously cor-
rected during the first 34 weeks. Seroma leakage through
the wound has been prevented by placing thin suction
drain tubes on the back. There were two cases of partial
dehiscence, one was 7 cm long, and the other was 5 cm
long. One of the dehiscence cases was on the flank site
of maximum tension and the other was in the supra-
gluteal area. There were three cases of micro-dehiscence
at the posterior midline, resulting from difficulty in
suturing the tip of the upper flap and/or favored by pos-
terior seroma draining through. Therefore, the incision
design was changed to eliminate the tip of the seagull-
wing flap (Fig. 52.9) and place posterior drains. In the
last 60 cases, there has been no complication other than
few abdominal seroma.
Excellent results were achieved on non-obese
patients who had thin torsos, producing an ideal sil-
houette (Figs. 52.15 and 52.16). In the moderately
obese patients, the correction was also very good, sig-
nificantly improving the silhouette at the waist, the
gluteus, and lateral thigh. The ideal silhouette was not
obtained in patients with other body contour deformities
52 Circular Lipectomy with Lateral ThighButtock Lift
Fig. 52.15 Excellent results in patients with mild obesity of the lower body with thin torso
that were left untreated, such as the internal thighs, the
upper back, the trunk, and the arms. The resulting scar
was located at the limits of the aesthetic units and
could be covered by thongs and bikinis in most of the
cases. In six patients, the scar could not be covered by
a thong, requiring normal underwear or bikinis,
because of scar widening or asymmetry. Four patients
presented unilateral widening of the scar at the flanks,
919
caused by dehiscence in one case but in the absence of
skin dehiscence in the remaining three cases
(Fig. 52.17). In four patients, the scar was high, two
presented asymmetry of the supragluteal scar. The
wide scars at the flanks that were not preceded by
dehiscence were probably due to technical failure
because this area of maximum tension requires metic-
ulous suturing. It is also possible that liposuction of the
920 H.J.M. Gracia

Fig. 52.16 Ideal silhouette is obtained with circular lipectomy in mild overweight patients

neighboring area compromised the integrity of the
superficial fascial system, producing subcutaneous
dehiscence. I found that the scars were less conspicu-
ous in non-obese patients than in obese patients. In all
the cases, the results were greater than patients expec-
tations. During the first 2 months, the gluteal shape
and projection on the lateral view are very poor, and
the buttocks look flat, but around the fourth month, the
area becomes round and youthful (Fig. 52.18).
The results were consistently good.
52 Circular Lipectomy with Lateral ThighButtock Lift 921

52.7 Discussion

The circular lipectomy with lateral thigh and buttock

lift is based on previous experiences of several
surgeons [2, 3, 717]. The circular lipectomy of
Gonzlez Ulloa was designed to eliminate the redun-
dant skin and fat tissues of the abdomen, flanks, and
lower back, but it did not improve the lateral thighs
and buttock contour or lift them either. The resultant
scar was higher than that left by the authors proce-
dure, requiring compensation triangles that left verti-
cal scars. Liposuction [ 7, 13, 14 ] , together with
the body contour surgery techniques of Baroudi,
advanced the treatment of body contour deformities
[6, 1012]. The different combinations proposed by
Baroudi have similar incisions, but the posterior ones
are lower, and the ones of the abdomen are different
[6]. Lockwood used incisions on the lower body lift
that are similar to those we use but lower and with
different design and marking of the area of resection
[17]. His results are outstanding but require several
stages. Also, he does not perform this procedure on
moderately obese patients. With the circular lipec-
tomy, it is possible to achieve several objectives in
one stage:
1. The gluteus is lifted and its size and shape is
improved.
2. The lateral thigh is lifted, improving the contour
and tightening the skin, eliminating cellulite.
3. The number and size of adipose cutaneous folds of
the lower and middle back are decreased, improv-
ing the waist silhouette.
4. Redundant flank tissue is eliminated.
5. Excessive abdominal skin and fat are eliminated.
6. The rectus abdominis muscle is plicated, improving
the waistline and abdominal silhouette.
7. The circumferences of the abdomen, waist, hips,
and thighs are significantly decreased.
8. The only scar left can be placed according to the
patients dressing habits and can be covered by a
thong in most cases [1].
Fig. 52.17 Scar widening at the flank in the absence of
dehiscence
922 H.J.M. Gracia

Fig. 52.18 (a) Flat gluteal shape and projection at 1 month after surgery. (b) Three months after surgery with buttocks starting to
appear better. (c) One year after surgery with round and youthful buttocks
52 Circular Lipectomy with Lateral ThighButtock Lift 923

References 9. Illouz YG, De Villers YT (1989) Body sculpturing by lip-

oplasty. Churchill-Livingstone, New York
10. Couch N, Laks H, Pilon RN (1974) Autotransfusion in three
1. Baroudi R, Keppke EM, Tozzi-Neto F (1974) Abdominoplasty.
variations. Arch Surg 108(1):121122
Plast Reconstr Surg 54(2):161168
11. Lockwood TE (1988) Fascial anchoring technique in medial
2. Baroudi R (1984) Body sculpturing. Clin Plast Surg
thigh lifts. Plast Reconstr Surg 82(2):299304
11(3):419443
12. Lockwood TE (1991) Superficial fascial system (SFS) of the
3. Baroudi R (1984) Lipolysis combined with conventional sur-
trunk and extremities: a new concept. Plast Reconstr Surg
gery. In: Hetter GP (ed) Lipolysis: the theory and practice of
87(6):10091018
blunt suction lipectomy. Little Brown, Boston
13. Lockwood TE (1991) Transverse flank-thigh-buttock-lift
4. Baroudi R (1989) Body contouring surgery. Clin Plast Surg
with superficial fascial suspension. Plast Reconstr Surg
16(21):263277
87(6):10191027
5. Gonzalez-Ulloa M (1959) Circular lipectomy with transposi-
14. Lockwood T (1993) Lower body lift with superficial fascial
tion of the umbilicus and aponeurolytic technique. Ciruga
system suspension. Plast Reconstr Surg 92(6):11231125
27:394409
15. Morales-Gracia HJ (2003) Circular lipectomy with lateral
6. Gonzlez-Ulloa M (1960) Belt lipectomy. Br J Plast Surg
thigh-buttock lift. Aesthetic Plast Surg 27(1):5057
13:179186
16. Newman MM, Hamstra R, Block M (1971) Use of banked
7. Illouz YG (1984) Illouzs technique of body contouring by
autologous blood and elective surgery. J Am Med Assoc
liposis. Clin Plast Surg 11(3):409417
218(6):861863
8. Illouz YG (1985) Surgical remodeling of the silhouette by
17. Testut L, Jacobs O (1952) Tratado de anatoma topogrfica.
aspiration liposis or selective lipectomy. Aesthetic Plast Surg
Salvat Editores S.A., Barcelona
9(1):721
 The Horseshoe Abdominoplasty
53
Richard Moufarrege and Elia Botros

53.1 Denition of Abdominoplasty (b) The extrinsic treatment consists in the removal
of excess tissue. This removal will act on the
Abdominoplasty is the functional and mainly aesthetic stretch line by two means:
restoration of the abdomen covering the skin in which (i) Possible removal of the stretch lines area.
the internal structure and skin appearance have been (ii) Expansion of this area will create a trompe-
destroyed following several aggressions consisting in lil improving effect.
important gain and loss of weight or the appearance 2. Skin excess treatment:
of serious stretch marks following one or multiple In the last 100 years, several abdominoplasty types
pregnancies. have been developed and can be classified in three
categories:
(a) Abdominoplasties treating the horizontal excess
53.2 Skin Answers to Different of skin (Fig. 53.1) [112]
Aggressions (b) Abdominoplasties treating the vertical excess
of skin (Fig. 53.2) [1315]
Depending on the body type and the individual consti- (c) Abdominoplasties treating both vertical and
tution, the answer to these aggressions will be of two horizontal excess of skin (Fig. 53.3) [1620]
types: The horseshoe abdominoplasty is classified in the
1. Intrinsic response: Stretch lines third category (Fig. 53.4) [19, 20].
2. Widening of the abdomen skin:
(a) Horizontally
(b) Vertically
53.4 The Horseshoe
Abdominoplasty
53.3 Principle of Abdominoplasty
53.4.1 Generalities
1. Stretched skin treatment:
(a) There is no intrinsic way of treatment. The Inspired by the partial inferior abdominoplasty
phenomenon is irreversible. described by El Baz [21, 22], the horseshoe abdomi-
noplasty is a mixed type of abdominoplasty thus
allowing the treatment of vertical and horizontal skin
R. Moufarrege (*) E. Botros
excesses with a horseshoe incision around the
Department of Plastic Surgery-Hotel, Dieu of Montreal
Hospital, Montreal University, QC, Canada Mount-of-Venus pubic area, avoiding the large
e-mail: plasticsurg_moufar@hotmail.com, incisions in the classical abdominoplasties (Fig. 53.5)
botroselia10@hotmail.com [19, 20].

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 925

DOI 10.1007/978-3-642-21837-8_53, Springer-Verlag Berlin Heidelberg 2013
926 R. Moufarrege and E. Botros

a b c

Fig. 53.1 Vertical abdominoplasties to treat horizontal excess of skin (widening of the waist). (a) Babcock. (b) Scheppelmann.
(c) Kuster

a b c d

e f g

Fig. 53.2 Horizontal abdominoplasties for vertical excess of skin treatment. (a) Kelly. (b) Thorek. (c) Gonzales-Ulloa. (d) Baroudi.
(e) Pitanguy. (f) Grazer. (g) Regnault
53 The Horseshoe Abdominoplasty 927

a b

c d e

Fig. 53.3 Mixed abdominoplasties. (a) Pick, Barsky. (b) Galtier. (c) Weinhold. (d) Flesh-Thebesus, Weisheimer. (e) Moufarrge

53.4.2 Indications and Limitations
Although a horseshoe abdominoplasty ranges from a
very small partial inferior abdominoplasty until very
high extended abdominoplasties with undermining
reaching the thoracic ribs, its indications are very lim-
ited and must meet very strict criteria. If the patient
does not meet these conditions, it is better to opt for a
classical incision with a very low curved line with an
upper concavity [20]. Conditions allowing the use of
the horseshoe are:
1. Slim patient without any fat to be removed under
the remaining skin
2. Patient without stretch lines at the level of the upper
flap edge
In the authors practice, horseshoe abdomino-
plasties do not represent any more than 5% of abdom-
inoplasty indications. If both of these two conditions
are not met, one can be forced to complete the horse-
shoe with a vertical medial incision after a resection
of the wedge with upper summit and inferior basis in
order to absorb the non-adaptable stretch lined edge
928
Fig. 53.4 Traction orientation in the horseshoe
against the inferior horseshoe around the pubic areas
(Figs. 53.6 and 53.7) [20].
53.4.3 Surgical Technique
Once the indication for a horseshoe abdominoplasty is
established, the horseshoe is drawn (Fig. 53.5). In
order to allow a better absorption of all the skin excess
resulting from the resection of the abdominal skin, a
special effort is made to extend the inferior extremities
of the horseshoe as far as possible (Fig. 53.8). The
upper flap is then elevated. Obviously, if the dermacha-
lasis involves the supraumbilical area, undermining
extends until the ribs (Fig. 53.9). On the contrary, if the
dermachalasis does not involve the supraumbilical
area, undermining will stop at the umbilicus. Laterally,
undermining will extend to the superior anterior iliac
spine (Fig. 53.9). As soon as dermachalasis is consid-
ered to involve the supraumbilical area, undermining
will involve the umbilicus. The authors philosophy in
the management of the umbilicus is very different from
the way it is treated in the traditional abdominoplasties.
R. Moufarrege and E. Botros
Fig. 53.5 The horseshoe first incision
Entire umbilical reconstruction is performed in the
abdominoplasties, including those with low upper-
concave incision. The umbilicus is separated from all
attachments with the fetal remnants of the umbilical
cord, and we close the resultant small hernia with a
2-0 cross stitch of polyglycolic acid (Vicryl, Dexon,
Polysorb).
The surgeon will evaluate at this stage the extent of
skin resection, that is to say, the level of the superior
incision in the undermined flap. This level will be
defined more securely by the mean of a medial vertical
incision starting at the middle of the inferior edge of
the horseshoe and progressing upward until reaching,
after many trials, the exact level of the skin resection
(Fig. 53.9). This level is reached by bringing together
progressively the extremity of that vertical incision to
the middle of the lower horseshoe edge (Fig. 53.9).
The thighs are not bent over the abdomen to remove
excess of skin, and closure is completed without ten-
sion. Once the upper limit of the incision designed, the
cutaneous resection is performed in two halves of
ellipse with their upper extremity perpendicular to the
vertical temporary medial line and their lower extremity
53 The Horseshoe Abdominoplasty
Fig. 53.6 The wedge a b
supplemental resection and its
result. (a) Wedge design (b)
Final scars
Fig. 53.7 Vertical medial scar over the horseshoe
making a 10 angle with the inferior extremity of the
lower edge of the horseshoe (Fig. 53.10).
In the authors classical abdominoplasties when the
horseshoe design cannot be applied, resection is com-
pleted with the removal of the fascia superficialis under
the remaining skin until ribs. This is not necessary in case
of horseshoe abdominoplasty because the subcutaneous
fat is very thin, i.e., 1015 mm. If the patient presents
any muscle diastasis, the muscle plication of the rectus
abdominis is performed before the reconstruction.
929
Fig. 53.8 First incision, extending the inferior extremity as far
as possible
53.5 Reconstruction of the Umbilicus
Once the upper flap is attached against the center of the
lower horseshoe edge, it is time to delimitate the posi-
tion of the new umbilicus. This will not have any rela-
tionship with the old umbilicus. It will be situated at
half distance between the two superior anterior iliac
spines.
The incision is marked having a much curved smile
shape with upper concavity. Its dimensions are
930 R. Moufarrege and E. Botros

a b

b
c
d d

g e
f

90
b
10

e f
53 The Horseshoe Abdominoplasty
b will result with a natural umbilicus avoiding that dis-
Fig. 53.10 (a) Excised skin before removal. (b) Excised skin
once completely separated from the remaining abdominal skin
15 15 mm (Fig. 53.11). The dermis of the upper flap
is liberated of its subcutaneous fat and fixed on the
aponeurosis with a high kick-up of that small flap up in
order to obtain a certain curtain effect on the upper
middle of the umbilicus (Fig. 53.12). That suture point
is called the superior cardinal point. The inferior cardi-
nal point is 15 mm below. Anchoring the two extremi-
ties of the incision is continued against the aponeurosis
with a pushdown technique with a 2-0 polyglycolic
acid suture (Fig. 53.13).
Fig. 53.9 (a) Different levels of skin resection depending on
the skin laxity and dermachalasis degree. The area designed by
A represents the undermining surface. (b) Abdomen after the
skin resection. (c) Undermining the upper flap after skin exci-
sion. (d) Designing the excision and the undermining lines. (A)
Undermining limit. (B) Excision limit. (e) Evaluation of the
931
Fig. 53.11 Incision for the umbilical reconstruction
The muscular space seen through the umbilicus that
is about 15 15 mm is allowed to granulate spontane-
ously. This will be completed within 23 weeks and
graceful appearance of round scar and a cylinder lead-
ing to the muscular wall.
Closing of the horseshoe will continue progres-
sively by always dividing every space between the
sutures in two equal parts (Figs. 53.1453.17).
53.6 Drainage
An aspirating drain (Jackson Pratt type) is inserted in
the dead space between the skin flap and the muscles
and is removed when it will drain less than 25 mL
daily; this will take between 5 and 10 days.
53.7 Precautions and Contraindications
Scar revision could be necessary after a year. The sur-
geon has to warn the patient of such a possibility.
It is absolutely contraindicated to proceed to any
abdominoplasty in case of an active-smoking context.
The author requests smoking cessation 3 months before
and after surgery.
53.8 Results
The patients have been happy with the results
(Figs. 53.1853.20).
resection height with a medial vertical incision in the upper
undermined flap. (f) Approximation of the central point between
the upper and lower incision after the delimitation of the skin to
be excised. This approximation is only a maneuver to confirm
the right height of the excision
932 R. Moufarrege and E. Botros

Fig. 53.12 (A) Umbilical A B

reconstruction, undermining
of the U-shape flap. (a)
Muscle. (b) Muscle
aponeurosis. (c) Subcutaneous
fat. (d) Inferior area of the
umbilicus. (B) Belly button
reconstruction: anchoring
dermis at 12 oclock (up) and
6 oclock (down)

a b

Fig. 53.13 (a) Anchoring the four cardinal points of the belly button. (b) Reconstructed belly button
53 The Horseshoe Abdominoplasty 933

Fig. 53.14 First suture in the closing procedure Fig. 53.16 Third series of sutures

Fig. 53.17 (a) Fourth series of sutures. (b) End of the horse-
shoe closing. In this patient, the incision continues in the inner
Fig. 53.15 Second series of sutures thigh fold in a combined abdomen and inner thigh lifting
934 R. Moufarrege and E. Botros

Fig. 53.17 (continued)

Fig. 53.18 (Left)

Preoperative. (Right)
Postoperative
53 The Horseshoe Abdominoplasty 935

Fig. 53.19 (Left)

Preoperative. (Right)
Postoperative
936 R. Moufarrege and E. Botros

Fig. 53.20 (Left) Preoperative. (Right) Postoperative

53 The Horseshoe Abdominoplasty 937

References 12. Regnault P (1975) Abdominoplasty by the W technique.

Plast Reconstr Surg 55(3):265274
13. Babcock WW (1916) The correction of the obese and
1. Kelly HA (1910) Excision of the fat of the abdominal
relaxed abdominal wall with special reference to the use of
wall-lipectomy. Surg Gynecol Obstet 10:229231
buried silver chain. Am J Obstet Gynecol 74:596611
2. Thorek M (1924) Plastic surgery of the breast and abdomi-
14. Schepelmann E (1918) ber Bauchdeckenplastik mit beson-
nal wall. Charles C. Thomas, Springfield
derer Bercksichtigung des Hngebauches. Beitr Klin Chir
3. Thorek M (1939) Plastic reconstruction of the female breast
3:372
and abdomen. Am J Surg 43:268278
15. Kuster H (1926) Operation bel Hngebrust und Hngeleib.
4. Gonzalez-Ulloa M (1960) Belt lipectomy. Br J Plast Surg
Monstsschr Geburtsh Gynk 73:316
13:179186
16. Galtier M (1955) Traitement chirurgical des obsits de la
5. Baroudi R (1984) Body sculpturing. Clin Plast Surg 11(3):
paroi abdominale avec ptose. Mem Acad Chir 8l(1213):
419443
341344
6. Baroudi R, Moraes M (1991) Philosophy, technical princi-
17. Galtier M (1962) Obesity of the abdominal wall with ptosis
ples, selection, and indication in body contouring surgery.
(pendulus abdomen): surgical treatment. Presse Med 70:
Aesthetic Plast Surg 15(1):118
135136
7. Pitanguy I (1967) Abdominal plastic surgery. Hospital
18. Weinhold S (1909) Bauchdeckenplastik. Zentralbl Gynk
(Rio J) 71(6):15411556
38:1332
8. Pitanguy I (1971) Technique for trunk and thigh reductions.
19. Moufarrge R (1997) The Moufarrge horseshoe abdomino-
In: Transactions of the fifth international congress of plastic
plasty. Aesthetic Surg J 17(2):9196
and reconstructive surgery, Butterworth, Melbourne 1971,
20. Moufarrge R (2005) Horseshoe abdominoplasty. In:
pp 12041210
Shiffman MA, Mirrafati S (eds) Aesthetic surgery of the
9. Pitanguy I, Yobar AA, Pires CE, Matta SR (1974) Aspectos
abdominal wall. Springer, Berlin, pp 121129
atuais das lipectomias abdominais. Bol Cir Plast Rev Bras
21. Elbaz JS, Flageul G (1979) Plastic surgery of the abdomen.
Cirurgia 19:149
Masson Publishing, New York, p 3961
10. Grazer FM (1973) Abdominoplasty. Plast Reconstr Surg
22. Elbaz JS, Flageul G (1989) Liposuccion et Chirugie Plastique
51(6):617623
de lAbdomen. Masson, Paris, p 74
11. Rgnault P (1972) Abdominal lipectomy: a low W incision.
International Journal of Aesthetic Plastic Surgery
 Mini-Abdominoplasty
Bruce A. Mast
54.1 Introduction
Patients with contour irregularities of the abdominal
wall present with varied histories and varied physical
findings. Some patients have had a massive weight
loss from bariatric surgery or non-surgical efforts.
Others have had more modest weight loss, while many
have had changes of weight and skin quality related
to changes from aging, pregnancy, and childbirth.
Therefore, each patient needs to be carefully assessed,
and based on the characteristics of each individual, the
proper type of contouring procedure can be provided
[1]. The assessment must evaluate the component
irregularities of the abdominal wall which consist of
varying degrees of adiposity, loose or redundant skin,
and laxity of the musculofascial units [2]. When these
components affect the majority of the abdominal wall,
particularly the supraumbilical region, a standard full
abdominoplasty with or without liposuction is usually
indicated. However, an operation of this magnitude
may not be necessary for those who present with more
limited or isolated deformities confined to the lower
abdomen. These patients can be treated very effec-
tively with a mini-abdominoplasty, with or without
liposuction of the abdominal wall or flank [3]. Mini-
abdominoplasty can provide these patients with excel-
lent correction of their abdominal deformities with
significantly less morbidity and faster recovery than
that which is associated with a full abdominoplasty
B.A. Mast
Division of Plastic and Reconstructive Surgery,
University of Florida, Gainesville, FL, USA
e-mail: bmast@accentmd.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_54, Springer-Verlag Berlin Heidelberg 2013
54
[4, 5]. This procedure can also offer an understandable
compromise for the patient who is not an ideal candi-
date for mini-abdominoplasty, but is unwilling to put
forth the physical or financial outlay necessitated by
the full abdominoplasty [6].
54.2 Clinical Findings and Patient
Selections
Ideal candidates for the mini-abdominoplasty are dis-
pleased with their lower abdominal contour, especially
when sitting. Often times, they are thin, physically fit,
and active, but distraught over their appearance in
clothes due to the lower abdominal bulge. Full exami-
nation of the patients abdomen is done in several posi-
tions: supine, sitting, standing, and the diving position.
This provides a full appreciation of the degree of
excessive soft tissue and the extent of musculofascial
laxity. Careful palpation of the abdomen in the supine
position allows assessment of rectus diastasis and the
superior extent of the diastasis. It further permits detec-
tion of abdominal wall hernias. The sitting position
will show a roll of excessive or loose soft tissue with a
lower abdominal bulge that may not be noticeable in
standing or supine position. The excess of tissue con-
fined to the lower abdomen is confirmed with the
patient standing, while downward traction is asserted
to the abdominal skin, demonstrating the absence of
sufficient laxity or excess above the umbilicus to bridge
the gap to the pubis required for a full abdominoplasty.
The diving, or waist-flexed, position allows the loose
skin to fall away from the abdominal wall and pro-
vides further assessment. In general, musculofascial
weakness and the loose skin should be confined to the
939
940
infraumbilical abdomen. Diastasis of the rectus should
be limited to the infraumbilical region or only 1 or
2 cm superiorly (Table 54.1, Figs. 54.154.3)
Contraindications to mini-abdominoplasty are lax-
ity of the abdominal musculofascial components above
the umbilicus, excessive or disproportionate soft tissue
in the upper abdomen, generalized laxity or soft tissue
excess of the entire abdominal wall, upper abdominal
hernias (usually incisional hernias), and patients
presenting after massive weight loss. Such patients
generally have excessive skin throughout the abdo-
men. As a general guideline, ptosis of supraumbilical
Table 54.1 Ideal candidate for mini-abdominoplasty
Clinical feature Description
Body type Overall fit and trim; not obese
Abdominal contour Lower infraumbilical bulge
Excess tissue Confined to lower abdomen
Musculofascial laxity Lower abdomen only
Rectus diastasis No more than 2 cm above umbilicus
Fig. 54.1 Ideal patient for mini-abdominoplasty. (Upper photos before surgery; lower photos after surgery)
B.A. Mast
skin over the umbilicus is indicative of excessive laxity
of the upper abdominal soft tissue that would not be
fully corrected with a standard mini-abdominoplasty
(Table 54.2, Figs. 54.4 and 54.5).
Some patients will have adiposity of the upper
abdomen and flanks. Examination should specifically
address these areas, especially in regard to excess skin.
If mild to modest fat accumulation is present, then lipo-
suction can be combined safely with the procedure.
However, an assessment of the degree of supraumbili-
cal fat and the extent of skin laxity must be accurately
judged so that loose skin will not be problematic after
surgery (Fig. 54.6).
54.3 Operative Technique
Mini-abdominoplasty is a procedure in which
infraumbilical skin is excised, and the umbilicus is not
translocated. The extent of skin excision varies with
individual circumstances. In most cases, liposuction is
54 Mini-Abdominoplasty
Fig. 54.2 Good candidate for mini-abdominoplasty. Greater skin laxity than patient in Fig. 54.1 mandates greater skin excision and
longer final scar. (Upper, before surgery; lower, after surgery)
also done. A mini-abdominoplasty in an ideal patient
will be described. The authors preferred methods will
be presented with alternatives discussed subsequently.
As with all body-contouring procedures, the patient
is marked preoperatively. As marking is started in the
standing position, the proposed placement of the scar
is confirmed with the patient such that assurance can
941
be provided for proper positioning within the panty
line or swimsuit line. It is best to have the patient wear
her favored swimsuit during the markings to assure
that the final scar will be hidden. However, it should be
stressed to the patient that the final position of the scar
cannot be guaranteed rather best efforts are put forth to
place the scar favorably.
942 B.A. Mast

Fig. 54.3 Excellent

candidate for
mini-abdominoplasty.
Very little redundant skin
and fat, but diastasis clearly
extends above the umbilicus.
(Upper, before surgery;
lower, after surgery)

The transverse pubic incision is marked in the region

Table 54.2 Contraindications for mini-abdominoplasty
of the superior aspect of the pubic hairline. This mark
Clinical feature Description
should be no higher than 68 cm above the superior
Body type Obese
aspect of the introitus in the midline. If a Pfannenstiel
Abdominal contour Excessive or disproportionate
upper abdominal bulging
scar is present, the incision line should be inferior to it
Excess tissue Includes upper abdomen or entire so that the associated subcutaneous fibrosis that tethers
abdomen the skin to the fascia can be removed. In most patients,
Musculofascial laxity Involves supraumbilical the incision needs to be extended past the pubis bilater-
abdomen ally to allow visualization of the abdominal muscula-
Incisional/ventral hernia ture and permit appropriate skin excision and closure.
Rectus diastasis Extends well above umbilicus The lateral extension extends up the inguinal crease to
54 Mini-Abdominoplasty 943

Fig. 54.4 This patient will obviously be inadequately treated with a mini-abdominoplasty. Excessive or redundant skin and adipose
exists throughout the entire abdomen

Fig. 54.5 This 38-year-old woman has delivered triplets. abdomen (note the mild ptosis of the skin above the umbilicus),
Casual inspection is deceiving, while a full examination demon- and rectus diastasis extends from pubis to xyphoid. Full abdomi-
strates the extent of the abdominal deformity. There is virtually noplasty is indicated
no excess fatty tissue, but her skin is loose throughout the

about the level of anterior superior iliac spine or further. one-third to one-half of the vertical height of the skin
The upper excision line is not drawn until the flap is between the pubis and the umbilicus. If the excision is
raised intraoperatively. However, for purposes of plan- more than this, it will likely lead to excess tension
ning, the skin to be excised usually encompasses about upon closure causing upward migration of the scar or
944
Fig. 54.6 This 43-year-old woman would like abdominal con-
touring. She has adiposity extending well above the umbilicus
and to the flanks, while the excess skin and bulging is mostly
excessive distortion of the umbilicus. If liposuction is
planned for the upper abdomen, flanks, iliac crests, or
thighs, these areas are also marked, while the patient is
standing. At the completion of marking, all the mark-
ings should be demonstrated and explained to the
patient with confirmation of scar placement.
B.A. Mast
confined to the infraumbilical abdomen. She was treated with
mini-abdominoplasty and full abdominal and flank liposuction.
(Preoperative on right; postoperative on left)
Mini-abdominoplasty can be performed under
several types of anesthesia. The author prefers a general
anesthetic, but intravenous sedation combined with
local anesthetic is also used [710]. In the latter tech-
nique, bilateral ilioinguinal nerve blocks are adminis-
tered, combined with direct infiltration of the incision
54 Mini-Abdominoplasty 945

Table 54.3 Anesthesia used for mini-abdominoplasty

Type Advantages
IV sedation with local anesthetic 1. CRNA or anesthesiologist
2. Limited time in recovery room
3. Low incidence of postoperative nausea
4. Lowest risk for thromboembolic
complications
General anesthesia 1. Maximum patient comfort
2. Maximum muscular relaxation
Epidural 1. Excellent patient comfort
2. Excellent muscular relaxation
Disadvantages
1. Potentially more pain
2. Muscular plication may be more difficult
1. Usually need anesthesiologist
2. Higher potential for postoperative
nausea
3. Longer time in recovery room
4. Increased risk for thromboembolic
complications
1. Need IV sedation in addition to epidural
2. Potential complications related
to epidural
3. Need specialized anesthetist/
anesthesiologist
4. Increased risk for thromboembolic
complications

line with the local anesthetic. Tumescent liposuction
solution consisting of 0.01% lidocaine with 1:000,000
epinephrine is also infiltrated into the lower abdominal
wall in the region of flap elevation. This augments the
anesthetic affect and provides greater patient comfort
[11, 12]. The use of epidural anesthesia has been spo-
radically reported, but the potential complications as
well as possible prolongation of pre-discharge recov-
ery must be considered (Table 54.3). If the operation to
be performed is only a mini-abdominoplasty, then
intravenous sedation combined with local anesthetic is
easily applicable. However, if combined with liposuc-
tion, breast surgery, or another procedure, then the
total length of the procedure must be considered,
affecting the selection of anesthetic, but also mandat-
ing consideration of prophylaxis for deep venous
thrombosis and the use of body-warming devices.
If liposuction of the abdomen is to be done, then the
superwet technique is used. Suction is usually done
prior to elevation of the lower abdominal flap since this
more readily allows the tumescent solution to remain
in place without proximity to a large open surgical site,
through which the fluid can easily egress. However,
this may not be possible in the upper central abdomen
without the use of a cannula access incision at the
upper aspect of the umbilicus. If this is needed, the
patient must be informed of this incision preopera-
tively. The entire upper abdomen extending laterally
can be suctioned fairly aggressively since the abdomi-
nal flap will not be elevated much above the umbilicus.
This preserves perforating vessels that perfuse the
abdominal skin such that the risk of ischemia is very
low. If an abdominal wall hernia is present, this must
be repaired prior to the liposuction to avoid intestinal
injury.
Upon completion of the liposuction, the abdominal
incision is created and carried through Scarpas fascia
down to the loose areolar plane just superficial to the
anterior rectus sheath and external oblique fascial
aponeuroses. The skin and subcutaneous tissues are
then elevated off the abdominal fascia superiorly
and laterally. The superior extent of mobilization is to
the point where the diastasis recti cease, usually no
more than a few centimeters above the umbilicus. If
supraumbilical dissection is necessary, the umbilicus
remains attached to the abdominal skin and the muscu-
lar wall, and care must be exercised around the umbili-
cal stalk to avoid devascularization. Lateral mobilization
of the flap is continued to about the level of the anterior
axillary line. If the anesthesia being used is intrave-
nous sedation with local anesthetic, electrocautery
should be avoided in ligation and division of larger
perforating vessels since these often contain sizable
sensory nerves. The electrical current is transmitted
into these nerves causing severe pain despite the rest of
the field being completely anesthetic. In such circum-
stances, suture ligation and sharp division should be
employed. These procedures will allow sufficient ante-
rior retraction of the skin unit such that abdominal wall
plication can be done under direct visualization.
946
Fig. 54.7 Plication of the diastasis of the rectus muscles
Dissection and retraction of the abdominal skin flap
permits inspection of the musculofascial component of
the abdominal wall and the anatomic cause of laxity
that contributes to the abnormal external contour.
Rectus diastasis is primarily confined to the infraumbil-
ical region, although some patients may have a more
minor aspect extending above the umbilicus. However,
even in these patients, the majority of the laxity is in
the lower abdomen. The laxity is corrected by muscu-
lofascial plication, providing reconstruction of the
correct anatomic relationships of the abdominal wall
musculature. This should result in parallel alignment
of the rectus muscles with a straight-line juxtaposition
at the linea alba. Accordingly, plication is undertaken
to remove the resultant bulging and restore a flat
abdominal wall. The plication lines on the anterior rec-
tus sheaths are marked to guide suture placement. The
elliptical or crescent marks come together in the mid-
line just above the suprapubic incision line and meet
superiorly at the upper aspect of the diastasis (Fig. 54.7).
The plication is done with inverted figure-of-eight
braided nylon sutures. These permanent soft sutures
require few knots, avoiding postoperative palpability,
even in the thinnest patients. Alternatively, a running
permanent monofilament suture can be used. If plica-
tion is necessary superior to the umbilicus, sutures
must be carefully placed so as to avoid strangulation of
the umbilical stalk. Others have described methods of
vertical and transverse plication that may be applicable
when the extent of laxity is not fully corrected by
a standard midline plication [13]. Correction of the
inferior diastasis must be done with care so as to avoid
bulging of the upper abdomen. This area may now
B.A. Mast
have a relative laxity if the inferior diastasis is corrected
aggressively. A balance between the upper and lower
abdominal wall myofascial unit must be achieved.
Following plication, the excessive skin and subcu-
taneous tissue is retracted inferiorly to overlap the
lower suprapubic incision. Aggressive excision that
results in a very tight closure should be avoided. This
could cause gross distortion of the umbilicus as well as
unfavorable scarring due to tension. In addition to a
wide scar, a very tight closure could also lead to supe-
rior migration of the scar as the looser pubic soft tissue
is pulled upward. Such a circumstance could lead to
a scar that is difficult to hide in the patients swimsuit
of choice. To avoid these results, skin excision is
judged with the patient nearly flat with the operating
table barely flexed. With the abdominal flap pulled
inferiorly at an appropriate tension, the midline point
of excision is marked, and the flap is incised longitudi-
nally in the midline. This point is secured temporarily
to the lower incision line in the midline. This leaves
two lateral triangles of excess tissue that can be
appropriately marked and excised.
Prior to closure, it is occasionally necessary to judi-
ciously defat the advancing abdominal flap or the pubic
soft tissue centrally so that the opposing tissues have
the same thickness and an appropriate contour can be
achieved. A closed suction drain is placed via a small
incision within the pubic hair or through the incision
line laterally. Scarpas fascia is then approximated
with interrupted absorbable suture. The midline suture
also incorporates the abdominal fascia just above
the pubis, acting to stabilize the position of the scar and
prevent superior migration with time. The skin is closed
with subdermal dissolvable monofilament and skin
adhesive. The soft tissues surrounding the suture line
are infiltrated with bupivicaine without epinephrine to
provide postoperative analgesia. In all cases, the umbi-
licus will be distorted to some degree, usually with a
slight vertically elongated appearance (Figs. 54.154.3,
54.5 and 54.6). An umbilicus to pubis distance of 9 cm
is a good parameter to use for a normal anatomic
relationship that provides a pleasing appearance. If this
distance is significantly less than 9 cm, particularly in
shorter patients, then translocation to the appropriate
position through a vertical, elliptical, midline inci-
sion may be necessary. Overall appearance within the
parameters of the patients particular body habitus
dictates the necessity of umbilical translocation, and
preoperative assessment should allow counseling to
alert the patient to the potential need for this maneuver
and the resultant scar.
54 Mini-Abdominoplasty
54.4 Postoperative Care
An abdominal binder or appropriate liposuction
compression garment is placed after the surgery.
The patient is discharged home after post-anesthesia
criteria are met and instructed to leave the dressings
and compression in place until seen for the first
postoperative office visit within 48 h of the proce-
dure. The patient is instructed to avoid strenuous
activities and heavy lifting for at least 1 month after
surgery. The surgical drain is usually removed within
1 week. After 1 month of healing, the patient is per-
mitted to gradually resume a workout regimen and is
cleared for all activities as tolerated after 6 weeks of
healing.
54.5 Complications
Virtually, all complications or adverse outcomes that
can occur with a full, standard abdominoplasty or lipo-
suction also apply to mini-abdominoplasty, but occur
much less frequently, since the surgery is not as exten-
sive. The mini-abdominoplasty uses incisions and dis-
sections that are considerably smaller, while abdominal
skin resection is of lesser quantity permitting the patient
to remain completely supine or erect following surgery.
This results in less pain and discomfort and affords a
quicker recovery such that most patients can return to
work within 7 days. Since the flap elevation is somewhat
limited, hematomas, seromas, flap ischemia, and wound
dehiscence occur very infrequently less than 10% of
the time [3]. Additionally, the mini-abdominoplasty
minimizes potential adverse aesthetic outcomes that
occasionally occur with full abdominoplasty, such as
straightening of the waistline, incisional dog-ears, and
difficulty concealing scars within swimwear. Never-
theless, suboptimal results can occur as with any body-
contouring procedure. Upper abdominal bulging may
result from overzealous musculofascial plication caus-
ing intra-abdominal decompression via a less tight
upper abdomen. Additionally, some patients may still
have residual skin excess or lower abdominal bulge,
usually due to their preoperative condition being more
amenable to a mini-abdominoplasty rather than full
abdominoplasty, but not being the ideal candidate for
the mini-abdominoplasty. For such patients, careful
preoperative assessment and counseling on the limita-
tions of the procedure is vitally important. Maximum
scar quality is achieved by the avoidance of excessive
tension at closure, complete elimination of ultraviolet
947
radiation (including tanning booths) for at least
6 months following surgery and the use of various scar
lotions/gels or silicone patching for scar management.
54.6 Conclusions
As with most deformities treated by plastic surgery, it
is important to analyze each deformity based on its
various components and customize procedures to
each particular patient. The mini-abdominoplasty rep-
resents such an approach. With careful patient selec-
tion, a significant aesthetic deformity can be corrected
with minimization of morbidity and convalescence
while providing the patient with a high standard of
care and a high level of satisfaction (Fig. 54.6).
References
1. Sozer SO, Agullo FJ, Santillan AA, Wolf C (2007) Decision
making in abdominoplasty. Aesthetic Plast Surg 31(2):
117127
2. Matarasso A (1996) Classification and patient selection in
abdominoplasty. Oper Tech Plast Reconstr Surg 3:714
3. Shestak KC (1999) Marriage abdominoplasty expands the
mini-abdominoplasty concept. Plast Reconstr Surg 103(3):
10201031
4. Greminger RF (1987) The mini-abdominoplasty. Plast
Reconstr Surg 79(3):356364
5. Wilkinson TS, Swartz BE (1986) Individual modification in
body contour surgery: the limited abdominoplasty. Plast
Reconstr Surg 77(5):779783
6. Mast BA, Hurwitz DJ (1996) Mini-abdominoplasty. Oper
Tech Plast Reconstr Surg 3:3841
7. Byun MY, Fine NA, Lee JYY, Mustoe TA (1999) The
clinical outcome of abdominoplasty performed under
conscious sedation: increased use of fentanyl correlated
with longer stay in outpatient unit. Plast Reconstr Surg
103(4):12601266
8. Bitar G, Mullis W, Jacobs W, Matthews D, Beasley M,
Smith K, Watterson P, Getz S, Capizzi P, Eaves F III (2003)
Safety and efficacy of office-based surgery with monitored
anesthesia care/sedation in 4778 consecutive plastic surgery
procedures. Plast Reconstr Surg 111(1):150156
9. Byrd HS, Barton FE, Orenstein HH, Rohrich RJ, Burns AJ,
Hobar PC, Haydon MS (2003) Safety and efficacy in an
accredited outpatient plastic surgery facility: a review of 5316
consecutive cases. Plast Reconstr Surg 112(2):636641
10. Rosenberg MH, Palaia DA, Bonanno PC (2001) Abdom-
inoplasty with procedural sedation and analgesia. Ann Plast
Surg 46(5):485487
11. Abramson DL (1998) Tumescent abdominoplasty: an ambu-
latory office procedure. Aesthetic Plast Surg 22(6):404407
12. Nguyen TT, Kim KA, Young RB (1997) Tumescent mini
abdominoplasty. Ann Plast Surg 38(3):209212
13. Cardenas Restrepo JC, Munoz Ahmed JA (2002) New tech-
nique of plication for miniabdominoplasty. Plast Reconstr
Surg 109(3):11701177
 Ultrasound-Assisted Abdominal
Liposuction
Peter M. Prendergast
55.1 Introduction
Liposuction of the abdomen is one of the most commonly
performed cosmetic surgical procedures worldwide. In
the United States alone, over 200,000 liposuction proce-
dures were performed in 2009 [1]. Since Dujarrier first
described his crude technique of fat removal using a
uterine curette in 1921, the safety and predictability of
lipoplasty techniques have improved dramatically [26].
Some of the landmarks in the evolution of modern lipo-
suction include the early work by Giorgio and Arpad
Fischer, who popularized the use of blunt cannulas for
atraumatic suction-assisted fat removal, and the intro-
duction of the tumescent technique by Klein in 1987
[7, 8]. Although the tumescent technique remains the
gold standard for anesthesia in most internal lipoplasty
techniques, there have been several refinements in the
techniques themselves as well as the technologies and
instruments utilized for fat destruction and aspiration.
These include the development of smaller multi-holed
cannulas for smoother, more-precise results and the
introduction of various assist devices designed to make
it easier on the surgeon, easier on the patient, or both.
Power-assisted lipoplasty employs motor-driven suction
cannulas that gyrate forwards and backwards at high
frequencies to disrupt and remove fat mechanically with
minimal effort. Laser-assisted lipoplasty techniques use
fine Nd:YAG laser-emitting probes to emulsify fat
through photomechanical or thermal destruction, with
or without subsequent aspiration. The concept of using
ultrasound to emulsify fat prior to or during aspiration
P.M. Prendergast
Venus Medical, Dundrum, Dublin 14, Ireland
e-mail: peter@venusmed.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_55, Springer-Verlag Berlin Heidelberg 2013
55
for body contouring is not new [9, 10]. Early experience
using ultrasound-assisted lipoplasty was met with dis-
appointment due to the high rate of complications [11].
The powerful large-diameter (46-mm) probes of the
first-generation devices emulsified fat with ease, but the
trade-off was a high rate of thermal injuries such as
burns and seromas. Second-generation devices featured
hollow ultrasound-emitting 5-mm cannulas that aspi-
rated simultaneously with ultrasound delivery. The
removal of protective wetting solution during delivery
of energy to the tissues probably contributed to the com-
plications seen with this technology. The enthusiasm for
ultrasound-assisted lipoplasty seen in the 1990s quickly
faded, with few advocating the benefits of the technol-
ogy [12]. In 2000, Sound Surgical Technologies LLC
of Louisville, Colorado, introduced a third-generation
ultrasound device for assisted lipoplasty called Vaser, an
acronym for vibration amplification of sound energy
at resonance. This innovative technology supersedes
earlier devices by employing less ultrasound energy
to achieve optimum emulsification of fatty tissues for
small or large areas, reducing collateral damage and
side effects [13]. Following tumescent anesthesia, solid
titanium probes emulsify fat without removing the pro-
tective wetting solution. Gentle suction follows with
specially designed small-diameter cannulas designed to
minimize trauma to vessels, nerves, and the fibrous
tissue matrix [14]. Ultrasound devices for assisted lipo-
suction are summarized in Table 55.1. Since its intro-
duction less than a decade ago, the Vaser technology has
been widely adopted and is the authors method of
choice for lipoplasty of the body and face. This chapter
describes the materials and method of abdominal lipo-
suction using third-generation ultrasound-assisted Vaser
technology.
949
950 P.M. Prendergast

Table 55.1 Technologies used for ultrasound-assisted liposuction

Technique Description Examples
First-generation ultrasound-assisted Powerful ultrasound-emitting solid 46-mm probes applied SMEI, Casales
lipoplasty to emulsify fat before aspiration. High complication rate
(burns, seromas) due to power
Second-generation ultrasound-assisted Powerful ultrasound-emitting hollow 5-mm cannulas with Lysonix, Mentor
lipoplasty simultaneous emulsification and aspiration
Third-generation ultrasound-assisted Less-powerful, grooved solid probes (2.24.5 mm) emulsify fat VASER
lipoplasty efficiently before aspiration

55.2 Technology ultrasound, specially designed VentX suction cannulas

The Vaser console consists of an integrated system
including all the elements required for flow rate-
controlled infiltration of tumescent fluid, tissue-
selective destruction of fat, negative pressure aspiration,
and collection of fat in disposable canisters (Fig. 55.1).
Foot pedals control infiltration and ultrasound deliv-
ery, and dials on the digital display component adjust
flow rate and ultrasound power output. The solid tita-
nium probes used to emulsify fat before aspiration are
small in diameter and contain grooves at the distal ends
in such an arrangement that ultrasound energy is deliv-
ered both from the tip and from the sides (Fig. 55.2).
A three-ringed probe delivers more energy from the
sides of the probe compared to a two- or one-ringed
probe and results in a larger halo of fat destruction
around the tip of the probe as it passes through the fat.
A one-ringed probe, on the other hand, delivers most
of its energy from the tip and is used for more aggres-
sive removal of fibrous fat. In addition to the number
of grooves, probes vary in diameter from 2.2 to 4.5 mm.
For ultrasound-assisted abdominal liposuction, the
3.74.5-mm probes are most useful, depending on
the volume of fat present (Table 55.2). Before use, the
solid titanium probes are gently screwed into the hand-
piece and tightened with a probe wrench with minimal
force (Fig. 55.3). An appropriately sized protective
cover is placed over the hilt of the probe near the hand-
piece. The Vaser system also allows pulsed or continu-
ous delivery of ultrasound energy. Pulsed delivery
(Vaser mode) delivers approximately ten bursts of
energy per second and reduces the absolute energy
delivered to the tissues. This is useful for delicate areas
or superficial sculpting to reduce the incidence of com-
plications such as burns and seromas. Following the
emulsification phase of the lipoplasty procedure with
are introduced for fat removal (Fig. 55.4). VentX
cannulas are designed to minimize trauma to tissues by
balancing the total area of the ports with the cross-
sectional area of the cannula. The port holes on these
cannulas are smaller than those on standard liposuc-
tion cannulas of the same diameter. A small hole in the
handpiece of the suction cannula also facilitates easy
flow of aspirate through the tubing, even when the
cannula is in the patient. This has been termed the
VentX effect [15].
55.3 Preoperative Considerations
The ideal candidate for abdominal liposuction has a
normal body mass index (BMI), good skin tone, protu-
berant areas of exercise- and diet-resistant fat, and no
comorbid illness. Obese patients and those with exten-
sive striae, skin laxity, or aprons of adipose tissue
are not ideal and may benefit more from abdomino-
plasty or combined lipoabdominoplasty procedures.
Similarly, patients with abdominal protrusion second-
ary to abdominal wall weakness or diastasis of the rec-
tus muscles achieve superior results with myofascial
plication. Importantly, patients undergoing liposuc-
tion should have realistic expectations. Demands to
remove all fat should not be entertained. A detailed
explanation of the procedure should be given, including
potential risks and complications, and expected out-
comes should be discussed. It is helpful to explain that
efforts to remove all fat are likely to result in a poor
result, skin irregularities or laxity, and increase the risk
of complications such as hematomas, seromas, and
asymmetry. Once the patient understands the concept
of body contouring, as opposed to simply removing fat,
and has realistic expectations, the likelihood of a suc-
55 Ultrasound-Assisted Abdominal Liposuction
Fig. 55.1 The Vaser
integrated system
cessful outcome is higher. During a detailed history and
physical examination, any factors that influence the
patients suitability or planning for the procedure are
carefully documented. These include drug allergies,
medications that interact with lidocaine, presence of
951
comorbid disease, BMI, presence of scars or abdominal
wall hernias, condition of skin, and the patients expec-
tations. If the patient is suitable and wishes to proceed,
a second preoperative visit is scheduled to conduct rou-
tine preoperative blood tests, measurements for a prop-
952 P.M. Prendergast

Fig. 55.2 The solid titanium probes used for Vaser-assisted lip- The arrow probe (shown here third from the right) is indicated
oplasty. Probes for body contouring vary in diameter from 2.9 to for extremely fibrous tissue (e.g., gynecomastia) and is rarely
4.5 mm and in number of grooves at their distal end from 1 to 3. used for abdominal sculpting

Table 55.2 Authors preferred Vaser probe selection according to volume of fat and density of tissues for abdominal UAL
Density Volume Probe Mode* Energy
Soft Very large 4.5 mm (2 grooves) Continuous 7080%
Soft Mediumlarge 3.7 mm (3 grooves) Continuous 7080%
Soft Small 2.9 mm (3 grooves) or 3.7 mm Continuous or pulsed 7080%
(2 grooves)
Slightly fibrous Mediumlarge 3.7 mm (2 grooves) Continuous 8090%
Slightly fibrous Small 2.9 mm (3 grooves) or 3.7 mm Continuous 8090%
(1 groove)
Very fibrous Mediumlarge 3.7 mm (2 grooves) or 3.7 mm Continuous 8090%
(1 groove)
Very fibrous Small 2.9 mm (3 grooves) Continuous 8090%
*All superficial ultrasound delivery within 1015 mm of the dermis should be performed on pulsed mode

erly fitting postoperative compression garment, and 55.4 Materials

preoperative photographs (Fig. 55.5). The author rou-
tinely prints outpatient photographs before the proce-
dure and creates new contours by drawing on the photos
using marker pens (Fig. 55.6). This exercise helps
the surgeon visualize the final result and decide how
much fat should be taken. More importantly, it helps
determine what should be left behind to achieve aes-
thetically pleasing contours. It also highlights asymme-
tries and the need to sculpt differently on either side.
Consent forms, pre- and postoperative instruction leaf-
lets, and a prescription for preoperative antibiotics and
analgesia are provided to the patient during the preop-
erative work-up.
The tumescent technique is currently the method of
choice for liposuction and ultrasound-assisted liposuc-
tion and obviates the need for general anesthesia or
sedation. As such, the procedure can be performed
safely in the office-based setting, allowing the patient
to return home the same day [16]. For office-based
abdominal liposuction, an essential stock inventory
includes premedications, medications for tumescent
anesthesia, and emergency medications (Table 55.3).
As well as the Vaser system itself, a range of probes,
VentX cannulas, the ultrasonic handpiece and cable,
instruments including scalpel, #11 blade, scissors,
55 Ultrasound-Assisted Abdominal Liposuction 953

a b

c d

Fig. 55.3 Probe connection to the Vaser handpiece before (c) The probe is gently tightened. (d) A protective cover is
use. (a) The solid titanium probe is screwed into the handpiece. screwed into the handpiece to cover the hilt of the probe
(b) The handpiece fits snugly into the supplied probe wrench.

Fig. 55.4 VentX cannula tips

with total area of ports
balanced with cross-sectional
diameter of cannula to reduce
tissue trauma

needle holder, artery forceps, skin ports, and consum-
ables such as needles, syringes, 4-0 skin sutures, sterile
gauze, and drapes are required (Fig. 55.7). Ancillary
materials include a patient monitor, vacuum autoclave,
and warming bath for tumescent solution.
55.5 Tumescent Anesthesia
During tumescent anesthesia, a mixture of physiologic
saline, lidocaine, epinephrine, and sodium bicarbon-
ate is infiltrated into the subcutaneous fatty layer until
954 P.M. Prendergast

a state of tumescence is reached. Tumescence is
characterized by firm, swollen tissue that is turgid and
somewhat fixed. Depending on the desired concentra-
tion of lidocaine in the tumescent solution, each bag is
prepared by adding 5001,000 mg of lidocaine to 1 L
of normal (0.9%) saline and then adding 12.5 mL
8.4% w/v sodium bicarbonate and 1 mg epinephrine.
Each bag should be clearly labeled immediately after
adding each medication (Fig. 55.8). Tumescent solu-
tion has some unique properties that contribute to
its remarkable safety and efficacy in the practice of
liposuction:

a b

c d

Fig. 55.5 Preoperative

patient for abdominal
liposuction, including
the flanks. (a) Left anterior
oblique. (b) Frontal. (c) Right
anterior oblique. (d) Left
lateral. (e) Posterior. (f) Right
lateral
55 Ultrasound-Assisted Abdominal Liposuction 955

Fig. 55.5 (continued)

e f

a b c

Fig. 55.6 Contouring plan for abdominal liposculpture. The preoperative photographs are printed so that markings can be made to
determine where and how much fat should be removed. (a) Frontal. (b) Left lateral. (c) Posterior

1. The dilution of lidocaine with saline to concentrations
of 0.050.1% and dispersion in fatty tissue alter the
pharmacokinetics entirely. The maximum safe dose
of lidocaine with epinephrine increases from 7 to
55 mg/kg [17].
2. Epinephrine has a dual role. It causes vasoconstric-
tion in the subcutaneous fat, creating an almost
bloodless field and reduces blood loss to less than
1% of liposuction aspirate. The vasoconstriction
also slows systemic absorption of lidocaine so that
956 P.M. Prendergast

Table 55.3 Inventory of essential stock medications for 55.6 Technique

office-based liposuction
Premedications 55.6.1 Marking
Cephalexin 500 mg
Ciprofloxacin 500 mg (penicillin-allergic patients) With the patient standing, markings are made first on
Lorazepam 1 mg the anterior abdomen using Sharpie fine permanent
Solpadol (paracetamol + codeine)
skin markers. The author uses different colors to map
Tumescent anesthesia
out the areas to be contoured, bony landmarks, areas
Physiologic 0.9% saline 1-L bottles
of caution, scars, and proposed incision sites (Fig. 55.9).
Lidocaine 2% plain
8.4% w/v sodium bicarbonate
Concentric rings represent prominences of fat to be
Epinephrine 1-mg ampules sculpted. Straight lines that radiate from these are areas
Emergency medications for less aggressive debulking or feathering. In practice,
Oxygen almost the entire abdomen and flanks should be sculpted
Salbutamol (inhaler/nebulizer) as one aesthetic unit rather than treating only localized
Atropine 1-mg ampules pockets of fat. The flanks should be marked by outlin-
Clonidine 0.1-mg tablets ing areas where fat interferes with the natural curve or
Hydrocortisone 100-mg ampules contour from the back to the hips. Two incisions are
Chlorpheniramine 10-mg ampules usually made close to the midline of the back and at the
upper outer buttock.
Superficial lipoplasty is required for slimmer
serum levels of lidocaine rise slowly and peak only patients who seek an athletic look. In these cases, mark-
414 h after infiltration [17]. ings should outline soft tissue landmarks such as the
3. Tumescent local anesthesia allows liposculpture linea alba, border of rectus abdominis (linea semiluna-
to be performed in the awake patient, eliminat- ris), and inguinal fold (Fig. 55.10). In males, the fleshy
ing the risks of intravenous sedation and general outline of external oblique and horizontal tendinous
anesthesia. intersections of rectus abdominis are marked.

Fig. 55.7 Materials for ultrasound-assisted liposuction using Vaser technology

55 Ultrasound-Assisted Abdominal Liposuction
Fig. 55.8 One-liter bags of tumescent solution containing normal saline, lidocaine, sodium bicarbonate, and epinephrine. The bags
should be clearly labeled immediately after preparation
55.6.2 Positioning and Draping
Superabsorbent drapes are placed on the operating
table to reduce pooling of tumescent fluid under the
patient during infiltration. These are covered with ster-
ile towels (Fig. 55.11). The patient is placed in the
supine position initially to contour the anterior aspect
of the abdomen. The hands are positioned behind the
patients head in order to expose the flanks so that
feathering can be performed from the anterior lower
and upper incisions (Fig. 55.12). The skin is prepared
with a chlorhexidine wash, and sterile surgical drapes
isolate the anterior abdomen. Sterile paper towels,
rather than drapes, are used for the sides to allow fluid
to soak through to the superabsorbent drapes under-
neath rather than run over the drapes onto the floor.
Once the front is completed, the patient turns to the
prone position for skin preparation of the back and
flanks, and new drapes are used to isolate the treatment
area (Fig. 55.13).
957
55.6.3 Inltration
Up to 3 L of tumescent fluid may be required for ultra-
sound-assisted liposuction of the abdomen and flanks.
As such, warming the fluid to 3740C prior to
infiltration may prevent hypothermia and reduce pain
[18]. Warmed solution does not reduce the ability of
epinephrine to cause the profound vasoconstriction nec-
essary for a relatively bloodless fat compartment.
Thorough infiltration of deep and superficial layers
of the entire anterior abdomen is performed through
inferior and superior incisions using a small-diameter
(17-gauge) blunt infiltration cannula (Fig. 55.14). A
homogenous fluid-filled fat compartment is essential to
transmit sound energy during UAL and prevent thermal
injuries to the skin or within the tissues. The author
commences tumescent infiltration in the deep layer of
fat above the deep fascia using slow, deliberate strokes,
while the other hand palpates the tissue externally,
always aware of the location of the tip of the cannula.
958 P.M. Prendergast

Fig. 55.9 Preoperative

marking. (a) Female patient
a
with multiple scars from
previous abdominal surgeries.
Red marker indicates areas
where liposculpture should be
cautious or avoided. (b) Male
patient. Note plan to feather
lipoplasty to flanks from the
anterior abdomen. Green
marker indicates proposed
incision sites

A moderate infusion rate of 200 mL/min is sufficient
but may be reduced to 150 mL/min in tough fibrous
areas such as the upper abdomen to reduce discomfort.
Once the tissues swell and become firm, the cannula can
be brought to the sensitive superficial tissue close to the
dermis. Superficial infiltration should produce a dim-
pled, peau dorange appearance in the overlying skin
(Fig. 55.15). This improves tumescence, fixes the tis-
sues somewhat, and provides a fluid medium for more
delicate, superficial work close to the dermis. Once
tumescence is achieved in the entire anterior abdomen,
skin ports are sutured into the incisions using a 4-0
suture to stem the flow of tumescent fluid and prepare
for Vaser-assisted lipoplasty (Fig. 55.16). It is necessary
to wait 2530 min following the end of infiltration
before continuing to allow complete diffusion of the
tumescent fluid to all compartments within the subcuta-
neous tissues, including the intralobular compartments
around the adipocytes. Since tumescence is a temporary
state, a top-up immediately prior to emulsification of fat
might be required to reestablish the firmness and turgid-
ity that stabilizes the tissues [19].
55.6.4 Emulsication
Once 30 min have elapsed since the end of infiltra-
tion, anesthesia, vasoconstriction, and tumescence are
usually sufficient to commence delivery of ultrasound.
A blunt instrument is used to ensure the port tip is
55 Ultrasound-Assisted Abdominal Liposuction
Fig. 55.10 For superficial ultrasound-assisted liposuction in
slim patients, soft tissue landmarks such as the linea alba and
linea semilunaris are marked. A concavity in the epigastrium is
also desirable for an athletic appearance
a b
Fig. 55.11 (a) Superabsorbent drapes placed under the patient prevent pooling of tumescent fluid. (b) The absorbent drapes are
covered with sterile disposable towels
959
under the dermis with a patent channel for the Vaser
probes between the port entry and target plane
(Fig. 55.17). An appropriately sized and grooved Vaser
probe is selected depending on the volume of fat
present and whether the tissues are soft or fibrous
(Table 55.2). When there is minimal resistance during
infiltration of tumescent fluid during the initial step,
the author starts with the 3.7-mm three-grooved probe
in the lower abdomen using 80% energy in continuous
mode. When the tissues feel tough and fibrous, the 3.7-
mm two-grooved probe is selected using 8090%
energy. Before the probe is inserted, a wet towel, folded
twice, is placed around the port to avoid inadver-
tent thermal injury should the probe come in contact
with the skin (Fig. 55.18). Gentle but deliberate, long
to-and-fro strokes are made with the operating hand
like the bow movements of a cellist (Fig. 55.19).
Movements should be graceful and continuous with no
torquing which could conduct excessive heat through
the skin port and result in a burn. Some resistance is
felt as the probe gently creates tunnels through the fat,
but it should not stop the probe in its path or require
grasping and pushing of the probe with the operating
960
Fig. 55.12 Patient in supine position with hands behind head
for lipoplasty of the anterior and anterolateral abdomen
Fig. 55.13 Patient in prone position for treatment of the flanks
hand. If excessive resistance is encountered, energy is
increased to 90%, or an alternative probe is selected.
The probe should course at an even depth throughout
P.M. Prendergast
its course, taking care not to tether the dermis by
coming superficial at one point (Fig. 55.20). Once
there is little or no resistance in the deep fat layer, the
probe is brought more superficially for further con-
touring, leaving at least 1 cm of superficial fat to
support the dermis and preserve the delicate subder-
mal vascular plexus (Fig. 55.21). The 4.5-mm probe
and three-grooved 3.7-mm probes, designed for deb-
ulking, should be avoided in the superficial layer.
Similarly, pulsed (Vaser mode) delivery is preferred in
the superficial tissues using lower energies (6070%).
Ultrasound delivery continues from each of the ports
until the entire anterior abdomen is treated. As treat-
ment continues, emulsified fat usually pours from the
skin ports (Fig. 55.22). The endpoint is loss of resis-
tance throughout the treatment planes. This usually
requires 6070 s of ultrasound delivery/100 mL of
tumescent fluid infiltrated. If it is found that access is
difficult during the procedure without levering the
probes, no hesitation should be made to place extra
incisions to ensure a complete treatment. As well as
emulsifying fat in the ipsilateral side, the probes are
long enough to pass to the contralateral side, and this
crisscrossing maneuver is important for smooth, even
results. As well as emulsifying all marked areas to a
point of minimal or no resistance, feathering should be
done by emulsifying to a lesser degree in border areas
to create smooth transitions between contours.
55.6.5 Aspiration
Once emulsification is complete, skin ports are removed
and an appropriately sized aspiration cannula is inserted.
The author uses the 3.7-mm VentX cannula for initial
debulking followed by the 3.0-mm cannula for further
refinements and superficial aspiration. The operating
hand moves forwards and backwards radially like the
spokes of a wheel with a continuous graceful move-
ment. Excessive force should not be required. The non-
dominant hand stabilizes the tissues over the cannula
and feels for the tip so that it stays in the correct plane
(Fig. 55.23). The pinch test is performed intermit-
tently to determine how much superficial fat remains
(Fig. 55.24). Unless skin quality is poor, the use of
Vaser with superficial liposuction allows redraping of
skin and results in excellent skin retraction (Fig. 55.25).
The endpoint is reached when the desired amount of
55 Ultrasound-Assisted Abdominal Liposuction 961

a b

c d

e f

Fig. 55.14 Tumescent infiltration of the abdomen. (ae) The
cannula passes radially around the entire abdomen through
the lower and upper incisions. The nondominant hand can be
used to grasp the tissue over the costal margin or push the ribs
down when passing over the ribs to reach the tough fibrous fat
of the upper abdomen. (f) Infiltration of the flanks also begins
from the lower incisions with the patient supine. (g) The area
above the umbilicus is approached from the upper two incisions,
ensuring to infiltrate thoroughly right up to the dermis around
the umbilicus. (h) As infiltration proceeds in every plane, the
tissues become firm and rigid and the overlying skin begins to
blanch due to vasoconstriction. (i) The flow rate can be reduced
to 150 mL/min for the fibrous upper abdominal region

debulking and improvement in body contour has been drainage of tumescent anesthetic fluid, resolution of
achieved based on the pinch test and careful inspection edema, systemic clearance of disrupted fat cells that
from different vantage points in the operating room. remain in the tissues, and skin retraction all contribute
A little under correction is appropriate, since further to improved results during the postoperative period.
962 P.M. Prendergast

g h

Fig. 55.14 (continued)

Fig. 55.15 Infiltration of the flanks with tumescent fluid. As Fig. 55.16 Skin ports are sutured into the incisions to stem the
the superficial tissues are infiltrated, the skin develops a peau flow of tumescent fluid and prepare for the insertion of the ultra-
dorange appearance sound probes
55 Ultrasound-Assisted Abdominal Liposuction
Fig. 55.17 A blunt probe is inserted to ensure the port is patent
and create an initial channel so the probe can glide easily into the
correct plane
Although results following Vaser of the abdomen can
be appreciated as soon as 12 weeks following surgery
(Figs. 55.2655.28), the final result with complete skin
retraction in the abdomen takes 46 months.
55.6.6 Postoperative Care
When all areas are treated, the abdomen and flanks are
massaged or milked towards the incision sites to
expel pools of residual tumescent fluid. Sterile dress-
ings are applied to the incisions that are left open to
drain. A tightly fitting compression garment is applied,
without foam, to keep the surface smooth, help skin
retraction, reduce edema, and provide comfort for
the patient. This is worn for 2 weeks day and night,
followed by another 2 weeks during the daytime only.
Antibiotics are continued for 5 days, and analgesia
is taken as required. When tenderness has subsided,
usually 12 weeks following the procedure, a course
of manual lymphatic drainage or Endermologie
helps soften tissues and reduce edema.
963
Fig. 55.18 A wet towel is folded and placed around the port to
protect the skin from the shaft of the ultrasound probe
55.7 Discussion
The introduction of vibration amplification of sound
energy at resonance (Vaser) technology has brought a
resurgence in UAL for body contouring. Improved
probe design and energy efficiency with Vaser allow a
significant reduction in power delivery to the tissues
[20]. Although the learning curve is short and the
safety record of Vaser is excellent, specific training in
the use of internal ultrasound for lipoplasty and the
technology itself is essential. Workshops and certifica-
tion programs in the use of Vaser are available for plas-
tic surgeons, dermatologists, and for other specialists
who wish to incorporate body contouring procedures
into their hospital or office-based setting [21]. Although
the extra step required for ultrasound-assisted abdomi-
nal liposuction adds to the operating time, in the
authors view, this is irrelevant given the benefits
gained. These include more precise contouring, ease of
use in fibrous tissues, the ability to work superficially,
greater skin retraction, and a quick and uncomplicated
postoperative recovery.
964 P.M. Prendergast

a b

c d

e f

g h

Fig. 55.19 Vaser emulsification of fat. (ad) Extent of treat- lower incisions. Note the finger placed in the umbilicus to feel
ment over abdomen from one incision. (eh) The probe passes for the probe tip as it emulsifies fat circumferentially around it
forwards and backwards in the deep fat first through upper and
55 Ultrasound-Assisted Abdominal Liposuction 965

Fig. 55.20 The Vaser probe has tethered the dermis by coming Fig. 55.22 Emulsified fat pours from the skin ports during
superficial or catching fibrous septae. The probe should be with- ultrasound delivery to the tissues
drawn completely to release the irregularity and replaced at the
correct depth

b
Fig. 55.23 Aspiration phase. The skin ports are removed and
the VentX cannula is inserted to remove the emulsified fat. The
nonoperating hand stabilizes the tissues over the cannula tip as it
passes forwards and backwards with minimal effort

Fig. 55.21 (a) Superficial use of Vaser in the abdomen and

(b) flank. The shape of the probe is visible through the skin.
Energy delivery should be reduced, and pulsed mode only should
be used in the superficial layers to avoid thermal injuries
966 P.M. Prendergast

a b

c d

Fig. 55.24 (a-d) The pinch test is performed intermittently during aspiration to check the amount of subcutaneous fat remaining.
Thickness should be the same throughout the abdomen to get even results without asymmetries or irregularities

Fig. 55.25 Superficial liposuction is possible in patients with

normal skin tone and allows more refined sculpting with good
postoperative skin redraping and retraction
55 Ultrasound-Assisted Abdominal Liposuction 967

a b

Fig. 55.26 (a) Preoperative. (b) Two weeks following abdominal UAL with Vaser under local anesthesia in a male patient. Contours
have improved despite residual postoperative edema

a b

Fig. 55.27 (a) Preoperative. (b) Seven days after UAL. Results continue to improve for up to 4 months following the procedure
968
a b
Fig. 55.28 (a) Preoperative. (b) Eleven days following UAL with Vaser in a female patient. Skin retraction is usual following
ultrasound delivery to the superficial tissues
References
1. The American Society for Aesthetic Plastic Surgery: cos-
metic surgery national databank statistics 2009. ASAPS
website www.surgery.org (accessed in 2011)
2. Flynn TC, Coleman WP III, Field LM, Klein JA, Hanke CW
(2000) History of liposuction. Dermatol Surg 26(6):
515520
3. Coldiron BM, Healy C, Bene NI (2008) Office surgery inci-
dents: what seven years of Florida data show us. Dermatol
Surg 34(3):285291
4. Housman TS, Lawrence N, Mellen BG, George MN, Filippo
JS, Cerveny KA, DeMarco M, Feldman SR, Fleischer AB
(2002) The safety of liposuction: results of a national survey.
Dermatol Surg 28(11):971978
5. Coleman WP III, Hanke CW, Lillis P, Bernstein G, Narins R
(1999) Does the location of the surgery or the specialty of
the physician affect malpractice claims in liposuction?
Dermatol Surg 25(5):343347
6. Hanke CW, Lee MW, Bernstein G (1990) The safety of der-
matologic liposuction surgery. Dermatol Clin 8(3):563568
7. Fischer A, Fischer G (1976) First surgical treatment for
molding bodys cellulite with three 5 mm incisions. Bull Int
Acad Cosm Surg 3:3537
8. Klein JA (1987) The tumescent technique for liposuction
surgery. Am J Cosm Surg 4:236267
9. Grippaudo F, Matarese M, Macone A, Mazzocchi M,
Scuderi N (2000) Effects of traditional and ultrasonic
P.M. Prendergast
liposuction on adipose tissue: a biochemical approach. Plast
Reconstr Surg 106(1):197199
10. Zocchi ML (1999) Basic physics for ultrasound-assisted
lipoplasty. Clin Plast Surg 26(2):209220
11. Grolleau JL, Rouge D, Chavoin JP, Costagliola M (1997)
Severe cutaneous necrosis after ultrasound lipolysis: medicole-
gal aspects and review. Ann Chir Plast Esthet 42(1):3136
12. Fodor PB (2004) Personal experience with ultrasound-
assisted lipoplasty: a pilot study comparing ultrasound-
assisted lipoplasty with traditional lipoplasty. Plast Reconstr
Surg 113(6):18521854
13. De Souza Pinto EB, Abdala PC, Maciel CM, dos Santos
F de P, de Souza RP (2006) Liposuction and VASER. Clin
Plast Surg 33(1):107115
14. Garcia O Jr, Nathan N (2008) Comparative analysis of
blood loss in suction-assisted lipoplasty and third-generation
internal ultrasound-assisted lipoplasty. Aesthet Surg J 28(4):
430435
15. Cimino WW (2006) VASER-assisted lipoplasty: technology
and technique. In: Shiffman MA, Di Giuseppe A (eds) Lipo-
suction principles and practice. Springer, Berlin, pp 239244
16. Prendergast PM (2010) Liposculpture of the abdomen in an
office-based practice. In: Shiffman MA, Di Giuseppe A
(eds) Body contouring: art, science, and clinical practice.
Springer, Berlin, pp 219237
17. Ostad A, Kageyama N, Moy RL (1996) Tumescent anesthe-
sia with a lidocaine dose of 55 mg/kg is safe for liposuction.
Dermatol Surg 22(11):921927
55 Ultrasound-Assisted Abdominal Liposuction
18. Yang CH, Hsu HC, Shen SC, Juan WH, Hong HS, Chen CH
(2006) Warm and neutral tumescent anesthetic solutions are
essential factors for a less painful injection. Dermatol Surg
32(9):11191122
19. Sattler G, Sattler S (2007) Physiodynamic concept of tumes-
cence. In: Hanke CW, Sattler G, Sommer B (eds) Textbook of
liposuction. Informa Healthcare, Boca Raton, Florida, p 43, 5
969
20. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA
(2002) Clinical application of VASER-assisted lipoplasty: a
pilot clinical study. Aesthet Surg J 22(2):131146
21. Master course in VASER liposculpture: European College of
Aesthetic Medicine (ECAM). Website www.ecamedicine.com
(accessed in 2011)
 Part VI
Extremities and Buttocks
 Brachioplasty
Sumeet N. Makhijani, Alain Polynice,
Jerome D. Chao, and James G. Hoehn
56.1 Introduction
Even to this day, brachioplasty continues to be a
cosmetic challenge to the plastic surgeon. A compro-
mise must often be made between the presence of
unsightly scars and the aesthetic desires of the patient.
Nonetheless, secondary to the greater number of
massive weight loss patients and the popularity of the
procedure, the number of brachioplasties performed
has increased every year since 2000 [1].
S.N. Makhijani (*)
Division of Plastic Surgery, Department of Sugery,
Bassett Medical Center, Cooperstown, NY, USA
e-mail: sumeet.makhijani@bassett.org
A. Polynice
Private practice, Williams Center Plastic surgery Specialists,
Latham, NY, USA
e-mail: apolynice@yahoo.com
J.D. Chao
Private practice, Certified Plastic Surgery of New York, PLLC,
Latham, NY, USA
e-mail: drchao@certifiedplasticsurgery.com
J.G. Hoehn
Division of Plastic Surgery, MC-61, Albany Medical College,
Albany, NY, USA
e-mail: hoehnj@mail.amc.edu
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_56, Springer-Verlag Berlin Heidelberg 2013
56
The first aesthetic brachioplasty was described in 1954
by Correa-Iturraspe and Fernandez [2]. However, numer-
ous other techniques have been presented over the last
50 years in order to produce a more optimal result. Famous
surgeons such as Pitanguy and Lockwood have each
advanced our understanding of the ideal shape and con-
tour of the upper extremity, the placement of scars, and the
ability to achieve long-lasting results. In addition, the iso-
lated or concomitant use of liposuction has also been an
important adjunct in the brachioplasty procedure.
This atlas chapter on brachioplasty illustrates our
technique for producing an aesthetically pleasing
result. The following pictures are taken in the pre-,
intra-, and postoperative settings with associated figure
legends describing the key points of each step of the
procedure. It has been our experience that attention to
these important details and a focus on a stepwise and
reproducible method will lead to consistently excellent
results and a satisfied patient.
56.2 Technique
The preoperative sequence is described in
Figs. 56.156.12.
The operative sequence is described in
Figs. 56.1356.21.
Postoperative results are in Fig. 56.22.
973
974
Fig. 56.1 Standard anterior preoperative photograph of patient.
The patient is in standing position with arm positioned at 90 of
elbow flexion. Notice the lipodystrophy of the arm, most notably
along the inferior aspect
Fig. 56.2 Use of the pinch test to determine the amount of
excess tissue to be resected
S. Makhijani et al.
Fig. 56.4 The patient is asked to contract his or her bicep, and
the bicipital groove is marked
Fig. 56.5 The mark placed at the bicipital groove is then placed
underneath the index finger, and traction is applied inferiorly on
the skin. A second mark is placed one fingerbreath above the
mark identifying the bicipital groove. This mark is above the
surgeons middle finger in the figure and will serve as the supe-
rior line of resection
Fig. 56.3 Marking performed along the anterior-inferior aspect
of the arm. A similarly placed line is positioned posteriorly
inferiorly. This area will be liposuctioned. Care is taken to
not liposuction too aggressively as this may lead to contour
irregularities
56 Brachioplasty 975

Fig. 56.6 The pinch test is again used to determine the b

amount of tissue to be resected based on the marks. It is critical
to not pinch too tight as this may lead to vertical bands upon
closure

Fig. 56.9 (a) The marks are connected. A line is drawn from
the medial epicondyle to the line above the bicipital groove mark
to the anterior axillary mark. (b) Note the fishtail marking
approaching the anterior axillary line. A vertical line is drawn
within the axilla that continues inferiorly to connect with the
posterior mark as determined by the pinch test
Fig. 56.7 The medial epicondyle of the arm is identified by
palpation and marked

Fig. 56.8 With the arm in standard position and the shoulder
rotated a few degrees anteriorly, a mark is placed inside the ante-
rior axillary fold. This will serve as the superior point of the
axillary incision. By locating this point inside the anterior axil-
lary fold, the axillary scar will be well hidden by the fold
976 S. Makhijani et al.

Fig. 56.10 The pinch test is again performed between the b

anterior and posterior lines to verify that a vertical band is not
created, and the appropriate amount of tissue is in the planned
resection

Fig. 56.12 (a) Measurement taken of the width of the area to be

excised on the right arm. (b) Symmetrical measurement taken of
the width of the left arm

Fig. 56.11 Final preoperative markings. Note the circular area

marked on the distal arm adjacent to the medial epicondyle that
denotes an area to be liposuctioned. A similar-sized area is
marked on the posterior upper arm

Fig. 56.13 Intraoperative photograph of the right arm. Note the

preoperative markings as well as the sterile drape utilized
56 Brachioplasty 977

a b

Fig. 56.14 (a) An incision is made near the medial epicondyle as well as on the posterior arm. (b) Infiltration of standard tumescent
solution is carried out, with approximately 500 mL per arm. (c) Completed infiltration
978 S. Makhijani et al.

Fig. 56.16 After liposuction has been completed

Fig. 56.15 (a) Liposuction is performed on the anterior upper

arm. A 3- or 4-mm cannula is used. (b) Liposuction is performed
on the posterior and inferior upper arm b

Fig. 56.17 (a) Adair clamps or sharp atraumatic clamps are

placed along the anticipated lines of resection. By doing so, the
surgeon can verify the lack of vertical bands across the arm.
(b) Note the smooth contour of the arm
56 Brachioplasty 979

Fig. 56.18 Incisions are made utilizing the previously described Fig. 56.20 Closure of the superficial fascial system (SFS) is
marks. Electrocautery is used to excise the outlined area. Care is performed using 2-0 Vicryl in a simple buried interrupted
taken to stay above the muscle fascia, thus preserving the neuro- fashion
vascular and lymphatic structures of the arm

Fig. 56.21 Final result after closure of the SFS. Note the
absence of vertical banding which has been resolved by redistri-
b bution of the closure tension. The skin can be closed in a multi-
tude of ways, but the authors approach is closure with 3-0 PDS
suture in a simple buried interrupted fashion followed by the
application of Steri-strips. A light compression dressing is then
applied from elbow to axilla

Fig. 56.19 (a) Sequential reclamping of the incision utilizing

Adair clamps preliminarily closes the area of excision. Failure to
do so in a timely manner could result in intraoperative swelling
resulting in a closure with tension. (b) Note the tendency of vertical
banding to occur. This banding will be resolved upon closure of
the incision
980 S. Makhijani et al.

Fig. 56.22 Postoperative views (a) Post-operative up close anterior views. (b) Post-operative up close posterior views. (c) Post-operative
anterior and posterior views of bilateral arms

References plastic-surgery-minimally-invasive-statistics.pdf. Accessed 8

Apr 2009
2. Correa-Iturraspe M, Fernandez JC (1954) Dermolipectomia
1. American Society of Plastic Surgeons. 2000/2007/2008
braquial. Prensa Med Argent 41(34):24322434
National Plastic Surgery Statistics. Available at http://www.
plasticsurgery.org/Media/stats/2008-cosmetic-reconstructive-
 Circumferential Para-Axillary
Supercial Tumescent (CAST)
Liposuction for Upper Arm
Contouring
Andrew T. Lyos
57.1 Introduction
Today, preoccupation with fitness has made muscular
definition in the female a sought after goal [13].
Well-proportioned arms and upper back with muscular
development are the goal of todays physically fit
women and prominently featured in todays fashion
[46]. The increase in bariatric surgery for the morbidly
obese has added to the group interested in aesthetic
improvement of their arms. Rejuvenation of the upper
arms continues to provide a challenge to both the sur-
geon and patient. Aging of the upper arm is extremely
variable and depends on numerous factors, the most
important of which appears to be genetics, the consis-
tency of upper body-toning exercises, obesity and the
variations of weight throughout life. The net result is
an unaesthetic appearance with skin laxity and lip-
odystrophy of various degrees with the most severe
form frequently designated the bat-wing deformity.
Traditional liposuction of the upper arms has failed
to meet the expectations of our patients. Commonly
reported undesired sequelae of liposuction of the arms
include worsening of skin laxity and wrinkling, central
over-ressection on the inferior brachial border, and the
lack of regional harmony [79]. Brachioplasty proce-
dures improve contour but are frequently unacceptable
to our patients due to the undesired sequelae of wid-
ened, misplaced or hypertrophic scars, contour irregu-
larities, numbness, and skin necrosis [1016]. CAST
A.T. Lyos
Division of Plastic Surgery and the Bobby R. Alford
Department of Otorhinolaryngology and Communicative
Sciences, Baylor College of Medicine, Houston, TX, USA
e-mail: info@lyosmd.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_57, Springer-Verlag Berlin Heidelberg 2013
57
liposuction alone or with minibrachioplasty has offered
a reliable technique for arm contouring which maxi-
mizes retraction of the skin [46].
57.2 Technique
57.2.1 Patient Classication
Patients are classified according to the scheme proposed
by Teimourian et al. (Table 57.1, Fig. 57.1) [17].
Category 1: Minimal to Moderate Subcutaneous
Fat with Minimal Skin Laxity: Patients generally have
circumferential increase in fat volume but adequate
skin tone and elasticity. These patients do well with
circumferential liposuction of the arm and para-axillary
area. Relatively small amounts of fat are removed.
Ultrasonic-assisted liposuction is not required.
Category 2: Generalized Accumulation of Sub-
cutaneous Fat with Moderate Skin Laxity: Patients
generally have an increased volume of fatty tissue cir-
cumferentially as well as noticeable loss of skin elastic-
ity with ptosis. Circumferential liposuction encourages
skin tightening. Minibrachioplasty may be required.
Ultrasonic energy can encourage enhanced skin retrac-
tion frequently reducing the need for skin excision.
Table 57.1 Upper arm contouring classification
Category 1 Minimal arm fat with good skin
tone
Category 2 Moderate fat with moderate skin
laxity
Category 3 Marked excess skin and fat
Category 4 Minimal to moderate fat and
marked excess skin
981
982 A.T. Lyos

a b

c d

Fig. 57.1 Upper arm contouring categories: (a) Category 1, (b) Category 2, (c) Category 3, (d) Category 4

Category 3: Generalized Obesity and Extensive
Skin laxity: Patients generally have more significant
lipodystrophy and skin laxity. Obese patients typically
accumulate a large volume of fat in the para-axillary
region and upper arm. Ultrasonic-assisted circum-
ferential liposuction maximizes the potential for ade-
quate skin retraction. Minibrachioplasty confided to
the axilla is frequently required for group 3 individu-
als. The larger the volume of fat removal, the better the
prognosis for skin retraction with CAST liposuction
and the shorter the brachioplasty scar if required.
Category 4: Minimal Subcutaneous Fat and Exten-
sive Skin Laxity: These individuals demonstrate marked
skin laxity and depletion of subcutaneous fat. Full bra-
chioplasty is capable of producing an aesthetically
pleasing contour of the arm and straight inferior bra-
chial boarder. The surgical scars can be detouring, par-
ticularly in those individuals who have Fitzpatrick
IIIVI skin type and those who scar poorly. CAST
liposuction combined with a minibrachioplasty con-
fined to the axillae can produce improvement of the
upper arm with some residual skin laxity, particularly
distally. As noted, the larger the volume of fat removed,
the greater is the potential for skin retraction, thereby
reducing the length of the brachioplasty scar.
57.2.2 Preoperative Marking
The upper extremity can be conceptualized as consisting
of nine zones (Fig. 57.2). Distal forearm, upper back,
deltoid, axilla, and lateral pectoral extensions are
included for regional harmony. Patients requesting arm
reduction were marked in the preoperative area in stand-
ing position. The arms were marked in abducted posi-
tion with 90 flexion at the elbow. Preoperative markings
divide the arm and contiguous para-axillary regions
into nine zones (Fig. 57.3). For individuals with exces-
sive skin laxity in addition to lipodystrophy, a minibra-
chioplasty is designed. Puncture site is marked at the
anterior and posterior axilla, medial and lateral distal
arm 1.5 cm proximal to the olecranon. Infrequently, a
puncture site is marked in the middle third of the poste-
rolateral arm. Preoperative marks were checked with
the arms in adducted relaxed position to ensure appro-
priate placement for minimal deductibility.
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring
a a
Fig. 57.2 Right arm para-axillary area with nine anatomical
zones: (a) Anterior. (b) Posterior
57.2.3 Anesthesia
CAST liposuction of the arms may be performed under
local or general anesthesia. It is the authors preference
to treat the arms under general anesthesia while per-
forming liposuction of multiple areas. Superwet or
tumescent anesthesia is utilized for hemostasis, com-
partment magnification, and postoperative analgesia
[18, 19]. A greater volume of infiltration is utilized to
minimize the thermal effect if ultrasonic-assisted lipo-
suction (UAL) is required [20]. For procedures per-
formed under general anesthesia, to each 3 L of lactated
ringers are added 50 mL of 1% lidocaine (500 mg) and
3 mL of 1:1,000 epinephrine. For procedures performed
under local anesthesia, the concentration of lidocaine
983
Fig. 57.3 Preoperative marking anterior and posterior left arm:
(a) Anterior. (b) Posterior
may be increase by the addition of 150 mL of 1%
lidocaine (1,500 mg) and 3 mL of 1:1,000 epinephrine.
The surgeon must be aware of the dose of lidocaine
being administer and keep the total lidocaine dose well
below 35 mg/kg [18, 2123]. The volume of infiltrate is
typically 8001,500 mL per arm.
57.2.4 Position
Arm contouring in the lateral decubitus position is
preferred. Although arm contouring can be performed
in the prone and supine position, access to the para-
axillary region is limited. The lateral decubitus posi-
tion allows for circumferential treatment.
57.2.5 Surgical Technique
Arm contouring is most frequently performed as part of
total body contouring. When done so, the procedure is
performed in an AAAA certified surgery center with
the assistance of a board-certified anesthesiologist. The
patient is prepped in standing position to the level of the
axilla. She is then placed on the operative table on a bean
bag in supine position. After achieving adequate general
endotracheal anesthesia, she is draped in a sterile fashion.
984 A.T. Lyos

a The patient is turned to the lateral decubitus position,

b arms to allow additional time for vasoconstriction.
Fig. 57.4 Position of the upper arm. (a) Preoperation.
(b) Positioning and draping
and an axillary roll is placed. The arm and upper fore-
arm are prepped with Betadine and wrapped in a sterile
towel from the elbow down, covering IV tubing and
anesthesia-monitoring devices (Fig. 57.4). The arm is
then place on a mayo stand padded with a pillow and
covered with a sterile towel. The arm is freely mobile,
offering the advantage of access to all incision sites. The
incisions are made with an 11 blade. Tumescent fluid is
infiltrated under pressure to achieve a peau dorange
appearance. In the lateral decubitus position, typically,
the back, hips, thighs, and buttocks are treated before the
The arm is conceptually divided into three regions
anteromedial, anterolateral, and posterolateral (Fig. 57.5).
CAST liposuction of the arms is site specific with pre-
tunneling and/or deep liposuction, superficial, or all-layer
liposuction. Circumferential pre-tunneling is performed
with a 3-mm Mercedes cannula through multiple access
sites. Ultrasonic-assisted liposuction (UAL), when uti-
lized, is performed with a Mentor Contour Genesis
(Mentor Corp., Dallas, TX) utilizing a 20-mm solid-tip
cannula with a generator setting of 75. Treatment is
limited to 23 min for the posterolateral and para-axillary
region utilizing the posterior axillary incision.

Anterolateral

Anteromedial

Fig. 57.5 Cross section Posterolateral

of the left arm demonstrating
three anatomical regions:
medial, anterolateral, and
posterolateral
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring 985

a a

b b

Fig. 57.6 CAST liposuction of the anteromedial upper arm Fig. 57.7 CAST liposuction of the anterolateral upper arm
through (a) anterior axillary incision and (b) distal incision through (a) anterior axillary incision and (b) distal ulnar incision

Circumferential liposuction is performed most aggres- 57.2.5.3 Posterolateral

sively in the posterolateral (one-third), less aggressively
in the anterolateral (one-third), and least aggressively in
the anteromedial (one-third).
57.2.5.1 Anteromedial
Pre-tunneling is performed from the olecranon and
axillary sites longitudinally (Fig. 57.6). If the pinch
test is 10 mm or less, only pre-tunneling is done. No
liposuction is performed under thin, anteromedial skin
due to the propensity for wrinkling, especially near the
axilla. Cross tunneling and/or deep suctioning is per-
formed from the middle third of the arm to create a
final pinch test of 1015 mm.
57.2.5.2 Anterolateral
Superficial liposuction from the anterior axillary site,
dorsoradial arm, and mid arm is performed with a
3 20-mm Mercedes cannula (Fig. 57.7). The final
pinch test should be 914 mm.
Ultrasonic energy is delivered through the posterior
axillary incision as described. All-layer liposuction is
performed with deep, superficial, and subdermal lipo-
suction frequently required (Fig. 57.8). A 3 20-mm
Mercedes cannula is used initially. For larger volume
extractions, a 4 30-mm cannula enables access to the
entire length of the posterolateral compartment. Avoid
over-ressection of the central region (zones 2 and 3) by
checking the pinch test frequently.
57.2.5.4 Para-Axillary
Ultrasonic-assisted liposuction is particularly useful
for the deltoid region, and upper back (zones 7 and 8).
No ultrasonic energy is delivered to the axilla proper
(zone 6). The fat is evacuated with 3- and 4-mm
Mercedes cannulas (Fig. 57.9). More aggressive lipo-
suction is performed with a 3-mm Gasperotti to encour-
age the formation of a confluent layer of collagen
forming circumferentially around the arm connecting
986
a a
b b
Fig. 57.8 CAST liposuction of the posterolateral upper arm
through (a) posterior axillary incision and (b) distal radial
incision
to the trunk. The axilla, deltoid, and lateral pectoral
extensions are treated with a 3-mm Mercedes cannula
to minimize wrinkling. The suture sites are closed with
a single 5-0 nylon suture.
57.2.6 Postoperative Care
Care is taken in applying Reston foam. The author pre-
fers Reston foam to the non-adherent Lipofoam for
CAST liposuction of the arms. The adherent side to
the Reston is covered with Bacitracin ointment or
Vaseline to allow adherence yet minimize the risk of
blistering. With the arm extended, the circulating nurse
grasps the anterolateral skin to elevate the dependent
posterolateral skin, and the sheet of Reston is placed
under the posterolateral skin to re-drape sagging skin
smooth along the posterior arm. Wrinkling is directed
anterolaterally. The arm is wrapped with a 4-in. ace
wrap from the elbow proximally. Drains are no longer
A.T. Lyos
Fig. 57.9 CAST liposuction of the para-axillary upper arm
through (a) posterior axillary incision and (b) anterior axillary
incision
used as reported previously [46]. The Reston foam
is removed the following day. Non-adherent Reston
or Lipofoam is applied, and a surgical compression
garment which extends below the elbow is placed.
The Reston may be kept in place for up to 1 week
depending on the degree of skin laxity. The compres-
sion garment is worn at all times for 6 weeks. For more
severe skin laxity, an additional 4 weeks of compres-
sion at least 12 h/day is recommended. The sutures are
removed at 67 days. Frequent inspection for seromas
is required for 6 weeks postoperatively. Persistent
postoperative pain most frequently represents a seroma
which should be treated with serial aspiration and
compression. Painful bands or scar tissue or focal nod-
ules representing fat necrosis are treated with massage
and microinjection of 0.2 cc triamcinolone (2 mg/mL).
Injection is performed deep to avoid thinning of the
skin. Limited range of motion of the shoulder due to
axillary tightness is treated with massage and range of
motion exercises.
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring
57.3 Minibrachioplasty Technique
The minibrachiolasty incision is marked in the
preoperative area with the arm abducted 90 from the
trunk. The crease marking the junction of the medial
arm with the axilla is located. The skin to be excised is
marked with a symmetric ellipse of tissue measuring
46 cm by 1215 cm in length. All attempts are made
to confine the resulting scar to the axilla and avoid
delectability, particularly posterior. The procedure can
be performed in lateral decubitus position; however,
the author prefers to perform both minibrachioplasties
in supine position following the completion of the
CAST liposuction. The dermatolipectomy is per-
formed initially leaving the superficial fascia intact to
avoid injury of the vital structures located in the axilla.
Metzenbaum scissors are then used, spreading in the
direction of the axillary vessels to identify the axillary
vein. After locating the axillary vessels, superficial
fascial system suspension sutures are placed of 2-0
Vicryl. Four to five sutures are pre-placed and tagged
prior to securing. Care is taken to incorporate the
superficial layer of axillary fascia to prevent migration
of the scar [14, 2426]. Advancement is performed
centrally to minimize standing cones. Standing cones
are excised anteriorly, if required. The subcutaneous
tissue is closed with 3-0 Vicryl. A subcuticular suture
of 4-0 clear PDS is placed. Interrupted 4-0 nylon
sutures are placed to re-enforce the incision and
removed at 56 days. Postoperative care is similar to
CAST liposuction of the arms with the exception that
range of motion of the arms, particularly abduction, is
limited for 46 weeks following surgery.
57.4 Discussion
CAST liposuction of the arms differs from traditional
(standard) tumescent liposuction of the arms as follows.
Traditional tumescent liposuction of the arms involves
deep liposuction over the posterolateral arm feather-
ing of anteromedially and anterolaterally without cir-
cumferential treatment and without ultrasonic energy.
Standard tumescent liposuction has the potential to
worsen skin laxity and sagging. CAST liposuction com-
bines several principles to obtain more predictable aes-
thetic results. Circumferential treatment of the upper
arm and para-axillary region creates a subcutaneous
987
confluence (lattice) of collagen deposition during
healing which promotes regional harmony. Small can-
nulas (34 mm) are utilized to minimize the risk of
contour irregularities. Liposuction is performed from
multiple directions in a multilayered approach. Circum-
ferential liposuction is performed most aggressively in
the posterolateral (one-third), less aggressively in the
anterolateral (one-third), and least aggressively in the
anteromedial (one-third). For this reason, the majority
of the delivery of the ultrasonic energy and the extrac-
tion of fat are done in lateral decubitus position through
a puncture site in the posterolateral axillary fold [46].
Liposuction through the posterior axillary incision min-
imizes the risk of over-ressection posterolaterally in
zones 2 and 3 and allows for excellent access in the
axilla and para-axillary region (zones 6, 7, and 8).
For individuals with moderate fat and moderate skin
laxity (Category 2), the application of ultrasonic energy
with tumescent infiltration allows for compartment
magnification and greater fat removal. Extraction of the
emulsion with small cannulas results in a smoother
appearance and enhanced skin retraction. Extraction
with small cannulas is done utilizing a multilevel, mul-
tidirectional approach. The majority of the liposuction
is done in the posterolateral arm where there is gener-
ally the greatest adiposity. The skin of the posterior lat-
eral arm is thickest and has the greatest potential for
contraction. Care is taken to avoid over-resection in the
thin-skinned areas of the anterolateral and anterome-
dial arm. This is particularly important in individuals
with photoaged Fitzpatrick I and II skin types, to mini-
mized worsening of wrinkles and ptosis in these areas.
For individuals with marked excess of skin and fat
(Category 3), CAST liposuction alone may provide the
degree of correction. In general, the greater the amount
of fat removal, the less likely skin excision will be
required. Skin excision in the form of minibrachio-
plasty offers the advantage of tightening of the skin in
zones 1 and 2 in the anteromedial and posterolateral
skin with an incision hidden in the axilla. No improve-
ment in the skin tightness of the skin anteromedially
or of the skin in zones 3 and 4. The scar of the mini-
brachioplasty is in general well tolerated as it rarely
widens or becomes hypertrophic. Although additional
skin can be excised, the dimension of the excised skin
needs to be confined to the axilla, particularly posteri-
orly, to avoid visibility from behind. An additional
advantage is that excised skin reduces the hair-baring
988
skin of the axilla and reduces hydrosis. As the distal
skin margin of the excision is longer than the proximal
margin, early postoperative wrinkling is common,
which improves within several months. Reported vari-
ations of modified brachioplasties or limited incision
techniques leaving scars extending out of the axilla
have been reported [2, 17, 2426]. Extension may be
in the form of a T or an L or may extend posteriorly to
the back. These reported techniques relied primarily
on skin excision rather than liposuction.
Individuals with minimal to moderate fat and
marked excess of skin (Category 4) who are seeking
arm rejuvenation are increasing due to the prevalence
of bariatric surgery. Elderly women will invariably have
Fig. 57.10 (a) Preoperative
26-year-old female. (b) Nine
months after CAST
liposuction with removal
of 600 mL of fat on the
right and 550 mL of fat
from the left
A.T. Lyos
wrinkling of the skin of their arms, just as they will
have wrinkling elsewhere. They will generally accept
an imperfect result which appears natural. CAST lipo-
suction provides improvement which the patients per-
ceive as being more natural than the improvement
resulting from a brachioplasty with anteromedial scar-
ring of the arm. It is important to avoid over-resection
anteromedially in zone 4 which results in wrinkling
above the elbow. Performing CAST liposuction and
minibrachioplasty does not obviate traditional brachio-
plasty in the future. For those with minimal to moderate
fat and extreme skin laxity, traditional brachioplasty
may provide the best alternative. Individuals well suited
for traditional brachioplasty are those over the age of
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring
Fig. 57.10 (continued)
b
60 years who are Fitzpatrick I or II skin types without
personal or family history of abnormal scarring. Dis-
advantages of traditional brachioplasty involve scar-
ring, possible delayed healing, and numbness. Great
care must be taken in the discussion of the risks involved
in a traditional brachioplasty and in the informed con-
sent process [14, 16].
Meticulous postoperative care is vital to obtaining
good results. Compression is essential to achieve accu-
rate re-draping of the skin. Most frequently, the skin is
loose and sagging posteriorly. Pulling the skin antero-
laterally to smooth any wrinkles anterior medially then
989
fixing it with Reston foam facilitating re-draping and
stabilization of the skin [4, 5, 8]. Weekly checks for
seromas are required for the first 4 weeks. Seroma for-
mulation is decreased with reduced duration of ultra-
sonic energy delivery and the use of a greater number
of liposuction access sites. Postoperative compression
is required for 6 weeks for optimal aesthetic results.
The primary attraction of CAST liposuction with or
without minibrachioplasty is enhanced skin retraction
with minimal scarring compared to a traditional brachi-
oplasty (Figs. 57.10 and 57.11). Extensive preoperative
education is advisable. Realistic expectations should be
990 A.T. Lyos

stressed in terms of the amount of improvement which 57.5 Conclusions

can be anticipated. Photographs of patients who have
undergone liposuction, with and without minibrachio-
plasty, as well as full brachioplasty should be available
to demonstrate realistic results and sites of surgical
scars. A financial policy should be spelled out prior to
the procedure regarding financial obligations should a
secondary procedure be required.
Liposuction of the arms in patient with aged and flac-
cid skin has traditionally produced disappointing
results. CAST liposuction was developed to maximize
skin retraction and regional harmony by compartment
magnification followed by circumferential treatment
of the arm and adjacent aesthetic units. Rigorous

Fig. 57.11 (a) Preoperative

55-year-old female. (b) Five
months postoperative after
CAST liposuction with
removal of 800 mL of fat on
the right and 800 mL of fat
from the left
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring 991

Fig. 57.11 (continued)

b

patient selection and education are essential as the
goal of CAST liposuction is improvement, not perfec-
tion. The postoperative care is demanding in order to
achieve accurate skin re-draping requiring complete
patient compliance. Minor complications including
seromas and wrinkling are not uncommon. The patient
must be aware that there may be a need for a second-
ary surgical procedure in the form of a modified bra-
chioplasty to treat redundant skin in the axilla and
upper arm.
992 A.T. Lyos

References 15. Pascal JF, Le Louarn C (2005) Brachioplasty. Aesthetic

Plast Surg 29(5):423429
16. Knoetgen J, Moran SL (2006) Long-term outcomes and
1. American Society of Plastic Surgeons (2009) 20002008
complications associated with brachioplasty: a retrospective
National plastic surgery statistics. Available at: http://www.
review and cadaveric study. Plast Reconstr Surg 117(7):
plasticsurgery.org/media/stats/2008 US-cosmetic-plastic-
22192223
surgery-minimal invasive-statistics.pdf. Accessed 25 Apr 2009
17. Teimourian B, Malekzadeh S (1998) Rejuvenation of the
2. Vogt PA, Baroudi R (1994) Brachioplasty and brachial
upper arm. Plast Reconstr Surg 102(2):545551
suction-assisted lipectomy. In: Cohen M (ed) Mastery of
18. Klein JA (1990) Tumescent technique for regional anesthe-
plastic and reconstructive surgery, 1st edn. Little, Brown,
sia permits lidocaine doses of 35 mg/kg for liposuction.
Boston, pp 22192236
J Dermatol Surg Oncol 16(3):248263
3. Lillis PJ (1999) Liposuction of the arms. Dermatol Clin
19. Rohrich RJ, Beran SJ, Fodor PB (1997) The role of sub-
17(4):783797
cutaneous infiltration in suction assisted lipoplasty. Plast
4. Gilliland MD, Lyos AT (1997) CAST liposuction of the arm
Reconstr Surg 99(2):514519
improves aesthetic results. Aesthetic Plast Surg 21(4):225229
20. Kenkel JM, Robinson JB, Beran SJ et al (1998) The tissue
5. Gilliland MD, Lyos AT (1997) CAST liposuction: an alter-
effects of ultrasound assisted lipoplasty. Plast Reconstr Surg
native to brachioplasty. Aesthetic Plast Surg 21(6):398402
102(1):213220
6. Gilliland MD (2002) Ultrasound-assisted circumferential
21. Klein JA (1993) Tumescent technique for local anesthesia
para-axillary superficial liposuction effect on arm contour.
improves safety in large volume liposuction. Plast Reconstr
Oper Tech Plast Reconstr Surg 8(2):100101
Surg 92(6):10991100
7. Illouz YG, DeVillers YT (1989) Body sculpting by lip-
22. Matarasso A (1999) Lidocaine in ultrasound assisted lip-
oplasty. Churchilll Livingstone, Edinburg, pp 279281
oplasty. Clin Plast Surg 26(3):431439
8. Schlesinger L (1990) Suction assisted lipectomy of the upper
23. Samdal F, Amland PF, Bugge JF (1994) Plasma lidocaine
arm: a four cannula technique. Aesthetic Plast Surg 14:271274
levels during suction-assisted lipectomy using dilute lido-
9. Grazer FM (1992) Atlas of suction assisted lipectomy.
caine. Plast Reconstr Surg 93(6):12171223
Churchill Livingstone, New York, pp 139140
24. Richards ME (2001) Minimal-incision brachioplasty: a
10. Correa-Iturraspe M, Fernandez JC (1954) Dermolipectomia
first-choice option in arm reduction. Aesthet Surg J 21(4):
brachuial. Prensa Med Argent 41(34):24322436
301308
11. Baroudi R (1975) Dermolipectomy of the upper arm. Clin
25. Richards ME (2005) Reassessing minimal-incision brachio-
Plast Surg 2:485494
plasty. Aesthet Surg J 25(2):175179
12. Guerrero-Santos J (2004) Brachioplasty. Aesthet Surg J 24:
26. Abramson DL (2004) Minibrachioplasty: minimizing scars
16161619
while maximizing results. Plast Reconstr Surg 114(6):
13. Pitanguy I (1980) Aesthetic plastic surgery of the upper and
16311637
lower limbs. Aesthetic Plast Surg 4:363372
14. Lockwood T (1995) Brachioplasty with superficial fascial
system suspension. Plast Reconstr Surg 96(4):912920
 Thigh Lift
58
Sadri Ozan Sozer and Francisco J. Agullo

58.1 Introduction

The thighs are a remarkably challenging area to obtain

esthetical and functional satisfaction from a patients and
from a surgeons standpoint. Skin laxity in the medial
thighs is one of the first signs of aging in the thighs. The
medial thigh is characterized by early relaxation and
very poor retraction, even after liposuction. The develop-
ment of these contour alterations can be accredited to
lack of exercise, body weight variations, and genetics.
These deformities are very difficult to correct with diet
and exercise alone. A full analysis of the patients defor-
mities and degree of laxity must be undertaken prior to
operative planning. Liposuction can be utilized in patients
with excess subcutaneous tissue without skin laxity.
Aggressive liposuction can result in contour abnormali-
ties. Yet, liposuction often fails to address the thin nature
of the medial thigh skin and its poor retraction.
A combination of removal of subcutaneous tissue
and excision of skin is often necessary to produce opti- Fig. 58.1 Dotted line depicts deep fascial structures for medial
mal results. An isolated horizontal crescenteric medial thigh lift anchoring, including ischial periosteum, Colles fascia,
thigh lift is reserved for patients with isolated medial pubis, and inguinal ligament
thigh ptosis and vertical skin laxity. If the patient also
has circumferential or horizontal skin laxity, then a thigh, the medial thigh lift must be combined with a
vertical extension should be added to the thigh lift. circumferential body lift or a spiral lift.
When there is circumferential thigh ptosis, which The classic medial thigh lift was characterized by
necessitates lifting of the anterior, lateral, and posterior multiple problems, including inferior migration and
widening of scars, deformity of the vulva and labia by
traction, and early recurrence [1, 2]. The use of deep
anchoring sutures to the deep layer of the superficial
S.O. Sozer (*) F.J. Agullo
fascia of the perineum, or Colles fascia, has eliminated
Department of Surgery, Texas Tech University Health Sciences
Center, El Paso, TX, USA many of these problems [3]. Furthermore, the anterior
extensions of the thigh lift can be anchored to the pubis
El Paso Cosmetic Plastic Surgery Center, El Paso, TX, USA
e-mail: doctor@elpasoplasticsurgery.com; and inguinal ligament, and the posterior extensions to
frankagullo@elpasoplasticsurgery.com the ischial periosteum (Fig. 58.1).

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 993

DOI 10.1007/978-3-642-21837-8_58, Springer-Verlag Berlin Heidelberg 2013
994
Fig. 58.2 Spiral lift. Tissue
excised extends from the
inner inside crease of the
buttocks, along the inguinal
crease and anterior iliac spine,
spiraling above the buttocks
and meeting the contralateral
incision at the sacrum
The vertical thigh lift involves a significant visible
scar on the extremity extending from the growing to
the knee. A transverse scar component is usually nec-
essary and depending on the patient may be extended
only anteriorly or posteriorly. Some patients, espe-
cially postbariatric weight loss patients, may require
an anterior and posterior resection resulting in a
T-shaped scar.
A spiral lift provides a total thigh lift. Through
a single incision easily concealed by underwear, the
procedure results in a medial, anterior, lateral, and
posterior thigh lift (Fig. 58.2). As originally
described by the authors, it is often combined with
autologous buttock augmentation with a dermal fat
flap [4].
It is not within the realms of this chapter to discuss
circumferential body lifts, but this procedure can easily
be added to a medial or vertical thigh lift and performed
at the same time. The combination also results in a
total thigh lift and is often utilized in massive weight
loss patients.
S.O. Sozer and F.J. Agullo
58.2 Technique
58.2.1 Preoperative Markings
Preoperative markings are a crucial component to
successful surgery and to achieving desired results.
Patients are marked preoperatively in standing posi-
tion with the knees apart. The symmetry of the inci-
sions is evaluated while patient is standing.
When performing only a medial thigh lift, the inguinal
crease and inferior buttock crease are marked. This is where
the scar will remain after the procedure is completed. The
extent of the resection is then calculated by lifting the
medial thigh with a standard pinch test (Fig. 58.3).
When adding a vertical component to the proce-
dure, a line is drawn slightly posterior to the medial
midline of the thigh extending from the inguinal crease
to the knee. This marks where the final scar will be
located. By marking it slightly posterior, the patient
enjoys the psychological benefits of not seeing the scar
when looking in the mirror. The length of the vertical
58 Thigh Lift 995

Fig. 58.3 Patient with

massive weight loss, with
a b
isolated medial thigh ptosis.
Medial thigh crescenteric lift
markings are illustrated. (a)
anterior and (b) posterior
views. Patient also has
markings for circumferential
abdominoplasty with
autologous buttock
augmentation

Fig. 58.4 Massive weight

loss patient with vertical and
a b
horizontal thigh skin laxity.
Markings for vertical thigh
lift are illustrated with an
anterior horizontal medial
thigh component. (a) anterior
and (b) posterior views.
Patient also has markings for
circumferential
abdominoplasty with
autologous buttock
augmentation

scar can be modified according to the patients defor- posterior to the line using the pinch test. Care must
mities and at times, may be made into a short scar. be taken not to exaggerate the amount of resection,
The extent of resection is then marked anteriorly and allowing for intraoperative swelling (Fig. 58.4).
996
a b
Fig. 58.5 Preoperative markings. Tissue to be excised is marked in red ink, the dermal fat flaps are marked in dark blue ink, and
areas of liposuction marked with blue concentric circles. (a) anterior, (b) lateral, and (c) posterior views
For a spiral lift, a line is drawn starting at the lateral
portion of the inferior gluteal fold, extending medially
to the upper inner thigh, proceeding interiorly and ante-
riorly through the pudendal region, moving along the
inguinal line through the anterior iliac spine to the pos-
terior iliac crest, above the buttocks, and to the sacrum.
At the sacrum, the line from the contralateral side is
joined forming a V. If the patient does not require a but-
tock lift, the lines do not have to be joined at the sacrum,
but should extend posteriorly to allow for sufficient lat-
eral thigh lift. The pinch method is utilized to estimate
the amount of possible skin resection (Fig. 58.5).
58.2.2 Surgical Technique
58.2.2.1 Medial and Vertical Thigh Lift
The patient is first placed in the prone position under
general anesthesia with the legs abducted. Compression
hoses and sequential compression devices are placed
for induction to avoid venous thrombosis. The medial
thigh is liposuctioned in the standard fashion after
tumescent infiltration when indicated.
The wedge excision of the inferior gluteal fold and
posterior portion of the medial thigh is accomplished
and left for completion once the patient is rotated to
the supine position. Skin and subcutaneous tissue are
S.O. Sozer and F.J. Agullo
c
excised down to the gluteus maximus fascia and con-
nective tissue of the ischial tuberosity. The inferior
edge of the wedge excision is then anchored in a
cephalad and medial direction to the connective tissue
surrounding the ischial tuberosity and gluteus maxi-
mus fascia with 2-0 polydioxanone (PDS). The objec-
tive is to lift the posterior thigh and shorten and elevate
the inferior gluteal fold. The skin and subcutaneous
tissues are then closed in layers.
If performing a vertical component, the area marked
to be excised is liposuctioned aggressively after infil-
trating with tumescent solution. The liposuction does
not extend past the area to be excised. The posterior
line is then incised, and the skin is raised anteriorly.
Due to the aggressive liposuction, only a network of
connective tissue is visible, making elevation of the
skin easy and preserving lymphatics and vessels. This
also allows for preservation of the greater saphenous
vein. The authors do not commit to the previously
marked anterior line of resection. Instead, tailor tack-
ing is done to avoid overresection. More often than
not, the anterior line of resection is lesser than the ini-
tially marked one due to intraoperative swelling.
The patient is then turned supine, reprepped, and
redraped, again with the legs abducted shoulder-width
apart. The medial thigh lift is liposuctioned in
the standard fashion after infiltration of tumescent
58 Thigh Lift
solution. If performing a vertical extension, liposuc-
tion is not performed outside of the area to be excised.
The anterior medial thigh crescent of skin and
subcutaneous tissue is excised, taking care to preserve
the deep fat and lymphatics. The inferior margin of
the incision is then suspended superiorly from the
superficial fascial system to the superficial perineal
(Colles) fascia medially, inguinal ligament anteriorly,
and periosteum of the anterior superior iliac spine
laterally with polydioxanone (PDS). The superior
and inferior edges are then approximated in a layered
fashion with subdermic running absorbable polyglac-
tin 910 (3/0 Vicryl) and subcutaneous running absorb-
able poliglecaprone 25 (4/0 Monocryl).
58.2.2.2 Spiral Lift
The patient is placed in the prone position under general
anesthesia with legs abducted to expose the medial thigh
and to maximize lateral resection. Traditional deep and
superficial liposuction of the flanks and back is performed
after the subcutaneous tissue is infiltrated with tumescent
solution consisting of 1 L of Hartmanns solution with
1 mg of epinephrine and 10 mL of 1% lidocaine.
The posterior portion of the medial thigh lift is accom-
plished in the same fashion as previously described.
The marked supragluteal and flank wedges of skin
are resected down to the fascia, and the gluteal flaps
are deepithelialized. The inferior border of the flap is
dissected at an oblique angle so that the base of the flap
lies more inferior to allow for greater caudal mobility.
The superior, medial, and lateral borders are dissected
in a plane perpendicular to the underlying fascia.
A pocket is then created for insertion of the flap by
undermining the buttock skin and subcutaneous tissue
caudally in the plane above the fascia, extending it a
sufficient length to reach the inferior gluteal crease.
The superior aspect of the flap is then detached in an
intramuscular plane inferiorly until the flap can be
rotated caudally 180 into the pocket and anchored
to the fascia with polyglactin 910 (3/0 Vicryl) suture.
The remaining buttock skin is then pulled superi-
orly over the flap and a drain is placed in each side.
The lateral thigh is undermined inferiorly deep to the
superficial fascial system using a Lockwood retractor.
The superficial fascial system is then approximated
with polyglactin 910 (0 Vicryl), and the skin and sub-
cutaneous tissue is closed in a layered fashion.
At this point, the patient is turned to the supine
position with the legs abducted to expose the medial
thighs. Liposuction is performed where necessary as
997
previously described. Thereafter, resection of a crescent
of redundant skin and fat at the superior medial thigh
spiraling from the flank towards the infragluteal fold is
made, thus joining the previous flank and infragluteal
excision sites. The Lockwood retractor is used for
limited undermining of the anterior and lateral thigh in
an inferior fashion deep to the superficial fascial sys-
tem. The medial thigh is not undermined. The medial
thigh lift is then completed as described above.
58.2.2.3 Postoperative Care
Immediately after surgery, a compressive garment is
used and kept for 4 weeks. Patients are encouraged to
use knee high compression stockings to decrease edema.
Patients are allowed to rest in bed in the most comfort-
able position for them, usually supine. Ambulation is
started the same day or the next morning depending on
concurrent procedures. Sitting is not restricted.
The patient may return to normal activities between 1
and 2 weeks, depending on concurrent procedures and
the extent of the medial thigh lift. Patients often complain
of pain at the deep anchor points of the medial thigh lift,
and reassurance and pain medications are suggested.
Complications that can occur after thigh lift include
delayed wound healing, scar migration, seromas,
dehiscences, lymphoceles, bad scarring, infection,
bleeding, nerve compression, neuromas, and sensory
loss. Dehiscence can be avoided with good technique
and tension-free closure. This is usually a result of
overresection of tissues. Scar migration is avoided
with solid anchoring to Colles fascia, inguinal liga-
ment, and ischial periosteum. Seromas and lymphoce-
les present 46 weeks after surgery and typically
resolve with aspiration and localized pressure. The use
of liposuction of the area to be excised has dramati-
cally decreased the incidence of lymphoceles. Sensory
loss is traditionally limited to the area around the scar
and resolves over a period of 6 months. Some patients
may require an additional more limited reduction in
the future due to recurrence of excess skin due to the
poor elasticity in massive weight loss patients.
58.3 Conclusions
Contour surgery of the thighs represents a challenging
area for the surgeon. Today, many procedures and
combinations exist to improve the contour of the
thighs. Proper patient and technique selection is key
in obtaining the desired results (Figs. 58.658.8).
998 S.O. Sozer and F.J. Agullo

Fig. 58.6 (Left) Before

surgery. (Right) Following
medial thigh lift in
combination with
circumferential body lift

Fig. 58.7 (Left) Before

surgery. (Right) Postoperative
after vertical thigh lift with
full medial thigh lift and
circumferential body lift
58 Thigh Lift 999

Fig. 58.8 (Left) Preoperative.

(Right) Postoperative after
a
spiral lift. (a) Anterior, (b)
Lateral, and (c) posterior
views

b
1000 S.O. Sozer and F.J. Agullo

Fig. 58.8 (continued)

c

Techniques such as deep fascial anchoring and aggres-
sive liposuction of the areas to be excised have
decreased the incidence of complications often associ-
ated with thigh contouring procedures.
3. Lockwood T (1988) Fascial anchoring technique in medial
thigh lifts. Plast Reconstr Surg 82(2):299304
4. Sozer SO, Agullo FJ, Palladino H (2008) Spiral lift: medial
and lateral thigh lift with buttock lift and augmentation.
Aesthetic Plast Surg 32(1):120125

References
1. Lewis J (1957) The thigh lift. J Int Coll Surg 27(3):330334
2. Planas J (1975) The crural meloplasty for lifting of the
thighs. Clin Plast Surg 2:495503
 Buttock Lift
Sadri Ozan Sozer and Francisco J. Agullo
59.1 Introduction
The trunk, buttocks, and thighs represent areas of
increased patient interest and surgical technique modi-
fication. Recently, there has been an increase in patients
seeking buttocks augmentation and contour restora-
tion. The multiple indications for buttock lifting
include ptosis, excess skin, asymmetry, double infra-
gluteal fold, and long buttocks. A buttock lift can be
achieved with several different techniques depending
on the patients contour and needs.
When performing buttock contouring procedures,
one must keep in mind the main factors that comprise
ideal buttocks. Endpoints considered aesthetically
pleasing include maximum gluteal projection at the
midlevel of the buttocks, verified by a horizontal line
from the point of maximal projection of the mons
pubis. Another sign is a short infragluteal fold with a
downward slope that does not extend past the union of
the semitendinosus muscle with the biceps femoris,
which is medial to the midaxial line of the thigh [1].
Other indications of an aesthetic contour include a
V-shaped crease in the proximal portion of the gluteal
crease and lumbar hyperlordosis [24].
Gluteal implants have been described with various
rates of complications and difficulties, hindering wide
acceptance [57]. Lipografting is an effective means
S.O. Sozer (*) F.J. Agullo
Department of Surgery, Texas Tech University Health
Sciences Center, El Paso, TX, USA
El Paso Cosmetic Plastic Surgery Center, El Paso, TX, USA
e-mail: doctor@elpasoplasticsurgery.com;
frankagullo@elpasoplasticsurgery.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_59, Springer-Verlag Berlin Heidelberg 2013
59
of moderately increasing buttocks volume, but does
not directly address ptosis [815]. Both techniques
achieve rounder and fuller buttocks, but are not appli-
cable in the presence of ptotic, long, or sagging but-
tocks. Options for buttocks lifting include the upper
lift [16, 17], dermo-tuberal-anchorage lower lift [18],
lateral lift, and medial butterfly lift [18].
The inferior gluteal lift described by Gonzalez [19]
is a very powerful and effective tool in the appropriate
candidate. It improves the inferior gluteal fold and the
skin and subcutaneous tissue of the superior posterior
thigh. The procedure is indicated in patients with mild
buttock ptosis with excess skin and subcutaneous
tissue in the inferior gluteal fold or banana fold. It
can also be used to improve a double infragluteal fold,
to correct infragluteal fold asymmetry, or to shorten a
long buttock when combining it with an upper buttock
lift. It is indicated when the maximum point of buttock
fullness is at the mid to upper portion of the buttocks,
which should coincide with the level of the pubic sym-
physis [3]. If the maximum point of fullness falls below
this line, then a superior approach and/or augmenta-
tion should be contemplated [17]. Furthermore, the
inferior gluteal lift technique is contraindicated when
the excess skin and subcutaneous tissue extends later-
ally toward the trochanteric area because this would
force the incision to extend laterally, resulting in a long
infragluteal fold.
A lateral buttock lift is indicated to correct moderate
cases of trochanteric laxity. This technique is usually
incorporated into extended abdominoplasties and/or
flankplasties. When indicated, the regularly excised tis-
sue can be utilized as an anteriorly (Fig. 59.1) or poste-
riorly (Fig. 59.2) based dermal fat flap to provide
1001
1002 S.O. Sozer and F.J. Agullo

Fig. 59.1 (a) (Left) Preoperative. (Right) After lateral buttock lift or flankplasty with dermal fat flap to provide fullness in lateral
upper thigh. (b) Dermal fat flap
59 Buttock Lift 1003

Fig. 59.2 (a) (Left) Preoperative. (Right) Following lateral buttock lift or flankplasty with dermal fat flap to provide fullness in
upper lateral buttocks. (b) Dermal fat flap
1004 S.O. Sozer and F.J. Agullo

fullness in the hips or superolateral gluteal area,

respectively. This procedure can be combined with fat
grafting to obtain greater volume and projection of the
buttocks.
The authors routinely utilize the upper buttock lift
with split muscle flap autoprosthesis augmentation in
cases of buttock ptosis and loss of volume since most
of our population presents with more advanced defor-
mities and routinely request a lift with augmentation.
A number of adipocutaneous flaps to address gluteal
augmentation in different settings have been described
in this region [16, 2025]. Most of these flaps originate
within the superior gluteal region and maintain volume
in the top half of the buttocks, lacking the ability to
reach the mid portion of the buttocks. The ideal flap
should be versatile, not vascularly compromised, result
in a superior gluteal concavity, and give the maximum
projection at the midlevel of the buttocks. In 2005, the
authors reported a series of turnover dermal fat flaps
for buttock augmentation in bariatric and aesthetic
patients undergoing lower body lifts in order to prevent
a flattened buttocks contour [25]. After more than 200
cases, the technique has evolved to include a portion of
the gluteus maximus muscle resulting in a better blood
supply to the flap, more caudal reach, and dramatic
decrease in fatty necrosis. The technique can be applied
to isolated buttock lifts [17], spiral lifts [26], and cir-
cumferential buttock lifts in bariatric and non-bariatric Fig. 59.3 Preoperative markings for buttock lift with autopros-
patients [25]. thesis augmentation

The inferior line is designed utilizing the pinching

59.2 Technique
59.2.1 Preoperative Markings
Preoperative markings are a crucial component to
successful surgery and to achieving desired results.
Patients are marked preoperatively in prone and stand-
ing positions. The symmetry of the incisions is evalu-
ated while patient is standing (Fig. 59.3).
The superior or cephalic line is marked first. By the
end of the procedure, this line will be lowered by 1 or
2 cm and will dictate the localization of the final scar.
The line is drawn starting above the intergluteal crease
extending in a curvilinear fashion a few centimeters
bellow the iliac crest. At the sacrum, the line from the
contralateral side is joined forming a V, creating an aes-
thetically pleasing V-shaped crease [2123]. This will
form a scar that is slightly arched, follows the skins
tension lines, and is easily concealed by underwear.
method to estimate the amount of possible skin resec-
tion. The direction of elevation of the ptotic buttocks is
caudal and slightly medial. These lines can be contin-
ued anteriorly with abdominoplasty or spiral lift mark-
ings given the appropriate indications.
A dermal fat flap originating between the superior
and inferior lines is marked within the medial two-
thirds of the supragluteal tissue marked for excision.
The flap is demarcated medially 23 cm lateral from
the midline. The lateral demarcation of the flap is
approximately three quarters of the distance from the
midline to the posterior axillary line and may range
between 5 and 15 cm in width depending on the patients
body habitus, buttock contour, and desired result.
The gluteal flap is based randomly on superior glu-
teal artery perforators. Perfusion to the skin overlying
the gluteal region is supplied by 2025 perforating
branches of the superior and inferior gluteal arteries,
both of which branch from the internal iliac artery
59 Buttock Lift
Fig. 59.4 Deepithelialization of buttock flaps and removal of
sacral and flank skin and subcutaneous tissue, leaving deep fat
attached
Fig. 59.5 Creation of pocket above gluteus maximus fascia and
anchoring of flap
[2730]. The abundant vascular supply of the gluteal
region provides robust perfusion to surrounding tissue
flaps [16].
Depending on the patients contour deformities, the
areas of liposuction are marked. Liposuction is rou-
tinely performed in the flanks, sacrum, and posterior
thigh, following the aesthetic units of the buttocks and
accentuating its final contour.
59.2.2 Surgical Technique
The patient is placed in the prone position under general
anesthesia with the lower extremities slightly abducted.
Liposuction is performed in the flanks, sacral area, below
the infragluteal crease, and other areas dictated by the
patients contour deformities. The subcutaneous tissue is
infiltrated of tumescent solution consisting of 1 L of
Hartmann solution with 1 mg of epinephrine and 10 mL
of 1% lidocaine. Deep and superficial liposuction of the
1005
Fig. 59.6 (a, b) Photo depicting elevation of flap with split gluteus
maximus muscle to allow for inferior mobilization of flap
areas marked with fat deposits is performed following
the traditional method.
The marked wedge of supragluteal skin to be
excised is resected leaving the subscarpal fat to aid in
lymphatic drainage. The marked gluteal flap is then
deepithelialized (Fig. 59.4). The flap is dissected down
to the fascia at a perpendicular angle superiorly, medi-
ally, and laterally. The inferior border of the flap is dis-
sected inferiorly in an oblique angle to the level of the
fascia. A pocket is created for insertion of the flap by
undermining the buttock in the plane above the gluteus
maximus fascia and extending it a sufficient length to
approach the inferior gluteal crease (Fig. 59.5). The
fascia in the superior, medial, and lateral border of the
dermal fat flap is divided. The flap is then raised by
partially dividing the superior insertion of the gluteus
maximus muscle to the posterior iliac spine and
sacrum. The Gluteus maximus is then split in order to
allow the flap to rotate caudally 180 (Fig. 59.6).
1006 S.O. Sozer and F.J. Agullo

a
a b

Deepithelialized

Pocket
undermined

Split muscle flap rotated

and soft tissue flap folded for
increased fullness

Fig. 59.7 (a) Flap rotated inferiorly and secured inferiorly to gluteus maximus fascia in previously created pocket. (b) Drain
placement and suspension of buttock skin and subcutaneous tissue over flap

The superior superficial tip of the flap is cut to assess
for adequate blood flow. The flap is rotated caudally
180 into the pocket and anchored to the fascia with
polyglactin 910 (3/0 Vicryl) suture. Securing the deepi-
thelialized surface upside down gives the flap a more
rounded and implant-like shape. The remaining buttock
skin is pulled in the reverse direction to cover the flap
and two drains are placed (Fig. 59.7). The superficial
fascial system is repaired with polyglactin 910 (0 Vicryl),
and the tissues are closed in a layered fashion.
The patient is then placed in the supine position,
and other concurrent procedures may be performed.
59.2.3 Postoperative Care
Immediately after surgery, a compressive garment
is used and kept for 4 weeks. Patients are allowed to
rest in bed in the most comfortable position for them,
usually supine. Ambulation is started the same day or
59 Buttock Lift
Fig. 59.8 (Left) Preoperative.
(Right) Postoperative after
autoprosthesis buttock
augmentation with
circumferential body lift
the next morning depending on concurrent procedures.
Sitting is not restricted.
The drains are left in place for 710 days and are
removed once the drainage is <30 mL/day. In our expe-
rience, isolated inferior gluteal lifts or horizontal thigh
lifts do not require drainage since there is not a large
dead space. The patient may return to normal activi-
ties between 1 and 2 weeks, depending on concurrent
procedures.
59.3 Conclusions
The high satisfaction rate, the ease of concealing the
incision with clothing, and the low complication
rate suggest that this is a reliable, versatile technique
1007
without extending the procedure significantly (<30 min).
The creation of an autologous buttock implant from a
split muscle flap provides additional projection during
autologous buttock augmentation. The flap has reliable
circulation, requires minimal additional operating
time, does not increase operative morbidity, and can be
custom designed for each patient. The flap achieves
maximum projection at the midportion of the buttocks
and creates a supragluteal concavity at the same time.
The procedure allows for a more substantial augmen-
tation when compared to fat grafting, and in our expe-
rience, is safer than implants, while allowing for a lift
at the same time. It has proven to be a reliable proce-
dure that can be utilized in isolated buttock lift with
augmentation, circumferential body lift, and spiral lift
(Figs. 59.859.11).
1008 S.O. Sozer and F.J. Agullo

Fig. 59.9 (Left) Preoperative

patient with buttock
elongation and ptosis. (Right)
Postoperative following
isolated buttock lift and
autoprosthesis augmentation.
Note the point of maximal
gluteal projection is at a
parallel line with the mons
pubis

Fig. 59.10 (Left)

Preoperative patient with
prior buttock augmentation
using round 270 mL silicone
implant that resulted in ptosis
and double bubble
appearance. (Right)
Postoperative after removal of
implants and buttock lift with
autoprosthesis augmentation
59 Buttock Lift
Fig. 59.11 (Left)
Preoperative. (Right)
Postoperative following spiral
lift with autoprosthesis
buttock augmentation
References
1. Mendieta CG (2006) Classification system for gluteal evalu-
ation. Clin Plast Surg 33(3):333346
2. Cuenca-Guerra R (2004) What makes buttocks beautiful?
A review and classification of the determinants of gluteal
beauty and the surgical techniques to achieve them. Aesthetic
Plast Surg 28(5):340347
3. Cuenca-Guerra R, Lugo-Beltran I (2006) Beautiful buttocks:
characteristics and surgical techniques. Clin Plast Surg
33(3):321332
4. Centeno RF, Young VL (2006) Clinical anatomy in aesthetic
gluteal body contouring surgery. Clin Plast Surg 33(3):
347358
5. Bartels RJ, OMalley JE, Douglas WM, Wilson RG (1969)
An unusual use of the Cronin breast prosthesis. Case report.
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7. Ford RD, Simpson WD (1992) Massive extravasation of
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1009
8. Cardenas-Camarena L, Lacouture AM, Tobar-Losada
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Aesthetic Plast Surg 20(4):291296
10. Chajchir A, Benzaquen I (1989) Fat-grafting injection
for soft-tissue augmentation. Plast Reconstr Surg 84(6):
921934
11. Lewis CM (1992) Correction of deep gluteal depression
by autologous fat grafting. Aesthetic Plast Surg 16(3):
247250
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grafting. Aesthetic Plast Surg 12(1):3538
13. Pereira LH, Radwanski HN (1996) Fat grafting of the but-
tocks and lower limbs. Aesthetic Plast Surg 20:409416
14. Peren PA, Gomez JB, Guerrerosantos J, Salazar CA (2000)
Gluteus augmentation with fat grafting. Aesthetic Plast Surg
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15. Toledo LS (1991) Syringe liposculpture: a two-year experi-
ence. Aesthetic Plast Surg 15(4):321326
16. Pascal JF, le Louarn C (2002) Remodeling body lift with
high lateral tension. Aesthetic Plast Surg 26(3):223230
1010
17. Sozer SO, Agullo FJ, Palladino H (2008) Autologous aug-
mentation gluteoplasty with a dermal fat flap. Aesthet Surg
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18. Gonzalez R (2006) Buttocks lifting. In: Gonzalez R (ed)
Buttocks reshaping and the posterior body contour. Editora
Indexa, Rio de Janeiro
19. Gonzalez R (2005) Buttocks lifting: the dermo-tuberal
anchorage technique. Aesthet Surg J 25(1):1523
20. Agris J (1977) Use of dermal-fat suspension flaps for thigh
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DM, Raposo-Amaral CM (2006) Bilateral lumbar hip
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26. Sozer SO, Agullo FJ, Palladino H (2008) Spiral lift: medial
and lateral thigh lift with buttock lift and augmentation.
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2326
 Liposuction of Lower Extremities
and Buttocks
Alberto Di Giuseppe, Guido Zannetti,
and Daniele Bordoni
60.1 Introduction
Suction-assisted lipoplasty (SAL) is generally regarded
as safe and effective with well-known and well-
documented clinical results and potential complica-
tions. For this method of lipoplasty, the fundamental
mechanism of tissue removal is avulsion, i.e., the fatty
tissue is pulled into a hollow suction cannula by vacuum
and then avulsed or torn by the movement of the can-
nula. Results and potential complications are a direct
function of the avulsive/cutting process.
Vaser-assisted lipoplasty (VAL) presents a funda-
mental change in the treatment and subsequent removal
of targeted fatty tissues. The fatty tissue is first selec-
tively emulsified using ultrasonic frequency vibrations
delivered on a metal probe, and then the emulsified tis-
sues are removed using a gentle, minimally avulsive
aspiration process. The Vaser systems high selectivity
for fatty tissue results in decreased overall damage to
the tissue matrix comprised of fat cells, vessels, nerves,
structural tissues, and lymph tissue. Vaser-assisted
lipolasty uses ultrasonic frequency vibrations to emul-
sify the fatty component of the tissue matrix but in a
A. Di Giuseppe (*)
Institute of Plastic and Reconstructive Surgery, School
of Medicine, University of Ancona, Ancona, Italy
e-mail: adgplasticsurg@atlavia.it
G. Zannetti
Department of Plastic and Reconstructive Surgery of,
Bologna, Italy
e-mail: guido.zannetti@aosp.bo.it
D. Bordoni
Institute of Plastic and Reconstructive Surgery,
School of Medicine, University of Ancona, Ancona, Italy
e-mail: danyburdo@hotmail.it
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_60, Springer-Verlag Berlin Heidelberg 2013
60
fundamentally different manner than earlier versions
of ultrasonic instrumentation for a lipoplasty, namely,
ultrasound-assisted lipoplasty (UAL). The primary
differences are that the Vaser system delivers signifi-
cantly less power to the tissues while simultaneously
increasing fragmentation/emulsion efficiently com-
pared to UAL devices and eliminates the simultaneous
aspiration feature of UAL devices.
Ultrasonic energy was introduced to the plastic
surgery community in the form of ultrasound-assisted
lipoplasty in the late 1980s and early 1990s. UAL tech-
nology was characterized by large-diameter (5 mm)
ultrasonic cannulas, simultaneous aspiration and emul-
sion, continuous energy delivery, and sharp-edged ele-
ments at the cannulas ends, usually associated with the
suction port holes. UAL technique was characterized by
generally longer application times than SAL due to low-
efficiency ultrasonic cannula designs to create the emul-
sion and low-efficiency aspiration due to the small
(2 mm) suction lumens in the ultrasonic cannulas. While
both excellent results and complications were reported,
there was no clear understanding of the causes for the
excellent results or the complications other than the
unfortunate general assignment to ultrasonic energy.
Vaser technology uses ultrasonic frequency vibra-
tions but delivers the energy to the tissues in a substan-
tially different manner than UAL. In brief, VAL
technology is characterized by small-diameter probes
(2.23.7-mm diameters), pulsed delivery of the ultra-
sonic energy, and grooved probe designs that provide
energy dissipation along the sides of the probes in
addition to the front face of the probes. VAL technique
is characterized by procedure times similar to or shorter
than typical SAL procedure times and incision sizes
comparable to SAL. The amount of power delivered to
1011
1012
Table 60.1 Partitioning,
H2O power, and efficiency Probe % Front
for four Vaser probes
3.70 100
3.71 65
3.72 55
3.73 42
the tissues and a method of measuring the efficiency of
each probe design (including other ultrasonic devices)
are summarized in the research published by Cimino.
60.2 Vaser Technology
The technological advancements incorporated into
Vaser technology are designed to deliver the absolute
minimum amount of vibratory energy to the tissues and
still achieve the desired emulsification/fragmentation of
the fatty component of the tissue matrix. These advance-
ments include the use of small-diameter solid probes in
the range of 2.23.7 mm, grooved probe designs to
increase efficiency, pulsed delivery of the vibratory
energy to reduce the average energy delivered, gentle-
aspiration-cannula designs to reduce tissue avulsion
while maintaining aspiration performance, and refined
instrumentation design with regard to size and weight to
provide more artistic use and movement.
The amount of energy delivered to the tissues by an
ultrasonically vibrating probe is roughly proportional to
the square of the diameter of the ultrasonic probe or can-
nula, meaning that small reductions in diameter result in
significant reductions in delivered energy. Therefore,
the design objective is to utilize the smallest possible
diameter probe that accomplishes the desired emulsifi-
cation in reasonable time. Generally speaking, probes
smaller than about 2 mm in diameter are too flexible to
control (unless they are very short), and probes larger
than about 4 mm in diameter present excessive amounts
of energy to the tissues. The performance tradeoff is that
these smaller-diameter probes have reduced contact area
with the tissue and will therefore take longer to achieve
the desired emulsification. To increase the efficiency of
the emulsification process and decrease the operative
time, grooves have been added to the tips of the probes
to provide additional emulsification. With this grooved
design, tissue that contacts the sides of the probes will
be emulsified in addition to the emulsification that
occurs on the front surface of the probe, significantly
increasing the emulsification efficiency and decreasing
operative time. Because the vibratory energy is dissipated
A. Di Giuseppe et al.
80% Efficiency Applicable
% Side Power (W) (mJ/mm) tissue type
0 5.1 80 None
35 7.9 125 Fibrous
45 9.3 150 Moderate
58 12.1 195 Soft
from the sides of the probe as well as the front surface
of the probe, the energy is less concentrated and results
in a softer and more effective emulsion of the fatty tis-
sue. The number of grooves determines the relative par-
titioning of the vibratory energy. Four identical 3.7-mm
probes were evaluated as having zero, one, two, and
three grooves.
For the 3.7-mm probes, the partitioning, the power
for an 80% setting, and efficiency (80%) characteristics
are in Table 60.1. The results show that increasing the
number of grooves moves more energy to the sides of
the probe. Note also that the overall power and effi-
ciency also rise, meaning that the probes with more
grooves are not only more efficient but are able to con-
tact more tissue. The applicability of the different probe
designs to different types of tissue (soft to fibrous) is
discussed in detail in the next section on VAL tech-
nique. The reader is referred to [1] for a more detailed
discussion of methods and meanings related to the
power and efficiency calculation.
The Vaser system can deliver the vibratory energy
to the tissues in two different forms. The first is called
continuous wave, a form where the vibration is on
continuously at constant amplitude, commonly used
in previous-generation UAL devices. The second form
is pulsed mode, a form where the vibratory energy is
delivered in short-duration bursts, referred to as Vaser
mode. The advantage of Vaser mode is that the peak
energy is delivered in short burst (the on condition)
and is strong enough to emulsify fatty tissue while the
average energy delivered over time is reduced com-
pared to continuous mode. Vaser mode delivers around
ten bursts per second to the tissues, fast enough so that
the Vaser is generally imperceptible to the surgeon
and fast enough so that the resultant on/off effect is
uniform, smooth, and repeatable with regard to emul-
sification of the tissue. If the burst rate is less than
about ten times per second, then the on/off effect of
the device begins to present a timing issue to the sur-
geon with regard to the forward and backward strokes
of the device and also tends to produce less-consistent
results because of the physical spacing of the on
periods in the tissue.
60 Liposuction of Lower Extremities and Buttocks
Emulsified fatty tissue is more easily removed with
aspiration cannulas than non-emulsified fatty tissue.
Therefore, only gentle aspiration is required. A series
of emulsion cannulas, called the VentX cannulas, were
designed for efficient emulsion removal and minimal
trauma to the tissue matrix.
60.3 VAL Technique
The following guidelines cover safe and effective use
and application of the Vaser system for VAL including
the infusion, emulsification, and aspiration phases.
60.3.1 Infusion
1. Infusion. Use sufficient and appropriate amounts of
wetting solution. Make sure that the wetting solu-
tion is uniformly and evenly distributed in the
intended fragmentation volume. A gentle firmness
and fullness in the targeted area is desirable. Allow
sufficient time for vasoconstrictive requirement
(usually at least 10 min minimum for 1:1,000,000
concentrations). Apply wetting solution slightly
beyond the marked boundaries and in all potential
port locations. If you cannot achieve a sufficient dis-
tribution of fluid, then do not use the Vaser system in
that location. The targeted ratio of wetting solution
in to total aspirate out is approximately 1.5:1. If
more than a 2:1 ratio is used, the Vaser system begins
to lose efficiency due to the presence of excessive
fluid. If less than a 1:1 ratio is used, then there will
not be enough fluid to easily form emulsion.
60.3.2 Emulsication
2. Incision protection. Skin ports are designed to pro-
tect the incision edges during the fragmentation
phase with minimal incision size (~4-mm inci-
sion) and also protect the incision edges during the
suction phase. The skin ports should go in easily;
otherwise, the incision is too small or the port is
hooked on the underside of the dermis.
3. Skin protection. Use a towel (wet or dry) to cover
the skin near the skin port. This protects the skin
in the accidental situation where the probe is
levered into any exposed skin near the skin port.
This is especially important across the lower
1013
abdomen when working in the upper abdomen
and near creased buttocks. Note: A single towel
layer will not protect the skin from prolonged
contact with the vibrating probe or if the probe is
levered strongly into the skin through the towel. If
prolonged contact or strong levering is unavoid-
able, use a triple-folded towel to ensure skin
protection.
4. Probe selection. Use the correct probe (see the
chart). Use initial settings as suggested in the
chart. Adjust the setting so that the probe moves
smoothly through the tissue. If the probe is drag-
ging or struggling, then all of the energy will be
used to penetrate the tissue, and very little emul-
sion will occur. In this case, move the amplitude
up a notch or two. If this does not solve the prob-
lem, then switch to a probe designed for more
fibrous tissues (see the chart).
5. Probe movement. Keep the probe moving at all
times. Move it smoothly at a speed that the tissue
and amplitude setting will allow without exces-
sive pushing. Do not let the probe sit (vibrate) on
the location. A speed just slightly slower than stan-
dard suction cannula movement is appropriate.
6. Torquing. Do not torque the probe! Move the
probe in and out like spokes of a well; do not level
(torque) the probe sideways or up and down. The
skin protector should not be used as a fulcrum!
Torquing will lever the probe into the skin protec-
tor so that frictional rubbing can cause heat build-
up in the skin protector.
7. Application time and surgical endpoints. Look for
a loss of resistance to probe movement in all
areas of the intended fragmentation volume as the
primary indicator of the surgical endpoint. Initial
application (continuous or Vaser mode) is for every
200 mL of wetting solution infused at a site. This
guideline usually results in only partial emulsifica-
tion of the target volume. (These times are ONLY
suggestions; your requirement will be dictated by
many factors that cannot be covered in this short
space.) Special note: For the upper abdomen, use
1 min of ultrasonic applications for every 200 mL
of wetting solution infused until experience allows
otherwise.
8. End-hits. Prevent end-hits or punching into the
dermis from below. Place incisions so that probe
movement is generally parallel to the skin. Do not
try to go around tight corners this may result in
potential end-hit or torquing of the probe.
1014
Table 60.2 Tissue type, Vaser probe selection, mode, and amplitude setting
Continuous
Tissue type mode Vaser mode
Very soft Yes Yes
Soft Yes Yes
Medium Yes Yes
Fibrous Yes 2.9 mm only
Very fibrous Yes No
9. Cross-tunneling. Cross-tunneling is highly desir-
able for more uniform fragmentation and to
improve the subsequent aspiration performance.
10. Fee air vibration. Keep the tip of the probe inside
the patient at all times. Do not vibrate the probes
in free air, or they may be subject to cracking.
11. Dry application. Do not reapply the Vaser probe
after a site has been aspirated (the site is dry).
One of the most critical understandings necessary
for successful VAL is the proper choice of the probe
for the tissue type, tissue volume, and anatomical
location. The key elements are (1) the diameter of the
probe and (2) the number of grooves located at the tip
of the probe. The smaller-diameter 2.9-mm probes all
have three grooves for maximum efficiency and can be
used on tissue from soft to fibrous because of their
small diameter. The 3.7-mm probes may have one
groove, two grooves, or three grooves and should be
selected based on the tissue type and intended applica-
tion. Tissue type ranges from very soft to very fibrous
in five grades as shown in Table 60.2. The probe design
and appropriate amplitude settings for each tissue type
are shown.
1. DO NOT VIBRATE THE PROBES IN FREE AIR.
Always keep the tip of the probe, at least the distal
12 cm, in contact with tissue or fluids and inside
the patient and skin port before initiating vibra-
tion. Vibrating the probes in free air can lead to
cracking of the probe due to unintended transverse
vibrations.
2. The 3.7-mm probes are intended for rapid debulk-
ing and contouring of medium to large volumes of
soft to fibrous tissue.
3. The 2.9-mm probes are intended for debulking and
fine contouring of smaller volumes of soft to
extremely fibrous tissue and for sensitive areas.
4. GENERAL VOLUME CONSIDERATIONS. If a
single anatomical site is expected to yield less
than about 500 mL, then consider using the 2.9-mm
A. Di Giuseppe et al.
2.9-mm/ 3.7-mm/ 3.7-mm/ 3.7-mm/
3-groove 3-groove 2-groove 1-groove
(any length) (any length) (any length) (any length)
6080 7080 7080
6080 7090 7090 7080
7090 8090 8090 7090
8090 8090 8090
8090 8090
probes. If the expected volume (single anatomical
site) is between 500 and 1,000 mL, then consider
using either the 2.9-mm probes or the 3.7-mm
probes, depending on how fibrous the tissue is and
the nature of the anatomical site. If the expected
volume is over 1,000 mL (single anatomical site),
then consider using the 3.7-mm probes.
For a given diameter, probes with more grooves
(rings) fragment tissue more efficiently, but do not
penetrate fibrous tissues as easily because a signifi-
cant amount of the vibratory energy is coupled from
the sides of the probe as opposed to the front surface.
Therefore, for a given diameter, probes with fewer
grooves (rings) are more appropriate for fibrous tis-
sues. If the tissue is too fibrous for a selected 3.7-mm
probe design, select a probe with fewer rings. For
comparison purposes, a 3-ring 3.7-mm probe distrib-
utes approximately 70% of its energy from the sides
and 30% from the front surface. A 2-ring 3.7-mm
probe distributes approximately 50% of its energy
from the sides and 50% from the front surface. A
1-ring 3.7-mm probe distributes approximately 30%
of its energy from the sides and 70% from the front
surface.
Smaller-diameter probes will penetrate fibrous tis-
sues more easily than larger-diameter probes, irrespec-
tive of the number of rings. The 2.9-mm-diameter
probes all have 3 rings because their smaller diameter
allows penetration of even the most fibrous tissues
with 3 rings.
General recommendations: Use the 3.7-mm
2-groove for most applications, 7080% amplitude.
Use the 3.7-mm 3-groove for larger volumes of very
soft tissue (7080% amplitude) or the 3.7-mm 1-groove
for more fibrous tissues (7080% amplitude). Use the
2.9-mm 3-groove probes for smaller volumes, sensi-
tive areas, fine contouring, or very fibrous tissues (60
80% amplitude). Ninety percent amplitude may be
used with any probe, but consider selecting a probe
60 Liposuction of Lower Extremities and Buttocks
more appropriate for the fibrousness of the tissue
if 90% amplitude is required for smooth, gliding
motion.
Use continuous mode for general use, if tissues are
quite fibrous, or for higher speed fragmentation. Use
Vaser mode for more delicate work, softer tissues, or
for finer sculpting.
60.4 VentX Cannula
1. The VentX effect significantly increases the effi-
ciency of aspiration when large amounts of fluid/
tissue are in the suction tube. The suction tube will
always appear to be empty because the VentX effect
does not have a strong impact on suction perfor-
mance during the final feathering and finishing steps
because very little tissue/fluid is in the suction tube.
2. The port size (slow width and length) and the can-
nula diameter determine the application of the can-
nula, the speed of the cannula, and the aggressiveness
of the cannula. The VentX cannulas use a port size
that maximizes tissue and fluid removal speed while
reducing suction trauma by incorporating generally
smaller port sizes that are optimized for the diame-
ter of the cannula. For more accurate comparison
between different types of cannulas, it is best to
compare cannulas with approximately equivalent
port sizes rather than equivalent diameters because
the port size determines the size and volume of the
avulsed tissue particles.
The recommended approach to selection of a VentX
cannula is to use a diameter one size larger than you
would normally use because the port sizes on the
VentX cannulas are smaller than those found on tradi-
tional suction cannulas.
The 4.6-mm SST-6 pattern is designed for rapid
emulsion removal and debulking with small ports for
reduced suction trauma. The port size on this cannula
is slightly smaller than the port size on a traditional
3.7-mm Mercedes. The 2.7-mm SST-6 pattern is
designed for general debulking and shaping with less
suction trauma than a standard 2.7-mm Mercedes. The
port size on this cannula is slightly smaller than the
port size on a traditional 3.0-mm Mercedes. The 3.0-
mm SST-6 pattern is designed for finishing and feath-
ering, or slightly slower but less-traumatic debulking.
The port size on this cannula is slightly smaller than
the port size on a traditional 2.4-mm Mercedes.
1015
S
I
P
Fig. 60.1 Layer of subcutaneous emulsification with Vaser
UAL. S superficial, I intermediate, P deep
60.5 Technique
The main characteristic of Vaser relies in the capability
to work as well as in the intermediate and deep fat
layers (as in standard liposuction) as in the superficial
layer (Fig. 60.1). Its similar to what has been described
in superficial liposuction, but with the ability to target
only the thin fat layer, preserving vascularization,
innervation, of the superficial dermal plexus. This abil-
ity preserves from devascularization of the skin. Care
should be used to prevent too aggressive removal of
fat in this layer [2].
Fat thickness varies from anatomical sites: on the
back, there is only one layer of fat, while in the thigh
there all the three classic layers represented: superfi-
cial, intermediate, and deep (Fig. 60.2).
The surgeon must adapt his behavior to the ana-
tomic site where he works. In order to recreate the
natural appearance of the lower body, the patient posi-
tion must respect the gravity forces, by bending the
surgical bed 3045%.
Figure 60.3 is a 43-year-old patient who presents
with a history of previous liposuction in flanks, tro-
chanters, buttocks, and thighs. She required correction
of adverse outcomes and residues of lipodystrophy,
and harmonization of the natural lines of the body.
Planning the trochanter and flank lipodystrophy means
to draw correctly the new lines of concavity in har-
mony with the rest of the body. Treated areas in this
patient are upper abdomen, periumbilical region, hips,
thighs, front and inner thighs, trochanters, and inner
buttocks. Vaser liposuction of the lower extremities
and buttocks has excellent results with few complica-
tions (Figs. 60.460.8).
1016
Fig. 60.2 Fat thickness
varies in different body areas.
Thigh and abdomen are the
thickest areas. Back and face
are the thinnest
Back
Fig. 60.3 (a) Preoperative 48-year-old female. (b) Correction
of trochanter deformity. The hand placed and compressing the
trochanter helps to define the new line to be sculptured. (c) Zone
of adherence. (d) Correction of flank deformity. The hand
compresses the flank excess and helps to draw the new line.
(e) Preoperative marking. Yellow is volume to be reduced, green
are areas to enlarge with adipose tissue, and red are areas to be
avoided. (f) Positioning. (g) Positioning on the operating table,
pillow to raise the iliac spines. (h) The back of the operating
table is tilted to favor the gravity of the tissues. (i) Preoperative
markings and preparation of the field with broken bed and
catheterization of the patient. (j) Sterilization of the field.
(k) Incision under buttock for infiltration with tumescent solu-
tion. (l) Complete the tumescent infiltration in the posterior thigh
and trochanter. (m) Tumescent infiltration in two layers: superfi-
cial and deep. (n) The infiltration and temporary suturing of the
entry holes are completed. (o) The Vaser system: upper is the
ultrasound system, under is the infiltration and suction pump,
and right is the 5-lb bag of the tumescent solution containing
the local anesthetic Naropin and the vasoconstrictor adrenaline.
(p) Once the tumescence on left side is completed, start infiltra-
tion on right side. (q) The infiltration speed is fixed at 200 mL/
min. (r) Infiltration of the interior knee. (s) After removal of the
suture, the dilator is introduced to spread the skin incision to
allow the insertion of the skin protector. (t) Skin protector on
site. (u) The 2-ring 3.7-mm probe is tested in the saline solution
in order to verify the correct sound and vibration of the probe.
(v) Vaser probes; 1, 2, and 3 rings in 2.9- or 3.7-mm probes.
(w) New probe: one-ring 4.5-mm probe for large volume
emulsification. (x) After waiting for a minimum of 10 min for
allowing adrenaline to work, the Vaser probe is introduced
in the skin protector and starts the action. (y) The probe works
initially in the superficial subdermal layers where tumescent is
A. Di Giuseppe et al.
Thigh
most effective. This phase is called undermining of the skin
integuments from the underlying fat tissue. (z) To protect the
skin from friction injuries, it is advisable to place a wet gauze.
The action of the probe follows the classic multiangular pattern.
(aa) The probe is directed on the trochanter and on the gluteus.
(bb) The probe is placed at the infero-posterior thigh region, the
so-called banana fold. (cc) The interior thigh region is treated on
the superficial and deep layers. (dd) Verifying complete under-
mining of skin from subcutaneous tissue. (ee) Rounding the glu-
teus. Upward rotation of the skin after full undermining of
superficial layers. (ff) Vaser timing: 15 min and 25 s in continu-
ous action. (gg) After completing Vaser emulsification, the sur-
geon starts aspiration of emulsified fat. (hh) While the first
surgeon continues aspiration of the emulsified fat, the assistant
starts the application of ultrasound on the contralateral side. This
helps shorten operating time. (ii) Body contouring is a step-by-
step procedure. With a 1.8-mm cannula, the surgeon verifies the
contour of the trochanter with a vertical action. All the skin must
be free of adhesion from underlying layers. (jj) The cannula is
used continuously, carefully modeling the trochanter and banana
fold. The flap must be uniform, and this is where mistakes can be
made easily. Too much aspiration in this phase causes a depres-
sion. (kk) The aspirate from one site. (ll) The appearance of the
new gluteal, trochanter, and upper thigh shape at the end of the
procedure. (mm) New shape of buttock, lateral gluteal sulcus,
and trochanter. (nn) Bed is bent to increase gravity effect of the
tissue. See the new contour of buttock thigh at the end of the
surgery. (oo) Position at the end of the surgery. (pp) Infiltration
of the anterior thigh. (qq) Vaser to anterior thigh. (rr) See the
color of aspirate, virtually bloodless. (ss) The surgeon completes
aspiration and modeling on one side while the assistant performs
ultrasound on the contralateral side. (tt) Postoperative patient.
Left: preoperative. Right: postoperative
60 Liposuction of Lower Extremities and Buttocks 1017

b
1018 A. Di Giuseppe et al.

Fig. 60.3 (continued) c

Gluteal
depression
over great
trocanter

d
60 Liposuction of Lower Extremities and Buttocks 1019

Fig. 60.3 (continued)

1020 A. Di Giuseppe et al.

Fig. 60.3 (continued)

g

h
60 Liposuction of Lower Extremities and Buttocks 1021

i j

Fig. 60.3 (continued)

1022 A. Di Giuseppe et al.

m n

Fig. 60.3 (continued)

60 Liposuction of Lower Extremities and Buttocks 1023

r s

v w

Fig. 60.3 (continued)

1024 A. Di Giuseppe et al.

x y

Fig. 60.3 (continued)

60 Liposuction of Lower Extremities and Buttocks 1025

aa bb

cc

Fig. 60.3 (continued)

1026 A. Di Giuseppe et al.

dd

ee ff

Fig. 60.3 (continued)

60 Liposuction of Lower Extremities and Buttocks 1027

gg hh

ii

jj

Fig. 60.3 (continued)

1028 A. Di Giuseppe et al.

kk ll

nn

mm

oo

Fig. 60.3 (continued)

60 Liposuction of Lower Extremities and Buttocks 1029

pp qq

rr

ss

Fig. 60.3 (continued)

1030 A. Di Giuseppe et al.

Fig. 60.3 (continued)

tt
60 Liposuction of Lower Extremities and Buttocks 1031

Fig. 60.3 (continued)

1032 A. Di Giuseppe et al.

PRE PLAN POST

a

Fig. 60.4 Thirty-eight-year-old female. (a) front view/back view; (b) Oblique view/ profile view
60 Liposuction of Lower Extremities and Buttocks 1033

PRE PLAN POST

Fig. 60.4 (continued)

1034 A. Di Giuseppe et al.

PRE PLAN POST

a

Fig. 60.5 Forty-two-year-old female. (a) front view/back view; (b) oblique view
60 Liposuction of Lower Extremities and Buttocks 1035

PRE PLAN POST

b

Fig. 60.5 (continued)

1036 A. Di Giuseppe et al.

Fig. 60.6 Forty-four-year-old female with asymmetry of spine and lipodystrophy. (a) back view (b) front view
60 Liposuction of Lower Extremities and Buttocks 1037

Fig. 60.7 Thirty-three-year-

old female. (Left)
a
Preoperative. (Right)
Postoperative. (a) front view;
(b) back view; (c) profile
view

b
1038 A. Di Giuseppe et al.

Fig. 60.7 (continued)

c
60 Liposuction of Lower Extremities and Buttocks 1039

Fig. 60.8 Thirty-four-year-

a
old female. (left) Preoperative.
(right) One week postopera-
tive. (a) back view; (b) front
view; (c) oblique view; (d)
oblique view; (e) profile view;
(f) profile view

b
1040 A. Di Giuseppe et al.

Fig. 60.8 (continued) c

d
60 Liposuction of Lower Extremities and Buttocks 1041

Fig. 60.8 (continued) e

f
1042 A. Di Giuseppe et al.

References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science and clinical practice. Springer, Berlin
1. Shiffman MA, Di Giuseppe A (2006) Liposuction: principles
and practice. Springer, Berlin
 Buttock and Hip Enhancement
with Implants
Jesus Benito-Ruiz
61.1 Introduction
Buttocks, together with breasts, are the most relevant
and important areas of the feminine appearance. In the
Mediterranean culture, many women seek advice to
improve these areas. Liposuction is the main tool used
to sculpt the buttocks, hips, and subgluteal areas to
provide a more harmonious contour. However, some
patients exhibit some degree of atrophy, which can be
solved by grafting their own fat or by using implants.
Some authors reported extremely good results exclu-
sively for fat autografting [13]. Others favored the
use of gluteal implants [48] or a combination of both
approaches.
Men also seek enhancement of their buttocks; how-
ever, in their case, the goal is to achieve a more muscu-
lar, masculine appearance.
61.2 Buttocks
61.2.1 Aesthetics of the Buttocks
When defining the beauty of the buttocks, one should
consider the anatomical areas surrounding them, includ-
ing the hips, thighs, waist, and back; thus, several areas
should be analyzed to obtain the best surgical results.
J. Benito-Ruiz
Department of Plastic and Aesthetic Surgery,
Antiaging Group Barcelona, Clnica Tres Torres,
Barcelona, Spain
e-mail: drbenito@antiaginggroupbarcelona.com,
drbenito@cirugia-estetica.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_61, Springer-Verlag Berlin Heidelberg 2013
61
The buttock is round and firm. Most of its projection
and fullness lies in the central area. The outer area can
be shallow. The most difficult area to address is the
lower portion. Implants are not effective in this area,
and other procedures, such as liposuction or direct exci-
sion of the skin, may be required.
The anthropological proportion (in all cultures)
between the waist and the buttocks is 0.7. This has
been correlated with sexual attraction and to the poten-
tial for fertility in females.
Cuenca-Guerra and Quezada [9] studied 1,320 pho-
tographs of nude women and measured 132 women to
establish several landmarks that contribute to the
beauty of the buttocks. These are:
The greater projection of the buttocks coincides
with an imaginary line that runs through the upper
aspect of the pubis (Fig. 61.1).
Lateral depression. This hollow area on the lateral
aspect of each buttock is formed at its deepest point
between the greater trochanter and the belly of the
gluteal muscles (Figs. 61.1 and 61.2).
Infragluteal fold. This horizontal crease is located
under the ischial tuberosity. It has a gentle upper
concavity, and it should not reach beyond the center
of the thigh. It is an indicator of ptosis (Fig. 61.2).
Supragluteal fossettes. These are two hollows
located on either side of the medial sacral crest.
They are formed in their deepest part by the poste-
rior superior iliac spine (Figs. 61.2).
V-shaped crease. Formed by two lines arising in
the proximal portion of the gluteal crease. Directed
toward the supragluteal fossettes, these lines are
formed by the insertion of the gluteus maximus in the
lumbodorsal aponeurosis. They can be enhanced by
liposuction over the sacrum (Figs. 61.2).
1043
1044
Fig. 61.1 The maximal projection of the buttock is at the level
of the pubis. The optimal projection is when the distance between
the trochanter and the apex of the buttock is twice the distance
between the trochanter and the pubis
Fig. 61.2 The main landmarks of the buttock, as described
by Cuenca-Guerra and Quezada [9]. 1. Lateral depression. 2.
Infragluteal fold. 3. Supragluteal fossettes. 4. V-shaped crease
J. Benito-Ruiz
An additional feature that may contribute to the
beauty of buttocks is lumbar hyperlordosis, which
gives the illusion of a more projected buttock.These
authors also established that, in a profile view, the
distance between the greater trochanter and the
point of maximal projection of the buttock should
be twice the distance between the greater trochanter
and the pubis (Fig. 61.1).
Centeno [10] distinguishes eight aesthetic units:
Two symmetric flank units
One sacral triangle unit
Two symmetrical gluteal units
Two symmetrical thigh units
One infragluteal diamond unit
Roberts [11] described significant variations in aesthetic
ideals among ethnic groups in the United States. Asian
Americans prefer a shorter buttock with a higher point of
maximum projection, providing the illusion of longer legs
and a more balanced proportion between the torso and the
extremities. Hispanic and African Americans seem to pre-
fer more projection compared with either Asian Americans
or White Americans. A higher point of maximum projec-
tion, deeper lumbosacral depression, and an absence of lat-
eral thigh depressions also appear to be favored by African
Americans. White Americans seem to prefer a more athletic
ideal, with greater definition of the muscular and bony anat-
omy and less anteriorposterior projection.
61.2.2 Relevant Anatomy
Awareness of the different anatomical structures of
the gluteal region is necessary to avoid any undesired
injuries. The fat of the subcutaneous tissue, which is
located under the skin, is fibrous and contains many septa
that run through it and join the muscular fascia and the
skin. This particular disposition is responsible for some
of the retractions that can be observed in this area.
The gluteus maximus originates from the lateral
margin of the sacrum, the posterior superior iliac crest,
and, to a lesser extent, the coccyx and sacrotuberous
ligament from whence its fascicles are directed down-
ward and obliquely toward the iliotibial tract and the
greater trochanter. The gluteus medius is easily distin-
guished from the gluteus maximus because of its verti-
cally oriented fibers and its disposition, which is
slightly more lateral and is covered by the gluteus
maximus. It is located in a triangular area delimited by
the anterior superior iliac spine, the tubercle of
the iliac crest, and the greater trochanter. The gluteus
61 Buttock and Hip Enhancement with Implants
Fig. 61.3 Anatomy. Observe the relationship between the exit
of the sciatic nerve and the position of the implant. A line from
the coccyx to the trochanter marks the exit of the nerve
maximus covers, at its lowest portion, the piriformis,
obturator, and quadratus femoris muscles.
The motor innervation of the gluteus maximus is
effected by the inferior gluteus nerve, which comes
from the pelvis to the gluteal area, crossing the great
sciatic foramen posterior and medial to the sciatic
nerve. The gluteus branch is the first collateral (infe-
rior gluteal nerve) and arises next to the inferior border
of the piriformis muscle. As soon as it arises, the infe-
rior gluteal nerve divides, and its branches run between
the muscle and its anterior fascia.
The gluteus minimus and the sciatic foramen with the
piriformis muscle are located under the gluteus medius.
Under the piriformis muscle, the sciatic nerve leaves the
pelvis to run over the deeper muscle layer (gemellus and
obturator muscles) to enter the thigh. The exit of the sci-
atic nerve from the pelvis occurs at the level of a line that
joins the coccyx with the greater trochanter, a little more
than a third of the way along a line from the posterior
superior iliac spine to the ischial tuberosity. It then
descends to about halfway between the ischial tuberosity
and the greater trochanter. This is an important landmark
because the lower edge of the implant will be placed
over this area in the intramuscular technique (Fig. 61.3).
1045
Fig. 61.4 Subcutaneous placement of the implant should not be used.
In this case, the implants are clearly seen at the bottom of his buttocks
61.2.3 Techniques Available
Gonzalez-Ulloa [12] introduced the possibility of
placing implants for buttock augmentation in the sub-
cutaneous plane. However, this position is associated
with too many complications and yields poor aesthetic
results (displacement, irregularities, and capsular con-
tracture) (Fig. 61.4).
In 1984, Robles et al. [4] described a technique that
involves the insertion of implants in the space between
the gluteus maximus and the gluteus medius via a verti-
cal incision in the sacrum. However, in this method, the
undermining must not pass below the inferior border of
the pyramidal muscle to avoid sciatic compression by
the prosthesis, which, in some cases, is placed too high.
In 1996, Vergara and Marcos [5] reported the pos-
sibility of using implants inside the gluteus maximus
but did not establish a method for achieving this. These
authors did not show the levels and limits of the under-
mining in detail; however, in 2003 [6], they provided a
detailed method, describing their technique as intra-
muscular and establishing that a 3-cm thickness was
necessary to cover the implant properly. De la Pea [7]
described a technique for subfascial placement and
1046
Fig. 61.5 Choosing the implant depends on the type of the buttock. In short buttocks (left), round implants have to be placed.
In long and/or flat buttocks (right), oval implants are preferred
designed new implants for this particular position.
The implants were bigger and were positioned lower
compared with the intramuscular technique. The pro-
cedure was devised to avoid the problems related to
high-positioned implants, leaving a double bubble
deformity. Gonzlez [8] described his technique for
the proper placement of the implants within safe
boundaries (the XYZ method) using intramuscular
placement, similar to Vergaras technique.
61.2.4 Choosing the Implant
The author uses implants manufactured by Polytech
(Dieburg, Germany). The implants can be round
(smooth), as described by Robles, or oval (smooth or
textured; Vergara). Choosing the implant depends on
the volume that is desired but mainly on the shape of
the buttock. For short buttocks, the best option is a
round implant, whereas for long or flat buttocks, the
best option is an oval implant. For men, we also prefer
oval implants as we want to get a more squared, oblique
shape. For women, the option of choice is the round
implant unless the buttock is longer than it is wide
or unless it is flat. As a rule of thumb, if the projection
of the sacrum in the lateral view is greater than the
J. Benito-Ruiz
projection of the buttock, we prefer oval implants,
whereas if the buttock projects over the sacrum, the
author chooses the round implant for short and medium
buttocks and the oval one for long buttocks (Fig. 61.5).
The round implants are manufactured in three
volumes: 200, 250, and 300 mL. The oval implants come
in volumes of 115, 215, 290, 360, and 450 mL. Round
implants provide a higher projection compared with oval
ones (mean, 1 cm more). The volume of the implant
depends on the measurements performed. We routinely
measure the vertical distance between the iliac crest and
the line between the coccyx and the trochanter and trans-
versely between a line drawn from the posterior iliac
spine to the lateral edge of the gluteus maximus. Taking
into account that these measurements are performed on
the surface of the buttock, without considering the thick-
ness of the muscle, we choose an implant that is 2 cm
smaller than the aforementioned measurements.
61.2.5 Surgical Technique
The author always combines liposuction with the place-
ment of the gluteal implants. Markings are performed in
a standing position. The areas to be liposuctioned are
drawn, namely, the lumbar, presacral, and subgluteal
61 Buttock and Hip Enhancement with Implants
Fig. 61.6 When enhancing a buttock, not only an implant is
placed, but also we have to address the surrounding areas.
Liposuction is performed at the lumbar and infragluteal areas
(shadowed). The implant is placed between the cranial attach-
ments of the gluteus maximus muscle and the line joining the
coccyx and the trochanter
areas. The hip is also treated if it is very voluminous.
The goal of liposuction around the buttocks is to enhance
the projection and the shape of the central area of the
buttock, where the implant will be placed (Fig. 61.6).
The implants are placed in the two upper thirds of the
buttocks. A line is drawn between the coccyx and the
greater trochanter. This line corresponds to the exit of
the sciatic nerve through the foramen and under the piri-
formis muscle. The implant will also be placed laterally
to a line drawn from the upper posterior iliac spine.
The patient is placed in the ventral decubitus posi-
tion with a small pillow under the pelvis to flex the hips
slightly. In our view, this position helps the dissection
of the pocket where the implant will be placed. Peridural
or general anesthesia is used, depending on the patients
preference. The markings are checked again as they
move slightly in relation to the bony landmarks.
The author always starts the procedure by perform-
ing liposuction. The areas to be aspirated are infiltrated
with Ringer lactate + adrenaline 1/1,000,000. The stab
1047
Fig. 61.7 The incision is placed 23 cm above the coccyx.
A subcutaneous tunnel is performed over the muscle, and then
blunt dissection is performed parallel to the muscle fibers
incisions for the cannulas are performed separately
from the incision for the placement of the implant. Only
3- and 4-mm cannulas are used for the liposuction, and
drains are never placed in the aspirated areas.
For the placement of the implant, the intramuscular
technique described by Vergara and Marcos [5] is uti-
lized. After isolating the anus with a polyvinylpyrroli-
done-impregnated gauze, a 7-cm incision is performed
in the intergluteus sulcus, about 23 cm above the coc-
cyx (i.e., the lower limit for the pocket between the
coccyx and the trochanter). We leave an intact strip of
skin of 34 mm in the middle of our incision. This strip
is deepithelialized and is used to anchor the closing
stitches. This prevents wound dehiscence, which is the
main complication of the procedure in our experi-
ence. The subcutaneous tissue lateral to this strip is
incised down to the presacral fascia, and a short tunnel
is created under the fascia of the gluteus maximus
muscle. This creates a tunnel that is 10 cm in length,
slightly oblique, and parallel to the muscle fibers
(Figs. 61.7 and 61.8). The approach to the pocket is
made in the muscle, with a blunt dissection parallel to
1048 J. Benito-Ruiz

the muscular fibers. Using a finger, we slip on the bone

Fig. 61.8 Initial subcutaneous tunnel showing the gluteus
maximus
and start the intramuscular dissection, leaving a thick-
ness above this area of 23 cm. Although dissection
is started using a finger, the handle of a Langebeck
retractor is then used. This is a good blunt maneuver to
create the pocket without damaging the muscle ceil-
ing. It is very important not to make the pocket parallel
to the surface (it should be oblique, following the axis
of the pelvis, 3045 downward) as there is a risk of
piercing the muscle at its lateral aspect, which may
lead to extrusion of the implant into the subcutaneous
area (Fig. 61.9). The limits of the pocket are the iliac
crest and its gluteus attachments at the upper aspect,
the lateral edge of the gluteus major at the lateral aspect
(medial to a line centered at the greater trochanter), and
the inferior line between the coccyx and the trochanter.

Fig. 61.9 The dissection in

the muscle has to be
performed following the
inclination of the iliac bone
(middle and lower). If the
dissection is performed as in
the upper, we will pierce the
muscle, and the implant will
extrude laterally
61 Buttock and Hip Enhancement with Implants
Fig. 61.10 Intraoperative. (Left) Textured oval implant, 250 mL, just before insertion. (Right) The implant has been placed at the
right buttock. Observe the difference with the left side
Fig. 61.11 The prosthesis is placed intramuscularly. A layer of
muscle will be protecting the sciatic nerve immediately
underneath
The pocket is packed with wet gauze while we dissect
the contralateral pocket.
Once both pockets have been created, the space is
checked, and any remaining muscular fiber is broken
bluntly or via electrocautery under direct vision using
an optic-light fiber retractor. The implants are then
1049
placed (Fig. 61.10). This can be slightly hazardous and
requires patience from the surgeon and the assistant.
The implant should be intramuscular so a layer of glu-
teus maximus muscle is left between the implant and
the deeper structures (sciatic nerve) (Fig. 61.11).
Drains are not usually placed. The muscle incision is
closed using 20 Vicryl sutures. The closure has to be
perfectly performed to try to separate the implant from
the subcutaneous and sacral tunnel completely.
The skin is then closed using 30 Vicryl sutures.
A small, 8-French drain is left under negative pressure
in the subcutaneous tunnel, which is extracted through
a stab incision and never via the sacral wound. The
interrupted subcutaneous sutures are anchored to the
deepithelialized strip of dermis left in the midline of
the access. Finally, the skin is closed with a buried,
intradermal 30 Monocryl suture.
The wound is dressed, and a girdle is placed. The
patient is placed on antibiotics and anti-inflammatory
drugs for 7 days. The patient can get up and sit 24 h after
the operation; however, she/he has to avoid the dorsal
decubitus position for 56 days. Patients cannot exer-
cise for 5 weeks and should wear a girdle at all times.
Lymphatic drainage of the aspirated areas is advised
during this period (two sessions/week). After this period,
they can resume normal activity (Figs. 61.1261.19).
61.2.6 Complications
The commonest complication encountered is wound
breakdown. This happened in 10% of the authors
patients. One case developed infection. If there is a
1050
Fig. 61.12 (Above) Preoperative 56-year-old male patient. (Below) 6 months postoperative with smooth, round, 250-mL implants
good separation between the subcutaneous tunnel
and the intramuscular pocket, wound dehiscence and
infection do not compromise the implants. It is for this
reason that we try to make a tight, waterproof clo-
sure of the muscular incision. Since we introduced a
modification for skin closure by leaving a presacral
dermal strip, we have not experienced any wound
dehiscence.
Other potential complications include seroma,
hematoma, sciatic nerve compression and pain, and
implant displacement.
Seroma has not been observed thus far; however,
this could be correlated with the liposuction rather than
J. Benito-Ruiz
with the surgical approach used for the placement of
implants. Bruising and ecchymosis are common, but
no hematoma requiring surgical intervention has been
encountered. Hematoma can provoke some pain and
discomfort to the patient.
Temporal sciatic nerve compression with pain can
happen in some patients as the lower edge of the
implant is located over the sciatic foramen. The intra-
muscular technique prevents the placement of the
implant directly on the nerve; however, the postopera-
tive pain and Lasgue sign that some patients experi-
ence shortly after the operation seem to be related to
the tension of the muscle and the extra volume caused
61 Buttock and Hip Enhancement with Implants
Fig. 61.13 (Above)
Preoperative 35-year-old male
patient. (Below) Postoperative
with smooth, round, 250-mL
implants
by the surgical hematoma. It is self-limited and can
be treated with nonsteroidal anti-inflammatory drugs
(ibuprofen 600 mg tid) and relaxant drugs (metocarba-
mol 380 mg tid).
Implant displacement is avoided by not performing
an extensive dissection of the pocket, especially later-
ally. Because the plane of placement is intramuscular,
it is extremely important to keep in mind the surgical
anatomy of the area and achieve a superior flap or cov-
ering of the implant that is at least 3 cm in thickness
[6]. The author observed a case of upward displace-
ment of the implant in a patient who started muscular
training very early. It was solved surgically by closing
the pocket at its upper limit and making a capsulotomy
1051
caudally. Patients must not engage in any exercise
before the fifth postoperative week.
61.3 Hip Implants
Since the introduction of the highly active antiretroviral
therapy for human immunodeficiency virus (HIV)
infection in 1996, a range of adverse effects collec-
tively termed lipodystrophy have been described,
including metabolic (dyslipidemia and insulin resis-
tance) and physical alterations [13, 14]. These can be
divided into central adiposity and peripheral atrophy.
The atrophy is especially visible in the face and in the
1052
Fig. 61.14 (Above) Preoperative 32-year-old female patient. (Below) Postoperative with 290-mL, smooth, oval implants
lower extremities, where it is characterized by thin legs
with very noticeable veins and buttock flatness. Our
efforts as plastic surgeons are focused on palliative
treatments for these physical changes.
Men can compensate for the lack of fatty tissue by
hypertrophying the muscle; however, in women, this
might produce a masculine appearance. Buttock implants
alone are not able to provide the typical rounded contour
J. Benito-Ruiz
of the feminine hips, so we devised a method to enhance
both the frontal and the profile contours [15].
61.3.1 Technique
All markings and designs are made while the patient is
upright (Fig. 61.20). For hip implants, the pocket is
61 Buttock and Hip Enhancement with Implants
Fig. 61.15 (Above) Preoperative 27 year-old male. (Below) Postoperative with 250 mL, smooth, round implants
centered slightly below the greater trochanter. Before
the operation is started, the markings have to be
redrawn as they rise when the patient is in the prone
position. A 4-cm incision is made on the edge of the
iliac crest, posterior to the anterior iliac spine and at
the level of the tensor fascia latae muscle (Fig. 61.21).
The fascia of this muscle is identified and sectioned
(Fig. 61.22). Dissection follows a downward direction
under the fascia, and the pocket for the implant is cre-
ated just over the hip joint (Fig. 61.23). This can be a
difficult area to dissect as it is also the area of insertion
of the tendon of the gluteus maximus muscle. Great
care must be taken not to connect the buttock pocket
1053
with the trochanteric pocket. The implant is placed
under the fascia of the tensor muscle (Fig. 61.24). The
wound is closed in layers.
Patients can sit and perambulate 24 h after the sur-
gery, must wear a compressive girdle for 1 month, and
must refrain from physical activities (exercise) for
5 weeks.
For hip enhancement, 100-mL oval implants are
used in all cases. So far, the author has operated on
eight cases: six patients with HIV infection and retro-
viral therapy and two cases after gender reassignment
surgery. In one case, the hip implant slipped into the
buttock pocket. The patient underwent surgery again
1054
Fig. 61.16 (Above) Preoperative 30 year-old female. (Below) Postoperative with 300 mL, smooth, round implants
during which a connection between the buttock and
the hip was discovered. The implant was positioned
on the fascia latae, and the connection was closed.
A capsular contracture of the implant developed on
this side.
Silicone implants provide enhanced projection
in this area and yield a lateral curvilinear contour
(Figs. 61.25 and 61.26). There are no specific implants
J. Benito-Ruiz
for this area, but the gluteal oval implant works well
for this purpose. The implant must be strictly under
the fascia of the tensor fascia latae muscle to avoid
visualization of the edges of the implant. Subcutane-
ous placement yields worse results, with visualization
of the edges of the implant and encapsulation (as
observed in one of our cases). Extreme care is neces-
sary in creating the pocket to avoid connecting the
61 Buttock and Hip Enhancement with Implants 1055

Fig. 61.17 (Above) Preoperative 25 year-old female. (Below) 1 year postoperative with 250 mL, smooth round implants

space under the fascia latae to that under the gluteus
maximus muscle.
Displacement is potentially the commonest compli-
cation that can happen with this technique. Thus far, we
do not know how the implant will behave in the long
term, with the movement of the hip and the pressure
exerted here by the greater trochanter. Fat grafting is an
alternative to implants in this area, and it is the first
option we think of when faced with these cases. Implant
augmentation in the hip area is indicated when fat graft-
ing is not possible because of a lack of donor sites or
because we want to ensure the result without being con-
cerned about fat resorption. The two techniques could
be used simultaneously to obtain a better projection.
1056 J. Benito-Ruiz

Fig. 61.18 (Above)

Preoperative 40 year-old
female. (Below) Postoperative
with 250 mL, smooth, round
implants
61 Buttock and Hip Enhancement with Implants 1057

Fig. 61.19 (Above) Preoperative 53 year-old female. (Below) Postoperative with 290 mL, smooth, oval implants. She had a long
buttock with a pronounced lateral depression
1058 J. Benito-Ruiz

Fig. 61.20 Typical markings

for a HIV patient with
lipodystrophy. The author
marks the areas to be
aspirated and the position for
the implants (250 mL oval for
the buttock and 100 mL oval
for the hip)

Fig. 61.21 Technique for placement of an implant over the hip.

The incision is made at the iliac crest, behind the upper iliac
spine. A subcutaneous tunnel is performed caudally and the
incision is performed at the fascia of the muscle. The tunnel goes Fig. 61.22 Intraoperative: incision at the fascia lata. The mus-
downward under the fascia lata to the trochanter cle is in the depth of the hole
61 Buttock and Hip Enhancement with Implants 1059

Fig. 61.23 Position of the

implant under the fascia lata
at the level of trochanter

Fig. 61.24 Placement of the 100 mL oval implant

1060 J. Benito-Ruiz

Fig. 61.25 (Above)

Preoperative 36 year-old
female with HIV
lipodystrophy. (Below)
Postoperative after 290 mL
oval implants for her buttocks
and 100 mL oval implants for
her hips
61 Buttock and Hip Enhancement with Implants 1061

Fig. 61.26 (Above)

Preoperative 24 year-old
male-to-female patient.
(Below) Postoperative with
oval 100 mL implants to
enhance the hip area
1062
References
1. Crdenas-Camarena L, Lacouture AM, Tobar-Losada A
(1999) Combined gluteoplasty: liposuction and lipoinjec-
tion. Plast Reconstr Surg 104(5):15241531
2. Roberts TL 3rd, Toledo LS, Badin AZ (2001) Augmentation
of the buttocks by micro fat grafting. Aesthetic Surg J 21(4):
311319
3. Mendieta CG (2003) Gluteoplasty. Aesthetic Surg J 23(6):
441455
4. Robles J, Tagliapietra J, Grandi M (1984) Gluteoplastia de
aumento: implante submuscular. Cir Plast Iberolatinoamer-
icana 10:4
5. Vergara R, Marcos M (1996) Intramuscular gluteal implants.
Aesthetic Plast Surg 20(3):259262
6. Vergara R, Amescua H (2003) Intramuscular gluteal implants:
15 years experience. Aesthetic Surg J 23(2):8691
7. de la Pea JA (2004) Subfascial technique for gluteal aug-
mentation. Aesthetic Surg J 24(3):265273
8. Gonzlez R (2004) Augmentation gluteoplasty: the XYZ
method. Aesthetic Plast Surg 28(6):417425
J. Benito-Ruiz
9. Cuenca-Guerra R, Quezada J (2004) What makes buttocks
beautiful? A review and classification of the determinants of
gluteal beauty and the surgical techniques to achieve them.
Aesthetic Plast Surg 28(5):340347
10. Centeno R (2006) Gluteal aesthetic unit classification: a tool
to improve outcomes in body contouring. Aesthetic Surg J
26(2):200208
11. Roberts TL (2005) Gluteal augmentation course. Presented at the
Aesthetic Meeting 2005, Annual Meeting of the American Society
for Aesthetic Plastic Surgery, New Orleans, LA, April 2005
12. Gonzalez-Ulloa M (1991) Gluteoplasty: a ten-year report.
Aesthetic Plast Surg 15(1):8591
13. Carr A (2003) HIV lipodystrophy: risk factors, pathogenesis,
diagnosis, and management. AIDS 17(Suppl 1):S141S148
14. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ,
Cooper DA (1998) A syndrome of peripheral lipodystrophy,
hyperlipidaemia and insulin resistance in patients receiving
HIV protease inhibitors. AIDS 12(7):F51F58
15. Benito-Ruiz J, Fontdevila J, Manzano M, Serra-Renom JM
(2006) Hip and buttock implants to enhance the feminine con-
tour for patients with HIV. Aesthetic Plast Surg 30(1):98103
 Liposculpture and Buttock
Augmentation with Fat Grafting
Arturo Grau
62.1 Introduction
The buttocks are perhaps the most admired feminine
attribute. It is possible to augment and/or model the
gluteus region with fat grafting after a prior liposuc-
tion. Getting perfect results in liposuction and buttock
augmentation with fat grafting is, however, remark-
ably challenging. Despite its long learning curve, we
can get very satisfactory results and a lot of patient
satisfaction. Taking it as a standardized procedure,
it becomes reproducible and avoids complications.
Getting good results with this procedure begins with
good patient selection, the way the markings are made,
the use of a standardized technique, and controlling the
patient in the postoperative period.
Localized fat deposits can be treated with liposuc-
tion, and the fat harvested can be used for modeling of
the gluteus area. The author has very good outcomes
with the results of fat grafting in an intramuscular
plane. Permanent results depend on the survival of the
adipocytes. The blood supply in the muscular plane is
much richer than in the subcutaneous plane, so the fat
grafted in the muscles of the buttock area is more likely
to survive. Making small tunnels of 35 mL per path
during the withdrawal of the cannula in the intramus-
cular plane guarantees the survival of these fat cells.
A. Grau
Facial and Body Cosmetic Surgery, Director of Multiclinica
Medical Center President, Paraguayan Academy of Cosmetic
Surgery (PACS), International Member of the AACS
Asuncin, Paraguay
e-mail: agrauestetica@hotmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_62, Springer-Verlag Berlin Heidelberg 2013
62
62.2 Technique
62.2.1 Preoperative Care
Complete blood and heart tests are run prior to sur-
gery, and 1 g of cefalexin and 500 mg of Cipro are
administered to the patient orally 6 h prior to
surgery.
62.2.2 Preoperative Markings
The preoperative markings are very important for good
results, especially in LS. It is very important to define
what we want to take out, so these fat deposits are
marked with circles in black. The more the number of
circles that define the fat deposits, the more fat there is
to take out. It is important to do these markings with
the patient standing up. This way you can note all the
excessive fat in the contour of the patient (Fig. 62.1).
The markings in blue limit the areas where the fat will
be grafted.
The results can be appreciated right after finishing
surgery (Fig. 62.2), and the results are long lasting
while the patient maintains her body weight after
surgery. If the patient gains weight again after sur-
gery, the results are not going to be the same, because
she will not gain fat in the same way she used to
(not in the waist where all the fat is extracted). The
patient that gains weight after fat transfer augments
the size in her arms and legs in larger proportions than
before.
1063
1064 A. Grau

a b c

d e

Fig. 62.1 Markings should be made in the standing position. Black markings indicate fat to be extracted. Note double circles where
greater amount of fat deposits are present. Blue marking indicate gluteal region for fat injection. Front view (a), back view (b), mid
front view (c), mid back view (d). The result immediately after finishing surgery in (e)
62 Liposculpture and Buttock Augmentation with Fat Grafting 1065

Fig. 62.2 (a) Preoperative. a

(b) Two years postoperative
1066 A. Grau

Fig. 62.2 (continued)

b
62 Liposculpture and Buttock Augmentation with Fat Grafting 1067

62.3 Surgical Technique

62.3.1 Anesthesia

The anesthesia is a peridural or epidural block with a

catheter with light sedation so that the patient does not
feel any pain at all and there is no concern about lido-
caine toxicity, since sometimes the infiltration volume
exceeds 2 L. If you have a well-trained anesthesiologist
who is used to doing this block, which is quite frequent
in women giving birth, you do not have anything to worry
about. Also with this anesthesia, the buttocks (where you
do not do tumescent anesthesia) are also blocked, so you
can do the fat grafting without pain whatsoever.
Then again if you are not able to find a good and
trustworthy anesthesiologist in your area, the tumes-
cent technique of anesthesia is always recommended.
Since most of the times this anesthesia is combined
with sedation, during the fat grafting it will be neces-
Fig. 62.3 The infiltration cannula is a 2-mm Klein infiltration
sary to do more sedation because the gluteus area is cannula with the length enough to reach the upper abdomen
not infiltrated with tumescent solution at any time. from the pubic area (30 cm)
Infiltration will deform this area, and it will be impos-
sible to determine what amount of fat to inject.
Anesthesia of the upper back, arms, and submental For the infiltration, a peristaltic pump is used that
fat is under tumescent. rotates in both directions allowing to infiltrate and suc-
tion with the same pump. The infiltration cannula is a
2-mm Klein infiltration cannula (Fig. 62.3) with the
62.3.2 Inltration length enough to reach the upper abdomen from the
pubic area (30 cm). Infiltration is done at a medium
Since epidural block anesthesia is used, lidocaine is velocity while liposuction is done at full speed. Equal
not necessary in the infiltration solution. Only amounts of solution are to be infiltrated on each side of
2 ampules of epinephrine per liter of saline solution at the areas, so it is important to measure the amount in
room temperature are used for the infiltration solution. each area. The infiltration should be symmetrical, and
With this concentration of epinephrine, there is much that will help obtain better results.
less blood loss during the procedure and the infiltration
ratio is as a super wet technique rather than a tumes-
cent one since the author has not seen any difference in 62.3.3 Liposculpture
over 9 years in the blood loss with both techniques.
The author started out with the tumescent that had The cannulas used are Mercedes style 3, 4, and 5 mm
1 ampule of epinephrine and moved on to 2 ampules wide and from 20 to 30 cm long. The thinner the can-
that really stopped the blood loss in a crucial way. nula, the more forgiving it is, so those who are starting
After that there was no real difference in super wet or out should be careful and start out with the thinner can-
tumescent. The author prefers super wet (1 L of infil- nulas. For trouble areas such as the trochanteric region,
tration distributed in front side and 1 L on the back inner thighs, and lower abdomen, 3-mm cannulas
side) because you have more control of the fat you are should be used unless the patient is really overweight,
taking out and you can appreciate the color of the fat and only in these cases should a 4-mm cannula be
harvested. The author has infiltrated more than 3 L of used. The peristaltic pump is then set to aspirate
this solution many times with absolutely no side effects switching the direction, and all the fat is harvested in
because of the epinephrine. the same sterile saline solution bag (Fig. 62.4).
1068 A. Grau

Fig. 62.4 The peristaltic

pump infiltrates the solution
a
and afterwards aspirates the
fat by changing the direction
of rotation. All the fat is
harvested in the same sterile
saline solution bag (a). A
closer view of the fat
harvested in the sterile saline
solution bag. Note the yellow
color of the fat extracted due
to the high concentration of
epinefine (two amps per liter)
and low aspiration pressure of
the peristaltic pump (just 4
mm/hg).

The cannula incisions should be made in areas that
will be hidden by the bikini garments. Just two 5-mm
incisions are performed in the pubic area for the whole
abdomen and front side of the waist (Fig. 62.5). Two
incisions are performed in the bikini line just outside
of the Michaelis rhomboid and one inferior to it for
treating the fat deposits of the back side of the waist,
hips, and Michaelis rhomboid (Fig. 62.6). For the
upper back, two incisions are performed where the
mark of the bra will be in the back. All these incisions
are hidden by the bikini. Now, the incisions performed
on the outer side for the trochanteric deformity are just
on top of the marking. These will be seen, so they need
to be as small as possible, and using a thin (3-mm)
cannula is better.
It is better to divide the body in areas or zones to
obtain greater and more-symmetrical results. The abdo-
men is divided into four zones: upper right, upper left,
62 Liposculpture and Buttock Augmentation with Fat Grafting
Fig. 62.5 Two 5-mm incisions are performed in the pubic area
for the whole abdomen and front side of the waist
Fig. 62.6 Two incisions are performed in the bikini line just
outside of the Michaelis rhomboid and one inferior to it for treat-
ing the fat deposits of the back side of the waist, hips, and
Michaelis rhomboid
lower right, and lower left. Equal amounts should be har-
vested from each side, and it is important to start out
liposculpturing the fat from the most distant area from
the incision point, so the fat harvested is brought towards
the incision. This is very important if you do not want to
leave depressions in the area. Start out with a 3-mm,
30-cm-long cannula for the upper abdomen (Fig. 62.7).
Then go to the waist with a 4-mm, 25-cm-long cannula
(Fig. 62.8), to end up in the lower abdomen with a 3-mm,
20-cm cannula (Fig. 62.9). Preoperative and postopera-
tive of the abdomen and waist are shown in Fig. 62.10.
The inner thighs are done with a 3-mm, 2025-cm
cannula depending on the length of the legs from an
incision just below the marking (Fig. 62.11). The knees
are done with the same cannula from an incision just
1069
b
Fig. 62.7 A 3-mm, 30-cm-long cannula is used for the upper
abdomen. Equal amounts of saline infiltration and fat extraction
should be performed for achieving symmetry, beginning from
the mid abdomen (a) and moving to the outter abdomen (b) in a
windshield wiper motion
below the marking (Fig. 62.12). The trochanteric region
is done with this same 3-mm, 25-cm-long Mercedes
cannula from an incision just superior to the markings,
also starting from the most distant part marked, going
very superficial, and bringing the fat harvested from
that area towards the incision (Fig. 62.13). This is the
only area where one goes from superficial to the deep
plane and one has to be very careful, harvesting the fat
in a windshield wiper motion to not leave any depres-
sions. The back side of the waist, the hips, and the back
are all done with a 4-mm cannula that can be from 25 to
30 cm long (Fig. 62.14). The waist is the only area that
permits the surgeon to withdraw all the fat, leaving
almost nothing, and the harvest begins in the deep
plane moving on to the superficial plane.
1070
a a
b b
Fig. 62.8 A 4-mm, 25-cm-long cannula is the best for the waist.
Here all the fat should be extracted to create a thin waist. Always
beginning from the inner area (a) and moving to the outer area.
Here one can grab the fat with the left hand so the cannula can
extract more fat leaving this area with only skin and muscle (b).
62.3.4 Buttock Augmentation
The last liter of fat aspirated is used for the grafting,
and it is recollected in a special autoclavable container
device made for this purpose that allows the remaining
solution to be drained after decantation (Fig. 62.15).
One gram of cefazolin is put into the fat harvested, and
nothing else is added. The use of platelet-rich serum
can be used.
The fat is then loaded into a 60-mL syringe from
the container (Fig. 62.16). Now it is ready to be grafted
into the buttocks. With a 2.5-mm cannula, 1215 cm
long, the fat is grafted into the muscles of the buttock
region. The grafting is started from a deep to a superfi-
cial plane, and the injection is done during the with-
drawal of the cannula. Small tunnels are made of 5 mL
each. So it is necessary to make many tunnels, and the
modeling of the area is done in this manner. It is the art
A. Grau
Fig. 62.9 A 3-mm, 20-cm-long cannula for the lower abdomen.
Here a small cushion of fat should be always left to obtain a
natural look. If excessive fat is extracted from the lower abdo-
men, it could look too flat and odd. Also it can be left with
depressions. Always from the center (a) to the outer area (b) in
a windshield wiper motion
of every surgeon to make and shape each buttock
(Fig. 62.17). It should be done calmly and with no
hurry. When the cannula finds some obstruction in its
path, it must be extracted and reinserted.
After a few intramuscular injections are done,
sometimes it is necessary to graft superficial into
the subcutaneous fat also, to model some buttocks that
do not shape well with only the intramuscular grafting.
The amount of fat grafted goes from 60 to 500 mL, but
the usual amount goes from 180 to 360 mL per side.
The results are visible immediately after surgery
(Fig. 62.18). CT scans have been made on one patient to
show the survival of the fat over time: The pre-injection
scan where the muscle is shown intact, the postoperative
at 7 days where the graft is visible inside the gluteus
major muscle, and after 3 months where the graft is
organized and living inside the muscle (Fig. 62.19).
62 Liposculpture and Buttock Augmentation with Fat Grafting 1071

a b

Fig. 62.10 (a) Preoperative. (b) Immediate Postoperative of the abdomen and front side of the waist. The back side is done after
finnishing the front side and turning the patient to ventral decubitus

a b

Fig. 62.11 The inner thighs are done with a 3-mm, 20 to 25-cm-
long cannula depending on the length of the legs and the amount of
fat to extract, from an incision just below the marking. Care should
be taken to only extract the exact amount of fat and not leave any
depressions, since it is very easy to over resect in this area. Opening
the leg and bending the knee is the best way to extract this area (a).
Always begin from the front side and move to the back side (b). I
divide the inner leg in three compartments. Front, mid and back.
Always finish one compartment before moving to the following
1072 A. Grau

Fig. 62.12 The knees are

done with the same cannula
from an incision just below
the marking. The fat is easier
to extract in an open leg
position

62.3.5 Wrapping

After finishing the procedure, the patient is wrapped

with skin color 5-cm Micropore. This avoids swelling
and also decreases pain in the first few days postopera-
tive. This wrapping is taken out at day 5 postopera-
tively (Fig. 62.20). To avoid pain during the withdrawal
of the wrapping, it is recommended that the patient
should shower with warm water just prior to taking it
off so that it will be wet and this way it comes off
easily.

62.3.6 Postoperative
Immediately after surgery, a compressive garment is
used over the tape wrapping and recommended to be
used for at least the first 15 days postoperative. Patients
are allowed to be in any position in bed, but most fre-
quently, sideways or ventral decubitus. Ambulation is
started the next morning after taking out the Foley cath-
eter left during surgery and the immediate postopera-
tive. The patients are encouraged to ambulate. Lymphatic
drainage and 3-MHz ultrasound is also recommended to
help avoid swelling, 3 times a week for the first month.
The patient may return to normal activities after day 5
and to exercise after the month. Abdominal muscle
exercises are not allowed until 2 months after surgery.
Patients do complain of pain over all the waist area,
which is the place where all the fat is extracted and
where the most trauma is done. Morphine-like analge-
Fig. 62.13 The trochanteric region is done with the same
3-mm, 25 cm cannula from an incision just superior to the mark-
ings, also starting from the most distant point marked and har-
vesting the fat towards the incision point. Here it is important to
go from superficial to the deeper plane. This way it is easier to
maintain the natural curve of the female thigh without leaving
depressions that are very easily left in this area
sics are used for the first few days, and this way they
can manage pain a lot better.
62.4 Complications
Since antibiotics are used even before surgery is per-
formed, there has not been a case of infection after
surgery. Seven years ago, there was one case of
62 Liposculpture and Buttock Augmentation with Fat Grafting 1073

a b

Fig. 62.14 (a and b) LS of the waist from the two incisions
done in the back. Here a 4-mm, 25 to 30-cm-long cannula is
used. All the fat should be extracted in order to achieve a thin
waist. (c) LS of the hip. (d) It is very important to finish one side
first before beginning the second. This way the amount of fat
extracted can be measured, to extract the same amount on the
second side. This will help achieve symmetry. The change in the
contour is already visible after just finishing one side. (e) LS of
Michaelis rhomboid, left side finished. (f) The whole LS of the
rhomboid finished.
1074
e to 6 months postoperative. The usual time for the
f
Fig. 62.14 (continued)
hematoma on one inner thigh that resolved with
drainage and volume transfusion of packed red blood
cells.
Prolonged edema is frequent, especially in the
waist, where all the fat is taken away, sometimes up
A. Grau
swelling to disappear is 24 months. Hyperesthesia
and paresthesia are possible complications but are
mostly temporary and disappear in a few months
postoperative.
Hyperpigmentation and hypopigmentation of the
skin are possible complications and disappear with
dermatologic treatment, but mostly over time.
62.5 Conclusions
Liposculpture and buttock augmentation are procedures
that can be combined together and represent a real chal-
lenge for the surgeon, over all for the beginning one. If
care is taken in making it a standardized procedure, the
surgeon will achieve better outcomes and more patient
satisfaction (Figs. 62.2162.24). The use of the equip-
ments detailed in this presentation such as the peristal-
tic pump and the aseptic fat container helps achieve
good results with lower risks. Absolutely no treatment
is done to fat harvested in this technique except the
addition of an antibiotic after simple decantation, and
the results are fabulous with cases documented after
more than 6 years. It is a safe and reproducible proce-
dure in well-trained hands. The surgeon starting out
with this procedure should go from less aggressive
extraction of the fat deposits to not leave sequelae as
depressions and asymmetry. But in time, one can go to
more aggressive extraction to really create changes in
the contour of who is seeking to look better.
62 Liposculpture and Buttock Augmentation with Fat Grafting 1075

Fig. 62.15 (a) The last liter of fat aspirated is used for the grafting, and it is recollected in a special autoclavable container device
made for this purpose. (b) Allows the remaining solution to be drained after decantation
1076 A. Grau

Fig. 62.16 The fat is loaded into a 60-mL syringe from the container

Fig. 62.17 (a) A 2,5-mm 1214-cm cannula is used for the

intramuscular fat injection. (b) The cannula goes inside the glu-
teus muscles and the injection is done during the withdrawal of
the cannula only injecting 3 to 5 mL per path
62 Liposculpture and Buttock Augmentation with Fat Grafting
Fig. 62.18 The results are visible immediately after finishing
surgery. Taking a photo at this time will show the patient how
she will look after the swelling diminishes, that will occur in 3
to 4 months postoperative. (a) Preoperative. (b) Immediate post-
operative, note the incisions in the upper back done where the
1077
bra will be hiding them. These are necessary for LS of the upper
back, where one can not reach from the bottom incisions. In
some cases to achieve a good buttocks contour, some fat must be
injected superficially in the subcutaneous plane to give the but-
tocks the proper shape
1078 A. Grau

a b

Fig. 62.19 (a) CT scan before the injection. (b) CT scan 7 days after the IM injection of fat. (c) CT scan 3 months after injection
showing permanent fat retention. (d) The same patient before surgery. (e) 5 days postoperative. (f) 3 months postoperative.
(g) 4 years postoperative
62 Liposculpture and Buttock Augmentation with Fat Grafting 1079

d e

f g

Fig. 62.19 (continued)

1080 A. Grau

a b

Fig. 62.20 (a) Wrapping with 3 layers of Micropore tape postoperative. (b) The use of some gauze between the skin and the tape
can help with the withdrawal. (c) The gauze prevents excessive sticking of the tape

Fig. 62.21 (a) Preoperative 25-year old female. (b) One month postoperative following liposculpture, buttocks augmentation with
fat injection and breast augmentation. Notice the persistent swelling at one month. (c) Fourteen months after surgery
62 Liposculpture and Buttock Augmentation with Fat Grafting 1081

Fig. 62.21 (continued)

1082 A. Grau

a b c

d e

Fig. 62.22 (a) Preoperative 22-year old female back view. before surgery. These details must be observed by the surgeon
(b) 5 days postoperative, same view. Notice that only one tro- before surgery. (c) Preoperative half-side view. (d) Immediate
chanteric area was treated due to a asymmetry that she had postoperative. (e) 15 days postoperative
62 Liposculpture and Buttock Augmentation with Fat Grafting
a b
d e
Fig. 62.23 (a) Preoperative 21-year-pld female weighing 52
kg. (b) Immediately after LS and Buttock augmentation (c) Two
months postoperative with 8-kg weight gain. Notice the fat
gained in legs and buttocks. Almost no fat gained in the waist
where all the fat is extracted. (d) Three years postoperative
1083
c
f
with 15-kg weight gain. (e) Secondary liposculpture to treat new
fat deposits. (f) Immediate postoperative after secondary LS. (g)
Preoperative front-side view. (h) Two months after surgery with
8-kg weight gain. (i) Three years after surgery with 15-kg weight
gain. (j) Markings for secondary LS
1084 A. Grau

Fig. 62.23 (continued)

g h

i j
62 Liposculpture and Buttock Augmentation with Fat Grafting 1085

Fig. 62.24 (a) Preoperative

27-year old female. (b) Five a b
days after LS and buttock
augmentation. (c) One month
after surgery still with
persistent edema. (d) Fourteen
months after surgery with a
12-kg weight loss. Notice that
the buttock still conserves the
same volume and shape as the
one month after photo (c)

c d
1086 A. Grau

Bibliography Coleman SR (1995) Long-term survival of fat transplants: con-

trolled demonstrations. Aesthetic Plast Surg 19:
421425
Roberts TL III, Toledo LS, Badin AZ (2001) Augmentation of
Fodor PB (1999) Defining wetting solutions in lipoplasty. Plast
the buttocks by micro fat grafting. Aesthetic Surg J 21(4):
Reconstr Surg 103:15191520
311319
Pereira LH, Radwanski HN (1996) Fat grafting of the buttocks
Shiffman MA (1998) Medications potentially causing lidocaine
and lower limbs. Aesthetic Plast Surg 20:409416
toxicity. Am J Cosmet Surg 15:35
Fodor PB (2002) Secondary lipoplasty. Aesthetic Surg J
Fodor PB (1993) Superficial liposuction. Aesthet Plast Surg
22(4):337348
13:1014
Lewis CM (1992) Correction of deep gluteal depression by
Jackson RF, Dolsky RL (1999) Liposuction and patient safety.
autologous fat grafting. Aesthetic Plast Surg 16:247250
Am J Cosmet Surg 16(1):2123
Gasparotti M, Lewis CM, Toledo LS (1993) Superficial liposcu-
Fodor PB (1995) Wetting solutions in aspirative lipoplasty: a plea
lpture. Springer, New York
for safety in liposuction. Aesthetic Plast Surg 19:379380
 Large Volume Fat Transplant
to Buttocks and Legs for 63
Enhancement and Reconstruction

Lina Valero De Pedroza

63.1 History
The author started with this technique early 1992 fol-
lowing requests and expectations of patients who were
very sensitive about the culture of beauty and requested
enlargement of the volume of buttocks, calves, and
ankles. Surgical techniques to enhance buttocks or
calves volume at that time, consisted of placement of
silicone implants below the gluteus maximus muscle
in the buttocks or over the internal gemellus muscle
for calves. There was no other technique known by
the author to enlarge ankles.
Those surgical techniques with placement of sili-
cone implants had been performed by the author; how-
ever, they were characterized by various inconveniences,
such as (1) very painful within the 20 postoperative
days, (2) very poor aesthetic results, and (3) permanent
and/or long-term disabilities consisting of persistent
pain when approaching the sitting position or when-
ever wearing heels. Seeking to obtain the optimal aes-
thetic results, reducing the recovery period, searching
for the ideal and persistent filler material that reduces
the side effects, and avoiding physical or aesthetic
complications, it was decided to adopt the fat grafting
tissue as a technique of beautification and reconstruc-
tion of the human body using large volumes of fat tis-
sue harvested by the liposuction technique. Supporting
this theory was the history of extensive related uses of
small quantities of fat tissue described in the medical
literature since 1893 to correct defects in soft tissues
and also encouraged by the pure concept of a graft as it
is described in plastic surgery, such as skin graft or hair
graft.
63.2 Technique
63.2.1 Fat Retrieval
Any anatomical area from below the neck is good to
retrieve fat tissue. I will mention those areas of major
concentration of volume such as the arms, back, abdo-
men, hips, knees, and buttocks.
63.2.2 Method
Tumescence with 1,000 mL saline and 1 mL epineph-
rine is performed in any area used as a donor site. Five
to ten minutes before harvesting are required to achieve
maximum hemostasis and to obtain a clean tissue.

L.V. De Pedroza
Plastic and Reconstructive Surgery, Universidad del Valle,
Medellin Bogot, D.C, Colombia, South America
e-mail: lvalero@lafont.com.co
63.2.3 Liposuction
Liposuction is performed with a mixture of ultra-
sonic assisted liposuction and traditional liposuction

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 1087

DOI 10.1007/978-3-642-21837-8_63, Springer-Verlag Berlin Heidelberg 2013
1088
at low pressure with machine. The introduction of
ultrasound assisted liposuction was made in 1997
and has been used to the present time. Since 1991,
machine liposuction has been performed at low
pressure.
63.2.4 Fat Tissue Graft
The fat tissue graft is placed in sterile glass flasks that
have been vapor sterilized. An amount of 13 L and
more is kept sterile with no contact with air until natu-
ral decantation of the cells is done. This takes about
1525 min to happen.
63.2.5 Decantation
After the natural separation of the fat is done by
placing the fat cells into the surface and the tumes-
cent liquid on the bottom of the flasks, harvested tis-
sue is ready to be transferred to a sterile syringe. For
large volumes, a 60-mL syringe is used, and for
small volumes, a 10-mL syringe is used to inject the
graft.
63.2.6 Materials
1. Cannulas from 3 to 5 mm wide are used to harvest
tissue. If tissue is retrieved with a 3-mm cannula,
injection of the graft is performed with a 3-mm
cannula.
2. Blunt cannulas to harvest and blunt cannulas to
graft are used.
3. Liposuction machine at low pressure (350 Hg) is
used to preserve the integrity of the cells which
could be disrupted under high vacuum pressure.
4. Syringe liposuction is recommended for small
amounts of fat tissue transplant.
5. Centrifugation of small amount of fat tissue to be
transplanted over the face and hands is recom-
mended in order to obtain a more precise quality
of graft free of liquid and avoid unnecessary
edema.
6. Avoid washing or exposing to the air is the main purpose
of manageability of the graft preserving its viability and
preventing its contamination, as a priority.
L.V. De Pedroza
63.2.7 Why to Choose Fat as a Tissue Filler
Fat tissue has three of its large list of characteristics
which makes it the ideal tissue filler:
1. It is composed of cells that have the property to be
hypertrophic.
2. It is composed of cells able to grow in volume, and
at the same time, it is a hyperplasic tissue.
3. It has a large amount of cells able to grow in vol-
ume (Hyperplasic nature). This property makes it
the ideal souffl to fill a depressed or deformed
anatomical area.
63.2.8 Ideal Placement of the Fat Graft
The nature of human anatomy places fat tissue under
the skin surface and over the muscular structure.
Also, intraperitoneally, fat covers all the abdominal
organs and structures with a large amount of the fat
cushion named epiplon. The authors work was
based on sculpting the normal anatomy of the human
body by reshaping and relocating fat tissue, and the
goals initially were based on enhancing the volume
of buttocks, ankles, and calves for beautification. The
graft was placed under the skin following the normal
anatomic growth and existence of the fat tissue.
Grafting large volumes of fat tissue is of great help
as a total body tissue filler and is great to reconstruct
body deformities from traumatic, congenital, or iatro-
genic. It produces excellent results in cosmetic
enhancement and is a long-term survival tissue that is
well tolerated and low in risks if the graft is adequately
manipulated by preventing its contamination and pre-
serving the survival of its cells while harvesting it.
63.2.9 Sinopsis of the Large Volume Fat
Transplant Technique
(a) Materials:
3 to 5 mm cannulaes.
Syringe suction.
Machine suction low pressure.
3 to 5 mm cannulaes blunt for injection.
Tumescence with 1000 cc saline and 1 mg
Epinefine.
Sterile glass 1000 cc flacks.
63 Large Volume Fat Transplant to Buttocks and Legs for Enhancement and Reconstruction 1089

(b) Donor sites areas: 4. Normal to the touch

Arms. 5. No side effects if manipulated sterile
Back. 6. Easy handling
Hips. 7. Long lasting permanent in life
Abdomen. 8. No functional changes
Buttocks. 9. It is a fat cells graft, not a fat (liquid) or oil
Knees. injection
(c) Methods:
Traditional suction machine.
Syringe suction. 63.4 Complications
U.S. Assisted liposuction.
Centrifugation for small amounts of fat trans- The author has had a small amount of slight complica-
plant tissue (for face and hands) tions, varying from skin vesicles from the skin tape,
(d) Recipient areas: redness, and edema of the ankles for 20 days postoper-
Buttocks. atively. There was one case of erysipelas that occurred
Hips. for traumatic reasons and was treated with penicillin
Muscular atrophies in Legs, Arms, Ankles. without losing the fat transplant volume injected over
(e) Manipulation of the graft: the legs. In summary; the clinical results and satisfac-
No washing. tion of our patients, the long term follow up, today 16
Natural decantation 1525 minutes in the sterile years of experience with this technique; makes us rec-
glass flasks. ommended it to all of our patients with reconstructive
Storage for 3045 minutes with NO contact with and cosmectic purposes.
air.
Direct suction from patients -to flasks-to sterile
syringes-to patient again as a graft. 63.5 Discussion
(f) Amount of fat volume transplanted:
Area Amount (mL) Since 1992 to the present year, the author has per-
Each buttock 240700 formed 3,720 cases of fat transplant to the buttocks
Each leg 150400 (Figs. 63.163.4). Thirteen hundred of those cases had
Each ankle 120280 calf and ankle enlargement together, and 722 cases had
Each hip 300750 reconstructive purposes. Sixteen hundred and ninety-
eight cases were performed for cosmetic purposes.
The average age of those patients ranged from 18 to
63.3 Specic Qualities of Fat Transplant 75 years old. Female patients were the 89% of the total
operated patients. Aging process produces an early
1. Fat is an autologous tissue appearance of sagging buttock, as early as in the
2. Hyperplasic tissue (large number of cells) 47-year-old females, and progresses every 5 years. The
3. Each fat cell has a hypertrophic capacity to grow in ideal filler product for rejuvenating and aging buttock
volume (the souffl effect) area is fat tissue harvested in large volumes.
1090 L.V. De Pedroza

a b

Fig. 63.1 (a) Preoperative 58-year-old female with aging process of the buttocks with wrinkles and loss of volume. (b) Eight
months postoperative after 300 mL of fat transfer to each side

Fig. 63.2 (a) Preoperative

28-year-old female requesting
increased volume of buttocks.
(b) One year following fat
retrieval from abdomen,
waist, and hips and transfer
of 300 mL of fat to each
buttock
63 Large Volume Fat Transplant to Buttocks and Legs for Enhancement and Reconstruction 1091

Fig. 63.2 (continued)

b

a b

Fig. 63.3 (a) Preoperative

27-year-old male with
agenesis of gemellus muscle
of the right leg. (b) Seven
years after 350 mL fat graft
over the agenetic musculature
of the right leg
1092 L.V. De Pedroza

Fig. 63.4 (a) Preoperative

72-year-old male with a
skinny legs. (b) Two and
one half years after 300 mL
fat transfer to each calf and
ankle

b
 Treatment of Venous Insufciency
with Sclerotherapy
Alessandro Frullini
64.1 Introduction
Sclerotherapy of varicose veins is the injection of drugs
capable of transforming the walls of varicose veins into
fibrotic cords. This has been used for many years in the
treatment of varicose veins, but the last 15 years has rep-
resented a true renaissance of sclerotherapy. This was
due to the introduction of sclerosing foam in this field.
The sclerosing foam (SF) is a mixture of gas and a
liquid solution with tensioactive properties. The behav-
ior of a sclerosing foam is different when injected as
compared to the action of a liquid solution because it
forms a coherent bolus inside the vein that avoids any
mixing of the drug with blood. In this way, it is possi-
ble for the very first time to achieve full control of drug
concentration inside the vein and time of contact
between the sclerosing agent and the endothelium.
Using a liquid sclerosing agent the true effect on
endothelium is due to the specific concentration of
sclerosant in a vein for a desired time. The combina-
tion of ideal time with ideal concentration gives opti-
mal sclerosis. This is easily achieved in smaller veins
like telangiectasias (where sclerotherapy has never
presented a problem), but is difficult to obtain in large
veins like the great saphenous vein. The liquid sclero-
sant is diluted with the amount of blood inside the vein
itself, but a sclerosing foam pushes away almost all the
blood creating a virtually bloodless field where the
ideal condition for sclerotherapy is achieved.
A. Frullini
Studio Medico Flebologico, Figline Valdarno, Florence, Italy
e-mail: info@venevaricose.it,
info@associazioneflebologicaitaliana.it
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_64, Springer-Verlag Berlin Heidelberg 2013
64
The year 2000 represented the turning point in foam
sclerotherapy when the three-way tap technique was
introduced, that was capable of preparing a good
extemporary foam with extremely reduced cost. An
ideal injection of air-based SF should be made no more
than 15 s after generation.
64.2 Technique
Foam can be used in every kind of classical sclerother-
apy, but larger trunks and recurrences are the best indi-
cations. Smaller veins or teleangectasias are not the best
indication for SF as for those small vessels the ideal
active concentration of sclerosant is easily reached with
liquid too. The author reserves polidocanol (POL) foam
(or very seldom sodium tetradecyl sulfate STS) for
resistant cases or for telangectatic matting that, on the
contrary, is a very good indication for SF. Tessaris foam
is difficult to push into these small vessels, but reducing
the liquid to air ratio to 1:2 or 1:1 ameliorates quality
and durability of foam, enhancing safety and results.
Reports on a reversible neurological and visual
deficit have been published with liquid and foam scle-
rosants. Despite the opinion of many authors on a rela-
tionship between foam sclerosants and patent foramen
ovale (PFO) on the development of such side effects,
the author has investigated the possible production of
vasoactive substances from the vein after the injection
of an irritative agent as a sclerosant drug. In such con-
dition, in an experimental model on rats, augmented
release of Endothelin 1 was observed. The author is
studying the possible role of Endothelin in the genesis
of neurological and visual disturbances after sclero-
therapy and present results seem encouraging. Among
1093
1094 A. Frullini

the major complications, a partial DVT (deep vein a

thrombosis) has been reported after sclerotherapy for
varices. However, in every case, the DVT was asymp-
tomatic and without sequelae at 3 months.
Many new options are now offered to patients and doc-
tors: surgery, thermal ablation (endo venous laser abla-
tion, radiofrequency closure and steam obliteration) and
endovenous chemical ablation (foam sclerotherapy).
Sclerotherapy is a treatment capable of achieving
good results in a safe and less invasive manner than
surgery or every other technique.
Thermal techniques are only a different way of
treating the saphenous trunk using a method that
is something very similar to surgical intervention:
b
The patients are in a (semi)operating room, a sterile
field is prepared, and anesthesia is given. Phlebectomies
will be done on tributaries in most cases. The only dif-
ference is that in the stripping operation the same fiber
(stripper) is retrieved, and a junctional ligature is made.
Moreover, gentle invaginating stripping under local
anesthesia seems to me less invasive, when properly
done, than laser ablation or radiofrequency closure.
If a different treatment of saphenous insufficiency
is to be found, at this time, only foam sclerotherapy
has the ideal prerequisites: it is cheap, 10 min for the
whole procedure, easy to perform for a trained doctor,
tributaries are treated at the same time as the saphen-
ous vein, and return to daily activity is resumed after a
15-min walk. No anesthesia is required at all and post-
treatment pain is absolutely absent.
Moreover, venous insufficiency it is not simply a Fig. 64.1 (a) Typical red and blue telangiectasia that is the best
defect that must be eliminated. It is a true disease with field of application of liquid sclerotherapy. (b) Larger telangi-
ectasias that are easily accessed but they carry a higher risk for
a natural evolution. The simplicity of foam sclerother- pigmentation
apy makes the treatment easily accepted by patients
even if more sessions are needed in subsequent years
to stabilize this condition. Neither surgery, nor thermal polidocanol is the preferred drug at a concentration rang-
ablation can claim the same benefits. This probably ing from 0.25% to 0.5%, the latter generally used.
means that foam sclerotherapy is going to become the Holding syringes in the proper way is the first step.
ultimate treatment for venous insufficiency, replacing The non dominant hand is the most important as it is the
every other treatment for most cases. one that flat and stabilize the target area (Fig. 64.2).
Keeping the syringe as parallel as possible to the skin is
very important. For this reason smaller 1 mL syringes
64.3 Sclerotherapy for Spider Veins could be useful. The vessel blanches during injection
and keeping the needle inside the vein for few seconds
Sclerotherapy plays a major role in the treatment of more prevents backflow of blood in telangiectasia before
telangectasias. Despite many physicians reserve such the onset of a good spasm (Fig. 64.3). Eccentric com-
treatment only for blue telangiectasias, sclerotherapy of pression with cotton rolls is not useful in my experience
tiny red telangiectasias can be successfully accomplished for red telangiectasia but keeping a digital compression
with good technique and little magnification (Fig. 64.1). or maintaining the needle inside the treated vein for a
Foam sclerotherapy is seldom necessary and liquid longer time until spasm appearance is advisable.
64 Treatment of Venous Insufficiency with Sclerotherapy 1095

Fig. 64.2 The non-dominant hand holds the skin creating a

b
firm surface on which needle enters easily and precisely

Fig. 64.3 Maintenance of the needle in situ for some time

avoids immediate blood refilling of the vessels

Figure 64.4 shows spider veins before and after

treatment with polidocanol 0.5% with follow up at
6 months. Foam sclerotherapy could be sometimes
useful like in larger telangiectasia with risk of bleed-
ing. In this case, polidocanol 0.5% foam Tessari
method with a lower air to liquid ratio (1:2) was used
achieving a good immediate spasm (Fig. 64.5). Fig. 64.4 Spider veins. (a) Before treatment. (b) After treat-
ment with polidocanol 0.5%. (c) Follow up at 6 months

64.3.1 Complications great saphenous vein insufficiency. The poor esthetic

Besides from general complications (e.g., allergy), for
spider veins treatment local complications are few if
proper technique is used and avoiding treatment in
patients with reflux on major axes. In Fig. 64.6 the patient
was treated for spider veins notwithstanding a severe
outcome caused large disappointment in the patient and
only several years later the pigmentations reabsorbed.
Cutaneous necrosis is very rare if not impossible using
liquid polidocanol 0.5% according to proper doses and
administration technique but it is a possible complication
of foam sclerotherapy for teleangectasias (Fig. 64.7).
1096 A. Frullini

a c

Fig. 64.5 (a) Blue bleb in CVI with high risk of bleeding. (b) Treatment of blue bleb with foamed polidocanol 0.5% (three way
technique). (c) Optimal spasm immediately after sclerosing foam injection

64.4 Sclerotherapy for Larger Veins
In the authors experience, more than 80% of saphenous
insufficiency can be effectively treated with echogu-
ided foam sclerotherapy. Inguinal and popliteal recur-
rences (Fig. 64.8) are the best indications but truncal
varices with a diameter below 1.2 cm have a similar late
outcome of stripped saphenous veins.
Patients are thoroughly examined with duplex ultra-
sound in the standing position and treatment is per-
formed in a supine position. The target vein is accessed
in a transverse scan but with lateral access. This makes
the injection much easier (Fig. 64.9).
A class 2 (3040 mmHg) thigh level is then used for
1 month. Occasional blood collection inside treated veins
is aspired directly or under echo-guidance (Fig. 64.10).
64 Treatment of Venous Insufficiency with Sclerotherapy
Fig. 64.6 (a) Severe pigmentation occurred after sclerotherapy
for telangiectasia in a patient with previously untreated greater
saphenous vein insufficiency. (b) Partial resolution of pigmenta-
tion after several years (after surgical stripping of the GSV)
1097
Fig. 64.7 Small cutaneous necrosis after foamed sodium tet-
radecylsuphate injection of red telangiectasias
Fig. 64.8 (a) Large varicose veins of the poplitea fossa. This is
a good indication for foam sclerotherapy as surgery may be
complex in such condition. (b) The success rate of treatment in
saphenous veins below 1.2 cm of diameter at medium follow up
after sclerotherapy are similar to surgery
1098 A. Frullini

a b

Fig. 64.9 (a) Echoguided sclerotherapy of SSV insufficiency with foamed polidocanol 3% (lateral injection with tranversal scan of
the target vein). (b) Thrombectomy is easily accomplished after saline solution injection and using a 20 gauge needle

b c

Fig. 64.10 (a) for sclerosed

veins located deeply, echo-guided
thrombectomy is very helpful.
Failing in retrieving blood
confirms the good quality
of vein occlusion (occlusion test).
(b) Great saphenous vein
insufficiency. (c) Two years after
echoguided foam sclerotherapy
with polidocanol 3%
 Part VII
Miscellaneous
 Labioplasty
Cristina Isac, Aurelia Isac, Nicolae Antohi,
and Tiberiu I. Bratu
65.1 Introduction
Labia minora reduction is the most common female geni-
tal surgery performed nowadays. Most consider that ide-
ally, labia minora and clitorial hood should not protrude
past the labia majora, although labia minora anatomy is
extremely variable and normal variants are the rule.
Enlarged or deformed labia minora are a source of low
self-esteem and sexual inhibition, from the aesthetic point
of view, but they may be a source of functional impair-
ment, as well. They can cause discomfort with wearing
tight-fitting clothes, during sports (cycling, walking), sit-
ting, or sexual activities. They may impair appropriate
hygiene, may cause constant irritation and pruritus.
C. Isac (*)
Department of Plastic Surgery, University Hospital for Plastic
Surgery and Burns, University of Medicine and Pharmacy
Carol Davila, Bucharest, Romania
e-mail: ina@drisac.ro
A. Isac
Department of Plastic Surgery , University Hospital for Plastic
Surgery and Burns, Bucharest, Romania
e-mail: ireliflorin@yahoo.com
N. Antohi
University Hospital for Plastic Surgery and Burns, Bucharest,
Romania
University of Medicine and Pharmacy Carol Davila,
Bucharest, Romania
e-mail: nantohi@yahoo.com
T.I. Bratu
Brol Medical Center Private Clinic, Timisoara, Romania
Department of Plastic and Reconstructive Surgery
University of Medicine and Pharmacy Victor Babes,
Timisoara, Romania
e-mail: office@brol.ro
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_65, Springer-Verlag Berlin Heidelberg 2013
65
The attention that this kind of operation has gained is
mainly due to increased media popularization. Women
are becoming more and more aware of genital area
appearance nowadays. Although some women seek sur-
gical reduction because of functional impairment, most
do apply for surgery because of psychological distress.
The causes for labial enlargement are not very clear.
They may be congenital, present from birth, or, more
commonly, from puberty, or may be acquired (chronic
irritation and inflammation, repetitive trauma, exoge-
nous androgens, after pregnancy or with age) [1].
The most important benefits of labial reduction sur-
gery, apart from the aesthetic outcome, are a better
hygiene, less chronic irritations, and lack of interfer-
ence with sexual intercourse [2].
Even a minimal variation of what is perceived to be
the norm can cause significant emotional distress
and impact on patients quality of life [3].
65.2 Anatomy
Figure 65.1 demonstrates the normal female genitalia
anatomy. The labia minora are two cutaneomucosal
folds located between the labia majora. The free border
extends from the clitoris to the posterior commissure
(fourchette).
It is widely accepted that labia minora are naturally
not perfectly symmetrical, with one labium being
larger than the other. The patients should be warned
about this and told that perfect symmetry can be,
anyway, hardly achieved after surgery.
Most commonly, both labia are diffusely enlarged
from the clitorial hood to the posterior fourchette;
sometimes, only one labium is enlarged.
1101
1102
Fig. 65.1 Anatomy of the female external genitalia
65.3 Surgical Techniques
Up to now, there has been no consensus concerning the
best procedure for labia minora reduction. Traditionally,
labia minora were reduced by amputation and oversewing
the edges. Thus, by removing the labial contour, the labial
edge is represented by the scar line. The method had
a great disadvantage: the labial edge was not preserved,
the normal labial contour is lost and, as a consequence, the
circular scar retraction narrowed the vaginal introitus. The
resulting scar can cause chronic irritation in contact with
clothes and may interfere with sexual intercourse.
The more recently developed techniques are based
on preservation of the normal free labial edge. The
goals of any one used technique should be:
1. Reproducibility
2. Hidden scars which do not interfere with the labial
edge
3. Noninterference with sexual activity
4. Long-term stable results
A technique widely and safely used is the excision
of a central V-wedge from the most protuberant part
and suturing of the anterior and posterior remaining
C. Isac et al.
flaps. This technique preserves the normal edge of the
labia with less chance of scar constriction and tender-
ness [1]. Many variations of this technique have been
described which will be briefly presented herein.
The central wedge and clitorial hood reduction is
the preferred techniques performed by the authors. As
it was described by Alter [1], the central wedge exci-
sion can be extended laterally. The inner wedge is
designed as a V with its tip to the vagina. The wedge
excision is designed to excise the most protuberant
part of the labium, be it more anteriorly or posteriorly
placed. More frequently this redundant tissue is
centrally located (Fig. 65.2). The angle and extent of
the wedge resection vary depending on the cutaneous/
mucosal excess and laxity.
Care is taken to excise the exact amount necessary.
Excising too much will produce tension on the inci-
sion line with high risk of wound dehiscence and
vaginal introitus narrowing. In order to avoid excis-
ing too much tissue, the surgeon should place two or
three fingers inside the introitus and stretch the labia
minora [4].
The frenulum of the clitoris extends to the upper
part of the labium minor. Frequently, the inner and
outer excision does not have the same shape. The outer
wedge excision may be prolonged laterally and anteri-
orly to the excess clitoral hood or redundant lateral
labium if these ones exist. This excision takes the form
of a hockey-stick (Fig. 65.3) [1].
In case the excess of the clitoral hood is either medial
or lateral, these clitoral folds can be excised conserva-
tively as separate lateral or medial ellipses. The clitoris
should never be exposed after hood excision. The inter-
vening subcutaneous tissue is carefully preserved while
the leading labial edge is carefully reapproximated.
The technique is performed as follows. A single dose
of antibiotic (usually a first generation cephalosporin) is
administered before the operation. The anesthesia is
general or regional.
First the markings are drawn with the patient in the
lithotomy position.
A solution containing lidocaine 1% and epinephrine
1:100,000 is injected into the labia. Marcaine may be
used instead of lidocaine to reduce postoperative pain.
Fifteen minutes are awaited for the epinephrine to
achieve its maximum vasoconstriction effect. Doing
so will reduce bleeding and intraoperative edema/
65 Labioplasty 1103

Fig. 65.2 Surgical markings showing planned internal V

markings b

Fig. 65.3 External hockey-stick extension of the V excision for

excess lateral labium; separate elliptical excision for clitorial hood

ecchymosis, shorten operative time and prolong the

anesthetic effect [5]. The blade is directed obliquely,
beveling the incision away from the outer margins, so
as to preserve enough subcutaneous tissue (Fig. 65.4).
Preserving as much subcutaneous tissue as possible
is essential to a good subcutaneous closure which
avoids wound dehiscence and fistula formation. Careful
hemostasis of the fine vessels is critical for a good
outcome.
The leading labial edge is closed with one mattress
suture to prevent wound separation (Fig. 65.5). The
Fig. 65.4 (a) Inner wedge excision, obliquely directed, pre-
serving as much subcutaneous tissue as possible. (b) Excision
completed and careful hemostasis
subcutaneous tissue is closed in layers with 50 PDS
or Monocryl (Fig. 65.6). The internal incision is closed
with a running suture and the external one with either
a running or interrupted sutures 50 PDS (Fig. 65.7).
1104
a a
Fig. 65.5 (a) Leading labial edges approximated. (b) One
separate mattress suture placed at the leading labial edge
The lateral clitorial hood is closed with 50 Monocryl
in the subcutaneous tissue and subcuticular or running
50 or 60 Monocryl, or PDS (Fig. 65.8).
One important thing that has to be underlined is the
closure in layers with a good approximation of the
subcutaneous tissue which helps in preventing wound
dehiscence, especially since the area is most often
humid and difficult to be kept dry.
C. Isac et al.
Fig. 65.6 (a) Subcutaneous tissue closure in layers. (b)
Subcutanoeus tissue closure completed
There are quite a few other techniques that have
been described all of which have the same principles of
preserving the labial free edge and hidden incisions.
Maas and Hage [6] developed a technique in which
the labia are resected in a W fashion (in a complementary
manner on the lateral and medial aspects of each labium)
so as the resulting edges are sutured interdigitated in order
to prevent labial edge scar retraction. The remaining
length of the labia is kept to a minimum of 1 cm. The
authors stated that the zigzag technique described leaves
no continuous scar at the labial edge and prevents trans-
verse or longitudinal scar contraction. The labials edge
roundness is preserved, and the anteroposterior color
change is gradual (in the wedge technique, the sudden
change in color from the lighter anterior one to the darker
posterior one may be a drawback, although minor).
For the same goal, Felicio [3] used an S-shaped
incision. Giraldo [7] reports on a central wedge exci-
sion and a 90- Z-plasty.
65 Labioplasty
a a
b b
Fig. 65.7 (a) Internal incision closure with a running suture.
(b) Internal incision sutured
Munhoz [4] reported on a posterior wedge resection
and superior pedicle flap. He states that the labial edge
is preserved, the skin texture and color are similar, and
the technique is simpler and less aggressive. There is
no horizontal or longitudinal scar contraction. However,
the tip of the flap may suffer in smokers and patients
with comorbid-associated diseases.
Choi and Kim [2] proposed another technique:
de-epithelialization of the central lateral and medial
parts of the labia followed by reapproximation of the
margins of the raw surfaces.
65.4 Postoperative
The patient may be discarded on the day of the opera-
tion. The dressing consists of a simple gauze between
the labia minora for approximately 2 weeks. Oral
administration of antibiotics is continued for 5 days
1105
Fig. 65.8 (a) External incision and clitorial hood closure.
(b) Immediate postoperative view
postoperatively. The postoperative discomfort is mini-
mal, and swelling subsides within 4 weeks. Sutures are
removed at 10 days.
Postoperatively, the patients are asked to rest and
to maintain good local hygiene in order to prevent
infection. The surgical wounds should be kept as dry
as possible. The patient is instructed to apply local
antibiotic ointment for 710 days. Baths and sexual
activities are to be avoided for 45 days.
65.5 Results
If meticulously performed, labioplasty is a safe method
which can bring excellent patient satisfaction. It is a
rather simple operation performed on an outpatient basis
which should make part of any plastic surgeons arma-
mentarium. The results are very good. Some of the
authors results are presented in (Figs. 65.965.13).
1106
Fig. 65.9 (a) Preoperative 13-year-old female with severe asymmetric bilateral labia minora hypertrophy. (b) Three months
postoperative after central wedge excision labial resection
65.6 Complications
Labial edge separation (wound dehiscence), hematoma,
and infection should be promptly treated, as they can
result in an unaesthetic scar, distortion of the remaining
labia minora edge and local fibrosis. Labial fistula also
requires prompt excision and suturing. Among the late
complications are cited widened scars, wound retrac-
tion, prolonged discomfort, dog-ears formation, over-
resected labia, labia minora asymmetry, and persistent
hypertrophy. The revisions rate for wound dehiscence
or fistula formation is greater in smokers.
65.7 Discussion
Hypertrophic labia minora are functionally and psy-
chosocially bothersome. They interfere with personal
hygiene, with sexual intercourse, with various sports
C. Isac et al.
(cycling, walking), and sitting. In these cases, as well
in those where the social well-being of the patient is
influenced by aesthetic concerns resulting in lack of
self-confidence and low self-esteem (although variation
in size is normal), surgery is indicated.
Currently, although minor labia enlargement repre-
sents a well-recognized physical deformity, there is
still no consensus regarding its definition. Munhoz [4]
takes a limit of 3 cm beyond which labia minora are
regarded as hypertrophic (they are measured horizon-
tally from the midline when placed in lateral traction
with minimal tension). Other authors extend this limit
to 4 cm, even 5 cm. However, individual preference is
taken into consideration in most cases.
Warren et al [8] recently proposed an algorithmic
approach of surgical procedures based on the degree
of labial hypertrophy and the patients preference:
deepithelialization for minor hypertrophy; for labia
measuring more than 4 cm, the superior pedicle
65 Labioplasty
Fig. 65.10 (a) Preoperative 25-year-old woman. (b) Six months postoperative after central wedge labial resection and lateral clito-
rial hood resection
technique [1, 4] is chosen if the patient desires to retain
the naturally darker labial edge, if not, the edge exci-
sion technique [3] is performed.
A poorly performed labioplasty can be very depres-
sive for the patient. On the other hand, a well-performed
labioplasty can achieve excellent results and the new
aspect can greatly enhance self-esteem. In addition to the
aesthetic outcome, better local hygiene, relief of chronic
irritation, and less interference with sexual intercourse
have been reported as the main additional benefits [4].
The advantages of the central wedge excision tech-
nique are:
1. Preservation of the free labial edge the free border has
a natural, nonredundant appearance from the clitoris to
the commissure, with no scar prone to contracture.
2. Hidden scars
3. The technique is less aggressive, simple and
straightforward
1107
4. There is less chance of chronic tenderness of the
scar line [1]
5. The innervation from pudendal nerves is maximally
preserved
6. There is less impairment in sensation or sexual
dysfunction
7. The aesthetic outcome is very satisfactory
One disadvantage is the sudden change in color
from the more pinkish anterior flap to the more
brownish and darker posterior one. This discrepancy in
color is rarely an issue.
Some other pathologies less encountered are
atrophy of the labia minora (treated with autoge-
nous fat grafting) and labia major hypertrophy
(which may be treated either with excisions in the
interlabial sulcus, medially, and in the hair-bearing
skin laterally Hunter [5] or syringe liposuction
Felicio [3]).
1108 C. Isac et al.

a b

Fig. 65.11 (a) Preoperative 22-year-old woman with bilateral labia minora hypertrophy. (b) Central wedge excision technique
immediate postoperatively and the fragments of tissue resected. (c) One month postoperative

65.8 Conclusions The central wedge excision technique with or

Female genital appearance is an important issue nowa-
days. The success of the procedures depends on patient
selection, careful preoperative planning, and meticu-
lous execution of the surgical technique. Preoperative
patient evaluation is critical in appreciating the optimal
amount of tissue to be resected [9].
without lateral clitoral hood excision is a simple and
consistent technique which gives satisfactory results
for the patients seeking solution to this kind of
problem, be it only aesthetically or as well functionally
bothersome. Reduction of the labia improves psycho-
social and physical comfort and sexuality in some
women [6, 10].
65 Labioplasty 1109

Fig. 65.12 (a) Preoperative 33-year-old woman with marked labia minora enlargement. (b) Preoperative markings. (c) Three
months after central inner wedge excisions with lateral hockey-stick extension and separate elliptical clitoral hood excisions
1110 C. Isac et al.

a b

c d

Fig. 65.13 (a) 38-year old female with markedly enlarged bilateral labia minora. (b) Preoperative marking of central wedge excision
(c) 3 months postoperative result. (d) Resected tissue shown

6. Maas S, Hage J (2000) Functional and aesthetic labia minora

References
1. Alter G (2008) Aesthetic Labia minora and clitorial hood
reduction using extended central wedge resection. Plast
Reconstr Surg 122(6):17801789
2. Choi HY (2000) A new method for aesthetic reduction of
labia minora (the deepithelialized reduction labioplasty).
Plast Reconstr Surg 105(1):419422
3. Felicio Y (2007) Labial surgery. Aesthet Surg J 27(3):322328
4. Mendonca A, Filassi J (2006) Aesthetic labia minora reduc-
tion with inferior wedge resection and superior pedicle flap
reconstruction. Plast Reconstr Surg 118(5):12371247
5. Hunter J (2008) Considerations in female external genital
aesthetic surgery techniques. Aesthet Surg J 28(1):106107
reduction. Plast Reconstr Surg 105(4):14531456
7. Giraldo F, Gonzalez C (2004) Central wedge nymphectomy
with a 90-degree Z-plasty for aesthetic reduction of the labia
minora. Plast Reconstr Surg 113(6):18201825
8. Warren Ellsworth, Mort Rizvi (2010): Techniques for labia
minora reduction: an algorithmic approach. Aesth Plast
Surg 34:105110
9. Girling VR, Salisbury M (2005) Vaginal labioplasty. Plast
Reconstr Surg 115(6):1792
10. Koning M, Zeijlmans I (2009) Female attitude regarding
labia minora appearance and reduction with consideration of
media influence. Aesthet Surg J 29(1):6670
 Total Body Lift After Extreme
Weight Loss
Dennis J. Hurwitz
66.1 Introduction
Total Body Lift (TBL) surgery is the aesthetic correc-
tion of skin laxity of the torso in as few stages as safely
possible. TBL surgery may also include recontouring
the upper arms and thighs. The goal is to address all
body contour changes after weight loss, aging, and/or
pregnancies as the case may be. TBL entails coordina-
tion of multiple body contouring operations. Conceived
in 2002, TBL surgery continues to evolve. The varia-
tions are as diverse as the presentations.
This chapter is a photographic essay of a recent
TBL operation on a 43-year-old massive weight loss
patient, which not only removed undesirable excess
and lax skin but also used her tissues to sculpture a
female form. The individual operations will be pre-
sented as well as the relationship between them. She
will have bilateral suture suspension mastopexy,
abdominoplasty, lower body lift with adipose fascial
flap, bilateral vertical medial thigh plasties, and ultra-
sonic-assisted lipoplasty of her trunk. She is 5 ft 5 in.
tall, weighs 147 lb. She had lost 90 lb after Roux-
en-Y gastric bypass 2 years prior to her body con-
touring surgery. She is unhappy about the appearance
of her thighs, torso, buttocks, waist, and breasts
(Fig. 66.1). She recognized that in addition to unac-
ceptable loose and protuberant skin of her torso and
D.J. Hurwitz
Department of Plastic Surgery, New York-Presbyterian
Hospital, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
e-mail: drhurwitz@hurwitzcenter.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_66, Springer-Verlag Berlin Heidelberg 2013
66
thighs and flat breasts, she exhibited an androgynous
figure. Due to her weight loss and prior breast reduc-
tion, her breasts were broad and flat with the upper
poles empty and the lower poles full and elongated.
Her loose-skinned torso is broad and boxy, without a
defined waist. Her abdomen has two large sagging
rolls and a ptotic mons pubis. Her buttocks are sag-
ging and flat. Her thighs are large with sagging skin.
Her mild upper arm fullness was of no concern. Her
preoperative laboratory screening was normal, and
she was placed on a high protein, arginine, and glu-
tamine amino acids, vitamins, and minerals 2 weeks
prior to the procedure.
Twelve days after her TBL surgery and prior to
flying home, a series of images captured the results
(Fig. 66.2). She had barbed suture suspension of
her breasts to the pectoralis muscle, leaving a better
shaped, and it projected her breasts with distinct
and properly positioned inframammary folds (IMF).
An extended central high tension lipoabdominoplasty
tightened, straightened, and sculptured her feminine
abdomen, with a well-positioned, depressed umbili-
cus. Her mons pubis plasty leaves a lifted and prop-
erly shaped mons. Her lower body lift and adipose
fascial augmentation lifted and filled out the but-
tocks, augmented her hips, and defined her waist.
Cosmetic and excision site liposuction (ESL) with a
spiral thigh plasty and medial vertical extensions gave
her proportioned, tightly formed inverted cone thighs.
To accomplish this feminine metamorphosis in 7 h,
detailed planning is needed, and a team of five sur-
geons and a physician assistant are enlisted. Published
techniques are employed along with a host of recent
refinements.
1111
1112 D.J. Hurwitz

Fig. 66.1 Total Body Lift

case: preoperative 54-year-old
woman who lost 100 lb
2 years earlier. She has
hanging skin and ptotic
breasts on a distinctly
masculine body build

66.2 Marking
On the night prior to her TBL surgery, she was marked
for her multiple operations (Fig. 66.3). Her abdomino-
plasty is marked first with her lying in bed, pulling up
on her upper abdominal skin. A vertical line is drawn
from the commissure of the labial majora to beyond her
umbilicus. A transverse line extending 6 cm on either
side of this midline marking is drawn over the pubic
region 8 cm from the labial commissure. This line is
continued laterally just below the crest of the anterior
superior iliac spines. The patient is turned lateral decu-
bitus with the upside leg abducted. This inferior inci-
sion line is continued directly posteriorly. The lax
lateral thigh skin falls to the hip where it is gathered to
mark the point that the superior incision line crosses the
lateral torso. Firm gathering between that point and the
inferior incision line along the lateral thigh encom-
passes the width of resection over the hip. Pushing the
buttock cephalad, the lower line along the lateral thigh
66 Total Body Lift After Extreme Weight Loss 1113

Fig. 66.2 Twelve days after

Total Body Lift, she is healing
well throughout. Her loose
and hanging skin has been
corrected. Her tightened
abdomen has a subtle
curvaceous form leading to a
depressed umbilical region.
Retention and advancement
of fatty adipose flaps have
symmetrically augmented her
breasts and buttocks, filled out
her hips, and narrowed her
waist. Her infragluteal folds
are well demarcated with
rounded definition separating
the lower buttocks from her
posterior thighs. Her scars are
symmetrical and well
positioned. Her breasts have
minimally improved
projection and superior
pole fill

is drawn across the buttocks to the upper aspect of the
intergluteal cleft. The upper line extends from the supe-
rior point at the hip to the lower back midline so as to
include all excess skin of the lower back and superior
buttocks. The patient is then turned to the opposite lat-
eral decubitus and goes through the same maneuver
and drawing. The patient then stands, and lower body
lift incisions are leveled, and the two excision gaps over
the upper buttocks are checked by pinching. These pre-
viously drawn lower buttock incision lines are checked
for proper placement and symmetry and are adjusted.
When she drops the buttocks, the lines which were
drawn horizontally on each side become hemi-elliptical.
Within the center of these ellipses over each upper but-
tock, an area for flap deepithelialization is drawn, which
are about 12 cm long and 10 cm wide. These are aligned
to each central buttock. Between these two islands of
skin that will be used for augmentation of the buttocks
in the lower midline of the back, we plan to discard a
segment of skin and fat.
The umbilicus is then outlined in a 2-cm by 3-cm
shield-like manner. Transverse lines are drawn, extending
1114 D.J. Hurwitz

Fig. 66.3 Completed

markings for her single stage
correction, designed to shape,
to remove loose skin, and to
feminize her contours by the
selective retention and
removal of adipose tissue.
The marking process is
described in the text.
The operation very closely
followed these markings.
The incisions are indicated by
the solid black lines for the
circumferential lower body
lift and abdominoplasty, and
the medial thigh vertical lines
for the thigh plasty. The plus
marks are within areas of
ultrasonic-assisted lipoplasty
of the epigastrium and
anterior thighs. The inner
thigh excision will first
undergo radical excision site
liposuction. The obliquely
crosshatched paramedian
posterior buttock excisions
are separated by a central
excision of skin and fat as
marked

from the umbilicus and parallel to the groins to the lateral
superior torso point for excision of all skin between the
umbilicus and the pubic area of the lower abdominal
wall. The adequacy of this resection is confirmed by
pinch and gathering of the tissues. Final confirmation
awaits upper incision and superior flap undermining
during surgery.
She is then laid supine on the exam table for mark-
ings of her medial thighs. With the right thigh abducted,
an incision line was drawn between the pubic area and
groin and continued between the labia majora and
medial thigh to beyond the palpable ischial tuberosity
posteriorly. With the leg then adducted, and the loose
medial thigh skin pushed to pubis, a parallel line is
drawn to include all this loose medial thigh skin. With
her hip moderately flexed and her foot flat on the table
and the leg adducted, I could then move the skin of
the anterior thigh medially to draw a straight line along
the medial thigh from the ischial tuberosity to the
medial condyle of the knee. That line places the closure
between the mid axial thigh and the posterior thigh.
Then, by gathering tissue in the middle of the thigh,
66 Total Body Lift After Extreme Weight Loss 1115

Fig. 66.4 The operation

starts prone with the thighs
strapped to arm boards
abducted 45. The foot of the
table is dropped to allow an
assistant to perform excision
site liposuction (ESL) of the
medial thighs followed by the
posterior thigh plasty. The
markings are for to the lower
body lift and posterior and
medial thigh lifts.
Crosshatched marks indicate
the area for deepithelialization
for the dermal adipose fascial
buttock augmentation. The
skin and fat between the flaps
will be excised

the posterior thigh skin could be pulled up, and a
roughly 8-cm-wide excision along the medial posterior
thigh was drawn, tapering it toward the labia majora.
Those markings were highlighted and the thighs
pushed together, creating a mirror image on the oppo-
site medial thigh. That faint image was redrawn and
checked for adequacy of skin and fat excision. The
anterior thigh was rather full of fat, and it was marked
for 12 plus removal of extra fat during the operation.
Next, we marked the current inframammary fold
(IMF) of each breast and determined that the right fold
was 2 cm too low, and the left IMF was 4 cm too low.
That decision was reinforced by her complaint that her
bra was needed to pull the base of her breasts. It slipped
up over the lower pole left of her breast when she
pulled up her bra to raise her breasts. The current and
raised IMF positions were registered over the sternum.
Furthermore, she disliked the fullness of the lower pole
of her breasts, the empty upper poles, and poor projec-
tion of the nipples. She thought her nipple position was
slightly low. She disliked her left lateral chest fullness,
so it was marked for liposuction. While I took her pho-
tographs, a final assessment of her markings were
made and minor adjustments drawn, followed by high-
lighting with indelible ink. She washed with chlorhexi-
dine the night before and the morning of her operation.
She self-administered a Fleets enema.
66.3 Operation
On the day of surgery, the faintly visible surgical
markings were remarked, and she was escorted to the
operating room. Sequential automatic pressure stock-
ings are activated. She is induced under general anes-
thesia on the OR gurney. Through a large-bore
angiocatheter, 500 mL of her blood is removed into
citrated transfusion bags, and that volume of blood is
replaced with saline, a process of normovolemic
hemodilution performed by our anesthesiologist. Her
blood is left in the room to be administered toward the
end of the operation. She is covered with a sterile sur-
geons gown to facilitate rolling her prone onto the
operating room table. Her face and endotracheal tube
are cradled in a special foam rubber headrest. All pres-
sure points are padded with extra foam rubber. The
foot of the operating room table is dropped as each leg
was secured to arm boards that are adducted 30 from
the table (Fig. 66.4). Her upper body is covered and
warmed with a Bair Hugger.
She is prepped with povidone-iodine solution and
draped in a sterile manner. Three liters of injectable
saline are prepared with a gram of Ancef, 5 ampules of
epinephrine, and 60 mL of 1% Xylocaine. Using an
infusion pump at 350 mL per minute, this fluid mixture
is infused with a blunt multiholed 2-mm cannula along
1116
Fig. 66.5 The steps of the buttock augmentation from the head
of the table. (Upper) The inferior and superior lower body lift
incisions have been made. The paramedian dermal adipose fas-
cial island flaps are isolated and droop laterally. There is an exci-
sion gap between the flaps. And the buttock space over the
gluteus maximus muscles has been dissected as exposed by
retraction rakes. (Lower) The two flaps for augmentation suture
advanced into their pockets after limited superior undermining
the lower body lift incision lines, over the gluteus max-
imus, and within the two medial thigh excision sites.
Three simultaneous operations are commenced. On
each side of the lower body lift, a surgeon and assistant
deepithelialize the adipofascial island flaps, while the
physician assistant is at the foot of the table suctioning
fat from the posterior and medial thighs. After the
deepithelialization of the adipose fat flaps, the two
upper teams make the inferior incision of the lower
body lift along superior border of the buttocks to the
lateral thighs at the depth of the fascia lata. The paral-
lel superior incision of the lower body lift borders the
adipofascial flap and continues over the hips toward
the umbilicus (Fig. 66.5). The skin and fat are elevated
over the superior half of each gluteus maximus muscle
from the paramedian midline to the lateral buttocks.
Then, the midline skin and fat bridging the two
D.J. Hurwitz
Fig. 66.6 Buttock lift: (Upper) The left buttock skin flap is
advanced over the flap and temporarily held in place with a
towel clamp, allowing definitive marking of the posterior thigh
plasty. The resected gap between the flaps is narrowed. (Lower)
Towel clamps have temporarily closed the lower body lift inci-
sion. The faded transverse dashed line is the predicted lower
incision if there had been no flap augmentation of the buttocks.
With the buried tissue, more skin is needed for the closure
adipofascial flaps are excised down to the muscular
fascia. Lateral to the adipofascial flaps, about one-third
of the fat and all of the skin are removed. After a lim-
ited back cut is made, the adipofascial flaps are suture
advanced with #1 braided Polysorb into the pockets
over the gluteus maximus muscle (Fig. 66.5). The but-
tock skin is then advanced over the adipofascial flap
and towel-clipped securely into position to the supe-
rior incision of the lower body lift (Fig. 66.6). Several
key sutures of 0-Polysorb were placed, and then the
closure was completed with a running #2 PDO Quill
SRS, and at the lateral extent of the incision, a single
suture of 0-Novofil secures the closure.
As the lower body lift incision is being closed, pre-
viously marked crescent excisions of skin are remarked
at the inferior portion of the buttocks, extending onto
the posterior thigh and ending as a narrow taper at the
66 Total Body Lift After Extreme Weight Loss
Fig. 66.7 Posterior thigh plasty: begins with remarking the
excision after completion of the lower body lift. (Upper) ESL of
the vertical medial thigh plasty leaves the defatted depression.
(Lower) The excess upper posterior thigh skin has been removed
down to fascia lata
lateral thigh. The vertical medial thigh planned
excision site is a depressed strip due to radical liposuc-
tion performed by the authors physician assistant.
First, saline tumescent fluid with epinephrine and
Xylocaine is infused, followed by passing the LySonix
4 mm golf tee tip inline suction probe for about 10 min
when the resistance has dissipated and then vigorous
liposuction with a 5-mm-diameter multiholed cannula
for subtotal removal of fat deep to the vertical excision
(Fig. 66.7). This excision of skin and fat extends deep
to gluteus maximus fascia through the fascia lata to
nearly expose the ischial tuberosity (Fig. 66.7). The
subcutaneous fascia and posterior thigh flap are
advanced and secured to the ischial tuberosity perios-
teum with several #1 braided absorbable sutures
(Fig. 66.8). These sutures are tied after all are placed
and after the leg is brought from its abducted position
from arm boards onto the returned footrest to the table
(Fig. 66.8). With the posterior thigh secured to the
1117
Fig. 66.8 (Upper) The left leg has been adducted back on the
operating room table to allow for suture advancement of the pos-
terior thigh subcutaneous fascia to the exposed ischial perios-
teum with #1 braided absorbable suture. (Lower) Both legs are
back on the table as the second (right) posterior thigh is about to
be advanced to the ischial tuberosity by tying the place with
large sutures. The wounds are then closed in two layers with #1
PDO Quill and 30 Monoderm
ischial tuberosity, a two-layer closure with #1 Quill
SRS (Angiotech Pharmaceuticals, Vancouver, Canada)
in the subcutaneous tissues is followed by 30
Monoderm in the dermis (Fig. 66.9). Finally, the pos-
terior limb of the vertical thigh plasty excision is made
through the skin and superficial fat. Prior to turning the
patient supine, medial thigh incision was temporarily
approximated with skin staples, and the lower body lift
closure is covered with Indermil glue.
With completion of the posterior portion of the
operation, the patient is turned supine. We wrap her in
a sterile surgical gown and roll her over onto the await-
ing gurney and then slide her back onto the operating
room table. Her legs are then placed in a slightly frog-
leg position (Fig. 66.10). The table was slightly flexed,
and she was again prepped and draped. To maintain
body temperature, the Bair Hugger forces warm air
1118
Fig. 66.9 At the completion
of the operation in the prone
position, both the lower body
lift and posterior thigh
incisions are closed with flap
augmentation of the buttocks,
revealing the tight-skinned
and curvaceous lower back,
buttocks, and posterior and
lateral thighs. The posterior
medial thigh plasty incision
is temporarily closed with
staples. The wide separation
of the buttocks exposing the
anus is temporary
over the upper body, head, and arms while simultane-
ous operations are being performed on the medial
thighs and the abdomen. One team starts the abdomi-
noplasty, and a second team completes the vertical
thigh plasty that was started with excision site liposuc-
tion (ESL) and incision of the posterior incision line.
The abdominoplasty starts with preparation of the
epigastric skin flap. First, the transverse superior
abdominoplasty incision is made across the umbilicus
(Fig. 66.10). The umbilicus was cut out, leaving a
shield-like 3 cm long umbilicus with dissection down
to abdominal wall. Ultrasonic-assisted lipoplasty of
the epigastrium is done, first with the LySonix probe
and then followed by the multiple 20-hole graded can-
nula liposuction. Very little bleeding occurs. The mid-
line of the flap was then directly undermined along the
linea alba from the umbilicus to the sternal notch
(Fig. 66.11). The dissection in the midline also allowed
for preservation of mid rectus perforating vessels as
much as possible. There is no weakness or diastema of
the rectus fascia above the umbilicus, so no imbrica-
tion of the upper abdominal fascia is performed.
The superior abdominal wall skin flap is directly
undermined only several centimeters, and then the rest
of the undermining to and slightly beyond the costal
margin was performed with LaRoe undermining for-
ceps (ASSI, Westhury, New York) that were used to
D.J. Hurwitz
make undermined openings and allow for preservation
of abdominal perforators (Fig. 66.12). When it is clear
that the upper abdominal flap can be pulled down to
the predetermined lower skin markings, that lower
incision is made from hip to hip across the pubis to the
muscular fascia, except over the groins where the inci-
sion stops at Scarpas fascia. The skin resection over
the groins leaves behind sub-Scarpal fat (Fig. 66.13).
The midline rectus fascia over the rectus muscle is
imbricated with a small needle number #2 PDO, 14 cm
long thread run in a horizontal mattress suture along
and after placement of the first 2 bites on either side of
the central area with a double-armed suture (Fig. 66.14).
The PDO suturing continues until the abdominal wall
is palpably tight.
The umbilicoplasty includes central high tension on
the superior abdominoplasty flap. The skin and stalk
have been previously isolated. Three sutures of 20
Maxon are placed in the rectus fascia at the 3, 6, and
9 oclock position around the stalk of the umbilicus
and left long with the needles attached. A 30 Prolene
is placed at the 12 oclock position of the skin of the
isolated umbilicus (Fig. 66.15). The umbilicus is too
long, so it is foreshortened with horizontal mattress
sutures from base of the umbilicus to mid stalk of
the umbilicus using 30 Maxon at the 3, 6, 9, and
12 oclock positions. These were tied tight, telescoping
66 Total Body Lift After Extreme Weight Loss 1119

Fig. 66.10 The patient has been turned supine and prepped
with Betadine for a two-team approach to her abdominoplasty
and vertical thigh plasty. Her upper body, arms, neck, and head
will be warmed with a Bair Hugger. Upon completion of the
abdominoplasty and while the second team is performing the
upper transverse portion of the thigh plasty, the first team
performs the bilateral mastopexy. (left) The abdominoplasty
begins with the superior incision, which extends transversely to
either side of the umbilicus and then circumscribes the umbili-
cus. (right) The incision is carried through the subcutaneous tis-
sues to the abdominal wall fascia

Fig. 66.11 The superior abdominal flap is undermined for several centimeters. (left) Except in the midline where it continues to the
xyphoid. (right) Midline undermining ends at the paramedian transrectus perforators

Fig. 66.12 After the midline undermining is completed. (left) The spreading underminer is used to create parallel tunnels,
A special spreading discontinuous underminer, LaRoe under- leaving behind the perforators
mining forceps, is used, which is lying on the abdomen. (right)
1120
Fig. 66.13 After mobilizing
the superior abdominoplasty
flap to determine the level
of the lower incision, it is
made across the groins and
pubis. (Left) The excess skin
and fat of the lower abdomen
are being dissected off the
abdominal wall, leaving
subfascia Scarpas fatty layer
with its neurovasculature.
(Right) At the abdominal
midline, the excess tissue
is removed directly from
white rectus fascia
the umbilicus 5 mm shorter (Fig. 66.15). The table is
flexed, and the patient is placed in Trendelenburg. The
superior abdominal flap is advanced and held in place
to the groin and pubic incision with towel clamps.
While the left side of the abdominoplasty incision
is being closed with vertical running suture of #2 PDO,
the central high tension abdominoplasty and umbilico-
plasty are performed.
After sighting the umbilicus up to the overlying
abdominal skin, the umbilicoplasty opening is made
approximately 3 cm superior to this sighting by deepi-
thelialization of a 2.5-cm-wide shield-like opening.
An inverted Y pattern incision is drawn on the deepi-
thelialized skin (Fig. 66.16). The inverted Y is incised
full thickness through the fat and fascia of the subcuta-
neous tissue, about 3 cm thick. No fat is removed. The
previously placed 20 Maxon sutures in the abdominal
fascia are pulled through the umbilicoplasty incision
and sutured as a horizontal mattress to the two lateral
and one inferior small deepithelialized flaps. The 30
Prolene suture at the 12 oclock position of the umbili-
cus is sutured to the apex of the inverted Y opening in
the advanced abdominal flap. After the abdominal wall
flap is brought down in position and held there with
towel clips, we tie each of the three Maxon sutures
from the rectus fascia to the corresponding deepitheli-
alized small inverted Y flaps. Advancing these three
deepithelialized flaps inferiorly to the base of the
D.J. Hurwitz
umbilical stalk causes high central tension to the epi-
gastrium and umbilication of the abdominal flap tissue
around the umbilicus. The closure tension along the
mons pubis is reduced.
The umbilicoplasty is completed with a running
30 Prolene between the umbilicus skin edge and the
skin of the abdominal wall. Through stab wound
incisions in the pubic area, #10 Jackson-Pratt drains
were placed along the lower abdominal wall incision
and sutured in place with 30 Prolene. The abdomi-
noplasty incision is closed with #2 PDO and 30
Monoderm.
Meanwhile after limited cosmetic liposuction of the
anterior thighs, the planned excision of vertical medial
thigh skin is removed. Since radical ESL was per-
formed, only the skin itself is removed through scalpel
cuts along the undersurface of the dermis (Fig. 66.17).
A finger breath pathway is made with blunt dissection
through the abdominal flap is preserved. The ellipsoid
excision site is approximated with towel clips. As no
skin laxity is detected, no edgewise further excision is
done. The vertical thigh wound is closed with running
horizontal mattress of #1 PDO Quill suture, followed
by 30 Monoderm.
Once the abdominoplasty closure has started, the
horizontal crescent-shape skin excision of the medial
thigh plasty is performed. While the thigh plasty is
being completed by another team, surgeon DJH went
66 Total Body Lift After Extreme Weight Loss 1121

Fig. 66.14 (Left) The width of the midline diastema is marked cial gap. (Right) The four throws of the Quill suture is pulled
by methylene blue. (Middle) Four throws of a horizontal running tight with each end, ready to suture close the central abdominal
mattress suture of #2 PDO barbed threads span the central fas- laxity

Fig. 66.15 (Left) The

umbilicus has a single 30
Prolene suture in the
12 oclock position. At its
fascial base, there are 20
Maxon sutures placed at 3, 6,
and 9 oclock positions which
were marked with methylene
blue. (Right) With the
suspension sutures left untied,
the height of the umbilicus
is shortened with horizontal
30 Maxon sutures
1122
Fig. 66.16 Final steps of her umbilicoplasty: (Upper left) The
pull-through site for the new umbilicus is deepithelialized. The
subcutaneous neurovasculature is preserved Y demarcates three
small flaps. The site was placed on the advanced abdominal flap
2 cm superior to the umbilical base on the abdominal wall.
(Upper middle) Incising an inverted Y incision creates three
small deepithelialized flaps. (Upper right) An inverted Y drawn
with Methylene Blue demarks three small flaps, a fingerbreadth
ahead and performed the suture suspension mastopexy.
The preoperative markings between the mons and labia
majora and the medial thigh are checked now that the
final tension of the abdominoplasty and the thigh plasty
has been achieved. The mons plasty is performed by
excising the skin only on either side of the mons, 6 cm
from the midline down to the labia and closing. It is
important to leave the fibrofatty tissue as preservation
leaves the lymphatics. After removal of the excess skin
and fat between the labia majora and upper thigh,
Colles fascia is identified so that several large braided
sutures approximate the medial thigh subcutaneous
fascia to it (Fig. 66.18). Then 0-PDO Quill closes
the horizontal crescent excision of the skin, creating
D.J. Hurwitz
passageway is made though the abdominal flap. (Lower left)
The previously placed three untied sutures are pulled through
the umbilicus opening. (Lower middle) The 30 Prolene umbi-
licus skin suture is closed to the 12 oclock position. (Lower
right) The three fascial sutures are sutured to the dermal flaps
and tightly tied to umbilicate the abdominal wall flap. The clo-
sure is completed with a circumferential umbilical running 40
Prolene
a T-type plasty between the vertical and horizontal
portions of the medial thigh plasty. Closure is with 20
Quill and 30 Monoderm.
During the completion of the medial thigh plasty,
the suture suspension mastopexy is being performed
on the previously reduced breasts. The central 40% of
the inferior scar is incised (Fig. 66.19). The breast is
elevated off the pectoralis muscle to the second rib
between the paramedian perforating vessels of the
sternum to the lateral border of the large flat muscle;
#2 barbed Prolene Quill SRS suspends the breast as it
is advanced on the pectoralis muscle. The first bite
goes through the pectoralis muscle to grab the second
rib periosteum (Fig. 66.19 upper right). The 2 large
66 Total Body Lift After Extreme Weight Loss
Fig. 66.17 Progression of the vertical limb of the thigh plasty
that is being performed by the second team while the abdomino-
plasty is being done by the first. (Upper left) The perimeter inci-
sion is made, and the distal half of the skin is detached. (Upper
right) The skin is detached through multipronged rake retraction
Fig. 66.18 With all the flaps in place under appropriate tension,
the skin suturing begins around the umbilicus along the abdomi-
noplasty and horizontal portions of the medial thigh plasties
1123
and incising against the dermis. (Middle left) There is a bed of
connective tissue, neurovasculature with a fine layer of adipose
tissue. (Middle right) Towel clips approximate the tissue. (Lower)
The two-layer closure of #1 PDO Quill and 30 Monoderm up to
the transverse portion of the medial thigh plasty
bites are taken along the undersurface of the breast
gland that had been elevated off the chest wall, deep
enough to get substantial pull but not too deep to get
dimpling in the skin (Fig. 66.19). After 2 breast bites
were placed, each about the size of the 38-mm tapered
needle that comes with the barbed Prolene suture, hori-
zontal sutures from each of the descending threads are
placed about the third rib, through the pectoralis mus-
cle (Fig. 66.19). This suturing is repeated twice until
reaching the sixth rib. The inferior portion of the inci-
sion is undermined with LaRoe forceps over the costal
margin. The inferior inframammary fold flap is then
sutured up to the position at the 5th rib using the #2
barbed Prolene, and then the subcutaneous tissue along
the inframammary fold is closed with 0 Quill followed
by 30 Monoderm.
1124 D.J. Hurwitz

Fig. 66.19 These are four

images of the suture
suspension mastopexy.
(Upper left) The mastopexy
begins with an incision along
the entire IMF scar of the
right breast. The clear,
double-needle Polyethylene
Quill suture lies on the breast.
(Upper right) The first suture
is placed deeply through the
pectoralis muscle over and
almost into the second rib.
(Lower left) Each limb of the
double-armed suture takes
two deep bites taken into the
undersurface of the upper
breast. The medial thread is
seen. (Lower right) The breast
has been suture suspended
with a three-series step-
ladder-like suspension

Body metamorphosis is complete at the end of her
TBL surgery on the operating room table (Fig. 66.20).
Surgical bra and long leg thigh garments are then
placed. The patient received her 500 mL of saved blood,
and 7 h after the operation began, she was taken to the
post-anesthesia recovery room. She was started on
Lovenox 40 mg subcutaneously twice a day until her dis-
charge 3 days later. Her postoperative swelling was mini-
mized with a low salt diet, properly fitted compression
garments, and twice a day electrophysiological massage
with Hivamat. Pain was initially controlled with intrave-
nous patient-controlled analgesia (PCA), which was
changed to oral oxycodone 3 days later. Healing went
well, except for two small mid buttock wounds, which
took 3 months of dressings to close. Three months later,
the patient is pleased with all areas of her Total Body
Lift, except for the poor projection of the upper poles of
her breasts (Fig. 66.21).
66 Total Body Lift After Extreme Weight Loss 1125

Fig. 66.20 At the completion

of the TBL, the patient is supine
in the semi-Fowlers position.
The skin is tight, reshaping
completed, and the scars are well
positioned

Fig. 66.21 The satisfied patient

sent me these photos of her
3-month result. Compare with
Fig. 66.1
 Penile Enhancement
Hassan Abbas Khawaja and Melvin A. Shiffman
67.1 Introduction
Fillers used for penile enhancement include fat, bovine
collagen, and collagen of human and pork origin [1, 2].
However, a variety of other dermal and subdermal
injectable fillers can be used, but all of these have
potential risks and complications. The authors have
utilized Gore-Tex (polytetrafluoroethylene) and silk
threads alone, and with fat together as lipo-Gore-Tex
in the penis with satisfactory results [3, 4].
67.2 Penile Thread Enhancement
Threads, Silk No 2/0 or Gore-Tex (polytetrafluoroethyl-
ene) CV 2, are used with a KH needle (Figs. 67.167.4)
[3, 4]. It is absolutely important to avoid ventral and
dorsal midline areas for thread insertion, otherwise
damage to the urethra and vessels can take place leading
to hematomas, infection, urethral damage, extravasation
of urine subcutaneously, stricture, stone formation in the
urinary tract, and other complications [3, 4].
KH needle with attached silk threads (or Gore-Tex
threads), 23 in number, is passed subcutaneously,
from point 1 towards point 2, along the marked path-
way. The KH needle with silk threads is now exiting
H.A. Khawaja (*)
Cosmetic Surgery & Skin Center, Lahore, Pakistan
e-mail: drkhawajaha@live.com, drkhawajaha@yahoo.com
M.A. Shiffman
Chair, Section of Surgery, Newport Specialty Hospital,
Tustin, CA, USA
e-mail: shiffmanmdjd@gmail.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_67, Springer-Verlag Berlin Heidelberg 2013
67
point 2. Threads at the back end are held in a fine artery
forceps. Threads at the advancing end are cut with a
fine small straight scissors, flush with point 2. Threads
are slightly retracted at the back end, and they go sub-
cutaneously [4, 5]. Now threads are cut at point 1, in a
similar fashion. Now, some traction is exerted with fin-
gers away from point 1, towards the pubis. This leads
to burial of threads at point 1. If difficulty is experi-
enced here in burying the threads, blunt end of a
smaller sized KH needle is used to push ends of threads
subcutaneously. The results are adequate enhancement
(Fig. 67.5).
67.3 Lipo-Gore-Tex Penile Enhancement
Gore-Tex implants are inserted first as described previ-
ously. Fat is harvested necessarily from the pubic area
and also from the lower abdomen and hip if required.
Fat is completely removed from the pubic area via a
3-mm keel cobra tip cannula. No stitch is applied to
entry point. Compression is applied postoperatively to
the pubic area. After decantation, purified fat is trans-
ferred using 2 points distally at 3 and 9 oclock posi-
tions using the smaller fat transfer cannula [6, 7] (8 cm
long, 1 mm broad). A maximum of 4050 cc of fat is
transferred (Fig. 67.6). It is important to avoid the 6
and 12 oclock positions, for inserting fat transfer can-
nulas, so that urethral and vascular damage is avoided.
Threads must be inserted prior to fat injection, which
should be slow and retrograde. If threads are inserted
after fat transfer, the advancing needle, leads to destruc-
tion of fat cells. Triple antibiotic ointment and oral
antibiotics (cefadroxil monohydrate) are continued for
up to 7 days postoperatively.
1127
1128 H.A. Khawaja and M.A. Shiffman

Fig. 67.1 KH (Khawaja

Hernandez) needle with silk
thread entering at point 1

2 1
AVOID VENTRAL & DORSAL MIDLINES

Fig. 67.2 KH needle with

silk thread traversing
pathway from point 1 to 2

2
1

Fig. 67.3 KH needle with

silk thread exiting point 2

2 1

Fig. 67.4 Similarly,
threads are passed all
around the penis, avoiding
the midline areas for thread
insertion. Threads can be
passed either from the base
toward the distal end or
vice versa
2 1
4 3
6 5
AVOID VENTRAL & DORSAL MIDLINES
8 7
10 9
12 11
67 Penile Enhancement
a a
Fig. 67.5 (a) Preoperative. (b) After penile thread enhancement
67.4 Complications
Extrusion and infection are two common complications
of penile thread enhancement [35, 9]. However, infec-
tion is rare with proper antibiotic coverage. Due to the
monofilamentous nature of silk, we do not use silk
threads along with fat in the penis. Granulomas, and
allergic reaction to Gore-Tex, also take place. In our
1129
Fig. 67.6 (a) Preoperative. (b) After lipo-Gore-Tex penile
enhancement
experience, about 20% of patients are sensitive to Gore-
Tex. It is advisable to perform a small Gore-Tex Needle
Thread Test to check sensitivity of the patient few weeks
prior to insertion of Gore-Tex in the penis. Penile fat
transfer complications are absorption, infection, cysts,
calcifications, skin necrosis, sinus formation, hemato-
mas, seromas, skin pigmentation, penile distortion, ure-
thral distortion, calculi in the urinary tract, lipomatosis,
1130 H.A. Khawaja and M.A. Shiffman

Fig. 67.7 Pubic pit after localized liposuction Fig. 67.8 Lipomatosis in the penis

embolism, etc. [1, 2, 6, 8]. However, following a careful

technique with slow, even, and retrograde injection of
fat, avoiding large spurts of fat, using proper antibiotic
coverage, and injecting no more than 4060 cc of fat per
session, these complications usually do not take place.

67.4.1 Pubic Pit

Liposuction of the pubic fat can increase length of the

organ up to 1 in. or more, depending on the amount of
fat present in the pubis. Localized superficial liposuc-
tion immediately above the base of the penis can result
in the formation of pubic pit (Fig. 67.7). Generalized
superficial liposuction should be carried out above the
base of the penis to avoid this depression.

67.4.2 Penile Lipomatosis

Penile lipomatosis can take place when 100 cc or more
fat is transferred into the penis. Absorption takes place in
some fat areas, while hypertrophy/hyperplasia in other
areas leading to this condition (Fig. 67.8). Liposhifting
can be performed to correct this deformity.
67.5 Double Bubble Penis
A double bubble penile deformity can take place as a
result of uneven fat injection, inexperience of the sur-
geon, performing fat transfer, after collagen, liquid
silicone, or after injecting a variety of dermal/subder-
mal fillers into the penis (Fig. 67.9). As a result of
Fig. 67.9 Double bubble penis
gravitational pull, and due to the peculiar anatomy of
the organ, penile mounds can form.
A variety of dermal and subdermal facial fillers can
also be used for penile augmentation. These includes
calcium hydroxylapatite, e-aminocaproic acid, hyaluronic
acid, hyaluronic acid and ethyl methacrylate, hydroxy-
apatite, hydroxymethylmethacrylate and ethylmethacry-
late in hyaluronic acid solution, methacrylate and
acrylate, methacrylate and copolymer, patient-derived
plasma emulsion, polyoxyethylene fatty acid and elastin
copolymer gel, polyacrilamide hydrogel (unpolymer-
ized acrylamide monomer), polyacrylamide hydrogel
67 Penile Enhancement
with polyvinyl microspheres, polyalkylimide, polydim-
ethylsiloxane oil (silicone), polyethylene microspheres,
polylactic acid, and polyvinyl alcohol, polyvinyl micro-
spheres suspended in Polyacrylamide Gel [1031].
However, all of them have potential risks and complica-
tions associated with their use.
Collagen should not be injected into patients with a
history of autoimmune diseases, such as dermatomyo-
sitis, lupus erythematosus, or rheumatoid arthritis
[10]. Charriere et al. [11] reported a positive skin test
in 3.8% of patients and adverse reactions in 2.3% of
patients with negative skin testing. Bentkover [12]
looked at the relevant biology of facial fillers and
found that bovine collagen is the most immunogenic
filler. Porcine and bioengineered human collagen
implants have very low immunogenicity, but allergic
reactions and elevations of IgG are possible. Cross-
linking and concentration affect the longevity of col-
lagen fillers. Most allergic reactions are localized and
consist of swelling and redness at the treatment site
[13]. Infections, such as recurrent herpes simplex,
abscess formation, tissue necrosis, and granulomatous
foreign body reactions were reported infrequently
[14]. Cooperman et al. [15] noted adverse reactions
occurred to pretesting of Zyderm I in 3% of patients.
In addition, 1.3% of patients experienced adverse
reactions despite a negative pretest. Reactions ranged
from localized swelling to induration, erythema, and
pruritis. Onset ranged from immediate to 3 weeks
after implantation. DeLustro et al. [16] found an esti-
mated 0.4% adverse reactions to bovine collagen after
one to seven treatments. Hanke et al. [17] described
sterile abscess (may be an atypical form of allergic
reaction) being seen more with Zyplast, and skin
necrosis has occurred in a significant number of
patients when Zyplast is injected into the glabellar
area. Hanke [18] described the following adverse
reactions to bovine collagen: transient erythema,
bruising, and needle marks that were temporary. Also
noted were local necrosis, infection, surface deformities
(beading), intermittent swelling, and systemic com-
plaints such as arthralgias, myalgia, headaches, nau-
sea, urticarial rashes, and partial blindness (injection
in glabella area). Three percent of patients had posi-
tive pretreatment skin tests. Less than 1% of patients
with negative pretesting demonstrated allergic reac-
tions. Cystic-abscess reactions are rare and occur most
commonly with Zyplast treatment and start with pain
followed by erythema and swelling. There are tender
1131
cysts that develop intermittently for 2 years or more.
Incision and drainage relieves the pain, and intermit-
tent systemic or intralesional steroids provide relief in
some patients. Ashinoff [19] stated that 33.5% of
patients have localized reaction when tested to bovine
collagen. In those patients who have negative skin
testing, 15% still get an allergic reaction that usually
subsides in 46 months; however, it can last up to
2 years. Adverse reactions include bruising, reactiva-
tion of herpes, and bacterial superinfection can occur.
Artecoll has short-term side effects that include swell-
ing, bruising, and sensitivity. Zyderm and Zyplast can
both have allergic reactions. Intra-arterial injection is
suspected in several cases of unilateral blindness
because of retinal artery occlusion.
Complications of bovine collagen that were described
by Grossman [10] include bruising that should resolve in
several day, temporary swelling, a white bump or raised
area from injecting too superficially that may last for sev-
eral months, necrosis and subsequent scar formation,
allergic reactions seen as erythematous papules, streaks,
or plaques. Homicz and Watson [20] described systemic
reactions to bovine collagen consisting of arthralgias,
myalgia, fever, and pruritis in less than 5 per 1,000
patients.
Autologous cultured fibroblasts serve as injectable
protein repair systems for correction of acne scars,
rhytides, and other facial scars [21]. The system uses
the patients own cultured fibroblasts to correct con-
tour deformities over time. Cosmoderm and Cosmoplast
contain lidocaine and should not be used in patients
with severe allergies manifested by a history of ana-
phylaxis or in patients with known lidocaine hyper-
sensitivity. Longevity, 36 months. Cymetra is not
recommended in patients exhibiting autoimmune con-
nective tissue disease, contraindicated in infected or
nonvascular sites. Since Cymetra is supplied in an
antibiotic-supplemented medium, it should not be
used in patients sensitized to those specific antibiotics.
Longevity, 39 months. Dermologen is an aseptically
processed suspension of collagen fibers prepared from
human donor tissue obtained from U.S. tissue banks and
lasts 36 months but has been known to last 9 months. It
takes two to three injection sessions over several months
in order to show maximal improvement.
Patients over 60 years are not candidates for Isolagen
because their skin is not capable of producing vigor-
ous fibroblasts [19]. The cells are alive and cannot be
stored so that careful planning and a reliable patient are
1132
essential. Correction may take 34 months because the
fibroblasts take time to produce new collagen [19].
Gradual improvement may be seen over 18 months.
Fagien [22] described the problem with Autologen
was that the tissue donor was the recipient but noted that
in a survey of 100 patients, that 98% would opt to use
their own skin. Donor skin of 5 cm [2] yields 1 cc of
collagen. This can be stored refrigerated in BioBank
for at least 5 years. The skin is processed by Collagenesis
Laboratories (Previously manufactured by Collagenesis
(Beverly, Massachusetts)) that is very similar to Cymetra.
However, Collagenesis filed Chap. 11 in the U.S.
Bankruptcy Court in Boston (#19656). Apesos and
Muntzing [23] found only a small subset of patients is
willing to donate skin for Autologen. Cosmoderm and
Cosmoplast have adverse reaction including infection,
reactivation of herpes simplex, and local necrosis (rare),
and injection into dermal vessels may cause vascular
occlusion, infarction, or embolic phenomena. Lack
of permanency from collagen of human origin has
been described by a number of authors [2428]. Hyper-
pigmentation over injection sites has been reported [29].
Moody and Sengelmann [30] described pretesting with
human collagen had reactions of mild, self-limited, and
nontender erythema. Apte et al. [31] reported on cases
of choroidal infarction following subcutaneous injec-
tion of human collagen in the forehead. Evolence (col-
lagen of pork origin) is not to be used in patients that
are hypersensitive to any collagen products or porcine
products, or if there is a history of severe allergies. Side
effects of Evolence include swelling, bruising, erythema,
pain, and palpable lumpiness.
References
1. Hernandez-Perez E, Marroquin-Burgos R (1993) Fat injec-
tion of the penis: a personal technique. Am J Cosmet Surg
10:135138
2. Hernandez-Perez E, Albarran FV (1999) Fat grafting in
male and female genitalia. Int J Cosmet Surg 7(1):8791
3. Khawaja HA, Hernandez-Perez E (2002) Gore-tex review:
guidelines for use, complications, prevention and treatment.
Int J Cosmet Surg Aesthet Dermatol 4(4):337343
4. Khawaja HA (2007) Silk threads for facial wrinkles and
depressed scars. Meso-Amer J Cosmet Surg (on-line)
1(1):8
5. Conley J, Baker D (1979) Thread augmentation for facial
rhytides. Ann Plast Surg 3(2):118129
H.A. Khawaja and M.A. Shiffman
6. Khawaja HA, Hernandez-Perez E (2002) Fat transfer review:
controversies, complications, their prevention and treatment.
Int J Cosmet Surg Aesthet Dermatol 4(2):131138
7. Fournier PF (1991) Fat transfer. In: Parish LC, Lask GP
(eds) Aesthetic dermatology. Mc Graw Hill, New York, pp
267275
8. Reed HM (1994) Augmentation phaloplasty with girth
enhancement employing autologous fat transplantation: a
preliminary report. Am J Cosmet Surg 11:8590
9. Schoenrock LD, Repucci AD (1993) Gore-Tex in facial
plastic surgery. Int J Aesthet Restor Surg 1:6368
10. Grossman KL (2000) Facial scars. Clin Plast Surg 27(4):
627642
11. Charriere G, Bejot M, Schnitzler L, Ville G, Hartmann DJ
(1987) J Am Acad Dermatol. Reactions to a bovine colagen
implant. Clinical and immunologic study in 705 patients.
21(6):12031208
12. Bentkover SH (2009) The biology of facial fillers. Facial
Plast Surg 25(2):7385
13. Siegle RJ, McCoy JP, Schade W, Swanson NA (1984) Intradermal
implantation of bovine collagen: humoral responses associated
with clinical reaction. Arch Dermatol 120(2):183187
14. Rzany R, Zielke H (2006) Complications. In: de Maio M,
Rzany B (eds) Injectable fillers in aesthetic medicine.
Springer, Berlin, pp 6777
15. Cooperman LS, Mackinnon V, Bechler G, Pharrisse BB
(1985) Injectable collagen: a six-year clinical investigation.
Aesthetic Plast Surg 9(2):145151
16. DeLustro F, Smith ST, Sundsmo J, Salem G, Kincaid S,
Ellingsworth L (1987) Reaction to injectable collagen:
results in animal models and clinical use. Plast Reconstr
Surg 79(4):581594
17. Hanke CW, Hingley HR, Jolivette DM, Swanson NA,
Stegman SJ (1991) Abscess formation and local necrosis
after treatment with Zyderm or Zyplast collagen implant.
J Am Acad Dermatol 25(2 Pt 1):319326
18. Hanke CW (1998) Adverse reactions to bovine collagen. In:
Klein AW (ed) Tissue augmentation in clinical practice: pro-
cedures and techniques. Marcel Dekker, Inc., New York
19. Ashinoff R (2000) Overview: soft tissue augmentation. Clin
Plast Surg 27(4):479487
20. Homicz MR, Watson D (2004) Review of injectable mate-
rials for soft tissue augmentation. Facial Plast Surg 20(1):
2129:145154
21. Boss WK Jr, Usal H, Chernoff G, Keller GS, Lask GP, Fodor
PB (2000) Autologous cultured fibroblasts as cellular ther-
apy in plastic surgery. Clin Plast Surg 27(4):613626
22. Fagien S (1998) Facial soft tissue augmentation with autolo-
gous and homologous injectable collagen (Autologen and
Dermologen). In: Klein AW (ed) Tissue augmentation in
clinical practice: procedures and techniques. Marcel Dekker,
Inc., New York, pp 97124
23. Apesos J, Muntzing MG II (2000) Autologen. Clin Plast
Surg 27(4):507513
24. Alster T, West T (1998) New options for soft tissue. Skin
Aging 7:32
25. Austin H, Weston G (1992) Rejuvenation of the aging
mouth. Clin Plast Surg 19(2):511524
67 Penile Enhancement
26. Devore D, Hughes E, Scott J (1994) Effectiveness of inject-
able filler materials for smoothing wrinkle lines and
depressed scars. Med Prog Technol 20(34):243250
27. Devore D, Kelman CD, Fagien S et al (1996) Autologen:
autologous injectable dermal collagen. In: Bosniak S (ed)
Ophthalmic, plastic and reconstructive surgery. WB Saunders,
Philadelphia, pp 671675
28. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML (1998)
Injectable hyaluronic acid gel for soft tissue augmentation. A
clinical and histological study. Dermatol Surg (24):13171325.
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29. Elson ML (1999) Soft tissue augmentation techniques:
update on available materials. Cosmet Dermatol 12:13
30. Moody BR, Sengelmann RD (2000) Self-limited adverse
reaction to human-derived collagen injectable product.
Dermatol Surg 26(10):936938
31. Apte RS, Solomon SD, Gehibach P (2003) Acute choroidal
infarction following subcutaneous injection of micron-
ized dermal matrix in the forehead region. Retina 23(4):
552554
 Complications of Cosmetic Surgery
Melvin A. Shiffman
68.1 Introduction
Aesthetic surgery is an elective surgery in order to beau-
tify the patient. Patients do not expect to have complica-
tions, but the possible risks and complications have to
be explained to the patient so that he/she can make a
knowledgeable decision concerning whether or not to
have the surgery. Complications may occur without any
deviation from the standard of care, and the surgeon has
to be aware as to what are the possible risks and compli-
cations, their prevention, and their treatment for every
procedure he/she may plan to do. This will allow early
diagnosis and timely treatment of a complication.
The rare and unusual complications are a challenge
to each surgeon, so particular attention should be paid
to understand which ones they are and how to diagnose
and treat them.
68.2 Abdominoplasty
Complications following abdominoplasty can occur at
any time with any patient despite adequate surgical
technique and patient care. These problems may cause
patient discomfort, delay recovery, require further sur-
gery, or threaten the patients survival. The surgeon
should be aware of the possible complications, their
prevention, their timely diagnosis, and their treatment.
The possible risks and complications must be dis-
cussed with the patient prior to surgery.
M.A. Shiffman
Chair, Section of Surgery, Newport Specialty Hospital,
Tustin, CA, USA
e-mail: shiffmanmdjd@yahoo.com
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery,
DOI 10.1007/978-3-642-21837-8_68, Springer-Verlag Berlin Heidelberg 2013
68
68.2.1 Asymmetry
If care is not taken in the initial marking prior to
surgery, asymmetry may result. The midline should be
marked above the umbilicus and in the area of the
pubis. If there is a very fatty abdominal wall, the mid-
line at the level of the pubis can be located either by
visualizing the anterior junction of the vulva or care-
fully spreading the pubic hair to find the direction of
the hairs that diverge to each side at the midline.
The transverse lower abdominal incision line should
be marked preoperatively so that the distance from the
midline is equal on each side. The height of the ends
of the lateral extensions should be equidistant from
some measurable point superiorly or inferiorly, such as
the anterior superior tubercle or the level of the top of
the ilium.
The amount of skin excised is determined by firm
traction on the skin flap at an equidistant point on each
side from the midline of the flap. This will prevent
excessive tension on one side of the flap compared to
the other.
Care must be taken to center the umbilicus to pre-
vent asymmetry involving the umbilicus.
Excessive fat or skin can be surgically excised to
correct asymmetry. Fat can also be liposuctioned in
areas of excess.
68.2.2 Bleeding (Bruising, Hematoma,
Exsanguination)
The presence of bruising following any surgical proce-
dure is accepted as a known consequence of the proce-
dure [13]. When a swelling filled with blood appears
1135
1136
in the abdominal wall shortly after surgery, the surgeon
must make a decision as to careful observation or some
form of drainage. When a hematoma first appears, the
clot can be aspirated only with great difficulty. Over
time (a few days), the fibrin precipitates and the
remaining fluid can be more easily aspirated with a
needle. If the hematoma is not aspirated, the serosan-
guinous fluid in the pocket will slowly become a typi-
cal serous fluid and thus a pseudocyst. When the
hematoma is increasing in size, surgery should be seri-
ously considered to ligate the bleeder surgically by
exploring the wound and emptying the clot. Mohammad
[3] reported a 9% incidence of hematoma.
Bleeding from the wound is easier to monitor than
hidden bleeding. Compression dressings, bed rest, and
ice packs sometimes will control the bleeding. If there
is persistent bleeding, surgical exploration is essential.
The wound is opened, any hematoma evacuated, and
the bleeder(s) ligated or electrocoagulated. The wound
may be closed with or without drainage, but it is safer
with a catheter or penrose drainage.
The presence of orthostatic hypotension should be a
warning that there may be inadequate fluid replace-
ment or excessive blood loss. Fluid should be replaced
if the hypotensive episodes persist. If there is no pro-
longed response, then there is probably excessive
blood loss even if there is no apparent bleeding from
the wound or expanding hematoma. Immediate hemo-
globin (Hgb) and hematocrit (HCT) should be obtained,
and if there is a significant drop from the preoperative
studies, then replacement of fluids should be rapid
with volume expanders such as Hespan or albumin. A
20% drop in Hgb or HCT is a reason enough to con-
sider blood replacement since these studies do not
equilibrate for 2448 h. Admission to a hospital emer-
gency room may be necessary to monitor the patient
over a period of time in order to determine if blood
replacement is necessary.
68.2.3 Dehiscence
Dehiscence following abdominoplasty usually occurs
at the tightest point of the abdominal incision closure
[1, 4]. This point is the center of the flap at the attach-
ment in the region of the pubis. The area darkens and
necrosis may occur followed by disruption of the clo-
sure, sometimes with the wound pulling apart. The
tight closure elongates the vessels resulting in spasm
M.A. Shiffman
and clotting of the vessels, which is followed by necro-
sis and disruption of the wound. Usually, the wound
does not pull far apart because the sutures lateral to the
disrupted area hold the wound together.
Other contributory causes include smoking, poorly
controlled diabetes mellitus, underlying hematoma or
seroma, and too much activity by the patient. Many
surgeons close the wound tightly with the patient
slightly flexed. The surgeon then expects the patient to
remain in that position for several weeks even while
walking around. Compliance with these instructions is
usually poor since it is virtually impossible to maintain
this position for any length of time, especially if the
patient has a history of back problems.
Treatment for dehiscence should be conservative
allowing the wound to slowly slough the necrotic tis-
sue, and the wound should heal by secondary intention
if the wound cannot be sutured closed because of
excessive tension. The necrotic tissue can be debrided
at appropriate intervals of time. Usually, the scar will
contract sufficiently to form a slightly widened scar
that can be revised if necessary (if the patient is dis-
satisfied with the appearance).
68.2.4 Dogears
The closure of the transverse lower abdominal wound
is started with a suture in the midline to properly posi-
tion the new umbilicus. The wound should then be
closed starting laterally on each side to give a flattened
appearance to the most lateral regions of the wound. If
there is excessive fatty tissue in the region where doge-
ars usually form, this tissue should be excised prior to
the closure.
Many times small dogears will resolve within
3 months without treatment. When there are persistent
dogears for more than 3 months, these can be excised
under local anesthesia, usually in an elliptical form.
Very large dogears and fullness in the area can be
treated by liposuction as well as excision.
68.2.5 Edema, Persistent
When edema is persistent, over 3 months, and does
not respond to conservative measures such as com-
pression, liposuction with tumescent solution should
be considered. Too much liposuction may result in
68 Complications of Cosmetic Surgery
damage to the skin or indentations. Therefore, the
liposuction should be conservative. At the same time,
there should be a determination as to whether there is
persistent edema or just too much residual fat.
68.2.6 Infection, Sepsis
Wound infection is a known consequence of any clean
surgery, occurring in 1% of patients in an outpatient or
office surgical center and 3% in a hospital [1]. It is not
unusual for slight erythema to occur around the sutures
without actual significant infection. If significant
wound erythema occurs while the patient is on antibi-
otics, the dosage may be increased or the antibiotic
changed. The wound should be watched very carefully
for progression of the infection that may require intra-
venous antibiotics that can be given as an outpatient or
in the hospital. Infections not responding to antibiotics
may require consultation with an infectious disease
specialist and may indicate early necrotizing fasciitis
or may evolve into toxic shock syndrome that can be
fatal. Complete blood count (CBC) should be obtained
as well as wound, where possible, and blood cultures.
Uncontrolled infection can be life threatening if
sepsis occurs. This may be indicated by fever, elevated
white count, and lethargy. Prompt treatment with
appropriate intravenous antibiotics is essential.
68.2.7 Necrosis
Necrosis is more likely to occur if the patient is a
smoker, if concomitant mid upper abdominal liposuc-
tion is performed, or if there has been prior extensive
liposuction to the abdominal wall [1, 2, 4]. Smokers
may say they will stop smoking, but there are some
who will continue to smoke despite all the admoni-
tions. There is nothing that can be done if the patient
does not stop smoking completely. The necrosis will
progress to its fullest extent, not only in the lower
abdomen but also at times in the periumbilical area and
upper abdomen.
Poorly controlled diabetes mellitus, very tight
wound closure, underlying hematoma or seroma, and
infection may contribute to the cause and extent of the
necrosis. If the patient has a prior transverse upper
abdominal scar (i.e., cholecystectomy, gastrectomy,
splenectomy), the triangle formed by the scar, the
1137
midline, and the tightly pulled abdominal skin flap
closure is susceptible to necrosis unless enough space
(at least 6 cm) is left between the old scar and the
transverse closure line to allow vascularity to the tri-
angle. It is helpful to place less tension on the flap
closure so that stretching of the vessels and thrombo-
ses are not added to the problem. Sometimes, the use
of a different type of resection may be necessary to
prevent necrosis. This usually means the addition of a
vertical midline scar [5].
The best treatment is observation with debridement
as needed and allowing the wound to heal by second-
ary intention. Placing skin grafts in a granulating
abdominal wound will shorten the healing time but
will not allow the wound to contract enough to decrease
the extent of scarring. It is surprising how small the
scar can be after complete healing and contraction
even if the whole lower abdominal wall has been
involved with necrosis. Scar revision is usually neces-
sary for wide or irregular scars.
68.2.8 Necrotizing Fasciitis
Necrotizing fasciitis is a result of infection from
Streptococcus or mixed infection, frequently with
anaerobic organisms. The infection results in thrombo-
sis of the subcutaneous vessels including vessels enter-
ing the fascia and underlying muscles. The tissues
become necrotic and require debridement as well as
proper antibiotics. Cultures of the tissues may reveal
the offending organism(s). The wound should then be
allowed to granulate and can be skin grafted when all
the necrotic tissue has been removed and granulations
are present.
68.2.9 Need for Further Surgery
There are a variety of reasons for further surgery
being necessary following abdominoplasty. These
include asymmetry, irregularities, dogears, necrosis,
inadequate skin resection, significant scar (hypertro-
phic or keloid), umbilical stenosis, or excessive fat
requiring liposuction. If a patient has excessive fat
prior to the abdominoplasty and the fat is not liposuc-
tioned at the same procedure, the patient should be
informed about the probable future need for liposuc-
tion before surgery.
1138
68.2.10 Perforation of Intraabdominal
Viscus
It is possible to perforate the bowel when repairing an
umbilical hernia, ventral hernia, or incisional hernia at
the same time as performing the abdominoplasty by
not opening the hernia sac to observe for attached
bowel or placing the sutures superficially only in well-
exposed fascia. Closing the midline fascia in a patient
with a very loose abdominal wall may not produce a
tight abdominal wall, and imbrication of the external
oblique fascia bilaterally would be necessary. The
junction of the external oblique fascia and the rectus
muscle sheath may have a Spigelian hernia, usually
just below the level of the umbilicus since the fascia is
very thin at that point.
Any patient complaining of more postoperative
abdominal pain than the usual patient or persistent
severe pain should be examined for rebound tender-
ness and absent bowel sounds. The patient should
be observed very carefully and at appropriate short
intervals of time to rule out perforation of a viscus,
blood vessel, or bladder. Abdominal x-ray series
may be indicated and possibly observation in the
hospital. If intraabdominal bleeding is suspected,
Hgb and HCT should be tested. If necessary, insert-
ing a needle with a catheter sheath into the abdomi-
nal cavity, removing the needle, and then inserting
sterile saline and observing for drainage of blood
should be done.
If a perforation is diagnosed, immediate surgical
intervention is indicated. Preoperative antibiotics
should be started. The abdomen should be care-
fully explored for possible multiple perforations, and
any observed bowel perforations should be closed
after thorough irrigation of the abdominal cavity.
Early intervention may prevent a severe infectious
process.
68.2.11 Recurrent Panniculus
Patients should be forewarned that weight gain after
abdominoplasty could result in recurrent fatty abdo-
men with panniculus that might require another surgi-
cal procedure. Pregnancy after abdominoplasty is a
risk for causing loose skin, stretching the muscles and
the midline, and striae. This may result in the need for
repeat abdominoplasty.
M.A. Shiffman
68.2.12 Recurrent Protrusion
of Abdominal Wall
Some patients have very lax abdominal wall muscles,
and there is a tendency for recurrent protrusion after
a seemingly adequate fascial repair. This can be
improved with repeat closure of the abdominal wall
fascia in the midline with the combination of lat-
eral wall (external oblique aponeurosis) tightening.
This repair can also be performed for the patient
who has recurrent protrusion from loosened or dis-
rupted sutures.
68.2.13 Scarring (Widened, Thickened,
Hypertrophic, Keloid)
Wide scars are frequent following abdominoplasty
because of the need for a tight closure to get a flat
abdomen [2]. When the skin loosens after 6 months,
it is possible to resect the scar in order to make it
thinner.
Certain individuals are prone to get hypertrophic
scars although this is unpredictable. Hypertrophic
scars may resolve without treatment. Keloid scars
occur in 15% of blacks, Asians, and Hispanics. There
are a variety of treatments available, usually used in
combination. Recurrence of keloids is common.
68.2.14 Sensory Loss
Loss of sensation in the abdominal wall is more com-
mon when liposuction is performed at the same time as
abdominoplasty [1, 6]. This sensory change is usually
temporary and resolves without treatment.
Injury to the lateral femoral cutaneous nerve has
been reported [1, 6]. This can result in permanent sen-
sory loss along the anterior, lateral, and posterior thigh.
It is possible to explore and reanastamose a transected
nerve if the nerve ends can be found and a large section
of the nerve has not been removed. This type of sur-
gery must be performed in a timely manner in order to
have any success. Usually, the sensory loss is not in
areas that will interfere with normal activity, and
patients may become used to the sensory loss over a
long period of time.
68 Complications of Cosmetic Surgery
68.2.15 Seroma
The use of drains following abdominoplasty usually
prevents the accumulation of blood but may not pre-
vent seroma formation [13, 7, 8]. The large flap with
an empty space extending from xyphoid to pubis is
readily filled with serous fluid with patient movement
that results in the rubbing together of raw tissues. If
there is a palpable fluid collection, this can be aspi-
rated and compressed to allow the tissues to seal. If
aspiration does not resolve the problem, injecting room
air to fill the cavity after fluid aspiration will almost
always result in sealing the cavity. Introduction of air
may have to be repeated if there is a larger cavity.
This method is less traumatic than excision of the
pseudocyst.
68.2.16 Skin Overhanging Scar
If not enough skin is resected in abdominoplasty or if
the transverse lower abdominal scar becomes adherent
to the underlying fascia, there may be a visible overlap
of the skin over the scar. This may require revision by
resecting the excess skin and/or freeing up the skin
scar attachment to the deeper tissue.
68.2.17 Thromboembolism
Patients who undergo surgery are at risk for venous
thromboembolic complications. This is especially crit-
ical in a cosmetic surgery patient who, having an elec-
tive procedure, would not expect to have the morbidity
or mortality associated with thromboembolic disease.
The cosmetic surgeon must be aware of the possibility
of thromboembolism in every patient and should take
a careful history to disclose predisposing risk factors.
The surgeon should also be aware of the clinical mani-
festations of pulmonary embolus in order to make a
timely diagnosis.
68.2.17.1 Risk Factors
Minor surgery <30 min in patients over 40 years of age
without additional risk factors and uncomplicated sur-
gery in patients under 40 years of age without addi-
tional risk factors are in the low-risk category. General
surgery in patients over 40 years of age lasting >30 min
and patients under 40 years on oral contraceptives are
1139
in the moderate-risk category [9]. High-risk category
would be major surgery in patients over 40 years of
age with recent history of deep vein thrombosis or pul-
monary embolism, extensive pelvic or abdominal sur-
gery for malignancy, and major orthopedic surgery of
the lower extremities.
Predisposing risk factors include age over 40 years,
malignancy, obesity, prior history of thromboembo-
lism, varicose veins, recent operative procedures, and
thrombophilia. These risks are further modified by
duration and type of anesthesia, preoperative and
postoperative immobilization, level of hydration, and
the presence of sepsis [10]. Medical problems associ-
ated with increased risk include acute myocardial
infarction, stroke, and immobilization [11]. Estrogen
therapy and pregnancy are common risk factors while
uncommon factors include lupus anticoagulant, neph-
rotic syndrome, inflammatory bowel disease, poly-
cythemia vera, persistent thrombocytosis, paroxysmal
nocturnal hemoglobinuria, and inherited factors such
as antithrombin III deficiency, protein C deficiency,
protein S deficiency, plasminogen activator deficiency,
elevated plasminogen activator inhibitor, and homo-
cystinuria [12].
Superficial calf vein thrombosis, proximal deep
vein thrombosis, and fatal pulmonary embolus increase
in incidence as the risk category increases from low to
high.
68.2.17.2 Clinical Manifestations
Superficial thrombophlebitis (an inflamed vein)
appears as a red, tender cord. Deep-vein thrombosis
may be associated with pain at rest or only during
exercise with edema distal to the obstructed vein. The
first manifestation can be pulmonary embolism. There
may be tenderness in the extremity, and the tempera-
ture of the skin may be increased. Increased resistance
or pain on voluntary dorsiflexion of the foot (Homans
sign) and/or tenderness of the calf on palpation are
useful diagnostic criteria.
Pulmonary embolism is usually manifested by one
of three clinical patterns: (1) onset of sudden dyspnea
with tachypnea and no other symptoms, (2) sudden
pleuritic chest pain and dyspnea associated with find-
ings of pleural effusion or lung consolidation, and (3)
sudden apprehension, chest discomfort, and dyspnea
with findings of cor pulmonale and systemic hypoten-
sion. The symptoms occasionally consist of fever,
arrhythmias, or refractory congestive heart failure.
1140
68.2.17.3 Diagnosis
Deep-vein thrombosis is best diagnosed with duplex
ultrasonography which combines pulsed gated Doppler
evaluation of blood flow with real-time ultrasound
imaging. Other diagnostic tests include x-ray venogra-
phy, radionuclide venography, radioisotope-labeled
fibrinogen, ultrasonography, and impedance plethys-
mography. Liquid crystal thermography detects
increases in skin temperature and is a useful adjunct to
ultrasonography or impedance plethysmography.
Ventilation-perfusion lung scan (VP scan) is a safe,
sensitive means of diagnosing pulmonary embolism.
Isotope pulmonary perfusion scan (Q scan) is more spe-
cific with inclusion of the isotope ventilation scan (V
scan). The definitive diagnosis can be made by pulmo-
nary arteriography, but VP scan can give a high degree
of certainty. Arterial blood gas typically shows reduc-
tion in PaO2 and PaCO2 while electrocardiogram shows
tachycardia but is best used for ruling out myocardial
infarction. Chest x-ray may show basilar atelectasis,
infiltrates, pleural effusion, or cardiac dilatation.
68.2.17.4 Prophylactic Treatment
Low-risk general surgical patients may be treated with
graduated compression stockings applied during sur-
gery, early ambulation, and adequate hydration [13].
Keeping the knees flexed on pillows during surgery and
avoiding local compression on any areas of the legs are
helpful. All patients are treated the same if there are any
low risk factors. The type of surgery does not matter as
long as general anesthesia or intravenous sedation is
given. Compression stockings (2030 mm support hose
is adequate) are applied in the operating room, and
ambulation is begun when the patient is awake and
capable of ambulating with assistance. When the patient
is ambulating on a regular basis during the day, the
compression stockings can be removed.
For moderate risk patients, low-dose heparin (5,000
units 2 h before surgery and then every 812 h until
ambulatory), low-molecular-weight heparin (LMWH),
dextran, or aspirin is recommended. Alternatively,
graduated compression stockings or intermittent pneu-
matic compression started during surgery are used
continuously until ambulatory, or a combination of
both is recommended [10].
All high-risk patients should be treated with low-
dose heparin or LMWH and combined pharmacologic
and mechanical methods.
M.A. Shiffman
Dextran can result in cardiac overload, and high-
dose aspirin (1,0001,500 mg/day) has limited efficacy
in preventing deep-vein thrombosis. In cosmetic sur-
gery, the use of aspirin or heparin may result in postop-
erative bleeding.
The best prophylaxis for low-risk cosmetic surgery
patients would appear to be mechanical methods includ-
ing knee compression stockings and early ambulation.
For low-risk patients, the knees should be slightly
flexed and extremity compression avoided [14].
68.2.18 Hereditary Hypercoagulable States
Patients with a family history of thrombosis, early-
onset or recurring thrombosis, thrombosis at unusual
sites, or warfarin-induced skin necrosis should be eval-
uated for possible underlying inherited hypercoagula-
ble disorders.
Antithrombin III (AT-III) is a heparin cofactor that
allows heparin to inactivate primarily factor IIa but also
factors IXa, Xa, XIa, and XIIa [15]. A deficiency in
AT-III predisposes to thrombosis by allowing uncon-
trolled activity of many of the coagulation factors.
Endothelial surfaces have receptors called throm-
bomodulin that function as anticoagulants because of
the ability to neutralize thrombin. The thrombin-
thrombomodulin complex activates protein C, a vita-
min K-dependent factor that is facilitated by protein S,
another vitamin K-dependent factor. Activated pro-
teins C and S metabolize activated factors V and VIII,
which results in downregulating the coagulation sys-
tem. Patients with protein C deficiency may have
recurrent episodes of superficial thrombophlebitis as
well as thromboembolism [16]. Patients with protein S
deficiency experience more arterial thromboembolism
including stroke [17]. Deficiency in protein C or S may
present as neonatal purpura fulminans in the newborn
or skin necrosis in adults treated with warfarin, a drug
known to cause a sudden fall in protein C or S.
Venous thromboembolism occurs in one out of
every thousand people with activated protein C resis-
tance (APC-R) responsible for up to 64% of the cases.
APC-R is due to a single point mutation in the FV
gene for clotting factor V. This mutated FV may be
referred to as factor V Leiden (FVL), FV:Q506 allele,
or APC-gene and is less efficiently degraded by APC.
A hypercoagulable state results from impairment of
68 Complications of Cosmetic Surgery
the inactivation of factor V by activated protein C.
This creates a lifelong increased risk of thrombosis
and thromboembolism.
Within the intact vessel, thrombin binds to throm-
bomodulin on the endothelial cell acting as an antico-
agulant bay activating the protein C system. Activated
protein C (APC), potentiated by cofactor protein S,
downregulates the activity of the coagulation system
(limits clot formation) by cleaving and inhibiting fac-
tors V (FV) and VIII [1820].
APC testing can be performed with DNA genotyp-
ing. This can differentiate acquired from inherited
APC-R. Approximately 10% of patients with APC-R
phenotype lack the FV mutation (genotype), and the
diagnosis of APC-R in these patients will be missed
[21]. The combination of phenotype and genotype
information aids in establishing prophylactic and ther-
apeutic guidelines.
Asymptomatic patients with APC-R who have never
had a thromboembolic event, as well as their family
members, should receive counseling regarding the
implications of the diagnosis and information concern-
ing the signs and symptoms of venous thromboembo-
lism [22]. Short-term prophylaxis with heparin should
be considered when there are high-risk circumstances
encountered such as immobilization, surgery, trauma,
or obstetrical procedures. After a thrombotic event,
these patients need extended anticoagulation, balancing
the risk of bleeding against the risk of recurrence when
therapy is discontinued. Empirical treatment is for at
least 1 year after two episodes of thromboembolism
and lifelong treatment after three episodes [23].
68.2.19 Toxic Shock Syndrome
Toxic shock syndrome has been reported in breast aug-
mentation [2426]. The syndrome is caused by the
exotoxins (superantigens) secreted with infection from
Staphylococcus aureus and group A Streptococci [27].
Knowledge of the criteria for diagnosis is important in
order to treat this potentially fatal disease. These
include [27]:
1. Fever (>102o)
2. Rash (diffuse, macular erythroderma)
3. Desquamation (12 weeks after onset, especially of
palms and sole)
4. Hypotension
1141
5. Involvement of three or more organ systems:
a. Gastrointestinal (vomiting, diarrhea at onset)
b. Muscular (myalgia, elevated CPK)
c. Mucous membrane (conjunctiva, oropharynx)
d. Renal (BUN or creatinine >2 times normal)
e. Hepatic (bilirubin, SGOT, SGPT >2 times
normal)
f. Hematologic (platelets <100,000)
6. Negative results on the following studies (if
obtained):
a. Blood, throat, or cerebral spinal fluid (CSF)
cultures
b. Serologic tests for Rocky Mountain spotted
fever, leptospirosis, and measles
Treatment consists of surgical debridement for
necrosis, antibiotics, circulatory and respiratory care,
anticoagulant therapy for disseminated intravascular
coagulation, and immunoglobulin [28]. Experimental
approaches have included use of antitumor necrosis
factor monoclonal antibodies and plasmapheresis.
68.2.20 Umbilical Stenosis
The advent of a contracting scar around the umbilicus
following abdominoplasty is not rare. There have been
different methods proposed for doing the umbilical
reconstruction during abdominoplasty in order to pre-
vent stenosis. The umbilical stenosis may result in
chronic inflammation and drainage that the patient needs
to have addressed. At the same time, a stenosed umbili-
cus is not a normal-looking umbilicus. Reconstruction
of the stenosis can be surgically performed.
68.2.21 Umbilicus: Loss or Off Center
The umbilicus should be evaluated for deviation from
the centerline preoperatively. If deviation is present,
then this should be pointed out to the patient, discussed
with the patient, and recorded in the medical record.
The deviation may need to be adjusted at the time of
surgery. Imbrication of the fascia next to the umbilical
stalk on the side opposite the deviation will result in
centering the umbilicus.
The centerline of the abdomen must be marked pre-
operatively. The umbilicus should be brought through
the abdominal wall at the appropriate height and in
1142
the marked midline. A deviated umbilicus can cause
patient distress and result in litigation.
When performing a modified abdominoplasty with-
out release of the umbilicus, there will usually be devi-
ation of the umbilicus inferiorly from removal of the
excess skin. The patient must be informed of this prob-
lem preoperatively since the lowered umbilicus may
not look normal especially in a bathing suit. The nor-
mal umbilicus is at the level of the iliac crests.
When the umbilical stalk is denuded of all the fat
during abdominoplasty, the blood supply should not be
disturbed since it comes through the underlying fascia.
However, if a full abdominoplasty is performed fol-
lowing a modified abdominoplasty, where the base of
the umbilicus has been transected and the umbilicus
lowered, the blood supply may not be sufficient and
necrosis of the umbilicus may occur. The physician
should be forewarned in a patient who has had a prior
abdominoplasty or tummy tuck to look for this possi-
ble problem by obtaining the prior surgeons records.
Smoking is a major cause of necrosis following
abdominoplasty, and this may affect the umbilicus or
the periumbilical region. Needless to say, the patient
must stop smoking at least 2 weeks prior to surgery
and for 2 weeks after surgery. There still remains the
problem of the patient who says smoking will be
stopped, but in actuality the patient continues to smoke.
When this information is divulged after surgery to the
surgeon or medical staff, there may be difficulties get-
ting the patient to stop smoking even when necrosis
is severe. The medical record should be excruciat-
ingly complete with every conversation, phone call,
and recommendation.
68.2.22 Discussion
The combination of liposuction with abdominoplasty is
associated with an increase in the risks and complica-
tions. Fat embolism syndrome has been reported [29] as
well as an increased incidence of thromboembolism.
Necrosis is more common, possibly because of injury to
the cutaneous vascular system. Matarasso warns about
the problem with liposuction of the mid upper abdomen
at the same time as performing abdominoplasty.
Benvenuti [30] reported an increased incidence of
inguinal hernias following abdominoplasty. Obesity
has been associated with increased complications
following abdominoplasty, 80% in obese and 33% in
non-obese patients [31].
M.A. Shiffman
Postoperatively, the surgeon should check the
patient at appropriate intervals of time depending on
the extent of surgery, patient age, and patient.
Awareness of the early symptoms or physical findings
of a complication is essential in order to make a timely
diagnosis. Proper studies should be obtained and treat-
ment begun as soon as possible in order to avoid a dan-
gerous or life-threatening problem.
If a diagnosis of a complication is difficult for the
attending surgeon to make, early consultation should
be obtained. If the surgeon intends to leave the area for
any reason, the patient should be informed and ade-
quate medical coverage obtained. This should be a sur-
geon who is experienced in performing the same
surgery performed on the patient. Any important or
critical patient problem must be relayed to the cover-
ing physician and records made available when
necessary.
68.3 Breast Augmentation
68.3.1 Areolar Retraction
Areolar retraction occurs from fibrotic bands extend-
ing from the dermis of the areola to the underlying fas-
cia (Fig. 68.1). Treatment consists of changing the
implant from the submuscular position to the submam-
mary position. Transection or resection of the fibrous
band alone will almost always result in recurrence of
the indentation.
68.3.2 Asymmetry
Asymmetry is a frequent problem since most females,
prior to surgery, have either one nippleareolar com-
plex (NAC) lower that the other or one breast larger
than the other. Preoperative photos will show the dif-
ference, and this should be pointed out to the patient
before surgery.
Postoperative asymmetry may be prevented by
doing a reverse crescent mastopexy for the higher
NAC.
68.3.3 Autoination, Spontaneous
There have been reports of spontaneous autoinflation
of implants [3236].
68 Complications of Cosmetic Surgery
a 68.3.4 Axillary Banding
b visible.
Fig. 68.1 Areolar retraction. (a) Preoperative. (b) Postoperative
with areolar retraction
1143
Transient axillary banding has been noted in patients
following transaxillary approach to breast augmenta-
tion [3740]. Maximovich [37] reported that micro-
scopic examination (done by Ellenbogen) showed the
band to be lymphatic in origin.
The band is more likely a phlebitis of a superfi-
cial vein of the axilla and medial upper arm (branch
of basilic vein) [41, 42] that is another form of
Mondors disease. A superficial lymphatic vessel
has never been reported to form a thick subcutane-
ous band and superficially would not be large enough
to form a fibrous band that would be palpable and
68.3.5 Bleeding, Hematoma
Manifestations of bleeding into the implant pocket
after surgery include swelling, increasing pain, and
tenderness. This should be treated with urgent surgi-
cal decompression with removal of implant, complete
cleansing of blood and clots in pocket, coagulation or
ligation of any bleeders, and reinsertion of the implant
(after cleansing with antibiotic solution). Drains are
usually not necessary. Any residual blood in the pocket
may result in capsule contracture. Instances of late
bleeding, weeks after surgery, have occurred.
Bleeding from the incision site should be treated
with local compression for at least 6 min (normal max-
imum of bleeding time). If this does not control the
bleeding, the wound should be explored and the offend-
ing vessels ligated or coagulated.
68.3.6 Bottoming Out
Bottoming out is a result of the implant sliding infe-
riorly behind the breast. This is usually caused by
the weight of a large implant and/or the patients
physiology (thin, weak fibrous capsule). This can be
treated by capsulorrhaphy suturing the lower portion
of the fibrous capsule at the inframammary fold
(securing the deep tissues by including muscle fascia
or periosteum) together with permanent suture,
supporting the inferior part of the capsule with a
hammock capsulorrhaphy [43], or by internal mas-
topexy with imbricating sutures of the anterior
fibrous capsule [44].
1144
Fig. 68.2 Calcifications in fibrous capsule
68.3.7 Calcications
Any long-standing fibrous capsule can develop calcifi-
cations (Fig. 68.2). These are usually asymptomatic.
The calcifications appear benign on mammography.
When the fibrous capsule is thick and calcifications
occur, capsule contracture may be present as well.
Calcifications may be associated with the presence of
the implant stabilization patch [45].
If the calcifications are extensive and associated with
symptomatic capsule contracture, capsulectomy should
be performed rather than capsulotomy. Otherwise, the
remaining calcified fibrous capsule may be palpable.
68.3.8 Capsule Contracture
Baker grade III or IV usually need surgical revision with
capsulotomy or capsulectomy. Both of these procedures
M.A. Shiffman
Fig. 68.3 Nerve entrapment. Arrow shows the fourth intercos-
tal nerve on the fibrous capsule of the implant
have a similar success rate. Capsulectomy is usually
associated with more bleeding and longer surgery time.
External compression capsulotomy is not recommended
since it has been associated with bleeding and implant
rupture and is painful if sedation is not used.
Instead of surgical treatment of capsule contracture,
there have been proposals that Accolate (Zafirlukast,
AstraZeneca Pharmaceuticals, Delaware) be used.
There has been some success with softening of the
capsule with the drug. The dose is 20 mg twice daily.
68.3.9 Chronic Pain
Chronic pain can occur following breast augmentation
from capsule contraction, nerve entrapment (Fig. 68.3),
neuromas, or submuscular placement of the prosthesis.
With fourth intercostal nerve entrapment, the pain may
be sharp or burning in character starting in the lateral
breast, over the nerve, and radiating to the nippleareolar
complex. Regional block of the fourth intercostal nerve
may help but usually surgical neurolysis is necessary.
Delayed onset (years) of breast and subscapular
pain was reported in 8 out of 146 patients who had
submuscular (under pectoralis major and serratus ante-
rior muscles) placement of the prostheses [46].
68 Complications of Cosmetic Surgery
68.3.10 Double Bubble
The cause of the appearance of a double bubble is
usually the implant placed under the pectoralis major
muscle and the inframammary fold lowered. The
attachment of the skin to the underlying fascia from
the original inframammary fold, if it is not adequately
broken up during surgery, gives the appearance of a
double bubble (Fig. 68.6). During surgery, the liga-
ment between the muscle fascia and skin should be
transected, and it may be necessary to make multiple
incisions into the fibrous tissue before expanding the
crease with the finger and/or a dissection paddle. This
can be resolved postoperatively by postoperative com-
pressions to push the fold outward (Fig. 68.4).
The treatment would be to take the implant out of
the subfascial space and replacing it into the submam-
mary space. The use of Gore-Tex or autologous fat to
fill the defect is unnecessary.
68.3.11 Elevated Platinum Levels
There has been one report by Lykissa and Maharaj
[47] that studied the platinum levels in a variety of
tissues of patients who have had silicone and saline
implants for augmentation. There was an increase in
the levels of platinum in implant patients, which was
higher than the normal population. However, there are
no symptoms or disorders attributed to these elevated
levels.
68.3.12 Fibrotic Retraction
Fibrosis at the inferior margin of the implant is rare
(Fig. 68.5). It is probably caused by excessive scarring
in the area such as with capsule contracture.
68.3.13 Galactorrhea
Rothkopf and Rosen [48] reported on a patient with
galactorrhea following breast augmentation. The pro-
lactin levels in the patient were elevated. It was pre-
sumed that the lactation was secondary to prolactin
elevation due to stimulation of the thoracic nerve end-
ings that produced impulses that travel via the dorsal
nerve roots to the hypothalamus and pituitary causing
a rise in prolactin secretion.
1145
There have been other reports of lactation following
breast augmentation [49, 50]. Bromocriptine 1.25 mg
daily orally will usually resolve the problem.
68.3.14 Idiosyncratic Allergic Reaction
There is one report of an idiosyncratic reaction to
textured Becker expander saline implants [51]. The
patient developed erythematous papules and pustules
that showed a perivascular lymphohistiocytic infiltrate,
which resolved with removal of the implants. The
textured shell patch was placed on the skin and itching,
hives, and urticarial plaques developed under the patch.
68.3.15 Improper Implant Placement
The implants may be placed too high because of inad-
equate dissection of the pocket at the inframammary
fold (Fig. 68.6). This is most common during the learn-
ing phase of the umbilical approach. More often, the
implant shifts upward when the patient is at home and
remains in that position too long. Postoperatively,
compressing the superior portion of the breasts with an
ace bandage will usually prevent the upward shift of
the prostheses. In the umbilical approach for breast
augmentation, there is a learning curve to produce an
adequate pocket and compression to keep the implant
in position. Many times in the umbilical approach, the
implant will slowly settle into the proper position.
When a patient requests a large cleavage fold, there
is only so much the surgeon can do depending on the
nipple position and what placement of the implant cen-
tered under the nipple will do. Placing the implant too
medial just to make cleavage is a serious error since
this is a cosmetic procedure and nipples shifted out-
ward are aesthetically poor (Fig. 68.7).
68.3.16 Infection
Infection is manifested by erythema, increasing pain,
swelling, and at times purulent drainage. If purulent
drainage is present, the wound should be opened and
the implant removed. The pocket is cleansed with anti-
biotic solution and the wound drained. The implant
can be replaced at least 3 months after complete wound
healing. Any sooner frequently results in recurrent
infection.
1146 M.A. Shiffman

c
68 Complications of Cosmetic Surgery
Fig. 68.5 Fibrotic retraction
Fig. 68.6 Implant placed too high
If there are symptoms without purulent drainage,
there may be mastitis rather than infection. The patient
is treated by increasing the dose of the antibiotic given
postoperatively or by a new antibiotic for 2448 h.
If there is improvement, then the antibiotics can be
continued until there is resolution. If there is no
Fig. 68.4 (a) Immediate postoperative double bubble with sub-
muscular implant. (b) Treatment consists of compressing the
inframammary fold with the ipsilateral hand and then compress-
ing the upper breast and implant with the contralateral hand
1147
b
Fig. 68.7 Implant placed too medial to give the patient more
cleavage. (a) Preoperative. (b) Postoperative
improvement, the implant should be removed, cultures
taken, the wound cleansed with antibiotic solution, and
a drain placed in the pocket. Again, implant replace-
ment is not done until at least 3 months have passed
after the wound is completely healed.
68.3.17 Lactation Problems
There have been reports of inability to produce enough
breast milk to breast-feed an infant following breast
augmentation [27, 5254].
The causes of unsuccessful lactation include inad-
equate glandular development [27], the periareolar
approach [52], severed milk ducts [52], altered nipple
sensation [52], and lack of or little breast changes
during pregnancy with little or no postpartum engorge-
ment [52].
using firm pressure several times at least four times daily to
stretch the attachment. (c) One month after treatment. Only
minimal attachment remains that resolved completely after
3 months
1148
Fig. 68.8 Scar malposition with inframammary incision sites
too high on the breast
68.3.18 Late Bleeding After Breast
Augmentation
There are multiple reports of late bleeding into the
pocket after breast augmentation [28, 5559]. Some of
the causes have been attributed to chronic inflamma-
tory reaction to the polyurethane-coated implant, gran-
ulating tissue with new capillary ingrowth, and the use
of corticosteroids in the saline prosthesis. Another
cause that should be ruled out is blood dyscrasia.
68.3.19 Malposition of the
Inframammary Scar
Breast augmentation scars should be as inconspicuous
as possible. Scars can be hidden in the transumbilical
approach as well as axillary approach. Axillary scars
can get thickened. The position of an inframammary
scar should be close to the inframammary crease,
within a centimeter, but not in the crease itself since
this can result in irritation of the scars by the bras-
sieres elastic band or wire rubbing the scar.
If the incision is placed too far above the inframam-
mary fold, it will cause a problem when performing a
repeat augmentation and inserting a larger prosthesis.
This can result in an inframammary scar to appear
even higher on the breast and away from the inframam-
mary fold (Fig. 68.8).
68.3.20 Migration of Implant
There is one report of a left breast implant migrating
into the thoracic cavity [60]. An axillary approach had
been used and the patient developed sudden dyspnea
M.A. Shiffman
during the operation on the left side, but this was
alleviated by the administration of oxygen. The basis
for the migration was believed to be from a large defect
of the chest wall, breast massage after surgery, and the
difference in pressure between the outside and the
inside of the chest wall. However, it is this authors
opinion that initially there was perforation into the tho-
racic cavity during surgery as the cause of the sudden
dyspnea during the procedure, and this evolved into
the large defect in the chest wall with subsequent
migration of the implant.
68.3.21 Mondors Disease
Mondors disease (superficial breast phlebitis, scleros-
ing breast phlebitis) is an obliterative phlebitis of the
thoracoepigastric vein, frequently with a history of
trauma. The phlebitis normally crosses the anterior chest
region and breast from the epigastrium or hypochon-
driac region to the axilla. The symptoms are usually a
red linear cord attached to the skin and not to the
deep fascia with slight to no discomfort (Fig. 68.9).
Manifestations usually disappear in 36 weeks without
treatment. For discomfort, minor analgesics and the
application of heat will help. Injection of steroids is not
usually necessary and surgical transection unnecessary.
A recent suggestion by Rassel, Borsand, and Jonov
for symptomatic Mondors disease is to stabilize the
proximal portion of the vessel with the operators
thumb, and very firm pressure is placed along the direc-
tion of the vessel with the operators opposite thumb as
if milking the vessel (Fig. 68.10). While the opera-
tors upper hand is stabilizing the vessel, the inferior
hand applies a firm downward stroke. This disrupts the
cord and resolves the problem including the pain.
68.3.22 Myospasm of Pectoralis
Major Muscle
Myospasm with spontaneous myoclonic jerks of the
left pectoralis muscle was reported following subpec-
toral breast augmentation [61]. This disorder that did
not respond to Klonopin, excision of a segment of the
lateral pectoral nerve, or open capsulotomy and
transection of the pectoralis major muscle head to the
humerus needed explantation to relieve the spasms.
The presumptive cause was myospasm from a mechan-
ical irritation of the nerve from the implant.
68 Complications of Cosmetic Surgery
a susceptible to complications such as infection and
b allow a knowledgeable and informed consent to the
Fig. 68.9 Mondors disease
68.3.23 Necrosis
The causes of necrosis include prior radiation therapy
for breast cancer, uncontrolled diabetes followed
by infection, late diagnosis of hematoma, smoking
(Fig. 68.11), infection, electrocoagulation too close to
the skin (Fig. 68.12), or a combination of these factors
(Figs. 68.13 and 68.14). Radiation reduces the vascu-
larity of the exposed area that makes the breast more
1149
necrosis. In combination with other factors such as
uncontrolled diabetes, smoking, or hematoma, the risk
of problems increases.
68.3.24 Neurologic Injury
The axillary approach to cosmetic breast surgery is an
excellent alternative to the inframammary, periareolar,
areolar, and umbilical incisions. The scar is rarely vis-
ible except with the arms raised but does occasionally
become hypertrophic. The risks associated with this
approach include all the usual risks of any breast
implant surgery plus the possibility of neurologic dam-
age, both motor and sensory.
The surgeon must be aware of the risks of the axil-
lary approach and convey those risks to the patient to
procedure. The surgery must be performed with cau-
tious attention to the nerves in the area and the meth-
ods to avoid injury to those nerves.
There can be a chronic pain syndrome not only
from injury to the fourth intercostal nerve but to other
sensory nerves higher on the chest wall.
68.3.24.1 Brachial Plexus
Injury to the brachial plexus is most often caused, at
the time of surgery, by positioning the arm in an
abducted position more than 90 from the side of the
body. Those patients susceptible to this type of injury
usually have some form of actual or potential thoracic
outlet syndrome. If the head is turned in the opposite
direction during surgery, there is even more likelihood
for brachial plexus nerve or vascular compression.
There is rarely a need to keep the arm abducted more
than 85 except, perhaps, in making the initial skin
incision at the high point of the axilla in the axillary
approach to breast augmentation.
Although the brachial plexus may be at risk with
the axillary approach to cosmetic breast surgery, the
plexus is superior to the axillary vessels and is most
likely to be injured when bleeding occurs from vessel
disruption and a hemostat or clip is placed to control
the bleeding without clearly visualizing the surround-
ing structures. This type of injury can occur following
a long period of compression to control the bleeding
without direct injury from a hemostat or clip. There
can be permanent injury to the inferior cord of the
brachial plexus (ulnar nerve distribution).
1150 M.A. Shiffman

a b

c d

Fig. 68.10 Mondors disease involving axilla. (a) Thumb firmly on proximal portion of the cord. (b) Opposite thumb on distal por-
tion of cord for firm stretch of cord. (c) Prior to stretch type of manipulation. (d) After manipulation

The brachial plexus has three cords from which the
infraclavicular branches are derived (Table 68.1). The
long thoracic nerve (nerve of Bell) is located along the
side of the chest wall on the outer surface of the serra-
tus anterior supplying filaments to each of its digita-
tions. This nerve is not normally at risk during breast
augmentation from any approach, but it is theoretically
possible to injure the nerve when doing a very wide
pocket dissection during a capsulectomy or in making
a megapocket in a patient with an extremely large
implant (over 800 mL). The one medical legal case
[62] encountered by the author was with a permanent
68 Complications of Cosmetic Surgery
a a
b
Fig. 68.11 (a) Preoperative. (b) Residual scarring of left breast
following breast augmentation in a smoker
long thoracic nerve injury causing a winged scapula in
a patient who had simple capsulotomies for breast
implants and not utilizing an axillary incision. The
neurosurgeon expert witness testified that the long tho-
racic nerve was injured by brachial plexus compres-
sion; however, he did not remember that the nerve has
three roots (fifth, sixth, and seventh cervical) which do
not pass through the thoracic outlet but descend behind
the brachial plexus and form the long thoracic nerve
inferior to the outlet. The most likely cause of injury in
this case was excessively tight dressings which com-
pressed the long thoracic nerve against the chest wall
below the axilla or an unrecorded fall with injury to the
lateral chest wall.
The lateral anterior thoracic nerve crosses the axil-
lary artery and vein piercing the coracoclavicular fas-
cia and enters the deep surface of the pectoralis major
muscle. It sends a filament to join the medial anterior
thoracic nerve in front of the axillary artery. The nerve
supplies the clavicular, manubrial, and sternal portions
of the pectoralis major muscle. This nerve can be
1151
b
Fig. 68.12 Skin necrosis with residual scar from electrocoagu-
lation too close to the skin
injured by dissecting too superiorly when forming a
submuscular pocket. Injury to the lateral anterior tho-
racic nerve may affect the strength of the pectoralis
major muscle which flexes, adducts, and rotates the
arm medially.
The medial anterior thoracic nerve enters and inner-
vates the pectoralis minor muscle, and two or three
branches end in the pectoralis major muscle. The nerve
supplies the lower sternocostal and abdominal portions
of the pectoralis major muscle as well as the pectoralis
minor muscle. This nerve is lateral to the lateral ante-
rior thoracic nerve. The medial anterior thoracic nerve
may be injured when dissecting a retropectoral pocket
using the axillary approach when the lateral edge of
the pectoralis major muscle is not identified before dis-
secting under the muscle and by approaching the mus-
cle from too superior a position. Injury to the medial
anterior thoracic nerve leaves no clinical muscle deficit
1152 M.A. Shiffman

Fig. 68.14 Patient post right lumpectomy and radiation therapy

for breast cancer had breast augmentation. Hematoma was diag-
nosed 1 week postoperatively, and because of the late diagnosis,
necrosis of the right nippleareolar complex occurred

Table 68.1 Infraclavicular branches of the brachial plexus

Cord Nerve Spinal origin
Lateral Musculocutaneous 5,6,7 C
Lateral anterior thoracic 5,6,7 C
Lateral head of median 6,7 C
Medial Medial anterior thoracic 8 C, 1 T
Medial antebrachial cutaneous 8 C, 1 T
Medial brachial cutaneous 8 C, 1 T
Ulnar 8 C, 1 T
Medial head of median 8 C, 1 T
Posterior Upper subscapular 5,6 C
Lower subscapular 5,6 C
Thoracodorsal 5,6,7 C
Axillary 5,6 C
Radial 5,6,7,8 C, 1 T

since the nerve only sends a few fibers to the pectoralis

Fig. 68.13 (a) Diabetic patient, post lumpectomy and radiation
therapy for cancer of the right breast, had bilateral augmentation
mammoplasty. Capsule contracture occurred on the right side
lifting the breast; there was uncorrected left breast ptosis, and
the patient had an infection developed in the wound and implant
pocket followed by necrosis. (b) Skin retraction following
removal of the right implant
major muscle and mainly supplies the pectoralis minor
muscle which helps to adduct the arm by rotating the
scapula downward and forward.
68.3.24.2 Intercostal Nerves
The sensory nerves, which are unrelated to the brachial
plexus, likely to be injured during the axillary approach
include the intercostobrachial nerves and the lateral
branches of the third and fourth intercostal nerves.
When forming a subpectoral pocket, injury to the
68 Complications of Cosmetic Surgery 1153

nerves is more likely to occur if the dissection is not

started anteriorly against the fascia of the pectoralis
major muscle prior to dissecting along the lateral edge
and then under the muscle.
One cause of injury to the fourth intercostal nerve is
placing a large implant (over 400 mL) in a subpectoral
pocket without making sure the nerve is carefully dis-
sected free from the intercostal muscles if the implant
impinges on the nerve. The nerve may not be transected,
but if folded posteriorly with implant compression,
there can be anesthesia of the nippleareolar complex
and/or a chronic pain syndrome with associated scar-
ring around the nerve.

68.3.24.3 Nerve Injury

The most common mistake after making the axillary
skin incision at the highest point of the axilla is
approaching the lateral edge of the pectoralis major
muscle from a superior-lateral direction rather than
from an antero-medial-inferior position. The proper
method is to make the skin incision and then pull the
skin antero-medially over the lateral edge of the muscle
and slightly inferiorly followed by dissecting down-
ward onto the muscle exposing the lateral edge [63].
By carefully staying on the muscle fascia and dissect-
ing around the muscle edge and under the muscle, the
submuscular pocket can be formed without approach-
ing any of the axillary nerves.
Elective intraoperative division of the medial tho-
racic (pectoral) nerve denervates the lower third of the
pectoralis minor muscle making it more flaccid and
has been used clinically to allow more anterior breast
projection and to minimize postoperative flexion-
induced breast deformity in the patient with retromus-
cular breast implants [64, 65]. There was no clinical
problem described with transection of the nerve.
Arm position during surgery with abduction to 90
or greater may result in brachial plexus or vascular
compression which can cause temporary or permanent
nerve damage. The surgeon should always be aware of
arm positioning at the beginning of surgery so that
excessive abduction does not occur. The elbow should
be padded to prevent ulnar nerve paresis.
68.3.25 Periareolar Scar Indentation
There have been some instances of depression of
the periareolar scar following breast augmentation
Fig. 68.15 Periareolar scar indentation
(Fig. 68.15) (Mirrafati SJ (2007) Personal communi-
cation, August 27, 2007). The cause has been attrib-
uted to the technique, after the skin incision, of
extending the dissection under the skin in an oblique
method pointing inferiorly to avoid damage to the
breast ducts or to dissect around the inferior portion of
the breast gland to avoid cutting through the breast tis-
sue. This creates a potential space after closure of the
skin incision since the subcutaneous fat may not line
up properly to fill the space under the skin. The usual
method is to dissect straight down through the breast
tissue to form the underlying pocket in the submam-
mary or subpectoral space. Cutting through the breast
tissue does not destroy any major ducts but does cut
smaller ductules. There have been no infections directly
attributed to transecting the small ductules.
68.3.26 Pneumothorax
Care must be taken when performing breast augmenta-
tion under local anesthesia. Any sharp needle inserted
into the tissues around the breast has the potential of
perforation into the pleural space causing a pneu-
mothorax or tension pneumothorax.
When an implant pocket is made in the retropec-
toral area, there is the possibility of pneumothorax
when a bleeder is electrocoagulated in the intercostal
space. This can leave a hole in the pleura. If noted at
the time of surgery, insert a Robinson catheter in the
1154 M.A. Shiffman

pleural space, complete the procedure, and insert the a

implant. Have the anesthesiologist expand the lungs
or, if under local anesthesia, have the patient take a
deep breath and then withdraw the catheter. The
implant will plug the small opening until fully healed.
General anesthesia can cause a pneumothorax [66]
when too much pressure is used in bagging the patient
especially if the patient has lung blebs. It is possible
for a spontaneous pneumothorax to occur when a lung
bleb ruptures without general anesthesia.
If a pneumothorax is suspected, a chest x-ray should
be taken. A pneumothorax that is less than 15% can be b
observed with repeat chest x-ray. If the air is increas-
ing or if the air is over 15%, then a tube should be
inserted into the chest, usually at the anterior second
intercostal space and connected to an underwater seal.
An unusual cause of pneumothorax in breast aug-
mentation was described by Fayman et al. [67]. Four
patients developed bilateral and one unilateral pneu-
mothorax after transaxillary approach to submuscular
placement of implants. Two patients were symptomatic.
The assumption was that air was trapped in the subpec-
toral pocket that was sealed by the implant and wound
Fig. 68.16 Rippling in a patient with textured saline implants
closure. The air was forced into the pleural cavity as a
result of the high pressure created in the subpectoral
pocket by the advancing implant. The problem was 68.3.29 Serous Fluid Drainage
resolved by placing a large-bore suction catheter into
the subpectoral pocket before the implant was inserted. Seroma is a tumor-like collection of serum in the tis-
sues. This postoperative collection of seroma fluid can
occur in breast augmentation surgery [68] and can result
68.3.27 Rippling in increased morbidity and in chronic serous drainage.
In a histopathologic study, it was noted that sero-
With the use of the saline implants, the problem of rip- mas may incite an inflammatory reaction that subse-
pling (skin waviness) has appeared more often. This is quently becomes a contributing factor in persistent
usually with the use of textured saline implants seroma formation [69].
(Fig. 68.16) and can be resolved by converting to a Movement of the textured implant in the pocket
smooth implant. may cause chronic tissue irritation and inflammation
with subsequent seroma formation. Removing and
exchanging a textured implant for a smooth one will
68.3.28 Scar: Hypertrophic, Keloid usually resolve the problem. If a smooth implant is in
place, then consider exuberant granulation tissue as a
Scars can be thickened, hypertrophic, or keloid. The possible cause. Exploration of the wound and curetting
thickened or hypertrophic scar can be treated with all the granulations will allow healing.
compression, silicone sheeting, or steroid injection.
Some hypertrophic scars will resolve spontaneously.
Keloid scars can be treated with the same modalities as 68.3.30 Synmastia (Symmastia)
the hypertrophic scar, bleomycin, 5-flourouracil, and/
or surgical excision. The keloid scar will recur in most Syn means with, together (Greek) while sym in the
instances but perhaps not quite as thick. dictionary always refers to the Greek syn. Therefore
68 Complications of Cosmetic Surgery
a the midline with the implants removed and suturing
b possibility of thromboembolism in every patient and
Fig. 68.17 Synmastia secondary to dissection of the pockets to
the midline of the sternum. (a) without tension (b) with tension
both spellings are correct. Synmastia is a fusion of
both breasts in the midline or, in breast augmentation
means the meeting or near meeting of both prostheses
in the midline.
Synmastia can be the result of dissection of the
pockets to the midline of the sternum thus weakening
the medial tissues which allows the implant to migrate
medially (Fig. 68.17) or of thin and weak tissues near
the sternum that, postoperatively, are pushed medi-
ally by the implants. Treatment consists approaching
1155
the anterior fibrous capsule to the underlying fibrous
capsule and fascia or periosteum bilaterally and then
doing lateral capsulotomies before replacing the
implants. The excess capsule can be excised or elec-
trocoagulated to expose a healing surface.
68.3.31 Thromboembolism
Patients who undergo surgery are at risk for venous
thromboembolic complications. This is especially crit-
ical in the cosmetic surgery patient who, having an
elective procedure, would not expect to have the mor-
bidity or mortality associated with thromboembolic
disease. The cosmetic surgeon must be aware of the
should take a careful history to disclose predisposing
risk factors. The surgeon should also be aware of the
clinical manifestations of pulmonary embolus in order
to make a timely diagnosis.
68.3.31.1 Risk Factors
Minor surgery <30 min in patients over 40 years of age
without additional risk factors and uncomplicated sur-
gery in patients under 40 years of age without addi-
tional risk factors are in the low-risk category. General
surgery in patients over 40 years of age lasting >30 min
and patients under 40 years on oral contraceptives are
in the moderate-risk category [9]. High-risk category
would be major surgery in patients over 40 years of
age with recent history of deep vein thrombosis or
pulmonary embolism, extensive pelvic or abdominal
surgery for malignancy, and major orthopedic surgery
of the lower extremities.
Predisposing risk factors include age over 40 years,
malignancy, obesity, prior history of thromboembo-
lism, varicose veins, recent operative procedures, and
thrombophilia. These risks are further modified by
duration and type of anesthesia, preoperative and
postoperative immobilization, level of hydration, and
the presence of sepsis [10]. Medical problems associ-
ated with increased risk include acute myocardial
infarction, stroke, and immobilization [11]. Estrogen
therapy and pregnancy are common risk factors while
uncommon factors include lupus anticoagulant, neph-
rotic syndrome, inflammatory bowel disease, poly-
cythemia vera, persistent thrombocytosis, paroxysmal
nocturnal hemoglobinuria, and inherited factors such
1156 M.A. Shiffman

Table 68.2 Thromboembolism protocol

Adult Deep Vein Thrombosis Prevention Assessment & Physician Orders
Instructions:
RN to complete Risk Factors & obtain physician orders & lab orders from MD
When complete< nursing to send a copy to the Pharmacy Department
Risk Factors (Circle ALL that apply) Physician Orders (check all that apply)
1 Minor Surgery Total Risk
1 Age between 41 to 60 years Points Level
1 History of prior major surgery (less than 1 month) 0 to 1 LOW Early aggressive mobilization
1 Varicose veins
Anti-embolism stockings
1 Inflammatory bowel disease
Sequential compression device
1 Swollen legs (current) Moderate
2 Heparin 5,000 units SQ every 12 hrs
1 Obesity
1 Oral contraceptive or hormone replacement therapy
Lovenox 40mg SQ daily
2 Age between 61 to 74 years Lovenox 30mg SQ every 12 hrs
2 Malignancy present or within last 6 months
2 Major surgery (more than 45 minutes)
Anti-embolism stockings
2 Laparoscopic surgery (more than 45 minutes)
Sequential compression device
2 Confinement to bed (more than 72hrs pre & post admission) Heparin 5,000 units SQ every 12 hrs
2 Immobilizing cast (less than 1 month)
3 to 4 High
2 Central venous access (less than 1 month) Heparin 5,000 units SQ every 8 hrs
3 History of DVT/PE Lovenox 40mg SQ daily
3 Family history of thrombosis Lovenox 30mg SQ every 12 hrs
3 Age 75 years or older Warfarin mg daily
Major surgery with additional risk factors
3 Anti-embolism stockings
(MI,CHF,sepsis, COPD)
Sequential compression device
Medical patient with additional risk factors (MI,CHF,sepsis,
3 Lovenox 40mg SQ daily
history of stroke, serious lung diseases, pneumonia)
5 or SCD + Lovenox 40mg SQ daily
3 History of increased clotting time Highest
more SCD + Heparin 5,000 units SQ
5 Elective total hip and/or knee replacement
every 8 hrs
5 Hip, pelvis or leg fracture (less than 1 month) Lovenox 30mg SQ every 12 hrs
5 Stroke (less than 1 month) (decrease to once daily when
5 Multiple traume (less than 1 month) strating coumadin)
Total Points
Absolute contraindications for anticoagulation: Laboratory Orders:
Active hemorrhage form wounds, drains, lesions CBC every other day if heparin or lovenox are
Heparin use in herparin-induced thrombocytopenia administered
Severe trauma to head, spinal cord or extremities with Daily PT/INR if warfarin is administered
hemorrhage within 4 weeks (parameters)
Active intracerebral or gastrointestinal hemorrhage Additional Lab orders (specify)
Known hypersensitivity to herparin or pork products (for heparin)
Warfarin therapy for contemplated major surgery
Risk Assessment completed by:

Signature:
Physician signature:
Date: Time:

Date: Time:

as antithrombin III deficiency, protein C deficiency,
protein S deficiency, plasminogen activator deficiency,
elevated plasminogen activator inhibitor, and homo-
cystinuria [12].
Superficial calf vein thrombosis, proximal deep
vein thrombosis, and fatal pulmonary embolus increase
in incidence as the risk category increases from low to
high.
Preoperative risk assessment should be determined
in every patient (Table 68.2).
68.3.31.2 Clinical Manifestations
Superficial thrombophlebitis (an inflamed vein)
appears as a red, tender cord. Deep-vein thrombosis
may be associated with pain at rest or only during
exercise with edema distal to the obstructed vein. The
68 Complications of Cosmetic Surgery
first manifestation can be pulmonary embolism. There
may be tenderness in the extremity and the tempera-
ture of the skin may be increased. Increased resistance
or pain on voluntary dorsiflexion of the foot (Homans
sign) and/or tenderness of the calf on palpation are
useful diagnostic criteria.
Pulmonary embolism is usually manifested by one
of three clinical patterns: (1) onset of sudden dyspnea
with tachypnea and no other symptoms, (2) sudden
pleuritic chest pain and dyspnea associated with find-
ings of pleural effusion or lung consolidation, and (3)
sudden apprehension, chest discomfort, and dyspnea
with findings of cor pulmonale and systemic hypoten-
sion. The symptoms occasionally consist of fever,
arrhythmias, or refractory congestive heart failure.
68.3.31.3 Diagnosis
Deep-vein thrombosis is best diagnosed with duplex
ultrasonography which combines pulsed gated Doppler
evaluation of blood flow with real-time ultrasound imag-
ing. Other diagnostic tests include x-ray venography,
radionuclide venography, radioisotope-labeled fibrino-
gen, ultrasonography, and impedance plethysmography.
Liquid crystal thermography detects increases in skin
temperature and is a useful adjunct to ultrasonography
or impedance plethysmography.
Ventilation-perfusion lung scan (VP scan) is a safe,
sensitive means of diagnosing pulmonary embolism.
Isotope pulmonary perfusion scan (Q scan) is more spe-
cific with inclusion of the isotope ventilation scan (V
scan). The definitive diagnosis can be made by pulmo-
nary arteriography, but VP scan can give a high degree
of certainty. Arterial blood gas typically shows reduc-
tion in PaO2 and PaCO2 while electrocardiogram shows
tachycardia but is best used for ruling out myocardial
infarction. Chest x-ray may show basilar atelectasis,
infiltrates, pleural effusion, or cardiac dilatation.
68.3.31.4 Prophylactic Treatment
Low-risk general surgical patients may be treated with
graduated compression stockings applied during sur-
gery, early ambulation, and adequate hydration [13].
Keeping the knees flexed on pillows during surgery
and avoiding local compression on any areas of the
legs are helpful. The type of surgery does not matter as
long as general anesthesia or intravenous sedation is
given. Compression stockings (2030 mm support
hose is adequate) are applied in the operating room,
and ambulation is begun when the patient is awake and
1157
capable of ambulating with assistance. When the
patient is ambulating on a regular basis during the day,
the compression stockings can be removed.
For moderate risk patients, low-dose heparin (5,000
units 2 h before surgery and then every 812 h until
ambulatory), low-molecular-weight heparin (LMWH),
dextran, or aspirin may be utilized. Alternatively, gradu-
ated compression stockings or intermittent pneumatic
compression started during surgery are used continu-
ously until ambulatory, or a combination of both is rec-
ommended [14]. Intermittent pneumatic compression is
more effective than graduated compression stockings.
All high-risk patients (unlikely in cosmetic sur-
gery) should be treated with low-dose heparin or
LMWH and combined pharmacologic and mechani-
cal methods.
Dextran can result in cardiac overload, and high-
dose aspirin (1,0001,500 mg/day) has limited efficacy
in preventing deep-vein thrombosis. In cosmetic sur-
gery, the use of aspirin or heparin may result in postop-
erative bleeding.
68.3.31.5 Hereditary Hypercoagulable
States
Patients with a family history of thrombosis, early-
onset or recurring thrombosis, thrombosis at unusual
sites, or warfarin-induced skin necrosis should be eval-
uated for possible underlying inherited hypercoagula-
ble disorders.
Antithrombin III (AT-III) is a heparin cofactor that
allows heparin to inactivate primarily factor IIa but also
factors IXa, Xa, XIa, and XIIa [15]. A deficiency in
AT-III predisposes to thrombosis by allowing uncon-
trolled activity of many of the coagulation factors.
Endothelial surfaces have receptors called throm-
bomodulin that function as anticoagulants because of
the ability to neutralize thrombin. The thrombin-
thrombomodulin complex activates protein C, a vita-
min K-dependent factor that is facilitated by protein
S, another vitamin K-dependent factor. Activated pro-
teins C and S metabolize activated factors V and VIII,
which results in downregulating the coagulation sys-
tem. Patients with protein C deficiency may have
recurrent episodes of superficial thrombophlebitis as
well as thromboembolism [16]. Patients with protein
S deficiency experience more arterial thromboembo-
lism including stroke [17]. Deficiency in protein C
or S may present as neonatal purpura fulminans in
the newborn or skin necrosis in adults treated with
1158
warfarin, a drug known to cause a sudden fall in
protein C or S.
Venous thromboembolism occurs in one out of
every 1,000 people with activated protein C resistance
(APC-R) responsible for up to 64% of the cases.
APC-R is due to a single point mutation in the FV
gene for clotting factor V. This mutated FV may be
referred to as factor V Leiden (FVL), FV:Q506 allele,
or APC-gene and is less efficiently degraded by APC.
A hypercoagulable state results from impairment of
the inactivation of factor V by activated protein C.
This creates a lifelong increased risk of thrombosis
and thromboembolism.
Within the intact vessel, thrombin binds to throm-
bomodulin on the endothelial cell acting as an antico-
agulant bay activating the protein C system. Activated
protein C (APC), potentiated by cofactor protein S,
downregulates the activity of the coagulation system
(limits clot formation) by cleaving and inhibiting fac-
tors V (FV) and VIII [1921].
APC testing can be performed with DNA genotyp-
ing. This can differentiate acquired from inherited
APC-R. Approximately 10% of patients with APC-R
phenotype lack the FV mutation (genotype), and the
diagnosis of APC-R in these patients will be missed
[22]. The combination of phenotype and genotype
information aids in establishing prophylactic and ther-
apeutic guidelines.
Asymptomatic patients with APC-R who have never
had a thromboembolic event, as well as their family
members, should receive counseling regarding the
implications of the diagnosis and information concern-
ing the signs and symptoms of venous thromboembo-
lism [23]. Short-term prophylaxis with heparin should
be considered when there are high-risk circumstances
encountered such as immobilization, surgery, trauma,
or obstetrical procedures. After a thrombotic event,
these patients need extended anticoagulation, balancing
the risk of bleeding against the risk of recurrence when
therapy is discontinued. Empirical treatment is for at
least 1 year after two episodes of thromboembolism
and lifelong treatment after three episodes.
68.3.32 Toxic Shock Syndrome
Toxic shock syndrome has been reported in breast aug-
mentation [2426]. The syndrome is caused by the
exotoxins (superantigens) secreted with infection from
M.A. Shiffman
Staphylococcus aureus and group A Streptococci.
Knowledge of the criteria for diagnosis is important
in order to treat this potentially fatal disease. These
include:
1. Fever (>102o)
2. Rash (diffuse, macular erythroderma)
3. Desquamation (12 weeks after onset, especially of
palms and sole)
4. Hypotension
5. Involvement of three or more organ systems:
a. Gastrointestinal (vomiting, diarrhea at onset)
b. Muscular (myalgia, elevated CPK)
c. Mucous membrane (conjunctiva, oropharynx)
d. Renal (BUN or creatinine >2 times normal)
e. Hepatic (bilirubin, SGOT, SGPT >2 times
normal)
f. Hematologic (platelets <100,000)
6. Negative results on the following studies (if
obtained):
a. Blood, throat, or cerebral spinal fluid (CSF)
cultures
b. Serologic tests for Rocky Mountain spotted
fever, leptospirosis, and measles
Treatment consists of surgical debridement for
necrosis, antibiotics, circulatory and respiratory care,
anticoagulant therapy for disseminated intravascu-
lar coagulation, and immunoglobulin. Experimental
approaches have included use of antitumor necrosis
factor monoclonal antibodies and plasmapheresis.
68.4 Breast Augmentation:
Subfascial Pocket
68.4.1 Introduction
The subfascial approach to breast augmentation has
had very good results with few complications. Surgeons
planning to perform the procedure should first observe
the technique and, better yet, get hands-on training.
The inexperienced surgeon is more likely to have com-
plications. The usual risks and complications follow-
ing breast augmentation should be discussed with the
patient prior to the surgery as well as the risk of mis-
placement of the implant below the pectoralis major
muscle instead of above the muscle.
The purpose of the subfascial pocket is to have less
capsule contracture and rippling while avoiding the sub-
muscular problem of distortion with muscle tension.
68 Complications of Cosmetic Surgery
68.4.2 Difculty Dissecting the Pocket
Parsa et al. [70], without having been trained for this
procedure, performed subfascial pocket dissection in
three patients. They had difficulties with the dissec-
tion, shredded the fascia, found it time-consuming,
and had increased blood loss. Experienced, trained
surgeons have no difficulty dissecting the pocket, have
little difficulty with bleeding, and can perform the
surgery in the same or less time than in doing the sub-
mammary or subpectoral pocket.
68.4.3 Incorrect Pocket
It is possible to place the prosthesis in a subpectoral
pocket accidentally instead of the intended submammary
pocket. This can occur with blind dissection or even with
the endoscope. Endoscopically, in the subpectoral pocket,
the anterior muscle may not be visible through the fat
layer under the muscle and may appear to be the fat
under the breast. Posteriorly, the pectoralis major muscle
should be visible if submammary, and the ribs should be
visible if subpectoral, but the pectoralis minor muscle,
which arises from the third, fourth, and fifth ribs and
inserts into the coracoid process of the scapula, may be
mistaken for the pectoralis major muscle.
68.4.4 Reported Complications
Stoff-Khalili et al. [71] described the complications in
69 patients having the subfascial approach. Baker
grade III capsule contracture occurred in 2.6% and
Baker grade IV in 0.0%. Rippling was noted in 1.5%
of patients, and there were no patients with hematoma
or seroma.
Graf et al. [72] reported on 263 patients with endo-
scopic transaxillary subfascial approach and had six
patients with grade II capsule contracture (2.3%), three
patients with unilateral hematoma (1.1%), and eight
patients with implant malposition requiring surgical
intervention (3%). There were no patients with implant
distortion from muscle contraction.
Ventura and Marcello [73] had 63 patients with sub-
fascial approach. There were two patients (2%) with
Baker grade II capsule contracture and one patient with
excess drainage that required surgical exploration.
There were no seromas or infections, and there was less
1159
edema and faster recovery than with submuscular or
subglandular placement.
Munoz et al. [74] had no capsule contractures in the
42 patients with the subfascial approach followed for
16 months.
68.4.5 Discussion
There are other reports on the use of the subfascial
placement of prostheses [7577].
Duman et al. [78] performed research using rabbits
that showed that the capsule formed was thinner and
less cellular in the fascia-covered implant group than
in the control group without fascia covering. Fascial
tissue may decrease capsule formation and probably
capsule contraction.
Capsule contracture occurs less often with the sub-
fascial pocket than with the submuscular implant
placement without the problem of the pectoralis major
muscle causing distortion with contraction.
68.4.6 Conclusions
The subfascial placement of implants has fewer compli-
cations than some of the other approaches. Training is
necessary in order to perform the procedure properly.
68.5 Breast Augmentation:
Transumbilical Approach
68.5.1 Introduction
The transumbilical approach to breast augmentation
has a few complications that differ from approaches
from the axilla, areola, or inframammary region.
Although the literature may seem to suggest that using
the endoscope is essential, many experienced surgeons
using the transumbilical approach do not rely on the
endoscope to check for bleeding or implant position.
68.5.2 Reports of Complications
Johnson and Christ [79] had 91 patients with the tran-
sumbilical approach for submammary breast augmen-
tation. One patient had excessive bleeding at the time
1160
of surgery and required an inframammary incision to
control the bleeder. Implant deflation occurred in one
patient, and two patients had subpectoral implantations
that were corrected through submammary incisions.
Vila-Rovira [80] reported on 145 patients using the
transumbilical approach. There were no cases of hema-
toma or infection. Postoperative pain was described as
mild. There were some cases of postoperative edema.
Twenty percent of patients had capsule contracture with
75% Baker grade I, 15% grade II, 6% grade III, and 4%
grade IV. Rippling occurred in 30% of patients (saline
implants were used in all 145 patients with 80% smooth
and 20% textured). Some patients had asymmetry, but
some of them were due to undetected preexisting ana-
tomical deformities. Areola sensory changes were tran-
sitory. A fibrous cord along the tunnel tract was
detectable in two cases but resolved after 68 weeks.
Caleel [81] reported on 513 patients. One patient
had bleeding, two patients had postoperative hema-
toma, one patient had implant leak, and three patients
had inadequate implant pocket dissection.
Sudarsky [82] operated on 90 patients of which 70
had follow-up. One patient had accidental submuscu-
lar entry into the pocket, and there were four capsule
contractures.
Songcharoen [83] treated 93 patients with the tran-
sumbilical approach. There were no infections, 1%
hematoma at the tunnel area, 3% implant leakage, and
4% with unequal breast size.
68.5.3 Incorrect Implant Pocket Position
Usually, the tunnel extending lateral to the nipple and
the breast not elevated will place the dissector in the
submammary plane on blunt dissection. If the tunnel is
placed medial to the nipple while the breast is lifted, the
pocket is usually in the subpectoral plane. Certainly, it
is a known complication of the transumbilical approach
to get the implant in the incorrect plane by accident.
The problem of not positioning the implant in the
correct plane, submammary or subpectoral, may be by
accident, may be from inexperience, or endoscopic
examination may have fooled the surgeon. When the
implant pocket is placed in the submammary position,
the endoscope will show fat visible superficially (ante-
riorly) and the pectoralis major muscle visible posteri-
orly. However, when a subpectoral pocket is formed,
M.A. Shiffman
there is usually a layer of fat under the muscle that may
be mistaken for the fat under the breast tissue. When
viewed posteriorly, the pectoralis minor muscle may
not be distinguished from the pectoralis major muscle
since it arises from the upper margins of the third,
fourth, and fifth ribs, and from the aponeuroses cover-
ing the intercostal muscles. The muscle fibers pass
upward and lateralward and converge to form a flat
tendon that inserts into the coracoid process of the
scapula. The endoscopic examination is not perfect for
determining implant pocket position.
An instrument to change implants from the subg-
landular to the subpectoral position was described by
Rey [84]. This instrument can be used without a sepa-
rate incision by developing the correct pocket (sub-
muscular) with the bullet dissector, inserting the
implant into the subpectoral space, and then removing
the implant from the false pocket. Rey developed
another instrument to lift the pectoralis muscle via the
umbilical incision and then placing the implant into
the correct pocket.
68.5.4 Implant Postoperatively Too High
This may occur because the inframammary fold por-
tion of the pocket was not dissected low enough, or
with a well-developed low pocket, the implant may not
have migrated downward enough to fill the inframam-
mary fold. This complication is more frequent with the
inexperienced surgeon. This is a well-known compli-
cation of the transumbilical approach.
68.5.5 Capsule Contracture
The capsule contracture rate Baker grade II to IV is 5%
with saline implants in the submammary position [80].
According to the Inamed Aesthetics statistics [85], the
capsule contracture rate with saline implants for Baker
grade III/IV is 7.2% for 1-year cumulative occurrence
and 8.7% for 3-year cumulative occurrence.
The causes of capsule contracture include patients
biophysiology, infection, bleeding, silicone oil leak-
age, and foreign bodies (talc from gloves, dust?). The
umbilical approach has very little bleeding [8689]
compared to other approaches, and this may be the
reason for the lower capsule contracture rate.
68 Complications of Cosmetic Surgery
68.6 Breast Reduction
68.6.1 Calcications
Yalin et al. [90] reported on mammographic and ultra-
sonographic findings of calcifications following breast
reduction (Fig. 68.18). Masses were seen with coarse
and thick spiculations, irregular margins, central radio-
lucencies, and amorphous and pleomorphic, dystro-
phic, coarse and branching microcalcifications. There
were eggshell-like oil cyst calcifications. Fat necrosis
and oil cysts are associated with all types of surgical
procedures in the breast.
Parenchymal redistribution, asymmetry, scarring,
parenchymal or retroareolar linear bands and calcifica-
tions, high position of the nipple, and discontinuity of
the ducts were reported by Brown [91] and Miller [92].
Mendelson [93] noted skin thickening of the lower
pole of the breast around the incision sites in the peri-
areolar area and inframammary fold. Spicules were
thicker and more curvilinear than the fine and straight
spiculations of breast cancer. There were needle-like
calcifications.
Mitnick et al. [94] reported calcifications following
breast reduction were found within the skin of the
breast, mainly at a periareolar location.
Mitnick et al. [95] noted suspicious mammographic
findings including 31 stellate lesions, 20 regions of
grouped calcifications, 2 nodules, and 1 area of trabe-
cular markings. Adenocarcinoma was diagnosed by
fine needle biopsy in five patients. There was a higher
incidence of contralateral breast cancer in patients who
had cancer on one side and breast reduction on the
other side.
Heywang-Kobrunner [96] reported calcifications of
fat necrosis and oil cysts that are round and have ring-
or eggshell-like wall calcifications with radiolucent
centers.
68.6.2 Cancer
Breast cancer has been diagnosed intraoperatively [97
99] and in the postoperative specimen following reduc-
tion [100]. This is the reason why all patients for breast
reduction should have a preoperative mammogram.
Lund et al. stated that breast reduction may reduce
the incidence of future breast cancer [101]. Of 1,245
1161
Fig. 68.18 Calcifications following breast reduction
cases having breast reduction followed for over 10 years
after surgery, there were 18 cases of breast cancer. The
expected number for the incidence of breast cancer in
the normal population would be 30.28 cases.
68.6.3 Cyanotic NippleAreolar Complex
The patient should be seen on the first postoperative
day in order to evaluate the nippleareolar complex for
cyanosis. If there is any question of the blood supply to
the nippleareolar complex, test for capillary refill that
should be less than 6 s. Six seconds or more requires
that the wound sutures be removed to relieve the ten-
sion and check the pedicle for rotation. With an
anchor incision, the sutures can be removed along
the lower half of the areola and along the vertical por-
tion of the wound. If necessary, remove all sutures and
allow secondary healing. Nitropaste has not been effec-
tive in preventing necrosis. Continued cyanosis with
refill of 6 s or more may be best treated with nipple
areolar transplant.
68.6.4 Excessive Breast Reduction
Some surgeons use techniques that consistently reduce
the breast excessively. A patient with a DD should not
be made an A cup but should be made a cup size that is
adequate for the height and weight. Agarwal [102] has
described a flap augmentation for excessive breast
reduction. Most of the time, implants can be used to
augment the breast to a proper size.
1162 M.A. Shiffman

68.6.5 Fat Necrosis a

As with any necrosis problem, there can be loss of

vascular supply to parts of the fat along incision sites.
This can result in postoperative drainage of an oily
substance or a mass that may have to be treated with
excision or drainage. An untreated area of fat necrosis
may result in a fat cyst followed by calcification.

68.6.6 Hematoma

Excessive bleeding with hematoma should be treated b

with exploration, evacuation of the hematoma, and
coagulation of any bleeders. It is probably prudent to
place a suction catheter or penrose in the space for at
least 24 h.

68.6.7 High NippleAreolar Complex

The cause of a postoperative high nippleareolar

complex is either bottoming out of the breast where
the breast falls behind the nippleareolar complex to
a more inferior position or because the surgeon has
Fig. 68.19 High nippleareolar complexes secondary to bot-
not adjusted to a lower position for the large breast toming out. (a) without bra. (b) with bra
weight stretching the skin (Fig. 68.19). The new
nipple point, instead of being at the inframammary
fold, should be adjusted 12 cm lower for the heavy
breast.

68.6.8 Infection

Infection should be treated with proper antibiotics, if

possible following culture and sensitivity. Cellulitis is
most often a strep infection. An abscess needs open
drainage with culture and sensitivity.

68.6.9 Necrosis

Necrosis of skin flaps can occur from inadequate

blood supply, torsion of the pedicle, excessive tension
on the skin or compression of the pedicle, thin flaps,
hematoma causing excessive tension, smoking, and
uncontrolled diabetes especially with infection (Fig.
68.20). Necrotizing ulceration was reported by Berry
et al. [103].
Fig. 68.20 Postoperative necrosis following breast reduction in
a diabetic with infection
Treatment consists of debriding the necrotic areas,
keeping the open wounds clean with saline soaks,
and secondary closure when the granulations have
68 Complications of Cosmetic Surgery 1163

properly formed. If secondary closure fails, then the

wound should be left open to close on its own.

68.6.10 Neurological

Pressure sensation (using the Pressure-Specified

Sensory Device) of the breast was measured at nine
points of the breast by Ferreira et al. [104]. All 25
patients had decreased sensation in all points measured
when the upper medial pedicle technique was used.
Hamdi et al. [105] noted loss of sensitivity of the
nippleareolar complex (NAC) with superior and infe-
rior pedicle techniques that resolved with the change
to the latero-central pedicle technique.

68.6.11 Pain

Gonzalez et al. [106] reported that headache, neck

pain, back pain, shoulder pain, and bra strap groove
pain present in 6092% of patients and 97% of patients
had at least three of these pain symptoms preopera-
tively. All patients had reduction of their pain, and
25% had complete elimination of pain symptoms after
reduction mammaplasty.
Chronic breast pain can occur following breast
reduction [107].
Fig. 68.21 Residual pigmented areola tissue along the vertical
scar following breast reduction
68.6.11.1 Phantom Breast Pain
Phantom breast pain at the site of the original nipple
locations has been reported following breast reduction
[108]. This was resolved with explanation to the patient
of the origin of the pain and with nonsteroidal anti-
inflammatory analgesics.

68.6.12 Retained Excess Areola

In patients for breast reduction with very large areolas,

the Wise pattern has to be modified to allow removal of
all the excess areola. Otherwise, the pigmented area of the
residual areola will mar the cosmetic result (Fig. 68.21).

68.6.13 Scar

Hypertrophic (Fig. 68.22) and keloid scars can occur

with any surgical wound. Fig. 68.22 Hypertrophic scar
1164
68.6.13.1 Pathology
Hypertrophic scars can be distinguished from keloid
scars microscopically. Both are characterized by exces-
sive deposits of collagen in the dermis and subcutane-
ous tissues following trauma or surgical injuries with
collagen bundles that appear stretched and aligned in
the same plane. Collagen bundles in keloids are thicker
and more abundant and form acellular node-like struc-
tures in the deep dermis.
68.6.13.2 Clinical Manifestations
Keloids may have a genetic predisposition and occur in
1520% of blacks, Hispanics, and Asians. Hypertrophic
scars are confined to the area of injury while keloids
grow beyond the confines of the original wound and
can appear nodular. Hypertrophic scars may regress
without treatment while keloids rarely regress. The
scars can cause disfigurement, contractures, pain, and
itching.
68.6.13.3 Treatment
Keloids and hypertrophic scars can be treated with
intralesional corticosteroids alone or in combination
with surgical excision, superficial radiation, laser, cry-
otherapy, or pressure therapy. Silicone sheeting used
8 h daily for 36 months is helpful in reducing the
height of a thickened scar. Keloids tend to recur in
about 80% of patients with most types of treatment.
Other therapeutic agents [109] include 5-fluorouracil,
verapamil (calcium blocker), bleomycin, interferon-a-
2b, histamine antagonist, or colchicine (with or without
penicillamine and b-aminopropionitrile).
Surgical excision of keloids followed by superficial
radiotherapy for two treatments, one per day, is very
helpful. The best way to remove the keloid surgically
is to excise the scar leaving about 1 mm of scar cir-
cumferentially and closing the wound with sutures in
the scar edges. The use of steroid in the edges of the
wound closure may be helpful in reducing the amount
of scarring.
In using corticosteroids, care should be taken to
inject the drug into the middle of the lesion. If injected
too superficially, there may be visible spots of chalky
material. There may be pain with injecting steroids
into the scar because there is very little to give to
the tissues and local anesthesia may be necessary.
The author uses a combination of triamcinolone
(40 mg/mL), 0.20.4 mL, 5-fluorouracil, 1 mL (50 mg),
and 1 mL 0.5% lidocaine with epinephrine for the
injection. Hypopigmentation in the scar may occur.
M.A. Shiffman
Inadvertent injection of steroids deep to the scar may
result in steroid fat atrophy.
68.6.14 Steroid Fat Atrophy
The treatment for fat atrophy secondary to steroid
injection has usually been with the use of fillers,
including autologous fat.
The author has a patient who was a postreduction
mammoplasty with implant augmentation patient with
postoperative hypertrophic scars that had been treated
in the inferior medial aspect of both breasts with ste-
roids resulting in complete loss of the fat of the inferior
medial portions of the breast fat 1 year before being
seen (Fig. 68.23). While performing a capsulotomy for
capsule contracture of the right breast, 300 mL of
saline was injected as tumescent fluid into the inferior
medial quadrants of both breasts for a total of 600 mL.
Thirty days after the procedure, the inferior medial
quadrants of the breast were found to be filled out to
normal proportions with fat.
Apparently, the steroids cause loss of the fat in the
cell but do not destroy the fat cells. Placing the steroid
crystals back in emulsion form allows the body to
remove these as foreign substances.
68.6.15 Discussion
Some form of complication occurs in about 10%
of patients. Mandrekas [110] reported the incidence
of:
Hematoma 0.3%
Nipple and/or pedicle necrosis 0.8%
Wound dehiscence 4.6%
Hypertrophic scars 3.3%
Loss of sensitivity of the nipple 1.3%
68.7 Facelift
68.7.1 Asymmetry
Asymmetry results from excess excision of skin from
one side of the face or from unequal pull on the flaps,
not in the same direction, on each side. Distortion of
the earlobe is common if the closure is performed
under any tension around the bottom of the ear.
Revision surgery may have to be performed.
68 Complications of Cosmetic Surgery 1165

Fig. 68.23 (a) Fat atrophy of the inferior medial quadrants of both breasts following steroid injections of the scars. (b) Thirty days
after tumescence with 300 mL saline on each side showing the fat content of the inferior medial quadrants to be normal

68.7.2 Bleeding sues are friable, the wound may have to be allowed to
heal with secondary intention.
Postoperative bleeding may occur if the vessels are not
completely ligated or electrocoagulated.
Other causes of bleeding include: 68.7.4 Dogear
1. Surgical technique
2. Aspirin or nonsteroidal anti-inflammatory drugs A dogear may occur in the temporal region or the pos-
(NSAIDS) terior neck. Most will tend to resolve over a few
3. Hypertension months. It is easier to repair the dogear at the end of
4. Anticoagulation drugs (coumadin) the surgical procedure, but revision may be performed
5. Blood dyscrasia at a secondary surgery.
6. History of easy bruising

68.7.5 Ear Deformities

68.7.3 Dehiscence
Excessive tension is the usual cause of ear deformity.
Tight wound closure with tension may result in wound Excision of skin around the ear should be performed
dehiscence. This may require resuturing but if the tis- after tension sutures have been inserted above the ear
1166
and behind the ear. Secondary surgery may be neces-
sary to correct a deformity.
68.7.6 Edema
Edema usually subsides within the first few weeks.
Chronic edema should be investigated for causes
other than the surgery. Diuretics are not usually
recommended.
68.7.7 Hair Loss
Hair loss can occur as the result of a tight closure and
tension on the hair-bearing tissues. Most of the time,
the hair will regrow over time. Repair of the area of
chronic hair loss may require excision (after 6 months)
of the bare region, or hair transplantation can be
performed.
68.7.8 Hematoma
An expanding hematoma (pain and swelling of the
side of the face) is a surgical emergency and requires
early wound exploration with evacuation of the hema-
toma and ligation of bleeder, and probably needs to be
drained at the time of closure [111].
68.7.9 Infection
Infection is rare (11 in 6,166 cases or 0.18%) [112].
Inflammation may be treated with topical steroids,
and any infection should be treated with appropriate
antibiotics. Heat applied locally is helpful.
68.7.10 Irregularities
Irregularities may be the result of coming too close to
the skin in developing the facial flap. Indentations of
the skin following facelift surgery can be treated with
a filler, preferably autologous fat. In one case, inden-
tation occurred from a very tight S suture in a modi-
fied facelift (S-lift) (Fig. 68.24). This resolved over a
couple of months without treatment except massage
of the area.
M.A. Shiffman
Fig. 68.24 This patient had an S-lift and 1 week after surgery
began to have a swelling of the right cheek. On examination
there was a soft swelling that became an indentation when
compressed by the finger. Simple observation with mild mas-
sage of the area allowed the problem to resolve that originated
from too tight a closure of the purse-string S suture in the
parotid fascia
68.7.11 Necrosis
Necrosis can be the result of the flaps being too thin or
the closure being too tight. Smokers are very suscep-
tible to flap necrosis if the smoking is not completely
stopped prior to and after surgery [113]. Especially
dangerous is electrocoagulation of bleeders on the skin
flap. The oozing of blood on the skin flap should be
treated with compression only.
68.7.12 Neurological
Any of the facial sensory or motor nerves in the area of
the facelift may be injured. Especially susceptible are
the branches of the facial nerve and the anterior and
posterior auricular nerves. Prevention is a necessity.
The surgeon should understand facial anatomy and the
three-dimensional relationship of the nerves.
Temporary paresis can occur with injection of local
anesthesia into the area of the nerve or from traction on
the nerve. This type of paralysis can be observed until it
clears. If there is any question of motor nerve transec-
tion, then studies should be performed to establish nerve
68 Complications of Cosmetic Surgery 1167

conduction. Early repair of a transected nerve will aid a

in more complete and earlier return of function.

68.7.13 Pain

Persistent facial pain is rare. If acute, following sur-

gery, this may suggest an expanding hematoma. If
chronic, branches of the sensory cervical nerves may
have been injured. The pain will usually subside within
6 months. Nerve blocks may give temporary relief.

68.7.14 Pigmentation Changes

b
Hyperpigmentation may follow facial ecchymoses even
with full resolution of the bruising. Sunlight exposure
may increase the possibility of hyperpigmentation.
Patients with telangiectasias may have developed
more after rhytidectomy.

68.7.15 Salivary Fistula

Sutures placed deep in the parotid fascia (part of the

SMAS) can result in a salivary fistula (rare) (Fig. 68.25).
Treatment would require removal of the offending
suture, bland diet, and Donnatol four times daily to
reduce the salivary flow. The fistula usually heals very
c
readily with this treatment.

68.7.16 Scar

Scars are usually a physiologic response to injury and

may be hypertrophic or keloid. Keloid scars can be
hereditary. Tight closure can contribute to a widened
scar (Fig. 68.26).
There are a variety of treatments for keloids and
hypertrophic scars including steroid injection, surgery,
5-fluorouracil injection, silicone gel sheeting, bleomy-
cin injection, or a combination of these.

Fig. 68.25 (a) Patient developed a soft swelling a few days

68.7.17 Seroma
Seroma may occur following an unrecognized hema-
toma under the skin flap. Syringe with needle drainage
followed by compression may resolve the problem.
after modified facelift. This was drained with a suction catheter.
The wound drained 120 mL clear fluid daily. (b) Following
removal of the vacuum reservoir there was no drainage after
1 min. (c) Following biting of a wedge of lime, there was drain-
age starting at the end of the catheter within 5 s. The diagnosis
of salivary fistula was confirmed
1168
Fig. 68.26 Scar at the anterior inferior portion of the ear
following S-lift. Surgical revision was necessary
Open drainage with suction catheter can be used for
persistent seroma.
68.7.18 Thromboembolism
As with any surgery, especially under general anesthe-
sia, the risk of thrombembolism is always present.
Prophylactic measures should be taken.
68.8 Liposuction
68.8.1 Introduction
Liposuction may be associated with a variety of com-
plications, most of which can be avoided. The more
aggressive the liposuction, especially in the superfi-
cial subcutaneous tissues and with large amounts of fat
removal, the more likely a complication will occur. It is
not so much what is removed that is important, but what
is left behind [114]. The surgeon performing liposuction
must be cognizant of the risks and complications from the
procedure, how to prevent them, and how to treat them.
Early recognition of a complication is essential, and
treatment should be started in a timely fashion. The
surgeon must inform the patient of the complication,
its probable or possible cause or causes, the proposed
treatment, and the length of time before complete
recovery. Consultation may be obtained and should be
done in a timely manner.
Fatal complications can occur (Table 68.3) [115].
M.A. Shiffman
Table 68.3 Fatal outcomes from liposuction [38]; 496,245
cases from 1994 to 1998; 130 fatalities (1/3817 cases or
26/100,000 [0.026%])
Disorder Fatalities
Thromboembolism 30
Abdomen/viscus perforation 19
Anesthesia/sedation/medication 13
Fat embolism 11
Cardiorespiratory failure 7
Massive infection 7
Hemorrhage 6
Unknown 37
68.8.2 Asymmetry
If the patient has asymmetry of the abdominal wall
preoperatively, this should be pointed out to the patient
and recorded with adequate photos. More fat may have
to be removed from one side or one area because of the
asymmetric accumulation.
Asymmetry can be avoided by being aware of the
amounts of fat and fluid removed from each side of
the abdomen so that there is no large discrepancy.
Observing the results carefully at the end of liposuc-
tion may disclose further areas that need correction.
Asymmetry can be corrected by removing more fat
from the excess area, liposhifting fat into the depressed
area, or reinjecting autologous fat.
Asymmetry that is present postoperatively may
need revision liposuction for removal of excess fat
from those areas affected. If there is a deficit in any
area that needs correction, injection of autologous fat
may be considered.
68.8.3 Bleeding, Hematoma
Tumescent technique in liposuction has reduced the
amount of bleeding to a degree that is usually minimal.
To prevent or limit bruising, the patient must be fore-
warned to stop all aspirin containing products, non-
steroidal anti-inflammatory drugs (NSAIDS) such as
ibuprofen, and herbals at least 2 weeks before and for
2 weeks after surgery. Excessive liposuctioning in a
single area may cause bloody fluid to appear in the
tubing, and this should forewarn the surgeon not to
continue surgery in that area unless further tumescent
68 Complications of Cosmetic Surgery 1169

solution is used. Compression over the areas of lipo-

suctioning will help to limit bruising. This includes
the use of garments, stretch tape, and foam dressings
(polyurethane pads).
Bleeding following liposuction may appear as
bright red blood coming from the incision site or may
be hidden and appear as orthostatic hypotension when
the patient tries to sit up or stand. Postoperative diz-
ziness and feeling faint should not be considered a
drug reaction or dehydration until after the Hgb or
Hct is checked. Intravenous fluid resuscitation may
be enough if the bleeding is not over 15% of the blood
volume, but some patients with more blood loss may
require Hespan, Dextran, albumin, or blood to restore
the blood volume. A low Hgb or Hct does not neces-
sarily require transfusion. The patients clinical status
is more important, and if vital signs are stable, con-
servative measures may be taken such as volume
replacement. The patient who has had an acute epi- Fig. 68.27 Indentation after liposuction of thighs
sode of bleeding and stabilizes with low Hgb or Hct
may be followed for at least a week, at which time the
Hgb and HCT should start to rise. It may take a few the key for prevention. Remember that excessive
weeks for the blood count to come back to normal, compression of an extremity can result in venous
but usually, the patient can resume normal activity thrombosis and possible embolic disorder.
after the Hgb reaches 8 g. If the bleeding continues Repeat liposuction (in an amount to break up the
and conservative measures do not work, surgical edematous tissues and flatten the region) of the area
exploration may be necessary. This is more likely with tumescent technique is usually helpful after several
with other concomitant procedures such as abdomi- months but must be followed by adequate compression
noplasty since compression in the areas of the lipo- dressings.
suctioning will usually stop any bleeding from small
vessels.
Hematoma in the tissues can be treated conserva- 68.8.5 Depressions (Grooves, Waviness)
tively with aspiration. This should be distinguished
from bruising that requires no treatment. A hematoma Excessive or superficial liposuction too close to the
that becomes a persistent untreated mass will form a skin may result in depressions (Fig. 68.27). Superficial
seroma and then a chronic pseudocyst. The pseudocyst liposuction should not get closer than 1 cm below the
can be treated with aspiration followed by injection of skin in most areas except the face and neck, and smaller
an equal amount of room air. This will usually cause cannulas (<3.5 mm) should be utilized in comparison
the walls to adhere to each other and prevent further to the deep liposuction that can be performed with can-
accumulation of fluid. nulas over 3.5 mm (3.55.0 mm depending on the
thickness of the fat layer).
Depressions can be corrected by selectively lipo-
68.8.4 Chronic Edema suctioning the areas around the depression and filling
the indented area with autologous fat [116]. If the
An infrequent occurrence, persistent edema in the area indentation is noted while performing the liposuc-
of liposuction can be distressing to the patient. This tion, autologous fat can be injected at that time. It is
may be due to excessive trauma to the tissues, but lipo- possible to fill defects with the liposhifting tech-
suction is a traumatic procedure causing so-called nique by tumescing the areas around the depression,
internal burn-like injury. Proper compression is usually loosening the fat with multiple criss-crossing tunnels,
1170
and molding the fat into the defect by rolling a large
cannula (610 mm) across the prepared areas toward
the depression [117].
The skin scar may become depressed and is usually
due to the suction staying on when the cannula is
removed and reinserted multiple times. This can be
prevented by turning off the suction before removing
the cannula or by having a finger vent in the handle of
the cannula.
68.8.6 Dissatisfaction with Results
The surgeon performing liposuction should try to gain
some insight into the patients body image. In other
words, exactly what does the patient want and expects
for the results of liposuction. Some expectations are
more than what can be delivered by the surgeon.
A detailed explanation of the limits to the procedure
of liposuction, the risks and complications, and the
presence of irregularities or asymmetries is an impor-
tant beginning for the patient to understand that sur-
gery, on the average, does not get perfect results.
Preoperative explanation that further refinements may
have to be performed to better approach the patients
expectations.
Beware of the dysmorphic personality where the
patient does not have a significant problem but per-
ceives a severe problem. This type of patient dwells on
a problem that does not really exist, and the surgeon
can never satisfy that patient.
68.8.7 Fat Embolism
Fat embolization results from release of fat droplets
into the systemic circulation [29, 118121]. Fat embo-
lism syndrome (FES) is an infrequent consequence of
fat embolization with pulmonary distress, mental sta-
tus changes, hypoxemia, pyrexia, tachycardia, throm-
bocytopenia, and petechial rash [122124].
Studies that can be used for diagnosing fat embo-
lism include computerized tomography (CT) [125127]
and magnetic resonance imaging (MRI) [128, 129].
Treatment consists of general supportive measures
with maintenance of fluid and electrolyte balance and
administration of oxygen, and endotracheal intubation
and mechanical ventilatory assistance when necessary
[130]. Treatment of respiratory symptoms has been
M.A. Shiffman
reported to improve with high-dose methylprednisolone
[131]. Huemer et al. [132] felt that heparin, cortisone,
and dextran have not demonstrated a beneficial effect.
68.8.8 Fibrosis
Subcutaneous nodularity following liposuction is often
a fibrotic reaction, usually with an inflammatory com-
ponent, that can be a residual of hematoma or seroma.
Infection, especially mycobacterial, can leave a mass
that will not resolve. Trauma to a surgical area result-
ing in a mass will usually resolve over time without
treatment unless there is an inflammatory component.
Normal scar formation will mature over 6 months and
then soften. The complete evolution of a scar can take
a year, but the biochemical changes are complete in
6 months.
68.8.8.1 Evaluation and Treatment
A postsurgical mass should be evaluated clinically to
rule out hematoma or seroma. Needle aspiration, under
sterile conditions, can frequently make the diagnosis.
If the mass persists for more than 3 weeks without evi-
dence of some resolution, ultrasound evaluation should
be considered even if fluid cannot be aspirated. If
serous fluid is found on ultrasound, the radiologist
should aspirate the liquid and inject an equal amount
of room air. Reevaluation by ultrasound in 1 week will
usually show resolution, but if any fluid persists, repeat
aspiration with injection of room air should be
performed.
If an infection is present, usually with erythema and
tenderness, aspiration of the pus with culture and sensi-
tivity (C & S) should be performed. Usually, the patient
is already on antibiotics, and the medication may need
to be stopped for 24 h before attempting a C & S. The
antibiotics may need to be increased in dosage or
changed. Residual subcutaneous fibrotic changes will
resolve over time if the infection is properly treated.
Incision and drainage may be necessary if the abscess is
large and/or does not respond rapidly to the antibiotics.
Following liposuction, folds in the garment can
result in indentations and subcutaneous fibrosis. The
garment should be checked on the first postoperative
day and the patient informed on how to prevent or limit
folds in the garment (especially an abdominal binder).
If subcutaneous fibrosis occurs, early treatment for the
problem should be undertaken. Early treatment will
68 Complications of Cosmetic Surgery
resolve the complication more rapidly than waiting for
the fibrosis to mature.
The conservative course of treatment for residual
fibrosis from any source consists of:
1. Start Medrol DosPak (7 day treatment taking the
full daily dose each day at one time with food).
2. At day 7, start nonsteroidal anti-inflammatory med-
ication (NSAID) daily for at least 8 weeks.
3. Ultrasound may be started at least 3 weeks after
surgery to the area at 3 W for 15 min twice weekly
for at least 16 treatments. Treatment within 3 weeks
of surgery may cause hematoma or seroma.
4. If there is no response after 8 weeks of ultrasound
treatment, injections into the fibrous tissue with
5-fluorouracil (5FU) at 50 mg doses may be
attempted on a weekly basis until resolution of the
mass. This can be combined with small doses of
steroid (1020 mg triamcinolone).
If steroids are used, the injection should be care-
fully administered into the fibrous mass, being careful
that the fluid does not extrude into the surrounding
fatty tissues. This may cause fat atrophy, which can be
easily treated by tumescing the tissues with normal
saline solution so that the precipitated steroid is reab-
sorbed. The mixture the author uses is 1 mL 5-fluorou-
racil (50 mg), mL triamcinolone [40 mg/mL] (total
20 mg), and 1 mL lidocaine (0.5%) with epinephrine
diluted in 1 mL of 0.5% lidocaine with epinephrine.
Surgical intervention with resection of the mass can
result in a skin scar that may not have been present
previously, indentation from removal of tissue, and
possibly a residual fibrous mass again. Surgery is a last
resort after conservative measures have been tried for
at least 6 months. Indentations that result from surgery
may require autologous fat transfer.
68.8.9 Hyperpigmentation
Hyperpigmentation following liposuction can be in
the scars or in the area of the liposuction. If there is
bruising and the patient gets into the sun, the skin
overlying the operated area can develop an increase in
pigmentation.
Treatment consists of 4% hydroquinone, cream or
gel, rubbed into the affected area twice daily. During the
day an effective sunscreen should be utilized and unnec-
essary sun exposure must be avoided or protective cloth-
ing worn. Sun exposure will cause repigmentation.
1171
Fig. 68.28 Liposuction with postoperative infection from
mycobacterium resulting in scars on thighs after drainage proce-
dures and excisions of masses
68.8.10 Infection
The occurrence of infection in a clean surgery case is
approximately 1% in outpatient surgery centers and
office surgeries and 3% in hospital surgeries. The ten-
dency to consider liposuction as minor surgery with
minimal care about sterility in the surgery suite can
be detrimental to the patient. Serious infections have
been documented following liposuction [133, 134].
Necrotizing fasciitis [135137] and toxic shock syn-
drome [138, 139] have been reported. The combina-
tion of both necrotizing fasciitis and toxic shock
syndrome can occur in the same patient (Farber GA
(1999) Personal communication, January 18, 1999).
When an infection appears 10 days to 6 weeks after
surgery and is in the form of a mass with overlying
erythema, mycobacterium should be considered. This
may be very difficult to diagnose through cultures of
the purulent discharge, but the physician must be per-
sistent. Vigorous prolonged treatment may be neces-
sary. Rifampin, 600 mg two to three times weekly
combined with isoniazide, pyrazinamide, ethambutol,
and/or streptomycin should be used for up to 6 months.
Side effects include hepatitis, arthralgias, thrombope-
nia, nephritis, optic neuritis, gastrointestinal distress,
and flu syndrome. An infectious disease consultant is
usually necessary. Scarring is not uncommon espe-
cially if the abscesses are drained surgically through
large incisions or persistent fibrous masses are excised
(Fig. 68.28). If there is a persistent fibrous mass fol-
lowing proper antibiotic treatment, and drainage if
necessary, the mass can be injected with steroids.
1172
Postsurgical infection should be diagnosed as early
as possible in order to prevent more serious manifesta-
tions of the infection such as necrosis, septicemia, or
toxic shock. Blisters may presage the appearance of
necrosis and should be treated and observed closely.
There are various dressings that may cause blisters
such as tape on the skin and Reston foam. Any signifi-
cant erythema is an indication of inflammation or
infection and should be treated as such with antibiotics
and close follow-up.
68.8.11 Lidocaine Anaphylaxis
The injection of lidocaine in small amounts as a local
anesthetic has been associated with death from allergic
reaction to the preservative, methylparaben [140, 141].
Anaphylaxis has been reported with lidocaine admin-
istration [142145]. Lidocaine is not a completely
benign medication, and the surgeon should be aware
and prepared for acute allergic reactions.
Treatment with ephedrine, oxygenation, and intra-
venous fluids can relieve the symptoms. Steroids may
be necessary, and if there is bronchospasm, intubation
may have to be done.
68.8.12 Lidocaine Toxicity
There is very little treatment for lidocaine toxicity
except for supportive measures. This problem can eas-
ily be avoided by keeping the lidocaine at a safe level
through the use of less than 35 mg/kg or, when abso-
lutely necessary, a maximum of 55 mg/kg in the total
tumescent fluid. The more rapid the infiltration of the
lidocaine, the more likely there will be lidocaine toxic-
ity. The epinephrine effect causing vascular contrac-
tion takes 15 min following injection. Therefore, the
lidocaine can be rapidly absorbed for the first 15 min.
However, just because a surgeon has infiltrated, with-
out mishap, 5060 mg/kg lidocaine in hundreds of
cases does not necessarily imply either that such a
large dose of lidocaine can be given with impunity, nor
that this dose recommendation is safe [146]. If gen-
eral anesthesia is used, the lidocaine total can be much
less or omitted.
A careful history must be taken to make sure the
patient has not been taking cytochrome P450 inhibi-
tors that may result in lidocaine toxicity even with the
total lidocaine dosage within the usually accepted
M.A. Shiffman
maximum [139]. Lidocaine occurs in the body as
unbound pharmacologically active lidocaine and pro-
tein bound inactive lidocaine. Factors affecting the
protein binding of lidocaine include age, stress, obe-
sity, hepatic function, renal function, cardiac disease,
cigarette smoking, use of oral contraceptives, beta
blockers, tricyclic depressants, histamine-2-blockers,
inhalation anesthetics, and anorexiants [147].
68.8.13 Loose Skin
Certain areas of the body being liposuctioned are prone
to develop loose skin because of the amount of fat that
needs to be removed and the lack of complete skin
retraction. Those areas most likely to have this prob-
lem include:
1. Abdomen: especially with large panniculus
2. Arms: especially elderly patients and very fat
patients
3. Medial thighs: postoperative loose skin is a major
problem in a large percentage of patients
Treatment for the loose skin requires a surgical
approach with significant scars. Abdominoplasty, usu-
ally modified, may have to be performed to resolve
loose hanging skin of the lower abdomen, brachio-
plasty to resolve loose hanging skin of the arm, and
thighplasty for the loose skin of the medial thigh.
68.8.14 Median Nerve Compression
Acute median nerve compression has been reported
[148] in three patients from the administration of large
amounts of intravenous fluids during liposuction. The
edematous compression of the nerve resolved with
elevation of the extremities and use of diuretics. The
range of intravenous fluids was 4,0006,000 mL.
Obviously, the anesthesiologist in each case did not
understand that small amounts of intravenous fluids
should be administered in liposuction cases, limiting
the amount to 250 mL or less per hour.
68.8.15 Necrosis
There may be skin necrosis after liposuction if the
cannula comes too close to the skin and disrupts the
subdermal plexus of vessels. Chronic smokers who do
not stop smoking before and after surgery have a high
68 Complications of Cosmetic Surgery
incidence of necrosis. Necrosis is more likely to occur
with the use of cannulas with sharp edges and turning
the openings toward the skin surface. Combining
excessive liposuction of the mid upper abdomen and
full abdominoplasty increases the risk of necrosis of
the abdominoplasty flap.
Necrotizing fasciitis has been reported following
liposuction [135137]. This disorder is an infection
with fulminant streptococcal group A infection or
mixed bacterial infection frequently with anaerobes
that involves the subcutaneous tissues and deep fascia,
producing thrombosis of the subcutaneous vessels and
gangrene of the underlying and surrounding tissues.
Treatment requires surgical debridement, antibiotics,
and, when necessary, hyperbaric therapy.
68.8.16 Need for Further Surgery
Since the surgeon can ordinarily improve the contour
deformities by about 50%, the patient may not be satis-
fied with the results. There also may be a need to refine
or correct the original procedure because of complica-
tions such as irregularities (grooves, waviness, and
indentations), asymmetries, perforation of vessel or
viscus, excessive scarring, bleeding, hematoma or
seroma, loose skin, necrosis, necrotizing fasciitis, and
infection. The patient should be warned preoperatively
of this possibility.
68.8.17 Neurologic Problems
Decreased sensation or sensory loss may occur but is
almost always temporary. Chronic pain may be due to
a small neuroma but is more often due to injury to the
underlying fascia or muscle. Injection of local anes-
thetic into the area of pain will usually relieve the com-
plaint for a short period of time. Multiple injections
may be necessary to relieve the pain permanently.
A neuroma can be surgically resected. If a scar in
the tissues (subcutaneous fat, fascia, or muscle) is teth-
ered to the skin, there may be chronic unrelieved pain.
The pain may have to be treated by release of the scar.
68.8.18 Perforation of Vessel or Viscus
Perforation of the abdominal wall is most likely to
occur in the presence of hernia or abdominal wall scar
1173
that can divert the direction of the cannula [115, 149,
150]. The nondominant hand should always feel the
end of the cannula. When the cannula is not palpable,
the surgeon should reassess his technique and consider
the possibility of perforation. Under local tumescent
anesthesia, perforation can be detected at the time of
surgery by the presence of abdominal pain.
If there is unusual abdominal pain or chest pain
postoperatively such as increasing pain or severe pain,
perforation must be considered. It may be difficult to
examine the abdomen directly by pressure because
liposuction alone will cause pain in the area. The pres-
ence of rebound tenderness usually indicates peritoni-
tis. Flat plate and upright abdominal x-rays may show
free air if the bowel is perforated. The patient may
have to be observed in the hospital if there is the pos-
sibility of viscus perforation.
Vascular perforation that causes significant blood
loss will result in abdominal pain, orthostatic hypoten-
sion, and shock. Insertion of a small catheter (Angiocath)
into the abdominal cavity and the instillation of some
sterile saline can produce bloody drainage consistent
with vascular injury. If the blood is totally retroperito-
neal, CT scan may be necessary. Emergency explor-
atory laparotomy is usually indicated.
Liposuction over the ribs can be aided by the use of
pressure on the lower ribs with the flat portion of the
nondominant hand that will result in the cannula easily
going over the ribs instead of under with perforation
into the chest. Severe chest pain, especially with dysp-
nea, may indicate perforation into the chest. Chest
x-ray will usually show a pneumothorax. Insertion of a
chest tube will relieve the pain and dyspnea.
68.8.19 Pulmonary Edema
Pulmonary edema has been reported [151], which was
presumed to be from rapid- and high-volume hypo-
dermoclysis. Pitman [152], commenting on this case,
believed that the cause of the pulmonary edema was
from excessive parenteral fluids being given.
Ordinarily, most individuals can tolerate large amounts
of intravenous fluids, up to 2,000 mL/h, since the
fluids enter the extravascular tissues within 15 min
of administration. However, where there is a large
amount of subcutaneous fluid from the tumescent
technique, the pressure of the fluid in the tissues does
not allow a gradient for the intravenous fluid to diffuse
out of the vessels.
1174
68.8.20 Scars
Significant scars following liposuction are not fre-
quent. It is rare to see hypertrophic scars or keloids.
Poor placement of incisions may result in easily visible
scars. Some scars may become depressed if the suction
on the cannula is maintained each time the cannula is
withdrawn from the incision. If using a machine for
vacuum, either stop the machine before withdrawal or
use cannulas with a vent hole in the thumb portion of
the handle for easy release.
Incision sites may be irritated by the multiple fast
passes of the cannula resulting in a reddening around
or in the scar. Steroid cream will resolve the problem.
The incision performed should be slightly larger than
the cannula. Some surgeons use a plastic plug in the
incision while performing liposuction that will prevent
the cannula from rubbing on the skin.
The use of large incisions is not indicated since
most cannulas are 6 mm or less and, more often than
not, are 4 mm or less. Some surgeons use microcan-
nulas (under 2 mm), but this requires many more skin
incisions and the liposuction takes longer to perform.
The treatment of hypertrophic or keloid scars
includes steroid injection, radiation, reexcision, sili-
cone gel sheeting, pressure therapy, or a combination
of these [153]. The combination of steroid and 5-fluo-
rouracil has been helpful in treatment. None of the
treatments is permanently effective for keloids in a
large percentage of patients; however, hypertrophic
scars have a tendency to resolve on their own over a
period of time.
Skin necrosis will usually result in a significant
scar. Treatment may require excision and careful
closure.
68.8.21 Seroma
The collection of serous fluid in the liposuction area
may be due to irritation of the tissues by the traumatic
procedure but is more frequently the result of concom-
itant over suctioning of a single area with undermining
of a flap allowing a cavity to form. Sometimes a hema-
toma may appear first and be replaced over time with
serosanguinous fluid and then serous fluid.
A persistent collection of fluid following liposuc-
tion may be treated with needle aspiration followed by
adequate compression dressings. This may need to be
M.A. Shiffman
repeated every few days. If the collection can be
reached through one of the liposuction incisions, a
drain can be inserted to reduce the fluid and kept in
place with compression dressings that need to be
changed every couple of days. Prophylactic antibiotics
may be used during the time the drain is in place. If the
collection becomes chronic (over 4 weeks), the fluid
should be aspirated and an equal amount of room air
injected into the cavity to cause irritation (Fig. 68.29).
Compression dressings are necessary after each such
treatment. Another method that is available but requires
adequate anesthesia is curetting the lining of the cavity
through a small incision or through one of the liposuc-
tion scars. If the liposuction is combined with abdomi-
noplasty and a chronic seroma occurs, the pseudocyst
may be excised through the abdominal scar, but this
may leave a visible deformity.
68.8.22 Thromboembolism
Superficial thrombophlebitis (an inflamed vein)
appears as a red, tender cord [115]. Deep-vein throm-
bosis may be associated with pain at rest or only dur-
ing exercise with edema distal to the obstructed vein.
The first manifestation can be pulmonary embolism.
There may be tenderness in the extremity, and the tem-
perature of the skin may be increased. Increased resis-
tance or pain on voluntary dorsiflexion of the foot
(Homans sign) and/or tenderness of the calf on palpa-
tion are useful diagnostic criteria.
Pulmonary embolism is usually manifested by one
of three clinical patterns: (1) onset of sudden dyspnea
with tachypnea and no other symptoms, (2) sudden
pleuritic chest pain and dyspnea associated with find-
ings of pleural effusion or lung consolidation, and (3)
sudden apprehension, chest discomfort, and dyspnea
with findings of cor pulmonale and systemic hypoten-
sion. The symptoms occasionally consist of fever,
arrhythmias, or refractory congestive heart failure.
Medium- and high-risk patients for thromboem-
bolism (over the age of 40 years, prior history of
thromboembolic disorder, surgery over 1 h, obesity,
postoperative immobilization, estrogen therapy) should
have the necessary precautions taken in the periopera-
tive period [9]. These include compression stockings
(TEDS) or intermittent compression garments. Failure
to warn female patients to stop estrogens (birth control
pills or replacement therapy) at least 3 weeks prior to
68 Complications of Cosmetic Surgery
surgery and 2 weeks after surgery increases the risk of
thromboembolism [154]. Liposuction of the abdomen
in combination with abdominoplasty is especially
risky for the occurrence of pulmonary embolism.
Thromboembolism has to be diagnosed early if
death is to be prevented. Any postoperative patient
a b
Fig. 68.29 (a) Preoperative 43-year-old patient with history of
liposuction of thighs 6 years previously. (b) One week after cir-
cumferential liposuction of legs with seromas of both legs. (c)
Areas of seroma marked after 5 months of repeated needle aspi-
rations and use of drains. (d1) Ultrasound of right thigh seroma
(arrow) 5 months postoperatively. (d2) Ultrasound of right thigh
1175
who develops shortness of breath or chest pain must be
considered to have the possibility of pulmonary embo-
lism, and a ventilation-perfusion lung scan obtained.
The use of intravenous heparin can be lifesaving and,
at times, may be started even before the diagnosis is
confirmed.
seroma (arrow) 1 week following one injection of room air into
the seroma. This shows marked decrease in the size of the cavity.
The left thigh was injected one time with room air and had com-
plete closure of the seroma. A second injection of room air into
the right seroma resulted in complete closure
1176
Fig. 68.29 (continued)
d
68.8.23 Toxic Shock Syndrome
There have been reports of toxic shock syndrome,
which is a potentially fatal disorder [137, 138, 155].
The syndrome is caused by the exotoxins (superanti-
gens) secreted with infection from Staphylococcus
aureus and group A Streptococci [156]. Knowledge of
the criteria for diagnosis is important in order to treat
this potentially fatal disease. These include [157]:
1. Fever (>102o)
2. Rash (diffuse, macular erythroderma)
3. Desquamation (12 weeks after onset, especially of
palms and sole)
4. Hypotension
M.A. Shiffman
5. Involvement of three or more organ systems:
a. Gastrointestinal (vomiting, diarrhea at onset)
b. Muscular (myalgia, elevated CPK)
c. Mucous membrane (conjunctiva, oropharynx)
d. Renal (BUN or creatinine >2 times normal)
e. Hepatic (bilirubin, SGOT, SGPT >2 times
normal)
f. Hematologic (platelets <100,000)
6. Negative results on the following studies (if
obtained):
a. Blood, throat, or cerebral spinal fluid (CSF)
cultures
b. Serologic tests for Rocky Mountain spotted
fever, leptospirosis, and measles
68 Complications of Cosmetic Surgery
Treatment consists of surgical debridement for
necrosis, antibiotics, circulatory and respiratory care,
anticoagulant therapy for disseminated intravascular
coagulation, and immunoglobulin [158]. Experimental
approaches have included use of antitumor necrosis
factor monoclonal antibodies and plasmapheresis.
68.8.24 Conclusions
Complications of liposuction are best avoided when
possible. The surgeon should be aware of the methods
to prevent and the available treatments for the various
complications. Aggressive liposuction by removing
very large amounts of fat and doing very superficial
liposuction in order to get more skin retraction can be
associated with an increase in complications. It may be
preferable to remove less than 5,000 of fluid and fat at
each sitting and repeat the procedure at a later date
than perform large volume or megaliposuction. The
risk of complications may then be reduced.
68.9 Mastopexy
68.9.1 Introduction
Each form of mastopexy has its own types of compli-
cations. Some general principles from many years of
past experience are presented to help the surgeon mini-
mize and possibly avoid the complications.
68.9.2 Asymmetry
Most patients have some asymmetry before surgery
and should be specifically discussed with the patient.
Correction of the asymmetry can be performed at the
time of surgery. Sometime the postoperative asymme-
try is from the procedure because of improper marking,
not following the original markings, or because there is
uneven healing and scarring from the procedure.
68.9.3 Bleeding, Hematoma
As with any surgical procedure, hemostasis at the time
of surgery is important. However, postoperative bleed-
ing is usually due to causes other than missing bleed-
ers at the time of surgery. Clots can be dislodged from
1177
hypertension, coughing, or too much motion of the
implant especially with textured implants. Medications
should be considered, especially aspirin and nonsteroi-
dal anti-inflammatory drugs (NSAIDS). The use of
Toradol after cosmetic procedures is a breach of the
standard of care since it is a drug that will inhibit plate-
let reaction and cause bleeding.
Hematoma should be treated immediately by
evacuation and coagulation of active bleeders since
distention of the tissues from the hematoma may result
in tissue necrosis especially of the nippleareolar
complex.
68.9.4 Bottoming Out
Most mastopexies do not fix the breast to the chest
wall by sutures and, therefore, the weight of the breast
can cause inferior migration with bottoming out as
the result. This will usually require fixation of the
breast to the underlying pectoralis major fascia with
permanent sutures to hold the breast in a high-enough
position and prevent future downward migration.
68.9.5 Flattening of the Breast
The periareolar mastopexy is very prone to flattening
of the breast, and patients should be forewarned of this
possible problem.
68.9.6 Infection
Possible infection can occur with any surgical proce-
dure. With the inset of fever and/or erythema, the sur-
geon should always be aware of possible inflammation
versus infection. Usually, the patient is on antibiotics
after surgery, and a decision has to be made as to
whether to increase the dose of the medication or start
a different antibiotic. If there is drainage, then culture
and sensitivity should be done and appropriate antibi-
otic utilized when the particular offending germ or
germs are known.
An abscess must be drained surgically and the cav-
ity irrigated with saline. A drain (penrose or suction
catheter) is usually necessary. If an implant is present,
the implant should be removed if the pocket is involved
and the implant replaced at least 3 months after com-
plete healing has occurred.
1178
Fig. 68.30 Necrosis following periareolar mastopexy
Fig. 68.31 Pleating following periareolar mastopexy
68.9.7 Necrosis
Necrosis, especially of the nippleareolar complex, is
unusual but can occur when the blood supply has been
compromised (usually from prior breast surgery) or
when there is infection or hematoma (Fig. 68.30).
Tight closure of the skin can result in necrosis if the
vessels become stretched and thrombose causing inter-
rupted blood supply. There is a slightly increased inci-
dence of necrosis when breast augmentation is
concomitantly used at the time of the mastopexy.
68.9.8 Pleating
The effect of closing the periareolar type of mastopexy
is prone to a pleating effect since the larger outer rim
is attached to a shorter inner rim, and the discrepancy
results in pleating (Fig. 68.31). This usually resolves
without treatment in 612 months. However, when the
pleating persists, the excess tissue may need to be
M.A. Shiffman
Fig. 68.32 Poor implant position following mastopexy
excised taking care not to disrupt the circumareolar
purse-string suture that holds the scar from spreading.
68.9.9 Poor Implant Position
If a breast augmentation is performed with the mas-
topexy, it is possible to place the implant in the proper
position since the pocket is determined preoperatively
with marking prior to the breast lift (Fig. 68.32). This
pocket position may need to be adjusted following the
mastopexy and before the implant is placed or after the
implant is in the pocket and the patient examined in a
sitting position.
68.9.10 Recurrent Breast Ptosis
Recurrent breast ptosis is usually a problem of loose
skin and gravity. Without fixation of the breast to the
underlying pectoralis major fascia by permanent
sutures, the breast may descend postoperatively either
within months or years.
68.9.11 Scar
Any surgical scar can become hypertrophic or keloid
(Fig. 68.33). Tight skin closure may result in widening
of the scar except with the purse-string suture(s) of the
68 Complications of Cosmetic Surgery
Fig. 68.33 Thickened scar following mastopexy
periareolar mastopexy. The hypertrophic scar may
resolve without treatment whereas the keloid scar may
become a difficult problem to treat since it tends to
recur in 80% of patients after treatment.
Kenalog (1020 mg) injection diluted with 5-fluo-
rouracil, 50 mg, seems to work fairly well for hyper-
trophic scars and keloids but requires reinjection every
few weeks. One must be careful to inject into the cen-
ter of the scar to prevent leakage into the deeper fatty
tissues with resultant steroid fat atrophy. If steroid fat
atrophy occurs, then tumescence with saline solution
that may be repeated in 30 days will usually resolve
the problem.
68.9.12 Discussion
It would behoove the surgeon performing mastopexy
to learn how to avoid and to treat the various possible
complications.
68.10 Discussion
Every cosmetic surgery using general anesthesia or
deep sedation has the potential complications of asym-
metry, bleeding, cardiopulmonary problems, death,
hematoma, infection, necrosis, need for further sur-
gery, prolonged pain, scar (hypertrophic or keloid),
seroma, stroke, and thromboembolism. This is besides
the specific possible complications for each type of
procedure.
Local anesthesia has the potential complication of
anaphylaxis to the preservative, methylparaben, in the
anesthetic agent.
1179
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 Index

A B
Aboudib, J.H., 770 Babcock, W., 887, 888
Abramo, A.C., 891 Bacterial infection, 164
Abscess, 218, 1131, 1177 Baker, D.C., 323
Accolate, 1144 Baker, S.B., 758
Acne, 152, 154 Baker, S.R., 10
scars, 155157, 172, 185, 186, 213, 214, 539, 540 Baker, T.J., 888
Aegineta, P., 755 Bames, H.O., 4, 9, 756
Ahn, M.S., 300 Banding, 979
Aiache, A.E., 6 Barnes, W.E., 19
Alam, M., 186 Baroudi, R., 888, 889, 921, 926
Al-Basti, H.B., 902 Barsky, A.J., 17, 888, 889, 927
Alexander, G., 17 Barton, F.E., 338, 344
Allergy, 116, 218, 232, 360, 410, 422, 443, 1129, 1131, Bauer, B., 276
1132, 1145 Baxter, H., 17
Alopecia, 520, 541 Becker, O.J., 18, 267
Alter, G., 1102 Beer, G.M., 771
Amastia, 814 Benelli, L., 8, 621, 622, 708, 747, 791, 840
American Society of Anesthesiologists Benelli round block, 847, 848
physical status classification, 108 Berdeguer, P., 407
Anaphylaxis, 1172, 1179 Bettman, A.G., 9, 344
Anderson, J.R., 21 Bichats fat pad, 340, 341, 345
Andrews, J.U., 747 Biesenberger, H., 4, 7
ANF. See Antitumor necrosis factor (ANF) Bircoll, M., 585
Ansari, P., 10 Bissoon, 205
Antithrombin III, 1156 Blair, V.P., 3, 4
Antitumor necrosis factor (ANF), 1177 Bleeding, 223, 333, 341, 388, 390, 557, 565, 686, 750, 1095,
Apfelberg, D., 15 1135, 1136, 1143, 1148, 1149, 1159, 1160, 1165, 1168,
Apte, R.S., 1132 1169, 1177, 1179
Aquinas, 557 Blepharochalasis, 471
Areolar retraction, 1142 Blepharoptosis, 235, 236, 242246
Ari, G., 4, 797 Blindness, 44
Arrhythmias, 1139, 1157, 1174 Body mass index (BMI), 110, 645, 950, 951
Asaadi, M., 407 Borges, A.F., 18
Asken, S., 406 Botti, G., 637, 638, 717, 720
Aston, S.J., 328 Bottoming out, 760, 1143, 1177
Asymmetry, 225, 311, 329, 388, 390, 410, 429, 543, 562, 563, Bourguet, J., 9, 344
572, 576, 581, 582, 605, 616, 617, 623, 624, 630, 631, Bradycardia, 164
645, 694, 712, 760, 768, 809, 830, 908, 919, 1001, 1106, Brandow, 399
1135, 1137, 1142, 1160, 1164, 1168, 1173, 1177, 1179 Brandy, D.A., 324
Atrophy, 152, 311, 329, 394, 395, 421, 729, 1043 Breast, 1178
Aubert, V., 4 pseudoptosis, 716
Aufricht, G., 4, 9, 756 ptosis, 4, 69, 705, 708, 710, 724, 1178
Aufricht keyhole, 776 Breasted, J.H., 20
Auriculo-cephalic angle, 268 Brent, B., 273
Autologous tissue, 1088 Brow lift, 485, 489, 505, 506
Axillary banding, 1143 Brown, A.M., 9

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 1185

DOI 10.1007/978-3-642-21837-8, Springer-Verlag Berlin Heidelberg 2013
1186 Index

Bruising, 218, 398, 410, 429, 441, 1050, 1131, 1132, Courtiss, E.H., 6, 15, 858
1135, 1169 Cramer, L., 6
Bruning, 415 Crikelair, G.F., 19
Brzozowski, D., 771 Crows feet, 299, 539
Buccolabial fold, 363 Cuenca-Guerra, R., 1043, 1044
Bukkewitz, H., 363 Cupello, A.M., 903
Burian, F., 9 Cupids bow, 433
Burn, 462, 543, 950 Cyst, 406, 412
Buttock implant, 1007 Cystosarcoma phyllodes, 758
Buttock ptosis, 1004 Cysts, 588, 728, 1129, 1131, 1161
Cytochrome P458, 91, 92, 114, 115, 119

C
Calcification, 569, 585, 588, 1129, 1144, 1161 D
Caleel, R.T., 1160 Dabbah, A., 772
Callia, W., 888 Dartigues, L., 796
Campers fascia, 59, 897 Davidson, B.A., 747
Cantrell, J.A., 9 Davis, J.S., 17
Capnography, 130 Davis, M., 772
Capsule contracture, 1144 Davis, W.B., 273
Capsulorrhaphy, 1143 Debridement, 1137, 1141, 1158, 1162, 1173
Cardenas-Camarena, L., 102 de Castro, C.C., 6, 903
Crdenas Restrepo, J.C., 892 Dehiscence, 616, 630, 767, 901, 904, 921, 947, 1050, 1136,
Cardim, V.L.M., 345 1164, 1165
Cardiotoxicity, 164 DeLustro, F., 1131
Cardoso, A.D., 6 de Martino, G., 16
Carpue, J.C., 20 Demel, R., 17
Cellulite, 205, 206, 212, 217, 908, 914, 916 De Pina, D.P., 892
Cellulitis, 321, 334 Depressions, 1169
Celsus, A.C., 16 Dermabrasion, 161, 167, 185
Chajchir, A., 13, 406 Dermatochalasis, 307
Chaouat, M., 901 Descamps, M.J.L., 640
Charriere, G., 1131 Desjardin, P., 887
Chassaignac space, 574 Diastasis, 900, 904, 946
Chemical peel, 147155, 167, 185, 540 Dieffenbach, J.E., 20, 21
Chemosis, 232 Dieffenbach, J.F., 4, 16, 267, 755
Chiari, A., 708 Diplopia, 232
Choi, H.Y., 1105 Diving position, 939
Chondritis, 278 Dogear, 487, 611, 766, 767, 947, 1106, 1136, 1137, 1165
Chongchet, V., 19, 267, 271 Dolsky, R.L., 14
Chopart, F., 3 Double bubble, 564, 709, 1008, 1130, 1145
Chrisman, B.B., 10 Dripps, 108
Christie, J.L., 115 Dry eye, 225, 232
Cilento, B.W., 300 Dubouset, J., 888
Cimino, W.W., 543, 1012 Dufourmentel, C., 6, 18, 772
Circular lipectomy, 907, 908, 910, 911, 913, 920, 921 Dujarrier, 10, 949
Cloutier, A.M., 17 Duman, A., 1159
Cocheril, R., 16 Durston, W., 4, 757
Coleman, S.R., 346, 393, 585, 587 DVT. See Venous thrombosis (DVT)
Colles fascia, 997, 1122 Dyschromia, 186
Colpaert, S, 271 Dyspnea, 110, 112, 164, 1139, 1174
Columellar grafts, 257, 259
Coma, 91
Connells sign, 290 E
Converse, J.M., 14, 18, 19, 267 Ear lobe
Conway, H., 4 deformity, 333
Cooperman, L.S., 1131 Ecchymosis, 305, 388, 1050
Coopers ligaments, 4, 48, 625, 635, 805, 808 Ectropion, 342
Corneal ulcer, 225 Edema, 96, 110, 191, 217, 223, 232, 305, 341, 388, 398, 543,
Cor pulmonale, 1139, 1174 967, 1136, 1137, 1156, 1166, 1169
Correa-Iturraspe, M., 973 Edwin Smith Papyrus, 20
Cottle, M.H., 21 Eisenberg, T.S., 605, 617
Index 1187

Elam, M.V., 15 Gasperotti, 985

Elbaz, J.S., 888, 925 Gaudet, F., 887
Eliasen, C.A., 757 Gemperli, R., 903
Elkwood, A., 300 Genioplasty, 263
Ellenbogen, R., 1143 Georgiade, N.G., 6, 756
Eltner, E., 17 Gersuny, R., 17
Ely, E.T., 16, 267 Gersvny, 415
Ely technique, 20 Giampapa, 368
Embolism, 1130 Gibsons principle, 277
End-hits, 1013 Gibson, T., 19, 267
Erol, .O., 364 Giebler, 10
Erythema, 164, 186, 191, 441, 445, 904, 1131, 1132, 1137, 1172 Giese, S.Y., 15
Estrogen, 99, 1139, 1155, 1174 Gigantomastia, 640, 643, 679, 682, 694, 704, 758
Exsanguination, 1135 Gillies, H.D., 3, 4
Giraldo, F., 1104
Glands of Montgomery, 809
F Glicenstein, J., 888
Fagien, S., 1132 Glogaus photoaging types, 160
Faivre, J., 9 Gluteal implant, 1001
Farina, R., 17 Ges, J.C., 7, 756
Farrior, R.T., 19 Goldman, L., 108
Fat atrophy, 1165 Goldman, M.P., 109
Fat emboli, 901 Goldstein, M.A., 17
Fat embolism syndrome, 1142, 1168, 1170 Goldwyn, R.M., 756
Fat embolus syndrome, 14 Goniometers, 760
Fat graft, 489, 495, 506, 510, 514, 515, 586588, 590, 591, Gonzalez, F., 770, 1163
1055, 1070, 1088, 1089 Gonzlez, R., 1046
Fat necrosis, 986 Gonzalez-Ulloa, M., 888, 889, 921, 926, 1045
Fat transfer, 193, 540, 585, 588, 591, 592, 1082 Goodman, W.S., 21
Fatty necrosis, 1004 Gordon, N.A., 109
Fayman, M.S., 491, 501 Gosain, A., 277
Feathering, 956 Graf, R.M., 1159
Felicio, Y., 1104 Granulating, 1137
Female pattern baldness, 519 Granulations, 1154, 1162
Female pattern hair, 520 Granuloma, 218, 1129
Fernandez, J.C., 973 Granulomatous, 443
Fibrosis, 543, 942, 1145, 1170, 1171 Grazer, F.M., 106, 888, 889, 891, 900, 901, 926
Fibrous, 4, 412, 1160 Greminger, R.F., 888, 890
capsule, 1144 Greuse, M., 770
fat, 950 Grolleau, J.L., 820
Fischer, A., 949 Gross, C.W., 15, 416
Fischer, G., 5, 10, 11, 1315, 87, 405 Grossman, K.L., 1131
Fishman, L.Z., 17 Gsell, F., 6
Fitzpatrick skin type, 158, 171, 184, 982, 987, 989 Guerrerosantos, 585
Fitzpatrick types, 539 Guillemain, 363
Flankplasty, 1002, 1003 Guinard, A., 4
Flesch-Thebesius, M., 888, 889, 927 Guinard, M., 755
Florez, M., 364 Gunter, G.P., 21
Fodor, P.B., 15 Gunter, J.P., 345
Fournier, P.F., 11, 1315, 87 Gynecomastia, 84, 747, 751, 753, 871, 872, 874, 877, 879, 880,
Freeman, M.S., 10 882, 883, 952
Freund, R.M., 300
Fulton, J.E., 407
Furnas, D.W., 20, 267, 275, 276 H
Hall-Findlay procedure, 8
Hamdi, M., 770, 1163
G Hammond, D.C., 708
Galactorrhea, 1145 Hamra, S.T., 10, 323, 344
Galland, 363 Hanke, C.W., 1131
Galtier, 927 Harris, L., 771
Galtier, M., 888, 889 Hatch, M.D., 17
Gasperoni, C., 15 Haug, R., 16
1188 Index

Hematoma, 47, 132, 252, 295297, 321, 328, 333, 341, 390, J
398, 410, 492, 631, 686, 697, 767, 768, 901, 947, 1050, Jabs, A.D., 757
1051, 11351137, 1143, 1149, 1159, 1160, 1162, 1164, Jackson, I.T., 891
1166, 11681171, 11771179 Jayes, P.H., 18
Hensel, J.M., 901 Johnson, G.W., 1159
Heparin, 1140, 1141 Jolly, R., 888
Hernandez-Perez, E., 364 Jones, E.H., 17
Hernia, 951 Joseph, J., 3, 7, 9, 16, 17, 21, 329
Hester, Jr, T.R., 6, 345, 903
Hetter, G.P., 14
Heywang-Kobrunner, S.H., 1161 K
Hinderer, U.T., 6 Kamer, F.M., 10
Hiragun, A., 406 Kaminski, M.V., 409
Hoeffiin, S.M., 10 Kaye, B.L., 19
Hollnder, E., 9, 311, 329 Keen, W.W., 16
Holmes, E.M., 17 Kelly, H.A., 887, 889, 926
Holmstrm, H., 235 Keloid, 152, 205, 218, 262, 278, 539, 694, 904, 1137, 1138,
Holt, J.A., 21 1154, 1163, 1164, 1174, 1178, 1179
Homans sign, 1174 Keratitis
Homicz, M.R., 1131 exposure, 224
Hoopes, J.E., 6 Kerrigan, C.L., 759
Horlock, N., 20, 280 Kesselring, U.K., 13, 888
Houseman, T.S., 118 Keyhole, 777, 779, 836
Huemer, G., 1170 Keyhole pattern, 760
Hunter, G.R., 902 Klein, A.W., 1067
Hypermastia, 759 Klein, J.A., 15, 16, 8789, 92, 101, 122, 949
Hyperpigmentation (PIH), 151153, 158, 159, 161, 163, 174, Kleins solution, 408, 409, 540
186, 190, 205, 217, 218, 457, 630, 631, 694, 1076, Kligmans formula, 158
1132, 1167, 1171 Kolle, F.S., 17
Hyperplasia, 1130 Koltun, R.K., 21
Hyperplasic, 1088 Kornstein, A.N., 747
Hypertension, 109, 111, 116, 341, 901, 1165 Kraske, H., 4, 7
Hypertrophic, 1088, 1106 Kristensen, H.K., 18
Hypertrophic scars, 185, 205, 218, 262, 328, 343, 558, 560, Kupfer, D., 758
629, 694, 753, 767, 1137, 1138, 1149, 1154, 1163,
1164, 1174, 1178, 1179
Hypertrophy, 278, 299, 638, 641644, 646, 670, 671, 674, 678, L
682, 690, 694, 702, 703, 719, 757759, 777, 801, 808, Laberge, L., 273
809, 812, 824, 828, 831, 1106, 1130 Lacrimal gland, 223
Hypoesthesia, 750 prolapsed, 220
Hypoglycemia, 125 Lagophthalmos, 224
Hypopigmentation, 163, 174, 185, 190, 630, 631, 694, 1076 Lalardrie, J.P., 6
Hypotension, 98, 121, 1141, 1158, 1169, 1174, 1176 Lasgue sign, 1050
Hypothermia, 131 Laser, 167170, 172, 174, 176174, 186, 190, 223, 232, 437,
539, 540
Lassus, C., 8, 708, 756, 791, 797
I Lejour, M., 7, 9, 708, 756, 770, 791, 797
Illouz, Y.G., 11, 13, 14, 87, 888 Lejour maneuver, 792
Indentations, 1137, 1173 Lembert, 17
Infection, 96, 174, 185, 278, 295, 321, 334, 388, 390, 398, 412, Lemmon, M.L., 9
423, 445, 565, 630, 631, 690, 691, 699, 750, 768, 901, Letterman, G., 759
904, 1049, 1129, 1137, 1145, 1147, 1152, 1159, 1160, Lexer, E., 9, 756
1162, 1166, 1168, 11701173, 11771179 Lid laxity, 227
Inframammary fold, 4, 47, 49, 564, 582, 605, 608610, Lidocaine toxicity, 88, 98
612615, 617, 633, 637, 641, 644, 652657, 664, 665, Local anesthetic toxicity
667, 669671, 675, 682, 705, 706, 716721, 724, 747, lipid emulsion, 116
755, 761, 763, 775777, 791, 793796, 798, 799, Lockwood, T., 888, 973, 997
805807, 809, 812, 814, 821, 824, 828834, 838, 840, Losken, A., 901
841, 844851, 862, 886, 1115, 1123, 1143, 1145, 1147 Loss of sight, 412
Israel, J., 21 Lotsch, G.M., 796
Isse, N.G., 338, 345, 361, 381 Loustau, H.D., 8
Index 1189

Luckett, W.H., 17, 18 Morgan, W.R., 14

Lund, K., 1161 Moufarrge, R., 781, 927
Lykissa, E.D., 1145 Mouly, R., 772
Lymphoceles, 997 Munhoz, A.M., 1105, 1159
Munoz Ahmed, J.A., 892
Muscular plication, 329
M Mustard, J.C., 19, 20, 267, 271, 273275, 277, 280
MacColumm, D.W., 17 Myalgia, 1141, 1176
MacKee, 147 Myospasm, 1148
Macromastia, 759
MACS. See Minimal access cranial suspension (MACS)
Maillard, G.F., 828 N
Malignant hyperthermia, 113 NAC. See Nippleareolar complex (NAC)
Maliniac, J.W., 4, 772 Nahai, F., 635
Mandel, M.A., 132 Nahas, F.X., 888, 891, 892
Mandrekas, A.D., 771, 811, 1164 Nasojugal groove, 422
Mangubat, 623 Nasolabial fat pad, 433
Marchac, D., 6, 756 Nasolabial fold, 31, 39, 186, 189, 191, 319, 338, 345, 363, 365,
Marino, H., 4 370, 389, 420, 421, 423, 426, 427, 429, 430, 441, 489,
Marionette lines, 191, 506, 508, 511 506, 508, 511, 514, 540
Marques, A., 888, 891 Necrosis, 96, 148, 169, 218, 278, 321, 327, 333, 406, 435, 443,
Marshall, D.R., 770 462, 541, 543, 588, 631, 690, 766769, 901, 1129,
Martins, P.A., 747 1131, 1136, 1137, 11401142, 1149, 1151, 1152, 1157,
Mastitis, 1147 1161, 1162, 1166, 11721174, 1178, 1179
Matarasso, A., 890, 901, 904 Necrotizing fasciitis, 904, 1137, 1171, 1173
Matarassuo Nerve compression, 1172
abdominoplasty classification system, 891, 892 Nerve entrapment, 1144
Matros, E., 300 Nerve injury, 295, 321, 334, 341, 384, 388, 390, 462, 496,
Maximovich, S.P., 1143 541, 1153
Mayer, D.M., 9 Netscher, D.T., 759
May, H., 4 Neuber, F., 405, 585
McDowell, A.J., 17 Neuroma, 1173
McEvitt, W.G., 18 New, G.B., 17, 18
McGregors patch, 34, 35 Newman, J., 407
McIndoe, A., 4 Nippleareolar complex (NAC), 1152, 1161
McKissock, P.K., 6, 7, 633, 705, 756 Nol, S., 9
McKissocks technique, 770, 772 Nolting, H., 21
Melasma, 151, 153, 158, 159, 161, 216 Nordzell, B., 273
Mendelson, B., 495
Mendelson, E.B., 1161
Menesi, L., 7 O
Mesogun, 207, 215, 216 Obesity, 109, 110, 112, 901, 907, 908, 916, 920, 921, 982,
Methemoglobinemia, 92 1142, 1155
Mettauer, J.P., 3 Orlando, J.C., 6, 756
Meyer, R., 6 Ostad, A., 16
Michaelis rhomboid, 1068 Owens, N., 20
Microcalcifications, 412 zmen, S., 771
Migration, 1148
Millard, 557
Miller, C.C., 9, 17 P
Minimal access cranial suspension (MACS), 323, 324, 328 Pain, 129, 186, 218, 305, 388, 390, 412, 759, 768, 900, 1050,
Mirrafati, S., 15 1087, 1124, 1143, 1144, 1163, 1167, 1174, 1179
Mitnick, J.S., 1161 Paletta, F.X., 18
Mitz, V., 9, 344 Pangman, W.J., 9, 10
Moelleken, B., 345 Parsa, F.D., 1159
Mohammad, J.A., 1136 Passot, R., 7, 9, 866, 870
Mondors disease, 1143, 11481150 Passot technique, 866
Monks, G.H., 16, 21 Paul, M.D., 345
Moody, B.R., 1132 Paulus of Aegina, 747
Morbid obesity, 907 Payr, E., 17
Morestin, H., 4, 17, 756 Pearl, C., 273
1190 Index

Peau dorange, 958, 962, 984 Ricketts, 249

Peker, F., 271 Rippling, 1154, 1159
Perbeck, L., 769 Robbins technique, 644, 682
Perforation, 1138, 1168, 1173 Robbins, T.H., 6, 633
Pers, M., 811 Robertson, D.C., 6
Petits triangle, 62 Roberts, T.L., 1044
Phlebitis, 119 Robles, J., 1045
Pick, J.F., 888, 889, 927 Roe, J.O., 20, 21
Pierce, G.W., 18 Rogers, B.O., 16
Pinch test, 813814, 916, 960, 966, 974, 975, 985, 995, 996, 1004 Rohrich, R.J., 31, 891
Pistor, M., 205, 209 ROOF, 70. See Retro-orbicularis oculi fat (ROOF)
Pitanguy, I., 6, 9, 633, 791, 888, 889, 891, 904, 926, 973 Roth, A.C., 769
Pitman, G.H., 115, 132, 1173 Rothkopf, D.M., 1145
Planas, J., 888 Round block, 798, 799
Planatome, 11 Roy, J.N., 21
Plato, 557 Rudolph, R., 545
Pleating, 1178 Ruff, G., 361
Pneumothorax, 1153 Ruttin, E., 17
Pollock, H., 904
Pontes, R., 6
Pousson, M., 7 S
Protein C, 1140, 1141, 11561158 Saldanha, O.R., 904
Protein S, 1140, 11561158 Salivary fistula, 1167
Pseudocyst, 904, 1136 Samdal, F., 115, 772
Pseudoptosis, 623, 637, 807 Sampaio-Goes, J.C., 7
Psillakis, J.M., 10, 338, 339, 344, 345, 892 Santana, P.M., 338
Ptosis, 10, 34, 219, 289, 290, 345, 389, 437, 542, 558, 561, Scapho-conchal angle, 268
563565, 576, 617, 623, 630, 634, 638, 640, 641, 644, Scarpas fascia, 59, 60, 904, 945
666, 669673, 678, 682, 690, 694, 701, 755, 763, 777, Scars, 4, 6, 7, 9, 11, 19, 96, 147, 151, 152, 156, 164, 171, 172,
778, 783, 801, 815, 817, 818, 824, 858, 865868, 908, 178, 185, 277, 278, 296, 297, 301, 328, 332, 343, 356,
940, 942, 1001, 1008 409, 412, 467, 545, 560, 565, 572, 577, 617, 621, 622,
Ptotic, 363 630, 631, 633, 634, 661, 671, 687, 690, 694, 699, 701,
Pulmonary edema, 132, 1173 702, 706, 716, 735, 747, 751, 755, 760, 761, 765, 768,
Pulmonary emboli, 901, 902 791, 799, 800, 828, 841, 857, 866, 892, 901, 904, 907,
Pulmonary embolism (PE), 129, 893, 1140, 1155, 1157, 908, 912, 919, 921, 931, 941, 944, 946, 947, 951, 956,
1174, 1175 975, 986, 987, 993995, 997, 1004, 1106, 1107, 1113,
Pulmonary embolus, 1139 1124, 1125, 1131, 11361139, 1148, 1149, 1153, 1154,
Pyriformis, 1045 1163, 1167, 1170, 1171, 1174, 1178, 1179
hypertrophy, 616
indentation, 1153
Q Schaeffer, B.T., 15
Quezada, J., 1043 Schaller, H., 755
Scheflan, 888
Schepelmann, E., 887, 888
R Schrudde, J., 10, 13
Ramirez, O.M., 338, 339, 345, 352 Schwarzmann, E., 4, 756
Ramsay Hunt area, 81 Scuderi, N., 20
Rash, 1141, 1176 Seizure, 91, 116
Rassel, 1148 Sensory loss, 1138
Raynauds disease, 321, 333 Sepsis, 904, 1137
Rees, T.D., 815 Sercer, A., 18
Regnault, P., 6, 768, 888, 889, 926 Seroma, 10, 96, 341, 398, 543, 565, 631, 750, 767, 895, 904,
Regnaults classification, 716 918, 947, 950, 989, 991, 997, 1050, 1129, 1137, 1139,
Renault, P., 630 1154, 1159, 1167, 1168, 1170, 1171, 11731175
Ren, W.T., 6, 7 Serosanguinous, 1136
Rthi, A., 21 Sheehan, J.E., 21
Retro-orbicularis oculi fat (ROOF), 223, 437 Shiffman, M.A., 904
Reverse telephone ear deformity, 280 Shull, B.L., 903
Rey, R.M., 1160 Sidman, R.L., 406
Ribeiro, L., 6, 747 Silberg, B.N., 15
Ribeiros technique, 797 Simon, B.E., 747
Index 1191

Simons classification, 748 Thrombosis, 1094, 1140, 1141, 1156, 1157, 1169, 1174
Skin Titley, O.G., 771
burns, 456458 Toledo, 406
contracture, 333 Tolhurst, D.E., 271
pleating, 626 Tonnard, P., 10, 323
Skoog, T., 6, 9, 344, 772 Townsend, P.L., 770
Skoog technique, 769 Toxic shock syndrome, 904, 1137, 1141, 1158, 1171, 1176
Sleep apnea, 113 Tracy, C.A., 769
Slezak, S., 770 Trichloroacetic acid, 167
SMAS. See Superficial musculoaponeurotic system (SMAS) Tuberous breast, 787
Smith, E., 20 Tubular, 811
Smoking, 109, 112, 152, 153, 321, 334, 359, 492, 634, 767, Tubular breast, 805, 811, 812, 815823, 827828, 831, 840, 842
893, 931, 1136, 1137, 1142, 1149, 1151, 1172 Tumescent anesthesia, 175, 953
Songcharoen, S., 1160 Tumescent technique, 102, 132
Spadafora, 888
Spira, M., 275, 278
Stal, S., 20 U
Stark, R.B., 19 Umbilical hernia, 1138
Stenstrem, S.J., 19, 267 Umbilical stenosis, 1137, 1141
Stenstrem technique, 20 Upper arm contouring classification, 981
Steroid fat atrophy, 1164
Stoff-Khalili, M.A., 1159
Straith R.E., 19 V
Stroke, 1140, 1155 Van Uchelen, J.H., 893, 903
Strombeck, J.O., 4, 68, 633, 756 Vascular ectasias, 186
Suborbicularis oculi fat (SOOF), 3739, 70, 229, 340, 341, 345 Velpeau, A.A.L.M., 7
Sulamanidze, 358, 361, 365 Venous thrombosis (DVT), 99, 110, 894
Superficial musculoaponeurotic system (SMAS), 9, 10, 29, Ventral hernia, 1138
3234, 311, 312, 318, 319, 321, 323, 326330, 333, Ventura, O.D., 1159
337339, 344, 355, 369, 373, 379, 381, 390, 485, 487, Verchere, 7
488, 510, 511, 541 Vergara, R., 1045
Sushruta, 16, 20 Vernon, S., 888
Suslov, 21 Vidaurre, S., 17
Swelling, 218, 223, 410, 429, 441, 445, 995, 1132, 1143 Vilain, B., 10
Synmastia (Symmastia), 784, 1154, 1155 Vila-Rovira, R., 1160
Villandre, C., 756
Viola, J.C., 891
T Vitamin K, 1140
Tachycardia, 116, 129 Vitiligo, 205
Tachypnea, 1139 Vogt, T., 13
Tagliacozzi, G., 3, 16 Voloshin, M.R., 21
Tail of Spence, 50 von Graefe, K.F., 21
Tamerin, J., 19 von Pfolspeundt, H., 21
Taufig, 15 Voss, S.C., 902
Tear trough, 185, 227, 231, 420, 421, 423, 430, 486, 490, 491,
498, 502, 508
Tebbetts, 571 W
Teimourian, B., 6, 14 Weaver, D.F., 18
Telangiectasias, 205, 1094, 1095, 1167 Webster, G.V., 20
Telephone ear deformity, 280 Webster, R.C., 9
Temourian, 13 Wechselberger, G., 828
Temple, C.L., 770 Weerda, H., 20
Tessier, P., 10, 338, 344, 345 Wegener, H.E., 20
Thigh plasty, 1123 Weiner, D.L., 6, 8, 756
Thigh ptosis, 993 Weinhold, S., 887, 889, 927
Thomas, T.G., 755 Weir, R.F., 21
Thoracic outlet syndrome, 1149 Wheisheimer, K., 889, 927
Thorek, M., 4, 888, 889, 926 Whitnalls ligament, 73
Thromboembolism, 98, 682, 902, 11391142, 1155, 1157, Whitnalls tubercle, 71
1158, 1168, 1174, 1175, 1179 Widgerow, A.D., 280
Thrombophlebitis, 1139, 1156, 1157 Wilkinson, T.S., 888
1192 Index

Wise keyhole, 760 Y

Wise pattern, 629, 706, 709, 716, 721, 723, 730, 733744, 799, Yalin, C.T., 1161
836, 1163 Young, F., 17, 18
Wise, R.J., 4, 6, 791
Woods, J.E., 772
Wood-Smith, D., 19, 20 Z
Wrinkles, 329, 330 Zecha, P.J., 904
Wringer, E., 49, 636, 809, 812 Zelickson, B., 187
Wu, W., 361 Zocchi, M., 15
Zukowski, M.L., 888

X
Xanthelasma, 212