Facial Plastic and Reconstructive Surgery: Clinical Reference Guide

Facial Plastic and
Reconstructive Surgery
Clinical Reference Guide
Facial Plastic and
Reconstructive Surgery
Clinical Reference Guide
Shaun C. Desai, MD
5521 Ruffin Road
San Diego, CA 92123
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NOTICE TO THE READER

Care has been taken to confirm the accuracy of the indications, procedures, drug dosages,
and diagnosis and remediation protocols presented in this book and to ensure that they
conform to the practices of the general medical and health services communities. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty,
expressed or implied, with respect to the currency, completeness, or accuracy of the contents
of the publication. The diagnostic and remediation protocols and the medications described
do not necessarily have specific approval by the Food and Drug administration for use in
the disorders and/or diseases and dosages for which they are recommended. Application
of this information in a particular situation remains the professional responsibility of the
practitioner. Because standards of practice and usage change, it is the responsibility of the
practitioner to keep abreast of revised recommendations, dosages, and procedures.
Library of Congress Cataloging-in-Publication Data
Names: Desai, Shaun C., editor.

Title: Facial plastic and reconstructive surgery : clinical reference guide /
[edited by] Shaun C. Desai.
Other titles: Facial plastic and reconstructive surgery (Desai)
Description: San Diego, CA : Plural, [2017] | Includes bibliographical
references and index.
Identifiers: LCCN 2016018358| ISBN 9781597569637 (alk. paper) | ISBN
1597569631 (alk. paper)
Subjects: | MESH: Face — surgery | Reconstructive Surgical Procedures — methods
| Cosmetic Techniques | Neck — surgery | Handbooks
Classification: LCC RD119 | NLM WE 39 | DDC 617.9/52 — dc23
LC record available at https://lccn.loc.gov/2016018358
Contents
Foreword xi
Preface xiii
Acknowledgments xv
Contributors xvii
Part I Facial Plastics Essentials 1
Chapter 1 Instrumentation and Tissue Handling 3

Matthew C. Gropler and Scott Walen
Chapter 2 Skin Anatomy and Wound Healing 15

Sean Timothy Massa and Scott Walen
Chapter 3 Facial Analysis 25

John J. Chi
Chapter 4 Photography 35
Jeffrey D. Sharon
Chapter 5 Alloplastic Implants and Genioplasty 41

Jennifer C. Fuller and David A. Shaye
Chapter 6 Ethics in Facial Plastic Surgery 53

Sarah A. Saxon and Demetri Arnaoutakis
Part II Facial Nerve 61
Chapter 7 Facial Nerve Anatomy 63

Jeffrey D. Sharon
Chapter 8 Evaluation and Management of Acute Facial 71

Nerve Paralysis
Irene A. Kim and Amit Kochhar
Chapter 9 Facial Reanimation 79

Jason C. Nellis, Leslie R. Kim, and Patrick J. Byrne
Part III Oculoplastic Surgery 93
Chapter 10 Brow Lift 95

Peter Papagiannopoulos and Peter C. Revenaugh
v
vi Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Chapter 11 Upper Eyelid Blepharoplasty 105

Lindsey M. McDaniel and Steven M. Couch
Chapter 12 Lower Eyelid Blepharoplasty 115

Michael G. Neimkin, John B. Holds, and
Steven M. Couch
Chapter 13 Asian Blepharoplasty 127

Chau Pham and Steven M. Couch
Chapter 14 Ptosis 135

Suzanne W. van Landingham and
Nicholas R. Mahoney
Chapter 15 Mohs and Eyelid Reconstruction 141

Suzanne W. van Landingham and Nicholas R. Mahoney
Part IV Aging Face 151
Chapter 16 Anatomy and Physiology of Aging 153

Andrea M. Park, Samuel Hahn, and
Gregory H. Branham
Chapter 17 Rhytidectomy 163

Jordan P. Sand, Samuel Hahn, and
Gregory H. Branham
Chapter 18 Management of the Midface 175

Emily Spataro, Samuel Hahn, and Gregory H. Branham
Chapter 19 Liposuction and Fat Transfer 181

Jennifer C. Fuller and David A. Shaye
Chapter 20 Skin Rejuvenation: Lasers, Peels, and Dermabrasion 187

Zain Husain, Qasim Husain, and Tina S. Alster
Chapter 21 Injectables for Rejuvenation 197

Theda C. Kontis
Part V Rhinoplasty 207
Chapter 22 Nasal Anatomy, Analysis, and Approaches 209

Kristin Stevens and Sofia Lyford-Pike
Chapter 23 Functional Nasal Airway 225

Andrew J. Thomas, Justin C. Sowder, and P.
Daniel Ward
CONTENTS vii
Chapter 24 Rhinoplasty: Upper Vault and Middle Vault 239

Leslie R. Kim and Ira D. Papel
Chapter 25 Tip Rhinoplasty 247

Christian A. Paquet and Jon-Paul Pepper
Chapter 26 Revision Rhinoplasty and Complications 263

Leslie R. Kim and Ira D. Papel
Chapter 27 Non-Caucasian Rhinoplasty 273

Ryan M. Smith and Peter C. Revenaugh
Part VI Hair Replacement 285
Chapter 28 Alopecia 287

Lisa Ishii
Chapter 29 Hair Transplantation 293

Lisa Ishii
Chapter 30 Regional Scalp Flaps and Tissue Expansion in 297

Aesthetic Hair Surgery
Sahar Nadimi and Sheldon S. Kabaker
Part VII Trauma 307
Chapter 31 Acute Soft Tissue Injury 309

Phong Le and Samuel L. Oyer
Chapter 32 Principles of Plating and Bone Healing 323

Regina Rodman and Robert M. Kellman
Chapter 33 Mandible Trauma 331

Chapter 34 Midface and Pan-Facial Fractures 339

Chapter 35 Orbit, Naso-Orbitoethmoid, and Nasal Fractures 347

Chapter 36 Frontal Sinus Fractures 357

Part VIII Scar Revision and Reconstructive Ladder 363
Chapter 37 Scar Revision 365

Kenneth J. Andrews and J. Regan Thomas
viii Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Chapter 38 Skin, Dermal, Cartilage, Composite, and 379

Bone Grafts
Rahul Seth and P. Daniel Knott
Chapter 39 Primary and Local Flaps 387

Natalie Justicz and Linda N. Lee
Chapter 40 Regional Flaps 403

Andrew T. Day, Hamad Chaudhary, and
Jeremy D. Richmon
Chapter 41 Free Tissue Transfer 415

Neil S. Sachanandani and Shaun C. Desai
Part IX Head and Neck Neoplasms 427
Chapter 42 Benign Skin Lesions 429

Tzyy-Nong Liou, Wee Tin K. Kao, Samuel Hahn,
and Gregory H. Branham
Chapter 43 Cutaneous Squamous Cell and Basal Cell 437

Carcinoma
Rebecca C. Hoesli and Chaz L. Stucken
Chapter 44 Melanoma 449

Adeeb Derakhshan, Joseph Zenga, and Shaun C. Desai
Chapter 45 Rare Skin Malignancies and Syndromes 459

Nancy P. Judd
Part X Pediatric and Craniofacial Surgery 463
Chapter 46 Cleft Lip 465

Zachary Farhood and Krishna G. Patel
Chapter 47 Cleft Palate 481

Adrian A. Ong and Krishna G. Patel
Chapter 48 Velopharyngeal Insufficiency 493

Janet Waimin Lee and Travis T. Tollefson
Chapter 49 Cleft Rhinoplasty 507

Lauren B. Moneta, Myriam Loyo Li, and
Tom D. Wang
Chapter 50 Craniosynostosis 515

Sherard A. Tatum
CONTENTS ix
Chapter 51 Microtia 525

Sachin S. Pawar
Chapter 52 Otoplasty 541

Andrew W. Joseph and Shaun C. Desai
Chapter 53 Congenital Vascular Lesions of the Head and Neck 551

Tara E. Brennan, Teresa O, and Milton Waner
Chapter 54 Global Surgery 559

David A. Shaye
Index565
Foreword
In today’s world of ever expanding medical knowledge, precise reference

guides are in demand by practicing physicians, residents and fellows in
training, and medical students. Even better is a book that provides both a
comprehensive day-to-day clinical reference and board review source and
can fit into the pocket of a white coat.
This text is a concise clinical reference guide solely devoted to facial
plastic and reconstructive surgery. No such portable guide has existed up
until now. Dr Desai has gathered an “all-star” multidisciplinary group of
authors who are true experts in their fields. Many are paired with coauthors
who recently finished training to give a unique combined perspective on
each topic. One could say that the chapters are written “by former train-
ees for present trainees.” The result is an easily accessible reference guide
organized to help the reader find vital information quickly and efficiently.
Doctors in the specialties of facial plastic surgery, plastic surgery,
oculoplastic surgery, oral and maxillofacial surgery, and dermatology will
find this guide indispensable in preparing for surgery or patient care.
Modeled after Dr Raza Pasha’s popular Otolaryngology Head and Neck
Surgery Clinical Reference Guide, this portable reference book fills a niche
in the reference world left empty too long.
— Ira D. Papel, MD
Associate Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
— Patrick J. Byrne, MD
Professor and Director
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
xi
Preface
As a resident, I memorized the famed “Pasha” textbook and carried it

everywhere for studying otolaryngology and truly felt it captured some of
the most important educational concepts in the field. However, during
my residency and facial plastics fellowship, I felt there was a lack of an
easy-to-read, concise, but comprehensive book encompassing all aspects
of facial plastic and reconstructive surgery. I wanted a “Pasha” for Facial
Plastic and Reconstructive Surgery. Hopefully, this clinical reference
guide can help fill that void both in the clinical setting as well as prepar-
ing for board exams.
In this first edition, I have tried to incorporate authors from all spe-
cialties — Facial Plastic and Reconstructive Surgery, General Plastic and
Reconstructive Surgery, Oculoplastic Surgery, and Dermatology — in an
effort to demonstrate that ultimately our common goal is the same: edu-
cation and the advancement of medicine for the betterment of our patients.
Second, I believe a multidisciplinary approach brings a broader range of
insight into often complex clinical challenges.
This reference book is organized into major sections of facial plastic
and reconstructive surgery similar to the compendium articles that are
suggested reading by the American Academy of Facial Plastic and Recon-
structive Surgery. Therefore, this book should encompass all aspects of
facial plastic and reconstructive surgery, from cosmetic to reconstructive
to craniofacial. All chapters are coauthored by nationally recognized sub-
specialists. I have tried to combine senior authors with junior authors to
help achieve a unique perspective on the relevant information needed for
a trainee. Lastly, each chapter follows a uniform easy-to-read outline to
facilitate quick review of a topic, but the comprehensive nature of each
chapter provides the depth required for written and oral standardized tests.
Please enjoy this first edition, and as always please let me know if
there are any errors that need to be corrected for future editions.
xiii
Acknowledgments
It is believed in my culture that the teacher, or “guru,” not only educates

but also inspires and passes on experience and knowledge. I was raised to
revere teachers as my elders and to respect them as such. I truly believe
I would not be in such a fortunate position if it were not for the countless
teachers in my life. While I could name hundreds of “gurus” that inspired
me, I want to specifically thank all my professors and friends in residency
and fellowship at Barnes-Jewish Hospital/Washington University in St
Louis, particularly Ryan Brown, Jason Rich, Scott Walen, Dan Sdrulla,
Courtney Voelker, Nancy Judd, Nsangou Ghogomu, Jordan Sand, Jason
Diaz, Alan Sclaroff, Alan Harvey, John Chi, Randal Paniello, Brian Nus-
senbaum, and Bruce Haughey who gave me a chance to learn and sup-
ported me throughout my training and beyond. To Gregory Branham,
who not only taught me facial plastic surgery, but more importantly the
art of humility and the nature of being a true gentleman — I am forever
indebted for your friendship and mentorship.
Also to my newer friends and colleagues in the Division of Facial
Plastic and Reconstructive Surgery at Johns Hopkins (Patrick, Kofi, Lisa,
Theda, and Ira) who continue to support me and my budding career.
A special thanks to Murry, Clint, Nikki, Wojciech, and Wade for con-
tinuing to not only be genuinely great partners but for always having my
back — I am truly honored to be in the same company with you all.
Furthermore, I want to thank all the authors for their dedication
and hard work for which this book would not be possible. Writing book
chapters can be quite laborious with a tremendous time commitment
and oftentimes does not gain the recognition it so truly deserves. It is
through the work of the 82 authors (attendings, fellows, residents, and
medical students) that contributed to this book that will hopefully make
this book a success.
To Jeff, the illustrator, and one of my best friends and “littermates,”
for his phenomenal drawings, brilliant insight, and dedication to making
this project work — this could not have been done without you. Your sheer
intelligence, witty humor, and massive heart never cease to amaze me.
Good luck at UCSF; they are lucky to have you.
Finally, I want to thank my parents for their devout love and support
— and who gave me the opportunity to follow my passion. They have
the classic immigrant success story, and it is only through their selfless
love and sacrifice that allowed me to succeed in this country and I thank
God every day for how fortunate to have them both in my life. To my big
brothers, Jay and Neel, for always picking me back up when I’m down,
xv
xvi Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
and for always being there. To Giorgos, Yasha, Vik, Neal, Akshay, and
Veena for their friendship. Finally, to Courtney, who has had to put up
with a whiney, irritable, and stubborn 30-something-year-old unshaven
Indian male for years but continues to somehow stick by his side with a
relentless beautiful smile.
I thought it would be most appropriate to end with a quote from
the famous Dr Charlie Cummings: “I truly have been blessed with more
friends and family than I will ever deserve in this lifetime.”
Thank you all and I hope you enjoy this first edition.
— Shaun C. Desai, MD
Contributors
Tina S. Alster, MD Facial Plastic and Reconstructive

Director Surgery
Washington Institute of Department of Otolaryngology-
Dermatologic Laser Surgery Head and Neck Surgery
Clinical Professor of Dermatology The University of New Mexico
Georgetown University Medical Albuquerque, New Mexico
Center Chapter 53
Washington, District of Columbia
Chapter 20 Patrick J. Byrne, MD, FACS,
MBA
Kenneth J. Andrews, MD Professor and Director
Department of Otolaryngology- Division of Facial Plastic and
Head and Neck Surgery Reconstructive Surgery
University of Illinois at Chicago Department of Otolaryngology-
Chicago, Illinois Head and Neck Surgery
Chapter 37 Johns Hopkins University School
of Medicine
Demetri Arnaoutakis, MD
St. Louis, Missouri
Resident
Chapter 9
Department of Otolaryngology-
Head and Neck Surgery
Hamad Chaudhary, MD, MS
University of Texas Southwestern
Instructor
Medical Center
Head and Neck Surgical
Dallas, Texas
Oncology
Chapter 6
Gregory H. Branham, MD Head and Neck Surgery
Professor and Chief Johns Hopkins University
Facial Plastic and Reconstructive Baltimore, Maryland
Surgery Chapter 40
Head and Neck Surgery John J. Chi, MD
Washington University School of Assistant Professor
Medicine Division of Facial Plastic and
Saint Louis, Missouri Reconstructive Surgery
Chapters 16, 17, 18, and 42 Washington University in Saint
Louis, School of Medicine
Tara E. Brennan, MD Saint Louis, Missouri
Assistant Professor Chapter 3
xvii
xviii Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Steven M. Couch, MD, FACS Charleston, South Carolina

Assistant Professor of Chapter 46
Ophthalmology and Visual
Sciences Jennifer C. Fuller, MD
Oculofacial Plastic and Resident
Reconstructive Surgery Department of Otolaryngology-
Washington University in Saint Head and Neck Surgery
Louis Massachusetts Eye and Ear
Saint Louis, Missouri Infirmary
Chapters 11, 12, and 13 Boston, Massachusetts
Chapters 5 and 19
Andrew T. Day, MD
Clinical Instructor Matthew C. Gropler, MD
Head and Neck Oncologic Resident
Surgery and Microvascular Department of Otolaryngology-
Reconstruction Head and Neck Surgery
Department of Otolaryngology- Saint Louis University School of
Head and Neck Surgery Medicine
Johns Hopkins Medical Saint Louis, Missouri
Institutions Chapter 1
Baltimore, Maryland
Chapter 40 Samuel Hahn, MD
Clinical Instructor
Adeeb Derakhshan, BS Facial Plastic and Reconstructive
Cleveland Clinic Lerner College Surgery
of Medicine Department of Otolaryngology-
Case Western Reserve University Head and Neck Surgery
Cleveland, Ohio Washington University
Chapter 44 Baltimore, Maryland
Shaun C. Desai, MD Chapters 16, 17, 18, and 42
Assistant Professor
Division of Facial Plastic and Rebecca C. Hoesli, MD
Reconstructive Surgery Resident Physician
Department of Otolaryngology- University of Michigan
Head and Neck Surgery Ann Arbor, Michigan
Johns Hopkins University School Chapter 43
of Medicine
John B. Holds, MD, FACS
Baltimore, Maryland
Clinical Professor
Chapters 41, 44, and 52
Departments of Ophthalmology
Zachary Farhood, MD and Otolaryngology-Head and
Department of Otolaryngology- Neck Surgery
Head and Neck Surgery Saint Louis University
Medical University of South Saint Louis, Missouri
Carolina Chapter 12
CONTRIBUTORS xix
Qasim Husain, MD Otolaryngology

Resident Boston, Massachusetts
Otolaryngology Chapter 39
New York Presbyterian Hospital
Cornell University Sheldon S. Kabaker, MD, FACS
Colombia University Clinical Professor
New York, New York Department of Otolaryngology-
Chapter 20 Head and Neck Surgery
University of California, San
Zain Husain, MD Francisco
Fellow San Francisco, California
Procedural Dermatology Chapter 30
Montefiore Medical Center
Albert Einstein College of Wee Tin K. Kao, MD
Medicine Otolaryngology Resident
Arlington, Virginia Washington University in Saint
Chapter 20 Louis
Saint Louis, Missouri
Lisa Ishii, MD, MHS Chapter 42
Associate Professor
Facial Plastic and Reconstructive Robert M. Kellman, MD
Surgery Secretary Treasurer
Johns Hopkins School of Eastern Section Triological Society
Medicine President
Baltimore, Maryland American Board of Facial Plastic
Chapters 28 and 29 and Reconstructive Surgery
Syracuse, New York
Andrew W. Joseph, MD, MPH Chapters 32, 33, 34, 35, and 36
Resident
Department of Otolaryngology- Irene A. Kim, MD
Head and Neck Surgery Resident Physician
Johns Hopkins University School Head and Neck Surgery
of Medicine University of California, Los
Baltimore, Maryland Angeles
Chapter 52 Los Angeles, California
Chapter 8
Nancy P. Judd, MD
Head and Neck Oncology Leslie R. Kim, MD, MPH
Head and Neck Surgery Instructor in Facial Plastic and
MAPMG Reconstructive Surgery
Falls Church, Virginia Department of Otolaryngology-
Chapter 45 Head and Neck Surgery
Johns Hopkins School of
Natalie Justicz, MD Medicine
Harvard Medical School Baltimore, Maryland
Residency Program Chapters 9, 24, and 26
xx Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
P. Daniel Knott, MD, FACS Boston, Massachusetts

Associate Professor and Director Chapter 39
Section of Facial Plastic and
Reconstructive Surgery Janet Waimin Lee, MD
Department of Otolaryngology Resident Physician
University of California, San University of California, Davis
Francisco Davis, California
San Francisco, California Chapter 48
Chapter 38 Tzyy-Nong Liou, MD
Amit Kochhar, MD Resident
Fellow Department of Otolaryngology
Facial Plastic and Reconstructive Washington University in Saint
Surgery Louis
Department of Head and Neck Saint Louis, Missouri
Surgery Chapter 42
University of California, Los
Myriam Loyo Li, MD
Angeles
Assistant Professor
Los Angeles, California
Facial Plastic and Reconstructive
Chapter 8
Surgery
Theda C. Kontis, MD, FACS Oregon Health and Science
Assistant Professor University
Johns Hopkins Medical Portland, Oregon
Institutions Chapter 49
Facial Plastic Surgicenter, LLC
Baltimore, Maryland Sofia Lyford-Pike, MD
Chapter 21 Assistant Professor
Phong Le, MD Head and Neck Surgery
Resident Physician University of Minnesota
Department of Otolaryngology- Minneapolis, Minnesota
Head and Neck Surgery Chapter 22
Medical University of South
Carolina Nicholas R. Mahoney, MD
Charleston, South Carolina Assistant Professor of
Chapter 31 Ophthalmology
Johns Hopkins University
Linda N. Lee, MD Baltimore, Maryland
Department of Otolaryngology Chapters 14 and 15
Division of Facial Plastic and
Reconstructive Surgery Sean Timothy Massa, MD
Massachusetts Eye and Ear Department of Otolaryngology-
Infirmary Head and Neck Surgery
Harvard Medical School Saint Louis University
CONTRIBUTORS xxi
Saint Louis, Missouri Teresa O, MD, M.Arch

Chapter 2 Co-Director
Lindsey M. McDaniel, MD Facial Nerve Center
Resident Physician Vascular Birthmark Institute of
Department of Ophthalmology New York/AVM Center
University of Missouri Lenox Hill Hospital
Columbia, Missouri Manhattan Eye, Ear, and Throat
Chapter 11 Hospital
New York, New York
Lauren B. Moneta, MD Chapter 53
Resident Physician
Department of Otolaryngology- Adrian A. Ong, MD
Head and Neck Surgery Department of Otolaryngology-
Oregon Health and Science Head and Neck Surgery
University Medical University of South
Portland, Oregon Carolina
Chapter 49 Charleston, South Carolina
Chapter 47
Sahar Nadimi, MD
Clinical Fellow of Facial Plastic Samuel L. Oyer, MD
and Reconstructive Surgery Assistant Professor
Aesthetic Facial Plastic Surgery Facial Plastic and Reconstructive
Clinic Surgery
Oakland, California Medical University of South
Chapter 30 Carolina
Charleston, South Carolina
Michael G. Neimkin, MD Chapter 31
Ophthalmic Plastic and Cosmetic
Surgery, Inc. Peter Papagiannopoulos, MD,
Instructor of Ophthalmology and MS
Visual Sciences Otolaryngology Resident
Washington University in Saint Rush University Medical Center
Louis Chicago, Illinois
Oculus Plastic Surgery Chapter 10
Atlanta, Georgia Ira D. Papel, MD
Chapter 12 Associate Professor
Jason C. Nellis, MD Division of Facial Plastic and
Resident Physician Reconstructive Surgery
Department of Otolaryngology- Department of Otolaryngology-
Head and Neck Surgery Head and Neck Surgery
Johns Hopkins University School Johns Hopkins University School
of Medicine of Medicine
Baltimore, Maryland Baltimore, Maryland
Chapter 9 Chapters 24 and 26
xxii Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Christian A. Paquet, MD University of Southern California

Division of Facial Plastic and Los Angeles, California
Reconstructive Surgery Chapter 25
Caruso Department of
Otolaryngology Chau Pham, MD
University of Southern California Department of Ophthalmology
Los Angeles, California and Visual Sciences
Chapter 25 Washington University in Saint
Louis
Andrea M. Park, MD Saint Louis, Missouri
Resident Chapter 13
Department of Otolaryngology
Washington University in Saint Peter C. Revenaugh, MD
Louis Assistant Professor
Saint Louis, Missouri Section Head, Facial Plastic and
Chapter 16 Reconstructive Surgery
Director, Facial Nerve Disorders
Krishna G. Patel, MD, PhD and Rehabilitation Program
Associate Professor Department of Otolaryngology-
Director of Facial Plastic Head and Neck Surgery
Reconstructive Surgery Rush University Medical Center
Medical University of South Chicago, Illinois
Carolina Chapters 10 and 27
Charleston, South Carolina
Chapters 46 and 47 Jeremy D. Richmon, MD
Associate Professor
Sachin S. Pawar, MD Johns Hopkins University School
Assistant Professor of Medicine
Division of Facial Plastic and Baltimore, Maryland
Reconstructive Surgery Chapter 40
and Communication Sciences Regina Rodman, MD
Medical College of Wisconsin Instructor
Milwaukee, Wisconsin Division of Craniofacial, Facial
Chapter 51 Plastic and Reconstructive
Surgery
Jon-Paul Pepper, MD Department of Otolaryngology
Director and Communication Science
USC Facial Nerve Center SUNY Upstate
Assistant Professor Syracuse, New York
Facial Plastic and Reconstructive Chapters 32, 33, 34, 35, and 36
Surgery
Otolaryngology-Head and Neck Neil S. Sachanandani, MD
Surgery Fellow, Reconstructive
Keck School of Medicine Microsurgery
CONTRIBUTORS xxiii
Department of Plastic Surgery David A. Shaye, MD

Chang Gung Memorial Hospital Massachusetts Eye and Ear
Houston, Texas Harvard Medical School
Chapter 41 Office of Global Surgery
Department of Global Health and
Jordan P. Sand, MD Social Medicine
Fellow in Facial Plastic and Harvard University
Reconstructive Surgery Department of Otolaryngology
Department of Otolaryngology- Centre Hospitalier Universitaire
Head and Neck Surgery Kigali
University of California, Los University of Rwanda
Angeles Boston, Massachusetts
Los Angeles, California Chapters 5, 19, and 54
Chapter 17
Ryan M. Smith, MD
Sarah A. Saxon, MD Department of Otolaryngology-
Assistant Professor Head and Neck Surgery
University of Texas Southwestern Rush University Medical Center
Medical Center Chicago, Illinois
Dallas, Texas Chapter 27
Chapter 6
Justin C. Sowder, MD
Otolaryngology Resident
Rahul Seth, MD, FACS
Assistant Professor
Facial Plastic and Reconstructive
University of Utah
Surgery
Salt Lake City, Utah
Chapter 23
University of California, San Emily Spataro, MD
Francisco Resident
San Francisco, California Department of Otolaryngology
Chapter 38 Washington University in Saint
Louis
Jeffrey D. Sharon, MD Saint Louis, Missouri
Division of Otology, Neurotology,
and Skull Base Surgery Kristin Stevens, MD
Department of Otolaryngology- Resident Physician
Head and Neck Surgery Department of Laryngology-Head
University of California, San and Neck Surgery
Francisco University of Minnesota
San Francisco, California Minneapolis, Minnesota
Chapters 4 and 7 Chapter 22
xxiv Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Chaz L. Stucken, MD Davis, California

Divisions of Head and Neck Suzanne W. van Landingham, MD
Surgery and Facial Plastic and Resident
Reconstructive Surgery Wilmer Eye Institute
University of Michigan Johns Hopkins University
Ann Arbor, Michigan Baltimore, Maryland
Chapter 43 Chapters 14 and 15
Sherard A. Tatum, MD, FACS, Scott Walen, MD, FRCS(C)

FAAP Assistant Professor
Professor Chief of Facial Plastic and
Otolaryngology and Pediatrics Reconstructive Surgery
Cleft and Craniofacial Center Saint Louis University
Division of Facial Plastic Surgery Saint Louis, Missouri
Upstate Medical University Chapters 1 and 2
Syracuse, New York Milton Waner, MD
Chapter 50 Director
Andrew J. Thomas, MD Vascular Birthmark Institute of
Resident Physician New York/AVM Center
Department of Otolaryngology- Lenox Hill Hospital
Head and Neck Surgery Manhattan Eye, Ear, and Throat
University of Utah Hospital
Salt Lake City, Utah New York, New York
Chapter 23 Chapter 53
J. Regan Thomas, MD, FACS Tom D. Wang, MD

Mansueto Professor and Chair Professor and Director
Department of Otolaryngology- Division of Facial Plastic and
Head and Neck Surgery Reconstructive Surgery
University of Illinois at Chicago Department of Otolaryngology-
Chicago, Illinois Head and Neck Surgery
Chapter 37 Oregon Health and Science
University
Travis T. Tollefson, MD, MPH, Portland, Oregon
FACS Chapter 49
Professor
Facial Plastic and Reconstructive P. Daniel Ward, MD, MS, FACS
Surgery Associate Professor
Cleft and Craniofacial Program Facial Plastic Surgery
Department of Otolaryngology- University of Utah School of
Head and Neck Surgery Medicine
University of California, Davis- Salt Lake City, Utah
Medical Center Chapter 23
CONTRIBUTORS xxv
Joseph Zenga, MD
Resident Physician
Washington University School of
Medicine
Saint Louis, Missouri
Chapter 44
Dedicated to my wonderful supportive family:
Dad, Mom, Neel, Debbie, Ethan, Jay, Michelle, and Courtney
Part
I
Facial Plastics Essentials
Chapter
1
Instrumentation and Tissue Handling
Matthew C. Gropler and Scott Walen
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Soft Tissue Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
General Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . 6
3
4 Facial Plastic and Reconstructive Surgery: Clinical Reference Guide
Instrumentation
Instruments
Blades
• #11: elongated tip with straight belly; stabbing incisions; straight cuts
perpendicular to skin in sawing motion; use in complex skin incisions
(geometric broken line scars, accurate angles with short sides)
• #12: small, pointed, and crescent shaped; use in mucosal cuts in
intranasal and intraoral
• #15: sharp tip with rounded belly; most surgeon preferred facial soft
tissue blade; angled incisions; use in undermining
• #15c: hybrid of 11 and 15 blade with elongated tip, low profile,
rounded belly; improved accuracy for complex incisions
• #69: used with Beaver handle to make incision in tarsus
Forceps
Fine Tissue Forceps
• For aligning delicate thin cutaneous edges, not used on larger tissue
pieces due to likelihood of cutting; narrow shaft does not obstruct
view; designed to be held like a pencil, must avoiding applying too
much pressure to prevent crush injury to skin edge
1. 0.5-mm Castroviejo: interdigitating with teeth angled forward
for improved ease of tissue handling
2. Bishop-Harmon: interdigitating with teeth set at a right angle
Tissue Forceps
• For aligning and manipulating thick cutaneous edges, used on large
flaps of tissue, must avoid applying too much pressure to prevent
causing pressure injury to skin edge
1. Adson: interdigitating with single tooth at right angle
2. Brown-Adson: interdigitating with multiple teeth at right angle;
distribution of pressure over larger surface area; less traumatic
Needle Holders
• Must grasp smaller needles used in facial plastics; accommodate wrist
pronation and supination
1. Webster: most commonly used needle holder in facial plastics;
smooth platform does not traumatize finer sutures typically used
in facial plastics
CHAPTER 1 Instrumentation and Tissue Handling 5
2. Castroviejo: used for finest sutures in facial soft tissue

reconstruction and microvascular surgery; locking and
nonlocking forms; held like a pencil
Retractors
• Single-prong skin hook: single hook minimizes trauma on the skin;
use in skin edge retraction; use in skin edge eversion during suture
placement; avoid too much retraction force to prevent puncture
wounds
• Double micro-prong skin hook (Guthrie): use in delicate thin skin
edge retraction; increased distribution of forces over 2 prongs reduces
likelihood of puncture wound
• Wide double-prong skin hook: use in thick skin retraction
• Senn-Mueller (Cat’s Paw): small multiple pronged hook
Scissors
• Kaye blepharoplasty scissors: tissue scissors, beveled edge with
slightly rounded tip and serrated cutting surface that grips tissue edges
to prevent slipping
• Wescott scissors: use in dissection of delicate tissue in periorbital
area; held like a pencil
• Straight Iris scissors: use in cutting of fine sutures used in facial
plastic surgery
• Stevens Tenotomy scissors: curved and blunted tips
• Freeman scissors: facelift scissors, useful for elevation of larger flaps,
outward beveled edge for undermining
• Straight Mayo scissors: large durable scissors; for cutting dressings
and larger sutures
Calipers
• Millimeter caliper: for appropriate and accurate measurement and
planning of reconstructions
• Castroviejo caliper (0–20 mm): use in flap design with accurate
measurements and sharp edge for skin marking
Soft Tissue Handling
Incision
• Incision principles: incisions should be placed in skin creases and
folds or parallel to skin creases or relax skin tension lines to minimize
scarring and improve aesthetic outcome
• Scalpel use: Start with stabbing motion with scalpel tipàtransition to
belly of blade to extend incisionàangle blade to bevel edge to promote
tissue edge eversionàend incision with scalpel tip
General Wound Closure

• In every closure, detailed wound edge approximation key to successful
closure
Cutaneous Edge Eversion

• Nontraumatic proper eversion skin edge margins to facilitate proper
suture placement
• Adson-Brown/Adson forceps: grip and evert skin edge; teeth to
reduce likelihood of crush injury to skin edge; must still apply limited
pressure to reduce likelihood of crush injury
• Single-prong hook: single-prong hook grips the skin edge and
middle finger is placed behind skin hook along skin to promote skin
edge eversion; wound edge eversion without risk of skin edge crush
injury
Tension-Free Closure
• Prevent wound dehiscence; promote tissue viability; improve long-
term wound aesthetic outcome
Undermining
• Uniform undermining of primary wound to promote closure and
aesthetic outcome; sharp dissection preferred in facial plastics is
general rule; dissection in subcutaneous plane to minimize vascular
injury and bruising
1. Scalpel based undermining: single/double skin hooks or
Adson-Brown/Adson forceps to control skin edge and apply
gently countertraction in nondominant hand and scalpel in
dominant hand
2. Scissors based undermining: single/double skin hooks or

Adson-Brown/Adson forceps to control skin edge and apply
gently countertraction in nondominant hand and scissors in
dominant hand
Deep Dermal/Subcutaneous Suture

• Sutures placed at dermal level, which enter and exit on opposing
edges at equal levels parallel to skin; proper placement promotes
wound edge eversion, reduces tension on wound edge, and closes
dead space; improper placement can lead to wound edge inversion
Mechanical Creep
• Elongation of skin beyond intrinsic extensibility using a constant load
over time; skin is viscoelastic; based on collagen realignment, fluid
displacement, and fragmentation of elastin fibers; use of a towel clap
or other commercially available products to facilitate
Hemostasis
• Hemostasis should be achieved to improve view of surgical field and
prevent hematoma occurrence
• Bipolar electrocautery used in facial plastics for hemostasis
Wound Apposition
• Goal to reduce wound tension and approximate edges
• Suture closure is the gold standard
Suturing Principles
• Sutures on the face should be placed 3–4 mm apart
• Goal of initial wound edge eversion due to scar contracture overtime;
lack of eversion or inversion at initial closure leads to scar depression
and worsened aesthetic outcome
• Full arc of needle should be used to promote edge eversion; too
distant placement of sutures of wound edge with scything causes
wound edge inversion, increased horizontal tension, and eventual
pressure necrosis (“railroad track”)
• Principle of halving: first suture placed at center of defect,
remaining defects are closed in a similar fashion, reduces bunching at
ends of defect
• Equalizing of edges: removal of a triangle of skin (Burow’s triangle)
from the long arm of the defect; creates equals arms and reduces
bunching at end of defect
Basic Cutaneous Susture Closures

• Simple interrupted suture: single rectangular/trapezoid shaped loop;
approximates tissue edges; allows for adjust height of suture level with
each throw; good to use over high-tension/motion areas such as lips
and irregular wounds; time-consuming
• Simple continuous suture (running): suture remains behind the
needle; allows for even distribution of tension and increased speed;
difficult to adjust varying wounds’ height levels; ideal use in linear
wounds under low tension
• Continuous locking suture: suture remains ahead of the needle
and crosses inside; allows tension to be set on each stich similar to
a interrupted suture while performing a continuous suture; places
increased pressure along skin edge, easier to remove
• Vertical mattress suture: first pass is thrown far from skin edge
(4–8 mm) and deep followed by a second pass thrown in same
vertical plane near the skin edge and shallow in opposite direction
of first pass; first pass takes tension off wound edge; second pass
approximates wound edge; maximum wound edge eversion; closes
dead space better than simple interrupted sutures
• Horizontal mattress suture: first pass thrown far from skin edge;
second pass is thrown in same horizontal plane in opposite direction;
maximum wound edge eversion; no improvement in dead space
closure; high rate of strangulation of tissue
• Intradermal/intracuticular suture: continuous suture placed
completely within the dermis; suture should be placed at exactly the
same depth within the dermis with each pass of the suture; improved
aesthetic outcome without penetrating epidermis; technically more
difficult
Tape
• Apply to minimal tension wounds; placed perpendicular to line of
closure with eversion wound edges with tissue forceps; subcutaneous
sutures should be placed first
Staples
• Apply to flat skin; avoid over convexities or concavities; avoid delicate
tissue or aesthetic borders; apply to wound with minimal skin edge
discrepancy; use tissue forceps to evert edges
Postoperative Dressing
• No dressing needed for incisions with limited undermining and
hemostasis
• Antibiotic ointment should be applied to incisions closed with

dissolvable sutures
Suture Materials
• Ideal suture: easy to handle, high tensile strength, no tissue reactivity
Principles
• Capillarity: ease of fluids to be wicked along suture; related to
suture’s capability to carry and transmit bacteria
• Elasticity: capability to regain initial length after stretching;
increased elasticity reduces pressure necrosis when tissue edema
occurs at suture site
• Coefficient of friction: tendency to resist motion against tissue
surface; increased friction leads to increased tissue damage;
monofilaments typically have lowest coefficient of friction; braided
sutures typically have higher coefficients of frictions; braided often
coated to reduce friction with silicon, organic waxes, polymers, etc
• Knot fixation: force needed to cause knot to slip; directly related to
coefficient of friction, elasticity, and plasticity
• Memory: ability to return or maintain original shape
• Pliability (flexibility): ease of use facilitates suture placement
and knot-tying; braided sutures typically more flexible than
monofilaments
• Tissue reactivity/inflammation: all tissues viewed as foreign by
immune system and thus produce some degree of inflammation;
natural sutures have greatest tissue response; synthetic absorbable
sutures have moderate tissue response; synthetic nonabsorbable
sutures have least tissue response
• Tensile strength: strain withstood prior to breaking; ability of suture
to withstand forces associated with healing process
Suture Degradation
• Synthetic absorbable: degraded via hydrolysis; rate of hydrolysis
proportional to degree of polymerization
• Natural absorbable: degraded via neutrophil proteolysis; variable
process that is less predictable than synthetic absorbable suture
hydrolysis
Suture Types and Applications

• Refer to Tables 1–1, 1–2, and 1–3
Table 1–1. Absorbable Sutures
Strength
Suture Brand Name Composition Filament Retention Uses
Natural
Plain gut Purified animal-derived collagen Monofilament 7–10 days Skin, subcutaneous, conjunctival
Chromic gut Chromium salt-treated plain gut Monofilament 14–21 days Mucosa, subcutaneous, tarsal
structures
Fast absorbing gut Heat-treated plain gut to accelerate breakdown Monofilament 5–7 days Skin
Synthetic
10
Polyglycolic acid Dexon Polyglycolic acid strands Braided 14–21 days Fascial deep closures
Polyglyconate Maxon Glycolic acid and trimethylene carbonate Monofilament 14–21 days Subcutaneous
Polydioxanone Polydioxanone II, Polyester of polydioxanone Monofilament 21–42 days Subcutaneous
PDS
Polyglecaprone 25 Monocryl Copolymer of glycolide and caprolate Monofilament 7–14 days Subcutaneous
Polyglactin 910 Vicryl Copolymer of lactide and glycotide Braided 21–28 days Subcutaneous, Mucosa
Polyglactin 910 Vicyrl Rapide Glycolide and lactide copolymer Braided 5–7 days Skin, mucosa
Polyglactin 910 Vicryl Plus Glycolide and lactide copolymer with Braided 21–28 days Subcutaneous
plus antibacterial antibacterial coating
Table 1–2. Nonabsorbable Sutures
Strength
Suture Brand Name Composition Filament Retention Uses
Natural
Silk Fibrin protein strands spun and braided, Braided 1 year Dry portion of lips, mucosa
wax coated
Synthetic
11
Nylon Synthetic Polyamide Monofilament 5 years Skin closure
Braided Deep tissue closure
Polyester Mersilene Polyethylene terephalate Braided 1 year Deep tissue closure
Ethibond Polyethylene terephalate coated with Braided 1 year Deep tissue closure
polybutylate
Polypropylene Prolene Polypropylene Monofilament 1 year Long-term deep tissue
closure, vascular repair
Table 1–3. Suture Size and Tissue Location

Cutaneous Subcutaneous/
Tissue Sutures Fascial Sutures
Eyelid and periorbital 6-0, 7-0 4-0, 5-0
Nose 5-0, 6-0 4-0, 5-0
Pinna 5-0, 6-0 4-0, 5-0
Lips and vermillion 5-0, 6-0 3-0, 4-0
Nasal and oral mucosa 3-0, 4-0 3-0, 4-0
General facial and neck 4-0, 5-0, 6-0 3-0, 4-0
Scalp 3-0, 4-0 2-0, 3-0
Musculocutaneous flaps 4-0, 5-0 2-0, 3-0
Suture Needles
Standard Needle Elements
• Point: tip of needle until full diameter
• Body: majority of needle; ends at change in contour of the swage
• Swage: end of needle that attaches to suture
Suture Needle Principles

• Bending strength: ability of needle to avoid deforming when passing
through tissue
• Ductility: capacity to be deformed without breaking
• Taper ratio: length-to-width ratio used as a measure of needle point
sharpness
Suture Needle Types and Applications

• Refer to Tables 1–4 and 1–5

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NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

Names: Desai, Shaun C., editor.

Part I Facial Plastics Essentials 1

Chapter 1 Instrumentation and Tissue Handling 3

Chapter 2 Skin Anatomy and Wound Healing 15

Chapter 3 Facial Analysis 25

Chapter 5 Alloplastic Implants and Genioplasty 41

Chapter 6 Ethics in Facial Plastic Surgery 53

Part II Facial Nerve 61

Chapter 7 Facial Nerve Anatomy 63

Chapter 8 Evaluation and Management of Acute Facial 71

Chapter 9 Facial Reanimation 79

Part III Oculoplastic Surgery 93

Chapter 10 Brow Lift 95

Chapter 11 Upper Eyelid Blepharoplasty 105

Chapter 12 Lower Eyelid Blepharoplasty 115

Chapter 13 Asian Blepharoplasty 127

Chapter 14 Ptosis 135

Chapter 15 Mohs and Eyelid Reconstruction 141

Part IV Aging Face 151

Chapter 16 Anatomy and Physiology of Aging 153

Chapter 17 Rhytidectomy 163

Chapter 18 Management of the Midface 175

Chapter 19 Liposuction and Fat Transfer 181

Chapter 20 Skin Rejuvenation: Lasers, Peels, and Dermabrasion 187

Chapter 21 Injectables for Rejuvenation 197

Part V Rhinoplasty 207

Chapter 22 Nasal Anatomy, Analysis, and Approaches 209

Chapter 23 Functional Nasal Airway 225

Chapter 24 Rhinoplasty: Upper Vault and Middle Vault 239

Chapter 25 Tip Rhinoplasty 247

Chapter 26 Revision Rhinoplasty and Complications 263

Chapter 27 Non-Caucasian Rhinoplasty 273

Part VI Hair Replacement 285

Chapter 28 Alopecia 287

Chapter 29 Hair Transplantation 293

Chapter 30 Regional Scalp Flaps and Tissue Expansion in 297

Part VII Trauma 307

Chapter 31 Acute Soft Tissue Injury 309

Chapter 32 Principles of Plating and Bone Healing 323

Chapter 33 Mandible Trauma 331

Chapter 34 Midface and Pan-Facial Fractures 339

Chapter 35 Orbit, Naso-Orbitoethmoid, and Nasal Fractures 347

Chapter 36 Frontal Sinus Fractures 357

Part VIII Scar Revision and Reconstructive Ladder 363

Chapter 37 Scar Revision 365

Chapter 38 Skin, Dermal, Cartilage, Composite, and 379

Chapter 39 Primary and Local Flaps 387

Chapter 40 Regional Flaps 403

Chapter 41 Free Tissue Transfer 415

Part IX Head and Neck Neoplasms 427

Chapter 42 Benign Skin Lesions 429

Chapter 43 Cutaneous Squamous Cell and Basal Cell 437

Chapter 44 Melanoma 449

Chapter 45 Rare Skin Malignancies and Syndromes 459

Part X Pediatric and Craniofacial Surgery 463

Chapter 46 Cleft Lip 465

Chapter 47 Cleft Palate 481