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The Art of Aesthetic Surgery
Principles and Techniques

Third Edition

Editor

Foad Nahai, MD, FACS, FRCS (Hon)

Professor of Surgery
The Maurice J. Jurkiewicz Endowed Chair in Plastic Surgery
Department of Surgery
Emory University
Atlanta, Georgia, USA

Associate Editor

Farzad R. Nahai, MD
Board Certified Plastic Surgeon
The Center for Plastic Surgery at MetroDerm
Atlanta, Georgia, USA

Section Editors

John G. Hunter, MD, MMM, FACS .

Chief, Division of Plastic Surgery Professor and Chair
Associate Chief and Director of Clinical Operations, Department of Plastic Surgery
Department of Surgery University of Texas Southwestern Medical Center
New York-Presbyterian Brooklyn Methodist Hospital Dallas, Texas, USA
Brooklyn, New York, USA
Attending Plastic Surgeon
New York-Presbyterian Hospital (Weill Cornell Campus)
Professor of Clinical Surgery (Plastic Surgery)
Weill Cornell Medical College
New York, New York, USA

William P. Adams Jr., MD W. Grant Stevens, MD, FACS

Program Director Clinical Professor of Plastic Surgery
University of Texas Southwestern Aesthetic Surgery Fellowship University of Southern California Keck School of Medicine
Associate Professor Director
Dept. of Plastic Surgery Aesthetic Surgery Fellowship
University of Texas Southwestern Marina del Rey, California, USA
University Park, Texas, USA

1653 illustrations

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 To Shahnaz
My best friend and partner of fifty years whose beauty is only surpassed by the loveliness that radiates from within.
ou are an inspiration to us all, and your patience, understanding, sacrifices, and encouragement have made me who I am.
Thank you for enriching my life.

—Foad Nahai, MD, FACS, FRCS (Hon)

 Contents

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Video Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Volume I
Part I Fundamentals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Section Editors: Foad Nahai and Farzad R. Nahai

1 The Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Foad Nahai

2 Psychological Considerations in Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

David B. Sarwer and Jacqueline C. Spitzer

3 Photographic Essentials in Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

, ,

4 Patient Safety in Aesthetic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Christopher A. Tokin, Christodoulos Kaoutzanis, Kent K. “Kye” Higdon, and James C. Grotting

5 Sedation and Anesthesia for Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Aaron M. Kearney, Sergey Y. Turin, and Sammy Sinno

Part II Business Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Section Editor: W. Grant Stevens

6 hy Offer Aesthetic Medicine in an Aesthetic Surgical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Ali A. Qureshi, Renato Saltz, and W. Grant Stevens

7 Optimal Correction and Patient Retention: A Personal Philosophical and Practical Approach to Your
Nonsurgical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
A. Jay Burns

8 The Spa and the Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Michael S. Byrd

9 Social Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Anthony Youn

10 Hiring and Training a Superstar Patient-Care Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Karen A. Zupko

11 Evidence-Based Pricing Strategies That Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Karen A. Zupko

Part III Nonsurgical Cosmetic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

12 Clinical Decision Making for Nonsurgical Cosmetic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

, ,

13 Over-the-Counter Skin Care and Nutraceutical Basics for the Aesthetic Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Mary P. Lupo and Katharine Saussy

14 A Scientific Approach to Cosmeceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Leslie Baumann

15 Botulinum Toxin Injection for Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Sean Michael Devitt and Steven Fagien

vii
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16 Soft-Tissue Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Vic A. Nanurkar

17 Non-Light-Based Skin Resurfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Christodoulos Kaoutzanis, Blair A. Wormer, and Galen Perdikis

18 Chemical Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Richard H. Bensimon and Foad Nahai

19 Lasers and Light-Based Devices in Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

Noelani E. González and David J. Goldberg

20 Sclerotherapy and Laser Vein Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206

Gilly Munavalli, Mitchel P. Goldman, and Robert A. Weiss

21 Nonsurgical Treatment of the Face and Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Michael P. Ogilvie and Julius W. Few Jr.

Part IV Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

22 Applied Anatomy in Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243

Alfonso Barrera

23 Clinical Decision Making in Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

Alfonso Barrera

24 Hair Transplantation: Follicular Unit Micrografting and Minigrafting—Current Techniques and Future Directions . . . . . 259
Alfonso Barrera

25 Reoperation, Refinement, and Treatment of Complications after Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Jack Fisher

Part V Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Section Editors: Foad Nahai and Farzad R. Nahai

26 Clinical Decision Making in Brow Lift: Brow Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283

Foad Nahai

27 Temporal Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Foad Nahai

28 Endoscopic Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .298

Foad Nahai

29 Endoscopic Brow Lift: My Personal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

H. Devon Graham III

30 Other Approaches to Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

Foad Nahai

Part VI Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Section Editors: Foad Nahai and Farzad R. Nahai

31 Eyelid and Periorbital Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .343

Amy Patel and Guy G. Massry

32 Clinical Decision Making in Aesthetic Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Foad Nahai

33 Upper Eyelid Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

Ted Wojno

34 Upper Blepharoplasty in the Asian Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

H. Joon Kim

35 Ptosis Surgery in the Blepharoplasty Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397

Ted Wojno

viii
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36 Lower Eyelid Blepharoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410

Mark A. Codner and Juan Diego Mejia

37 Transconjunctival Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425

Foad Nahai

38 The Lower Eyelid Pinch Blepharoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

fi

39 Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458

Ted Wojno

Volume II
Part VII Midface Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Section Editors: Foad Nahai and Farzad R. Nahai

40 Clinical Decision Making in the Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Foad Nahai

41 Midface Recontouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

Patrick Tonnard, Alexis Verpaele, and Adriana Cely

42 Endoscopic Rejuvenation of the Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505

Renato Saltz, Gabriele Miotto, and Carlos Casagrande

Part VIII Surgical Rejuvenation of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517

Section Editors: Foad Nahai and Farzad R. Nahai

43 Clinical Anatomy of the Face and Neck: Visualizing the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Joel E. Pessa and Foad Nahai

44 Clinical Decision Making in Facelift and Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Foad Nahai

45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Michael J. Cammarata and Sydney R. Coleman

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573

Patrick Tonnard, Alexis Verpaele, and Igor Pellegatta

47 Short-Scar Rhytidectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .594

Daniel C. Baker

48 Extended SMAS Technique in Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

James M. Stuzin

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline . . . . . . . . . . . . . . . . . . . . . . . . . . . .634
Timothy Marten and Dino Elyassnia

50 Simultaneous Facelift and Facial Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687

Timothy Marten and Dino Elyassnia

51 Facial Implant Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .725

Imran Ratanshi and Michael J. Yaremchuk

52 Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749

Foad Nahai

53 Secondary Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771

Timothy Marten and Dino Elyassnia

54 Reoperative Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817

James C. Grotting, Nirav B. Patel, and William J. Vinyard

55 Avoidance and Management of Complications in Facial Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .844

Foad Nahai

ix
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Part IX Rejuvenation of the Cheeks, Chin, Lips, and Ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861

Section Editors: Foad Nahai and Farzad R. Nahai

56 Rejuvenation of the Aging Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .863

Christopher D. Knotts, Byron D. Poindexter, Robert K. Sigal, and George Weston

57 Refinements in Otoplasty Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871

Kayvan Shokrollahi and Jamie Barnes

58 Rejuvenation of the Chin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .882

Stephen E. Metzinger, Salvatore Lettieri, and Aldo B. Guerra

Part X Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895

Section Editor: Farzad R. Nahai

59 Applied Anatomy of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897

Rod J. Rohrich, Paul N. Afrooz, William P. Adams Jr., and Joel E. Pessa (Dedicated to the memory of Jack P. Gunter)

60 Clinical Decision Making in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .905

Farzad R. Nahai

61 Primary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913

Paul N. Afrooz and Rod J. Rohrich

62 Tip Grafting for Nasal Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953

63 Asian Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970

, ,

64 Ethnic Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .983

Ashkan Ghavami and Sean Y. Saadat

65 Revision Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1002

, ,

Volume III
Part XI Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Section Editor: William P. Adams Jr.

66 Applied Anatomy of the Breast. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1023

Kristin A. Boehm and Foad Nahai

67 The Process of Breast Augmentation: Optimizing Clinical Decisions and Outcomes in Breast Augmentation . . . . .1036
William P. Adams Jr. and Foad Nahai

68 Choosing the Right Breast Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1041

David A. Sieber

69 Breast Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1051

Patrick Mallucci

70 Fat Grafting of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1066

Emmanuel Delay and Andreea Carmen Meruta

71 Composite Primary and Revision Breast Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1084

, ,

72 Capsular Contracture: Current Science, Prevention, and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1098

Nicholas Lahar, Jason Roostaeian, and William P. Adams Jr.

73 Primary and Revision Augmentation Mastopexy: Techniques and Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1106

Robert Cohen

74 Clinical Decision Making in Breast Reduction and Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134

Foad Nahai

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 Contents

75 Medial Pedicle Vertical Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1152

Elizabeth J. Hall-Findlay

76 Breast Reduction: The Lateral Pedicle Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1182

Moustapha Hamdi

77 Short-Scar Mammaplasty with a Pectoralis Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195

Ruth Graf, Maria Cecília Closs Ono, and Thomas M. Biggs

78 Alternative Approaches to Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1209

, , ,

79 Control and Precision in Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1235

James C. Grotting and Stephen M. Chen

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1258

J. Peter Rubin and Jonathan Toy

81 Management of Breast Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274

Glyn Jones

82 Treatment of Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1284

Alfredo Hoyos and David E. Guarin

Part XII Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291

83 Applied Anatomy in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1293

Alfredo Hoyos and Mauricio Perez

84 Clinical Decision Making in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1316

85 Noninvasive and Minimally Invasive Techniques for Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1327

Lawrence S. Bass, Jason N. Pozner, and Barry E. DiBernardo

86 Liposuction and High Definition Liposculpture: Basic Techniques and Safety Considerations . . . . . . . . . . . . . . . . . . .1341
Alfredo Hoyos and Mauricio Perez

87 Screening and Safety Issues in the Massive-Weight-Loss Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1361

Christopher K. Patronella, Stephanie Nemir, and Olivier A. Deigni

88 Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1372
Sepehr Egrari

89 Decision Making in Upper Back Contouring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1387

Joseph P. Hunstad and Alexandra C. Schmidt

90 Body Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1396

91 Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1409
Dennis C. Hammond and Jonathan Nathan

92 Gluteal Augmentation with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1444

Ashkan Ghavami and Vicky Kang

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . .1461

94 Aesthetic Abdominal Surgery in Men: BodyBanking with Autologous Fat Contouring and Silicone Six-Pack
Implant Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1474
Jordan D. Frey and Douglas S. Steinbrech

95 Male Massive-Weight-Loss Chest Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1483

96 Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1490

xi
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Part XIII Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1499

Section Editor: John G. Hunter

97 Applied Anatomy in Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1501

Franziska Huettner and John G. Hunter

98 Clinical Decision Making in Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1506

John G. Hunter

99 Surgical and Nonsurgical Female Genital Rejuvenation: Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction: Part 1—Patient Selection and Preoperative
Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1509
Christine A. Hamori

100 Surgical and Nonsurgical Female Genital Rejuvenation: Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction: Part 2—Psychological Considerations and Patient
Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1518
Gemma Sharp

101 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 1—Labia Minora Reduction Surgery Using
Edge Excision Techniques and Nonwedge Flap Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1523
Ryan E. Austin, Frank Lista, and Jamil Ahmad

102 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2—Central Wedge Labiaplasty and Clitoral
Hood Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1536
Gary J. Alter

103 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 3—Surgical Alteration of the Clitoral Hood . . . . . .1544
Carlo M. Oranges

104 Surgical Alteration of the Labia Majora and Mons Pubis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1550
John G. Hunter and Yhelda Felicio

105 Vaginal Rejuvenation and Perineoplasty, Surgical Alteration and Minimally Invasive Procedures: Part 1—
Vaginal Rejuvenation and Perineoplasty, Surgical Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1558
John R. Miklos and Robert D. Moore

106 Vaginal Rejuvenation and Perineoplasty, Surgical Alteration and Minimally Invasive Procedures: Part 2—
Vaginal Tightening, Surgical and Nonsurgical Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1572
Lina Triana

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1579
Michael P. Goodman

108 Female Genital Rejuvenation: Labia Minora Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1589

Michael P. Goodman

r Gender-Affirming Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1605

Section Editor: John G. Hunter

109 Clinical Decision Making for Gender-Affirming Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1607

Wilmina N. Landford, Paula M. Neira, and Devin O’Brien Coon

110 Gender-Affirming Surgery: Patient Selection and Preoperative Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1615

Ara A. Salibian, Steven Lamm, and Rachel Bluebond-Langner

111 Gender-Affirming Surgery: Facial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1620

Ara A. Salibian and Rachel Bluebond-Langner

112 Gender-Affirming Surgery: Top Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1623

Tareq Ammari, Emily Sluiter, Katherine Gast, and William M. Kuzon Jr.

113 Gender-Affirming Surgery: Genital Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1637

David M. Whitehead and Loren S. Schechter

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-1

xii

Preface
It has been almost twenty years since my good friend
and mentor John Bostwick, then chief of plastic surgery
at Emory, and Karen Berger, another good friend who,
at the time, was the CEO of Quality Medical Publishing,
encouraged me to undertake the task of editing a text-
book on aesthetic surgery. Their input and advice led to
the publication of the first edition of The Art of Aesthetic
Surgery in 2005. Six years later, in 2011, the second edition
was published. The first two editions were an immense
undertaking for me, but also rewarding and educational.
Both editions were written to address the enormous
demand for and interest in cosmetic surgery and the
need for comprehensive information on that topic. I had
not anticipated the warm reception both editions would
receive from colleagues throughout the world, and I have
been delighted, humbled, and gratified to witness its
continued popularity and enthusiastic readership. Recent
translations into Chinese, Korean, and Russian attest to the
ongoing global need for education in aesthetic surgery. I
never imagined, twenty years ago, that today I would be
writing the preface for a third edition.
hy a third edition Surely twice was enough for a project
of this magnitude. The answer is obvious: this is a dynamic
field continuing its rapid and significant growth, with
numerous, exciting new developments. Interest in this topic
has not abated over the years; in fact, it has grown stronger
and more vibrant. While many of the procedures touted
nine years ago are still being performed, others have been
replaced by new, less-invasive approaches or techniques that
emphasize volume replacement to enhance rejuvenation
procedures. Furthermore, new technology, noninvasive tech-
niques, and a number of new devices, fillers, and products
have enhanced our ability to provide our patients a broader
spectrum of options and improved outcomes. Clearly, after
nine years there was a need for a revision of the book to
reflect these dramatic and ongoing changes.
Today, nonsurgical cosmetic treatments, such as
injectables, continue to gain in popularity, whereas the
decline we had seen in some surgical approaches to facial
rejuvenation seems to be reversing. Nowhere is this change
more dramatic than in the area of brow rejuvenation.
Another important trend has been the emphasis on volume
enhancement in periorbital and facial rejuvenation, as well
as surgery of the breast. In keeping with these trends, we
have increased coverage of nonsurgical treatments and
injectables and have added new sections and chapters
dealing with volume and its role in facial rejuvenation and
the role of fat grafting in breast surgery.
In contrast to the reduction in the number of invasive
surgical procedures for facial rejuvenation being performed
today, there has been a dramatic increase in breast and
body-contouring procedures, in normal-weight patients,
and in individuals who have lost massive amounts of weight.
Accompanying this burgeoning interest and demand have
been advances, the development of new procedures,
Preface
and refinements of existing techniques. In keeping with
advances and demand for genital rejuvenation, we have
expanded that section and added a new section on gen-
der-affirming surgery.
I did not approach the task of this revision lightly. As
with the first two editions, it involved many late nights
and weekends spent writing and editing. A busy practice,
numerous academic and societal commitments, a journal
editorship, and an effort to bring more balance into my own
life were all forces working against such an undertaking.
Why, then, did I feel this was the right time to take on the
responsibilities and make the time commitment for editing
a third edition Obviously, there was more than one reason.
My commitment to learning and teaching was a primary
motivator. From my earliest writings on muscle and mus-
culocutaneous flaps, to the editing of two editions of this
three-volume work on aesthetic surgery, I have always felt
an obligation to contribute to the literature and to help
advance our specialty. This book represents a continuation
of my lifelong dedication to this process. It has been a
wonderful way to reach out to young and experienced sur-
geons alike and to offer them insight into the remarkable
contributions made by leading experts worldwide. During
academic travels and interactions with plastic surgeons and
trainees all over the world, I have witnessed their interest
in aesthetic surgery and their desire to master the basics
of aesthetic surgery and learn about the latest techniques.
This new edition has been written to address that need and
to provide information on current advances that emphasize
safe and best practices to all aesthetic surgeons.
Recognizing my many commitments and the increasing
scope of the specialty led to the decision to invite others
to assist me; namely, my son, Farzad Nahai as coeditor and
section editor; Dr. effrey enkel and Dr. ohn Hunter as
section editors, with each responsible for two sections; and
Dr. William Adams and Grant Stevens as section editors. I
felt this would not only lighten my load and speed up the
time to publication but would allow the coeditors to add
their expertise.
Every chapter has been revised with new material added.
Twenty new chapters, reflecting the growth and diversity
of our specialty, have been included. The amount of online
material has also grown, with nineteen operative videos,
fourteen of which are new, included in this edition. The
entire book is also available online for quick and portable
reference. It is with great pleasure that I welcome 105 new
contributors who, along with our previous contributors,
bring valuable insights and considerable expertise to this
new edition. The contributors, drawn from all parts of
the globe, represent several disciplines, including the four
core specialties. These contributors, all of whom have
distinguished themselves as educators and innovators,
have graciously succumbed to my gentle arm-twisting and
that of the section editors to provide us with outstanding
chapters on a diverse range of topics.
xiii
 Preface
The positive feedback we have received on the clinical
decision-making chapters prompted the expansion of exist-
ing chapters and the inclusion of new ones. The additions
reflect the increase in the number of options now available
for each patient. These chapters reflect my own and the
section editors’ daily decision-making process, not only in
the operating room but also in the clinic, where we evaluate
new patients and care for them after the operation.
My personal interest and fascination with human
anatomy dates back to my first year in medical school. I
recall one of my teachers telling the class, “You will learn
anatomy three times and forget it three times.” He went on
to say that unlike other knowledge we would acquire over
the years, anatomy would never change. Of course, he was
right; anatomy does not change. However, it is important
to note that we change, and our understanding of anatomy
evolves and deepens with experience.
Back then, I never imagined that one day as a practicing
plastic surgeon not only would I remember all the anatomy
I learned, but I would also learn intricate details that were
unimaginable then. Little did I know that in some modest
way I would even contribute to that knowledge base. Interest
in anatomic detail as it applies to aesthetic surgery continues
with further clarification of facial anatomy, such as the fat
compartments and more detailed descriptions of anatomy of
the trunk and breast relating to emerging body-contouring
procedures. In keeping with these new findings, all anatomy
chapters have been appropriately updated.
xiv
The topic of patient safety also assumes a more promi-
nent position in this edition, with a major chapter on safety
considerations in aesthetic surgery, as well as specific chap-
ters on problems and complications in different anatomic
regions.
All volumes have been significantly updated with new
information each chapter reflects the latest information
presented by experts responsible for advancing our knowl-
edge in those areas.
As the book progressed from first to third edition, the
cover also changed. The first edition cover with a modern
rendition of The Three Graces was replaced with an even
more contemporary rendition of The Three Graces. The third
edition carries the masters version of The Three Graces.
It is my wish that readers will receive this third edition
with enthusiasm equal to that of the first two editions. I
hope that it will provide a source of new information, stim-
ulate thought, and foster innovation. As with any writing
project, this book has been a major undertaking, but it has
also been a labor of love. I have learned as much as I have
taught, and I continue to marvel at the outstanding work
being done by my colleagues around the world. I am grat-
ified to be able to share our learning and work with you in
these pages. My goal for this book is to provide trainees, as
well as experienced practitioners, with a solid foundation
for learning basic principles and techniques in aesthetic
surgery in order to enable them to build on it and advance
this specialty that we all love.
Foad Nahai, MD, FACS, FRCS (Hon)

Acknowledgments
This book is intended to serve as a testament to all the
surgical pioneers who laid the foundation for modern aes-
thetic surgery, as well as a tribute to current contributors
worldwide whose ingenuity and skill are paving the way for
future developments. While acknowledging my mentors,
I also credit the young surgeons in whose training I have
been privileged to participate. Their enthusiasm and quest
for knowledge continues to stimulate me.
This work would never have been completed with-
out the support and encouragement of my family, my
partners, those with whom I work on a daily basis at
the Emory Aesthetic Center, and my friends at Thieme
Publishers. I would be remiss if I didn’t mention all of
them by name.
My wife, Shahnaz, has been a support and a part of my
professional life for fifty years. She, more than anyone,
has put up with my unusual hours and weekends away
from home. My son, Farzad, now associate editor of
this work, and my daughter, Fariba, have always been
interested in what I do and have encouraged me in my
efforts. My partners at the Emory Aesthetic Center Grant
Carson—Bert Losken, Monte Eaves, Gabi Miotto, and
Vince Zubowicz—provided encouragement, advice, and
most of all, support in looking after my patients while I
was working on the book. Trina Walker, my patient care
coordinator, has been my right hand for her hard work
and support.
It is an honor for me to be included in the third edition of
The Art of Aesthetic Surgery, for so long referred to by me
as “dad’s book.” When my father approached me to assist
with the organization, writing, and editing of this book, I
was thrilled—thrilled for the opportunity to contribute to
the project in a meaningful way, but especially to have the
chance to share this experience with him, working closely
together to learn the ins and out of putting together a book
like this one. It has been a joy for us to collaborate, so I am
most grateful to my father for inviting me to be a part of
this project and for his continued guidance, mentorship,
patience, and leadership. As special as it is for him to share
a passion for plastic surgery with me and work together on
the common goal of publishing this third edition, it is an
equally special experience for me.
The support of my wife Dana and my children Marcelle
and Andre has also been important. I especially appreciate
their understanding when I have needed to leave the house
in the morning before they are awake to work on the book
before my clinical day starts.
I would like to also recognize my mentors and their
influence on me as a surgeon. The influence of my
Acknowledgments
Farzad Nahai, in addition to his role as section editor,
worked diligently, capably assisting me with all aspects of
putting this work together. The section editors—W. Grant
Stevens, effrey M. enkel, illiam P. Adams, and ohn G.
Hunter—all lightened my load and assured that this publi-
cation would be the best possible.
I am indebted to all at Thieme, notably my friend and
adviser Sue Hodgson, who demonstrated her profession-
alism and talent as an editor in her willingness to work
and rework with me until we both felt we had a superb,
scholarly, and “aesthetically” appealing product. Judith
Tomat not only encouraged but also managed to corral all
the contributors and section editors (and the editor as well)
into submitting their manuscripts and videos in a some-
what timely manner. Sarah Landis provided the follow-up
to process content for publication, gathering missing ele-
ments and keeping all aspects of the book in order and on
target. Illustrators Brenda L. Bunch, Amanda Behr, Graeme
Chambers, Amanda Tomasikiewicz, and Bill Winn provided
quality images to accompany the text.
I acknowledge the outstanding contributors to the book,
not only the original contributors who updated and in
some cases totally rewrote their chapters, but also the new
authors whose contributions have filled in any deficiencies
that may have existed in the second edition. I am most
grateful to them for so generously and readily sharing their
expertise with us.
Foad Nahai, MD, FACS, FRCS (Hon)
dad on my career as a surgeon is immense and goes
beyond the scope of this note to fully recount and detail.
Stephen Mathes, whom I’ve been fortunate to know
since I was a kid, was my chief during residency. He
taught me the value of hard work and commitment to
the patient. He was taken from us too soon, but I feel
so fortunate to have had the time with him that I did.
Bill Hoffman (who coauthored the photography chapter
with me) was a big influence on me during my time as
a resident. To this day I recall and still abide by many
of his wise practices and anecdotes. David Young, Keith
Denkler, Lorne Rosenfield, and Gil Gradinger were also
major influences during my training and remain dear to
me to this day.
I must make a special mention with regard to Ron
Gruber. Ron was kind enough to allow residents who were
interested in rhinoplasty to spend time with him in his
private practice. I went to his office quite often, and Ron
was always very welcoming and eager to teach me about
rhinoplasty. Much of what I know about rhinoplasty
and the success of my rhinoplasty practice I owe to Ron.
Much of my chapter on rhinoplasty and my approach to
xv
 Acknowledgments
rhinoplasty is based on his mentorship and the approach
he taught me. Without Ron’s gracious time and teaching,
I would probably not be the rhinoplasty surgeon I am
today.
I would also like to mention my staff and partners at The
Center for Plastic Surgery at MetroDerm, who supported
Thank you to Suzanne, Matthew, and Ashley for the many
sacrifices you have made to allow me to pursue my profes-
sional dreams. Your boundless support continues to be the
backbone of my successes.
Thank you to the students, residents, and fellows who
have allowed me the privilege of teaching. You have driven
I thank Foad ahai, MD, for conceiving of and first pub-
lishing in 2005 this internationally and critically regarded
masterpiece in aesthetic plastic surgery. The impact of the
initial text on the aesthetic surgery community, as well
as its second edition in 2011, cannot be overstated. I am
honored and humbled to be included by Dr. Nahai as a
coeditor for this Third Edition, entrusted with the devel-
opment of two new sections: female genital rejuvenation
surgery and gender affirming surgery. Both additions
I would like to acknowledge Dr. Foad Nahai and all of the
section editors for their tireless work in completing this
edition of The Art of Aesthetic Surgery. I would also like to
xvi
me in my clinical practice to where I could take the time
needed to work on this book.
Lastly, none of this would be possible without the
excellent team at Thieme, especially Judith Tomat and Sue
Hodgson, who both put in a lot of time and hard work to
help make this third edition become a reality.
Farzad R. Nahai, MD
me to pursue excellence and allowed me to be a small part
of your accomplishments.
To my patients, I am indebted to each of you for allowing
me to care for you. It has been my pleasure and honor to
do so.
reflect remarkable changes in aesthetic surgery that have
occurred since publication of the second edition and illus-
trate just how state-of-the-art The Art of Aesthetic Surgery
has been and continues to be.
I also thank my chapter coauthors and all the authors
who generously contributed chapters to both sections that
I edited. I also offer very special thanks to Ms. udith Tomat
of Thieme Medical Publishers for her constant assistance,
support, and positivity throughout the editorial process.
John G. Hunter, MD, MMM, FACS
thank all of the authors who contributed to this landmark
aesthetic surgery and medicine textbook.
W. Grant Stevens, MD, FACS
I acknowledge all surgeons who rise above the noise and
seek to truly move the needle with advancement of the art
and science of breast surgery.
William P. Adams Jr., MD
 Contributors

Contributors

William P. Adams Jr., MD Leslie Baumann, MD

Program Director CEO Skin Type Solutions
University of Texas Southwestern Aesthetic Surgery Miami, Florida, USA
Fellowship
Associate Professor Omar E. Beidas, MD
Dept. of Plastic Surgery Plastic Surgeon
University of Texas Southwestern Orlando Health Aesthetic and Reconstructive Surgery Institute
University Park, Texas Orlando, Florida, USA

. C
Plastic Surgery Founder and CEO
Private Practice Bengtson Center for Aesthetics and Plastic Surgery
Miami, Florida, USA Co-Founder, Plastic Surgery Imaging, LLC
Grand Rapids, Michigan, USA
Jamil Ahmad, MD, FRCSC
Director of Research and Education Richard H. Bensimon, MD
The Plastic Surgery Clinic Private Practice
Mississauga, Ontario, Canada Portland, Oregon, USA

. .
Assistant Clinical Professor of Plastic Surgery Clinical Professor of Plastic Surgery
University of California School of Medicine Baylor College of Medicine
Los Angeles, California, USA ICON, American Association of Plastic Surgeons
Houston, Texas, USA
Tareq Ammari, MBBS, BSc (Hons), MRCSed
Specialty Doctor in Plastic Surgery
Laura and Isaac Perlmutter Associate Professor of Plastic
Department of Plastic Surgery
Surgery
National Health Service
Hansjörg Wyss Department of Plastic Surgery
United Kingdom
New York University Langone Health
Ann Arbor, Michigan, USA
New York, New York, USA
E. C C
. C
Plastic Surgeon
Plastic Surgeon
The Plastic Surgery Clinic
Private Practice
Mississauga, Ontario, Canada
Premier Image Cosmetic and Laser Surgery
Atlanta, Georgia, USA
C.
New York, New York, USA
. C
Medical Director
Jamie Barnes, MBChB, MRes, MRCS, FRCS (Plast)
EpiCenter Skin Care and Laser Center
Specialty Registrar in Burns and Plastic Surgery
Dallas Medical Skin Solutions
Whiston Hospital
Dallas, Texas, USA
Liverpool, United Kingdom
. E .
C Byrd Adatto, PLLC
Clinical Assistant Professor Dallas, Texas, USA
Department of Plastic Surgery
Baylor College of Medicine Michael J. Cammarata, BS
Houston, Texas, USA University of California–San Francisco
San Francisco, California, USA
. C
Clinical Assistant Professor Genevieve F. Caron, MD, FRCSC
Department of Plastic Surgery Plastic Surgeon
Zucker School of Medicine at Hofstra/Northwell Department of Plastic Surgery
New York, New York, USA CIUSS Est-de-l’Ile-de-Montreal
Montreal, Quebec, Canada

xvii
 Contributors

C C .
Director, Plastic Surgeon Plastic Surgeon
Casagrande Clinic Private Practice
Florianópolis, Brazil Deigni Plastic Surgery
Houston, Texas, USA
C
Plastic Surgeon E
Department of Aesthetic Plastic Surgery Plastic Surgeon
The Carolina Clinic Lyon, France
Bogotá DC, Colombia
Sean Michael Devitt, MD
Stephen M. Chen, MD Plastic and Reconstructive Surgeon
Private Practice University of Texas Southwestern
Richmond Plastic Surgeons Dallas, Texas, USA
Richmond, Virginia, USA
E.
C Plastic Surgeon
Plastic Surgeon Medical Director
Twin Cities Cosmetic Surgery New Jersey Plastic Surgery
Minneapolis, Minnesota, USA Montclair, New Jersey, USA

.C E C
Private Practice Medical Director
Plastic Surgeon Egrari Plastic Surgery Center
Northshore Plastic Surgery Bellevue, Washington, USA
Mandeville, Louisiana, USA
E C
.C C Marten Clinic of Plastic Surgery
Clinical Assistant Professor of Plastic Surgery San Francisco, California, USA
Department of Surgery
Emory University C
Atlanta, Georgia, USA Private Practice
Cosmetic Oculoplastic Surgery
Robert Cohen, MD, FACS Boca Raton, Florida, USA
Medical Director
Scottsdale Center for Plastic Surgery Yhelda Felicio, MD
Paradise Valley, Arizona, USA Department of Plastic Surgery
Health Secretary of the Ceará State of Brasil
.C Plastic Surgery Service
Clinical Assistant Professor Fortaleza, Ceará, Brazil
Department of Plastic Surgery
University of Pittsburgh Medical Center . .
Pittsburgh, Pennsylvania, USA Director
The Few Institute for Aesthetic Plastic Surgery
Devin O’Brien Coon, MD, MSE Clinical Professor
Assistant Professor of Plastic Surgery and Biomedical University of Chicago Pritzker School of Medicine
Engineering Plastic Surgery
Johns Hopkins University Chicago, Illinois, USA
Baltimore, Maryland, USA

C C Associate Clinical Professor

Specialist Plastic Surgeon Department of Plastic Surgery
Geelong, Victoria, Australia Vanderbilt University
Nashville, Tennessee, USA
Robert T. Cristel, MD
Department of Otolaryngology–Head and Neck Surgery .
Division of Facial Plastic and Reconstructive Surgery Hansjörg Wyss Department of Plastic Surgery
University of Illinois–Chicago New York University Langone Health
Chicago, Illinois, USA New York, New York, USA

xviii
 Contributors

David E. Guarin, MD
Assistant Professor of Surgery Plastic Surgeon
Division of Plastic Surgery Department of Plastic Surgery
University of Wisconsin Plastic UV Research Team
Madison, Wisconsin, USA Universidad Del Valle
Cali-Valle del Cauca, Colombia

Assistant Clinical Professor Aldo B. Guerra, MD, FACS

David Geffen UCLA School of Medicine Guerra Plastic Surgery Center
Division of Plastic Surgery Scottsdale, Arizona, USA
Los Angeles, California, USA
Private Practice .
Ghavami Plastic Surgery, LLC Founder of the Gunter Center for Aesthetics and Cosmetic
Beverly Hills, California, USA Surgery
Founder of the Dallas Rhinoplasty Symposium
. Dallas, Texas, USA
Skin Laser and Surgery Specialists of New York/New Jersey
Clinical Professor of Dermatology
Past Director of Mohs Surgery and Laser Research Professor of Plastic Surgery
Icahn School of Medicine at Mount Sinai Department of Plastic Surgery
Clinical Professor of Dermatology University of Pittsburgh
Chief, Dermatologic Surgery Pittsburgh, Pennsylvania, USA
UMDNJ–Rutgers Medical School
Adjunct Professor of Law E . C C
Fordham Law School Private Practice
New York, New York, USA Banff Plastic Surgery
Banff, Alberta, Canada
Mitchel P. Goldman, MD
Volunteer Clinical Professor of Dermatology Moustapha Hamdi, MD, PhD
University of California–San Diego Professor and Head of Plastic Surgery Department.
Medical Director, West Dermatology Brussels University Hospital
San Diego, California, USA Vrij Universiteit Brussel
Brussels, Belgium
Noelani E. González, MD
Instructor, Dermatology Dennis C. Hammond, MD
The Mount Sinai Hospital Partners in Plastic Surgery
New York, New York, USA Associate Program Director
Spectrum Health Integrated Plastic Surgery Residency
Michael P. Goodman, MD Grand Rapids, Michigan, USA
Medical Director
Caring for Women Wellness Center Christine A. Hamori MD
Davis, California, USA Director of the Cosmetic Surgery and Skin Spa
Duxbury, Massachusetts, USA

Professor . C
Department of Plastic Surgery Associate Professor
Universidade Federal do Paraná Program Director
Curitiba, Paraná, Brazil Department of Plastic Surgery
Vanderbilt University Medical Center
H. Devon Graham III, MD Nashville, Tennessee, USA
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery .
Ochsner Medical Center Stephen J. Mathes Endowed Chair
New Orleans, Louisiana, USA Professor and Chief
Division of Plastic and Reconstructive Surgery
C. University of California–San Francisco
Clinical Professor San Francisco, California, USA
Division of Plastic Surgery
University of Alabama–Birmingham
Private Practice Plastic Surgeon
Grotting Plastic Surgery Total Definer Medical
Birmingham, Alabama, USA Bogota, Colombia

xix
 Contributors

C
Plastic Surgeon Department of Plastic Surgery
Lenox Hill Hospital Northwell Health University of Texas Southwestern Medical Center
Manhattan Plastic Surgery Dallas, Texas, USA
New York, New York, USA
C . C
Joseph P. Hunstad, MD, FACS Plastic Surgeon
Associate Clinical Professor The Austin-Weston Center for Cosmetic Surgery
Plastic Surgery Division Reston, Virginia, USA
University of North Carolina–Chapel Hill
North Carolina . .
Director, the American Society for Aesthetic Plastic Surgery Reed O. Dingman Collegiate Professor of Surgery
President, HKB Cosmetic Surgery Center Section of Plastic Surgery
Huntersville, North Carolina, USA University of Michigan
Ann Arbor, Michigan, USA
John G. Hunter, MD, MMM, FACS
Chief, Division of Plastic Surgery
Nicholas Lahar, MD
Associate Chief and Director of Clinical Operations,
Plastic and Reconstructive Surgery
Department of Surgery
Lahar Plastic Surgery
New York-Presbyterian Brooklyn Methodist Hospital
Beverly Hills, California, USA
Brooklyn, New York, USA
Attending Plastic Surgeon
Don Lalonde, MD, FRCSC
New York-Presbyterian Hospital (Weill Cornell Campus)
Professor, Surgery
Professor of Clinical Surgery (Plastic Surgery)
Dalhousie University
Weill Cornell Medical College
Division of Plastic Surgery
New York, New York
Saint John, Canada
C
Steven Lamm, MD
Illinois Cosmetic and Plastic Surgery
Clinical Professor of Medicine
Professor of Surgery (Plastic a Reconstructive)
Director of the Preston Robert Center for Men’s Health
University of Illinois College of Medicine at Peoria
Department of Medicine
Peoria, Illinois, USA
New York University
New York, New York, USA
Associate Medical Director
Myovant Sciences .
Los Angeles, California, USA Plastic and Reconstructive Surgery
Johns Hopkins Hospital
C Baltimore, Maryland, USA
Assistant Professor, Plastic and Reconstructive Surgery
Department of Surgery Salvatore Lettieri, MD, FACS
University of Colorado, Anschutz Medical Campus Assistant Professor
Aurora, Colorado, USA Division of Plastic Surgery
Mayo Clinic
. Phoenix, Arizona, USA
Division of Plastic Surgery
Northwestern University Walter C. Lin, MD
Chicago, Illinois, USA Attending Surgeon
The Buncke Clinic
. San Francisco, California, USA
Professor and Chair
Department of Plastic Surgery C C
University of Texas Southwestern Medical Center Founder, Medical Director
Dallas, Texas The Plastic Surgery Clinic
Trillium Health Parnters
.
Assistant Professor
Assistant Professor
Division of Plastic and Reconstructive Surgery
Department of Ophthalmology
University of Toronto
Emory Eye Center
Toronto, Ontario, Canada
Atlanta, Georgia, USA

xx
 Contributors

Adi Maisel Lotan, MD Gabriele Miotto, MD, MEd

Department of Plastic and Reconstructive Surgery Assistant Professor
Shaare Zedek Medical Center Division of Plastic and Reconstructive Surgery
Jerusalem, Israel Emory University School of Medicine
Associate Program Director
. Aesthetic Fellowship at Emory Aesthetic Center
Department of Plastic Surgery Atlanta, Georgia, USA
University of Texas Southwestern Medical Center
Dallas, Texas, USA Robert D. Moore, DO, FACOG, FPMRS, FACS
Director, Cosmetic Vaginal Surgery
. Beverly Hills Sunset Surgery Center International, Dubai
Clinical Professor of Dermatology UAE
Tulane Medical School Miklos and Moore Urogynecology and Aesthetic Vaginal
New Orleans, Louisiana, USA Surgery
Atlanta, Georgia; Beverly Hills, California; Dubai, UAE
C C
Malucci London C
London, United Kingdom Medical Director, Founder
Dermatology, Laser, and Vein Specialists of the Carolinas,
C PLLC
Founder and Director Charlotte, North Carolina, USA
Marten Clinic of Plastic Surgery
San Francisco, California, USA Farzad R. Nahai, MD
Board Certified Plastic Surgeon
. The Center for Plastic Surgery at MetroDerm
Beverly Hills Ophthalmic Plastic Surgery Atlanta, Georgia
Beverly Hills, California, USA
Clinical Professor of Ophthalmology Foad Nahai, MD, FACS, FRCS (Hon)
University of Southern California Professor of Surgery
Los Angeles, California, USA The Maurice J. Jurkiewicz Endowed Chair
Department of Surgery
Emory University
Plastic Surgeon Atlanta, Georgia
Private Practice
Medellin, Colombia .
Director and Founder
Andreea Carmen Meruta, MD Bay Area Laser Institute
Surgeon Chairman, Dermatology
Plastic Surgery Department California Pacific Medical Center
Centre Leon Berard San Francisco, California, USA
Lyon, France
Breast Institute Jonathan Nathan, MD, MBA
Monza Hospital Plastic Surgeon
Bucharest, Romania Private Practice
Chicago, Illinois, USA
E. C
Clinical Associate Professor Paula M. Neira, JD, MSN, RN, CEN
Tulane University School of Medicine Clinical Program Director
Department of Surgery Johns Hopkins Center for Transgender Health
Division of Plastic and Reconstructive Surgery Johns Hopkins Medicine
Aesthetic Surgical Associates Baltimore, Maryland, USA
New Orleans, Louisiana, USA
Stephanie Nemir, MD, PhD
. C Assistant Professor and Director of Breast Reconstruction
Director of Urogynecology and Cosmetic Vaginal Surgery Department of Surgery
Miklos and Moore Urogynecology Paul L. Foster School of Medicine
Adjunct Professor of Obstetrics and Gynecology Texas Tech University Health Sciences Center–El Paso
Emory University El Paso, Texas, USA
Atlanta Georgia, USA

xxi
 Contributors

. Joel E. Pessa, MD, FACS

Associate Plastic and Reconstructive Surgeon Clinical Research
Division of Plastic and Reconstructive Surgery Department of Medicine and Oncology
Advocate Christ Medical Center Heldermon Lab
Oak Lawn, Illinois, USA University of Florida School of Medicine
Gainesville, Florida, USA
Maria Cecilia Closs Ono, MD, PhD
Plástica and Craniomaxillofacial Surgeon .
Adjunct Professor Medical Director
University Federal of Paraná The Austin-Weston Center for Cosmetic Surgery
Department of Surgery Reston, Virginia, USA
University Federal of Paraná
Curitiba, Paraná, Brazil Jason N. Pozner, MD, FACS
Sanctuary Plastic Surgery
C . Boca Raton, Florida, USA
Department of Plastic, Reconstructive, Aesthetic, and Hand Adjunct Clinical Faculty
Surgery Cleveland Clinic
Basel University Hospital Department of Plastic Surgery
University of Basel Weston, Florida, USA
Basel, Switzerland
Ali A. Qureshi, MD
Private Practice
Department of Oculoplastics Irvine, California, USA
Cedars-Sinai Medical Center
Los Angeles, California, USA Imran Ratanshi, MD, MSc, FRCSC
Attending Surgeon
Nirav B. Patel, MD, MS, JD, FCLM The Plastic Surgery Group at City Centre
Associate Plastic Surgeon Department of Surgery
Marietta Plastic Surgery Fraser Health Region
Marietta, Georgia, USA Surrey, British Columbia, Canada

C . C Rod J. Rohrich, MD, FACS

Director, The Aesthetic Center for Plastic Surgery Clinical Professor of Plastic Surgery
Houston, Texas, USA Baylor College of Medicine
Clinical Professor of Surgery Past Chair, Distinguished Teaching Professor of Plastic
Division of Plastic Surgery Surgery
University of Texas Medical Branch Dallas, Texas, USA
Galveston, Texas, USA
Jason Roostaeian, MD
I Associate Clinical Professor
Plastic, Reconstructive and Aesthetic Surgeon Department of Plastic Surgery
Private Practice David Geffen School of Medicine at UCLA
Milano, Lombardy, Italy Los Angeles, California, USA

C
Professor and Chair Professor
Department of Plastic Surgery University of California–San Francisco
Vanderbilt University Medical Center Stanford University
Nashville, Tennessee, USA Private Practice
Burlingame, California, USA
Mauricio Perez, MD
Medical Writer and Editor J. Peter Rubin, MD, FACS
Department of Plastic Surgery Chair
Dhara Clinic Department of Plastic Surgery
Bogota, Colombia UPMC Endowed Professor of Plastic Surgery
Professor of Bioengineering
University of Pittsburgh
Pittsburgh, Pennsylvania, USA

xxii
 Contributors

Sean Y. Saadat, MD Gemma Sharp, PhD, MAPS, FCCLP

Plastic Surgeon National Health and Medical Research Council Early Career
Plastic and Reconstructive Surgery Fellow
UCLA Health Head of the Body Image Research Group
Los Angeles, California, USA Clinical Psychologist
Monash Alfred Psychiatry Research Centre
Ara A. Salibian, MD Monash University
Hansjörg Wyss Department of Plastic Surgery Melbourne, Victoria, Australia
New York University Langone Health
New York, New York, USA C C E
LLM, FRCS (Plast)
Renato Saltz, MD, FACS Professor
Adjunct Professor Consultant Burns and Plastic Surgeon
Division of Plastic Surgery Mersey Regional Centre for Burns and Plastic Surgery
University of Utah Whiston Hospital
Salt Lake City, Utah, USA Merseyside, United Kingdom

Sheena Samra, MD David A. Sieber, MD

Surgeon Private Practice
Facial, Plastic, and Reconstructive Surgery San Francisco, California, USA
Lasky Clinic
Beverly Hills, California, USA .
The Austin-Weston Center for Cosmetic Surgery
. Reston, Virginia, USA
Associate Dean for Research
Director, Center for Obesity Research and Education
College of Public Health Private Practice
Temple University Chicago, Illinois, USA
Philadelphia, Pennsylvania, USA
E
Research Associate
Tulane Dermatology Department of Surgery
New Orleans, Louisiana, USA Michigan Medicine
University of Michigan
Loren S. Schechter, MD, FACS
Ann Arbor, Michigan, USA
Plastic Surgeon
Clinical Professor of Surgery
Jacqueline C. Spitzer, MSEd
University of Illinois at Chicago
Senior Project Director
Attending Surgeon
Temple University
Rush University Medical Center
Philadelphia, Pennsylvania, USA
Weiss Memorial Hospital
Morton Grove, Illinois, USA
. C
Founder, New York Institute of Male Plastic Surgery
Co-Founder, Gotham Plastic Surgery
Plastic Surgeon
Attending Surgeon
Scheflan Plastic Surgery
Lenox Hill Hospital
Tel Aviv, Israel
New York, New York, USA
Alexandra C. Schmidt, MD
.
Plastic Surgeo
Facial Plastic and Reconstructive Surgery
Private Practice
St. Louis Facial Plastic Surgery
Blue Water Plastic Surgery Partners
St. Louis, Missouri, USA
Raleigh, North Carolina, USA

xxiii
 Contributors

W. Grant Stevens, MD, FACS Simeon Wall Jr., MD, FACS

Clinical Professor of Plastic Surgery Private Practice
University of Southern California Keck School of Medicine The Wall Center
Director Shreveport, Louisiana, USA
Aesthetic Surgery Fellowship Assistant Clinical Professor
Marina del Rey, California Department of Plastic Surgery
University of Texas Southwestern Medical Center
James M. Stuzin, MD Dallas, Texas, USA
Clinical Professor of Plastic Surgery (Voluntary)
University of Miami School of Medicine Robert A. Weiss, MD
Miami, Florida, USA Assistant Clinical Professor
Department of Medcine, Gastroenterology
C . Mount Sinai Beth Israel
Breast Surgical Oncology New York, New York, USA
Plastic and Reconstructive Surgery
Hawaii Pacific Health
Honolulu, Hawaii, USA Senior Partner
The Austin-Weston Center for Cosmetic Surgery
Reston, Virginia, USA
Medical Director
Coupure Center for Plastic surgery David M. Whitehead, MD, MS
Co-Director, Tonnard and Verpaele Associates Assistant Professor of Surgery
Ghent, Belgium Division of Plastic Surgery
Department of Surgery
Dean M. Toriumi, MD Donald and Barbara Zucker School of Medicine at Hofstra/
Professor Northwell
Department of Otolaryngology Head and Neck Surgery North New Hyde Park, New York, USA
Rush University
Chicago, Illinois, USA
Director, Oculoplastic and Orbital Surgery
C C Department of Ophthalmology
Associate Clinical Professor The Emory Clinic
Division of Plastic Surgery Emory University School of Medicine
University of Alberta Atlanta, Georgia, USA
Edmonton, Alberta, Canada
Blair A. Wormer, MD
Lina Triana, MD Plastic and Reconstructive Surgery
Corpus y Rostrum Surgery Center Novant Health Presbyterian Medical Center
Cali, Colombia Charlotte, North Carolina, USA

. .
Division of Plastic and Reconstructive Surgery Clinical Professor of Surgery
Northwestern University Feinberg School of Medicine Harvard Medical School
Chicago, Illinois, USA Director, Harvard Plastic Surgery Training Program
Chief of Craniofacial Surgery Massachusetts General Hospital
Alexis Verpaele, MD, PhD Boston, Massachusetts, USA
Medical Director
Coupure Center for Plastic surgery C
Co-Director Assistant Professor of Surgery
Tonnard and Verpaele Plastic Surgery Associates Oakland University William Beaumont School of Medicine
Ghent, Belgium Youn Plastic Surgery, PLLC
Troy, Michigan, USA
. C
Medical Director and Founder .
Vinyard Institute of Plastic Surgery, LLC President
Port St. Lucie, Florida, USA Karen Zupko and Associates, Inc.
Medical Management Consulting Firm
Chicago, Illinois, USA

xxiv
 Video Contents

Video Contents

Volume I
.

Video 18.1: Croton Oil Peel

Video 24.1: Advances in Aesthetic and Reconstructive Hair Transplantation

. E

. C

. E E C

. C C

Volume II
.

Volume III
.

Video 75.1: Medial Pedicle Vertical Breast Reduction

. E E

xxv
 Part I
Fundamentals

I

1 The Patient
Foad Nahai
Abstract
First impressions do count. The patient’s interaction with and
impressions of the surgeon’s website, staff, office environment,
and nurses, as well as the surgeon will significantly impact the
choice of surgeon. It is the overall experience that counts. Careful
attention to enhance and facilitate all facets of the patient’s
interaction with the surgeon and staff is essential.
Keywords
office and staff responsibilities, first consultation, patient
experience, patient financial responsibility, preoperative visit,
postoperative visit
1.1 A Well-Informed Patient Is a
Happy Patient
Our patients are bombarded with information about cos-
metic medicine and surgery; it is a pervasive theme in our
youth-oriented society, appearing in print, electronic, broadcast,
and, most prominently, on social media. Although some of the
information obtained from these sources may be helpful, much
of it is self-serving and intended to entice rather than enlighten.
Advertising and social media postings for aesthetic surgery are
calculated to bring patients into the surgeon’s office, often by
promising more than can be delivered while minimizing risks,
complications, and the possibility of unfavorable or suboptimal
results. ebsites and social media devoted to cosmetic medicine
and aesthetic surgery often overload patients with information
promoting one procedure over another. Although the informa-
tion in itself is not detrimental, it can be confusing. Patients may
not have the medical background, experience, or sophistication
to sort through this material to make an informed decision. The
more conflicting the information they receive, the more confus-
ing it becomes, and often the more unrealistic their expecta-
tions. It is the surgeon’s responsibility to educate the patient by
presenting the facts in an unbiased manner. Even then, patients
may not be able to reach a decision and may rely on the surgeon’s
recommendations, trusting his or her knowledge and abilities.
It is this basic concept of trust that is being eroded through
the blatant marketing of aesthetic procedures and materials to
the public. The implication from this promotional activity is that
aesthetic surgeons are mere vendors of a commodity. Having a
breast augmentation is not like buying a bra or other piece of
lingerie, and a facelift is not like purchasing a high-end luxury
automobile, where one shops for the most convenient dealership
or the best discounts. Nothing could be further from the truth.
e are not selling a product; we are providing a service a
service that is personal and customized to each patient, one that
carries risks unlike those encountered at the beauty salon or spa.
This is a high-end service that encompasses the entire patient
1 The Patient
experience. This experience begins with the patient’s initial on
line search and viewing of social media postings and the physi-
cian’s website (Fig. 1.1), leading eventually to a telephone inquiry
or an electronically scheduled appointment. It progresses through
encounters with the receptionist, patient coordinator, nurse, and
surgeon, and culminates in the surgical procedure. The success
of this experience has traditionally been strongly dependent on
the surgeon’s skill, experience, and judgment. Today the surgeon’s
skill in managing social media may well be as important.
ot all surgeons have the same experience, medical knowledge,
training, surgical expertise, or technical ability. The well-informed
patient should choose a surgeon based on trust not on hype,
social media presence, or cost.
Fig. 1.1 Your website is the face of your practice to the world.
1.2 The First Consultation
The decision to seek cosmetic treatments or aesthetic surgery is
usually not spontaneous. Most likely the patient contemplated
this possibility for months, if not years, before looking online
and picking up the phone to make an appointment with a plastic
surgeon. Some patients may have extensively researched the
procedure, the surgeon, and the surgeon’s practice through the
Internet, social media, and, in particular, the surgeon’s website.
Even today, others rely solely on the recommendations of friends
and family. These recommendations are best when based on
personal experience. Satisfied patients are the ideal source of
referrals and are far more valuable than any advertising, pro-
motions, social media presence, or even the best marketing that
money could buy.
The initial consultation does not necessarily begin with the first
phone call to schedule an appointment. Most likely the prospec-
tive patient has already visited the practice’s website, and the first
contact may have been through the website (Fig. 1.1).
3
 I Fundamentals
1.2.1 The First Telephone Contact
The website and the first telephone contact leave a lasting impres-
sion with the patient; if those contacts are unfavorable, the patient
may decide against making an appointment or fail to keep it. Prompt
responses to the patient’s inquiry through the website and proper
telephone etiquette are of utmost importance. The phone should be
answered after a maximum of five rings, and the voice that greets
the caller should be cheerful and inviting, announcing the name
of the practice and the name of the person answering, followed by
How may I help you This greeting should be spoken in a clear,
understandable voice. Such an encounter will leave the caller with
a positive impression. Conversely, an unfavorable impression may
be left when the phone is answered by a programmed voice reeling
off a list of options, each requiring a separate button to be pushed,
until the irritated caller is either disconnected or put in touch with
the appropriate person. This type of impersonal answering system
can alienate potential patients. By the time the annoyed caller
actually reaches a live person, she or he is no longer in any mood
to discuss aesthetic surgery. In any high-end service, immediate
contact with a caring individual is essential.
In most offices, the caller is first connected with the person respon-
sible for scheduling appointments. This person must understand
the importance of flexibility, even for surgeons who are fortunate
enough to have large practices with few immediate openings for new
patients. Impressive as it may sound to inform a patient that there
are no openings because the surgeon is fully booked for 18 months or
longer, in most cases this will only encourage the prospective patient
to look elsewhere. e live in a world where everyone is busy. Most
of our patients value their time as we do and have only specific days
and times when they can afford to miss work for a doctor’s appoint-
ment. This is particularly true for those seeking aesthetic surgery,
who usually do not wish to ask for sick time or announce to their
supervisor that they are going to see a plastic surgeon.
Although we may not always be able to accommodate every
patient’s scheduling needs for every office visit, it is important to
do so for the initial consultation. For this reason, some practices
offer evening and Saturday office hours. Patients should be asked
how soon they would like to schedule the appointment. Then every
effort should be made to schedule the appointment as close to that
date as possible without overcommitting the surgeon, yet leaving
sufficient time for the initial consultation. (In my practice, at least 1
hour is allotted.) Although patients assume that doctors are never
on time, patients still make every effort to arrive as scheduled. It is
a matter of common courtesy, whenever feasible, to see patients at
the appointed time. Obviously, this is not always possible. It is good
practice, however, to notify patients if you are running late, either
before they arrive, if possible, or on their arrival.
The scheduler should record the caller’s name, address, and contact
information. It is also important to inquire about the reason for the
consultation. Some individuals may be reluctant to disclose this infor-
mation to a stranger on the phone. The scheduler should explain that
while patient privacy is of the utmost importance, these questions
are being posed to determine whether the practice offers the proce-
dure that the patient is seeking. It also provides valuable information
for the surgeon to help prepare for the patient’s initial consultation
and to ensure that sufficient time is allotted for that appointment.
Patients seeking removal of a skin lesion may not require as much
time at the initial visit as someone seeking facial rejuvenation.
4
Once the appointment is made, patients are told that a package
will be mailed to them or can be downloaded from the website.
Most practices now offer patients the option of filling out their
initial paperwork online, thus eliminating the need to do so in
the doctor’s waiting room during the initial visit. Some patients
may not want to receive mail, phone calls, faxes, emails, or other
communications that are identified as coming from a plastic sur-
geon’s office. Special care should be taken to cater to these needs.
The scheduler should ask where the patient would like to receive
correspondence from the office. Some thought should be given
to using envelopes and fax cover sheets without any indication
that communications are coming from a plastic surgeon’s office;
envelopes should have a street address without a practice name or
logo. In the interest of patient confidentiality, the scheduler should
also specifically ask patients how they wish to be contacted by the
practice for example, by home, cell, or office phone or by email.
The information package sent from the office should include
general information about the practice; maps and directions, spe-
cific information about the surgeon, including qualifications and
practice philosophy; a letter detailing what will happen during
the initial consultation; and a brochure on the procedure the
patient is seeking. Most, if not all, of this information is probably
already available on the surgeon’s practice website. However, it
is important to remember, even today, that not all patients are
Internet-savvy, and some may prefer a hard copy; therefore the
printed material serves as a reliable resource for all patients
regardless of their technical know-how.
Maps and directions to the surgeon’s office should be sufficiently
detailed to allow patients to locate the office easily. Parking should
be ample and convenient. Any special parking instructions should
be detailed in the information package. Even though a patient is
looking forward to the visit with the plastic surgeon, this initial
consultation is a stressful event; getting lost or frustrated over
finding a parking space will merely add to a patient’s anxiety.
An example of the type of patient letter that is sent with our
practice information package is shown in Fig. 1.2.
1.2.2 Contact with the Receptionist
The patient’s first face-to-face encounter in the surgeon’s office
will be with the receptionist, who should greet the patient and
notify the patient coordinator or nurse of the patient’s arrival. It is
disconcerting for a patient to walk into the surgeon’s office for the
first time only to find that no one is there to greet him or her; even
worse is when two or three staff members are engrossed in con-
versation or occupied on the telephone and the patient is ignored.
It is also essential that we respect the patient’s privacy during
this sign-in process; several points merit particular attention:
• Sign-in lists where the patient signs his or her name under the
name of the previous patient should be avoided.
• The receptionist should sit in an enclosed space, preferably
in a glass-enclosed area, to maintain privacy yet allow the
receptionist to have full view of the waiting room.
• The receptionist or nurse should refrain from loudly announc-
ing the patient’s name in the waiting room.
• Under no circumstances should the patient be greeted with
such words as ou are here to see Dr. ahai about your breast
enlargement

• In most states in the United States and in some other countries,
the practice is required to display a Patient’s Bill of Rights and
the privacy statement.
Once a patient has signed in, he or she should be told when to
expect to be taken to the consultation room to meet with the
patient coordinator. If there is a delay, the patient is given an
estimate of the waiting time, and coffee or a soft drink can be
offered. henever possible, an explanation is provided for the
delay. If the delay is inordinate or unacceptable, the patient is
offered the choice of rescheduling or waiting. Very rarely, if I
am running unacceptably late a half hour or more the fee for
the initial consultation will be waived and the patient’s parking
charges paid as a gesture of goodwill.
1.2.3 Contact with the Nurse or Patient
Coordinator
The patient is then escorted to one of the examination rooms.
In my practice, the nurse meets with the patient first. A history
is taken, and the completed health questionnaire, which the
patient has downloaded from the website or received in the
mailed package sent out before the initial office visit, is reviewed.
An overall personal history questionnaire (Fig. 1.3) and general
intake information sheet (Fig. 1.4) must be filled out.
At this time the patient usually discusses the reason for the
consultation with the nurse. This takes from 10 to 20 minutes,










1 The Patient
depending on the patient, the nurse, and the procedure. I then
review this information before meeting with the patient.
1.2.4 Contact with the Surgeon
I greet the patient, introduce myself, and immediately ask, hat
can I do for you e then discuss the patient’s goals and what
he or she hopes to accomplish through aesthetic surgery. ext
we review the patient’s history, including pertinent information
on general health and specific information concerning previous
aesthetic treatments, procedures, and skin care.
Procedure-specific information is discussed in detail. For exam-
ple, patients desiring eyelid work are asked about any history of
eye problems such as dry eyes, glaucoma, or risk factors for the
latter, such as high blood pressure or family history (Fig. 1.5).
Any woman desiring breast surgery is asked specifically about
her family history of breast disease, including cancer, history of
breast masses and biopsies, mammography, and childbearing
history (Fig. 1.6). If the patient is contemplating liposuction or
body-contouring procedures, we discuss lifestyle, exercise, nutri-
tion, and weight control (Fig. 1.7). For abdominal procedures, we
discuss previous abdominal operations, including liposuction and
hernia surgery. For facial rejuvenation procedures, I ask whether
patients are currently smoking, but I am also interested in their
smoking history that is, whether they have ever smoked, for












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Fig. 1.2 Patient letter. Fig. 1.3 Personal history questionnaire.

5
 I Fundamentals
Fig. 1.4 General intake information.
how long, how heavily, and whether and when they stopped. I
ask about previous aesthetic procedures, including injectable and
noninvasive treatments. I question all patients about a history of
phlebitis or deep venous thrombosis (DVT).
Once the history has been reviewed, I return to the reason for
the consultation. Throughout this consultation, I know that the
patient is assessing me as a person, a physician, and a surgeon.
Clearly, he or she has no way of realistically evaluating my knowl-
edge of aesthetic surgery or my technical abilities. In all likelihood,
patients will base their decisions on my demeanor and how warm,
caring, and attentive I appear my bedside manner. Meanwhile,
I am assessing the patient. Are his or her goals realistic ill I be
able to meet these goals Do I like the individual If we have a
complication, will I be able to maintain patient confidence while
we resolve the problem I am particularly attentive to the patient’s
body language, eye contact, tone of voice, and most of all, his or
her enthusiasm and interest during the consultation. I observe the
patient’s appearance, hairstyle, makeup, clothing, and accessories.
These not only reflect the patient’s tastes but also attention to
detail and how exacting the individual will be as a patient. I am
concerned when an individual who is sloppily dressed and poorly
groomed comes in seeking aesthetic surgery. In a similar manner,
the appearance and grooming of the surgeon leaves an important
impression about the surgeon’s attention to detail and the care
and meticulous surgical technique that he or she offers to each
6
Fig. 1.5 Blepharoplasty questionnaire.
patient. I certainly would be hesitant to let any sloppily dressed or
poorly groomed physician or nurse take care of me
It is not unusual for patients to come in after researching the
procedure on the Internet or on other physicians’ websites. In all
likelihood they have sought consultation elsewhere as well. They
may have been given conflicting advice and information, which
they may or may not share with me. Close to the end of our con-
sultation, I now ask them whether I have told them anything that
they were not aware of or anything that conflicts with information
they may have found or been given elsewhere.
Most patients respond that they were aware of some but not all
of the information that we provided. In my experience, this new
information is almost always related to expected outcomes and
complications. It amazes me that even today I see patients who
have researched breast augmentation on the Internet and have
had consultations elsewhere, but may not be aware that breast
implants are not permanent.
I never pressure patients to make a decision during the initial
visit. In fact, I encourage them to ask questions, take home the
materials we provide, and return for a second visit, which is
complimentary, before making a final decision. However, we
do arrange for our patient coordinator to quote fees and discuss
scheduling during this first visit.
I follow up every new consultation with a personal letter
rather than a form letter, summarizing our discussion and a brief

Fig. 1.6 Breast surgery questionnaire.
description of my recommendations and points that need to be
stressed, such as that shown in Fig. 1.8; I remind patients that
I would be happy to meet with them again before they make a
decision or schedule a procedure.
1.3 Motivation
A well-motivated patient is a happy patient. Understanding
patient motivation is an essential goal of the initial consultation.
uestions probe the reasons for seeking surgery. For whom is
the patient pursuing the operation is it to please someone else
Does the patient think that this will change his or her life The
best patients are those who are seeking surgery for themselves
so they can look and feel better in their own eyes. The best
motivation is self-improvement. ith most patients, I am able to
understand what motivates them after a few minutes. Sometimes
I will ask patients whether they hope that the aesthetic surgery
will change anything in their lives and inquire as to whose idea it
was for them to have this procedure.
Almost always, teenagers seeking rhinoplasty or other aesthetic
procedures suitable for their age are accompanied by a parent. I make
it a point to address the teenagers directly and have them, rather than
the parent, tell me what they would like. I usually tell them that they,
not their parents or their surgeon, will have to live with the result, so
they need to carefully consider what they are requesting. Although I
1 The Patient
Fig. 1.7 Body contouring questionnaire.
will allow the parents to express their opinions, I make it clear to the
patients that they should make the final decision.
Patients often have hidden agendas secret and personal rea-
sons for seeking this procedure. They are reluctant to share this
with the surgeon, the staff, or even their family and friends. These
hidden agendas may include attracting a significant other, seeking
a promotion, or simply responding to a life-altering event. Beware
of this hidden agenda, because even if the procedure yields an
excellent result, these patients will never be happy unless the
requirements of the hidden agenda have been fulfilled.
1.4 When to Say No
ot every person I see is a candidate for a surgical procedure.
I classify noncandidates into six general categories, as follows:
1. Those seeking the procedure before they are ready for it (for exam-
ple, breast augmentation for teenagers, facelifts in women who do
not need them or who will see little difference, or rhinoplasty in
12-year-olds)
2. Those with unrealistic expectations (for example, those patients
who believe that aesthetic surgery will change their lives, save a
marriage, or make them look like swimsuit models or movie stars)
3. Patients on whom I would prefer not to operate (for example,
those who are overly demanding, noncompliant, abusive to
office staff, or aesthetic surgery junkies )
7
 I Fundamentals
Fig. 1.8 Follow-up letter to prospective breast surgery patient.
4. Another surgeon’s unhappy patient who has a reasonable result
but remains extremely critical of the original surgeon
5. Patients who are psychologically unstable
6. Those who are seeking to improve on problem areas or imperfec-
tions that are not readily recognized by others; these individuals
may well have body dysmorphic disorder (BDD)
Patients in group 1 are counseled that it is too early for the pro-
cedure they are seeking. I explain to these patients that I would
like them to be my patients and that I will operate on them at
the appropriate time. A woman seeking a facelift before she is
truly ready will be offered skin care, other ancillary procedures,
and injectables, if appropriate, until she is ready for a surgical
procedure. I explain to teenagers seeking augmentation that it
is best to wait until their breasts have stopped growing. Beyond
that, there are Food and Drug Administration (FDA) restrictions
to consider. I will make an exception for teenagers with signifi-
cant breast asymmetry and promise the 12-year-old that as soon
as her nose is fully grown, we will take care of it.
I explain to patients in group 2 that I do not believe I can
provide them with the result they are looking for or meet their
expectations. I also let them know that I am concerned that they
will be unhappy or displeased with me.
Patients in group 3 require special tact. I tell these demanding
patients that I do not believe that our office will be able to provide
them with the level of service that they are seeking. To the abusive
8
patient I explain that the office staff and I are a team and, because
the patient has already indicated an unwillingness to work with
my office staff, I cannot care for this individual because I will not
work without my colleagues. Finally, to the patient who has an
insatiable desire for plastic surgery, I say, ou have had it all, and
it is too early to have any more.
Dissatisfied or unhappy patients in group 4 are told that they
have had a reasonable result, that they are being unduly tough on
their previous surgeon, and that I doubt I can significantly improve
on what has been done. My major concern is that a patient with
an average result who is trashing the original surgeon will one day
say the same about me, regardless of the result. Any patient who
walks in and unjustifiably claims that they were butchered or
mutilated is an immediate noncandidate.
Group 5 includes psychologically unstable patients whose
instability is not always readily discernible. I advise them to seek
counseling and treatment before considering aesthetic surgery.
In fact, anyone under psychiatric care at the time of consultation,
regardless of my own personal impression of his or her suitability,
is referred back to the psychologist or psychiatrist for clearance
before scheduling. It is not uncommon today to see patients who
are taking antidepressants such as fluoxetine (Prozac) or bupro-
pion ( ellbutrin). This by itself does not disqualify them, as long
as they are stable individuals. Most of the time the antidepressants
have been prescribed by their internist or family physician for mild
depression rather than for any severe psychiatric condition. Most
of these individuals are suitable candidates for aesthetic surgery.
Group 6 individuals may appear normal to the untrained; how-
ever, their insistence that a small blemish or minimal deviation
from the norm is a major deformity that is ruining their lives and
incapacitating them is an indication of BDD. These individuals
should be referred for counseling. Surgical or other procedures on
these patients lead to further dissatisfaction, disappointment, and
anger. Extreme caution should be exercised in handling this group.
I discuss the options available to the patient and make my
recommendations. I explain that I prefer to operate in our ambu-
latory surgical center, which is certified and inspected by the oint
Commission on the Accreditation of Healthcare Organizations
( CAHO, or simply oint Commission) and the state of Georgia. I
tell patients that anesthesia will be provided under the supervi-
sion of a board-certified anesthesiologist and that I personally will
perform the entire operation. I explain that they will be charged
for the consultation that day, and if I operate on them, they will
be expected to prepay for the surgery. All follow-up visits before
and after the operation are included in the charges for the surgery.
I do not discuss specific fees and charges; our patient coordinator
does that. I do, however, explain to patients that I will perform
revisions, if needed, at no additional charge. Although rare, should
a complication necessitate the services of other physicians or hos-
pitalization, those expenses would be the patient’s responsibility.
ears ago, Dr. Gil Gradinger shared with me a letter that he gave to
his patients on this subject. I still use a modified version (Fig. 1.9),
which patients are asked to read and sign before surgery.
However, my no-charge policy for revisions does not always
apply to liposuction patients, who often return seeking revisions
and repeat liposuction after weight gain, thereby obviating the
results of the original procedure. To avoid future misunderstand-
ings, we talk to these patients preoperatively about the impact of
weight gain on long-term liposuction results. Liposuction patients

Fig. 1.9 Agreement concerning fees.
are asked to read and sign an additional form regarding weight gain
and repeat procedures (Fig. 1.10) so that they fully understand that
additional liposuction after a substantial weight gain (10 pounds
or more) will not be considered a revision but a new procedure.
1.5 Surgeon Shopping
Currently the public is being advised to seek two if not more
consultations before selecting a plastic surgeon, so most
patients will see at least one another surgeon before proceeding.
Although a second or third opinion is not unusual today, I would
be wary of patients who have seen numerous plastic surgeons.
Occasionally a patient comes in with an information package and
video images from another practice and a file full of information
and images downloaded from the Internet. Sometimes the
patient tells me that a different procedure was recommended by
others. This in itself is not a red flag to me, but it requires extra
time and discussion. I explain that each surgeon will recommend
an operation that, in his or her hands, comes as close as possible
to the patient’s desired goal. I assure the patient that I have done
the same. The fact that my recommendation differs from that of
the other surgeon (or surgeons) does not necessarily mean that I
am correct and the other surgeons are not; it simply means that
I have recommended a procedure that, in my hands, would give
the patient the best result.
1 The Patient
Fig. 1.10 Agreement concerning liposuction revisions.
I tell patients who have seen other surgeons that they should
not base their choice of physician on price, on who has the fanciest
or sparsest office, or on convenience of location. Rather, the choice
should be based on the overall impression of the physician and
the office staff, rapport with them, and most of all, confidence and
trust. I explain to patients that, even in the best of hands, compli-
cations are possible, and that they should have enough confidence
and trust in the surgeon they choose to allow him or her to handle
any problems through to resolution. Patients often make the
mistake of going to another physician once they have developed a
complication, even though the original surgeon would be equally
capable of dealing with it. These patients often blame themselves
and are convinced that they made the wrong choice. I tell them
that if they choose me, they should have enough confidence to
allow me to handle any complication unless I recommend that
they see someone else.
1.6 Patient Education
I discuss outcomes, risks, and complications with the patient
during the initial consultation. All are informed that all
procedures carry risks and that cosmetic treatments and
aesthetic surgery are no exception. I explain that the risk of
a life-threatening complication is not greater than the risk
of flying and significantly less than that of driving around
9
 I Fundamentals
Atlanta. Once the patient is reassured in terms of general risks,
I address specific risks. All of my patients are told that infection
and bleeding are common risks to all aesthetic procedures but
are extremely rare. I do prepare them for postoperative bruising
and swelling, which may accompany any cosmetic procedure
or aesthetic operation. I explain to all facelift patients that in
my hands the most common complication is hematoma, and the
risk is currently below 1 ; the risk is higher in men, in persons
with uncontrolled high blood pressure, and in anyone who is
troubled by postoperative nausea and vomiting. I tell them
that every precaution will be taken to minimize the risk, but it
cannot be eliminated entirely. I add that the risk of permanent
nerve damage is extremely rare on the order of 1 in 1,000 cases
or less. I inform them that all surgical procedures leave scars
and that the quality of the scar reflects not only the surgeon’s
skill (most patients believe that scars are related solely to the
surgeon’s skill and that plastic surgery leaves no scars) but also
the patient’s body chemistry, location of the scar, and tension. I
stress that we can improve on any obvious, unsightly, or unac-
ceptable scar through conservative means, and a scar revision
can be done, if needed, at no additional charge.
I also explain to my patients that although serious complications
are rare, revisions may sometimes be necessary. I will reoperate on
a patient whose result falls short of my own expectations as well
as those of the patient. These revisions are at no cost to the patient.
However, if I feel that the result is the best I can achieve and the
patient is still dissatisfied, then I recommend a second opinion. In
addition to my explanations, the patient coordinator also reviews
the more common complications associated with each procedure,
such as capsular contracture, implant failure, and nipple and are-
olar sensory changes following breast augmentation. Eventually
patients also receive a letter and informed consent form, which
they are asked to read, initial on each page, and sign on the last
page. These documents enumerate the complications.
e also discuss postoperative management, including an over-
night stay in our suites if needed, the frequency of postoperative
visits, restriction of work and other activities, and the expected
time to full recovery. I do not minimize the length of time needed
for complete resolution of all bruising and swelling. I tell all facelift
and blepharoplasty patients that it may take up to 5 weeks for
them to look normal without makeup.
My first encounter with the patient lasts from 15 to 30 minutes.
After that the patient is sent to the photography room, where our
professional photographer will do the video imaging. I have found
video imaging to be very helpful with facial aesthetic procedures,
rhinoplasty, and breast augmentation. Video imaging is not rou-
tinely offered to our body contouring patients, although there is
now some new software that may well make video imaging for
body contouring as reliable as it has been for the face and nose.
Three-dimensional imaging, though currently very expensive,
may one day contribute further not only to video imaging but also
to preoperative and postoperative evaluation of results.
All patients are given the opportunity to review our preop-
erative and postoperative album. Most will have already seen
similar images on our website. It is not unusual for patients to
base their decision even to come in for a consultation on the
before and after images that are posted on the website. Without
exception, we show preoperative and postoperative breast reduc-
tion and mastopexy images so that the patient will have a clear
10
understanding of the location of the scars. After the video imaging
session, I review the projected result and discuss with the patient
whether that result is realistic and how close we can approximate
it. o promise or implied guarantee of a result is made. At this
time the preoperative and postoperative album is reviewed with
the patient if needed. Usually it is the patient coordinator and
the photographer who show the album to the patient. We do
encourage our patients to bring in photographs to demonstrate
what they like. For example, rhinoplasty patients bring in images
of noses that they like and those they do not; the same is true
for breast augmentation patients. Reviewing these images with
the patient provides me with further insight into the patient’s
aesthetic goals. For facial rejuvenation patients, we ask that they
bring in photographs taken 5, 10, and even 15 or 20 years earlier
so that we can better assess their features.
At the end of the consultation, the patient spends additional
time with the patient coordinator, who will discuss fees, schedul-
ing, and the preoperative routine. The coordinator again describes
the procedure, risks, likely outcomes, and expected recovery. If
an overnight stay is planned, an album containing images of our
overnight suites is shown to the patient. Occasionally the patient
will ask to see the operating rooms and overnight suites. If there
is an unoccupied overnight suite and the recovery room is empty,
we will accommodate this request. A video tour of our facilities is
also available on our website.
Most patients will, in fact, schedule, or at least ask to have time
reserved, at that initial visit. e do encourage them to think about
things and offer them a return visit before they schedule or the
option to schedule by telephone.
1.7 Financial Responsibilities
Although the major source of patient dissatisfaction is a result
that does not meet expectations, financial misunderstandings
and problems with fees are also common sources of patient
anger. Far too many patients who were initially happy with their
excellent results become dissatisfied and find fault with their
results if unexpected charges appear long after the operation has
been completed. Financial surprises should be avoided if at all
possible.
My patient coordinator clearly delineates the patient’s finan-
cial responsibilities during the initial visit. The patient is given
an itemized quote that includes the surgeon’s fee, facilities fee
(including anesthesia), charges for an overnight stay, and any
implantable devices. It is also made clear that if other procedures
are added between the time the patient has prepaid for the
procedure and the actual operation, there will be additional fees.
The coordinator also explains that if any specimens are removed
(such as moles, breast tissues, or breast implants) and sent to the
pathologist, there will be a separate bill from the pathologist. We
cannot provide them a quotation for the pathologist’s services;
this must come from the pathology laboratory.
In our own surgicenter we do not charge the patient extra if a
planned procedure takes longer than anticipated. However, this
may not be the case if the procedure is scheduled elsewhere.
Far too many patients have prepaid for a 4-hour procedure in a
hospital-based surgicenter only to be billed later for extra time
when the procedure runs long. Under these circumstances it
 1 The Patient

should be made clear to the patient that although the surgeon’s

fee is prepaid in full, the surgicenter facility fees are only an esti-
mate, and the actual amount will vary according to the length
of time, materials, and equipment used in the surgicenter. The
patient may, in fact, receive a bill for the balance several days,
weeks, or even months after the procedure. If this policy has
been clearly explained, patients are less likely to be dismayed
and upset.
Another cause of confusion about financial responsibilities
concerns cases in which a combination of aesthetic and recon-
structive procedures is performed (for example, nasal airway
surgery and cosmetic rhinoplasty or second-stage breast
reconstruction combined with aesthetic facial surgery or body
contouring), where a third party is responsible for the recon-
structive portion and the patient for the aesthetic portion. It may
sometimes be difficult, if not totally impossible, to delineate the
patient’s financial responsibility exactly for these procedures. e
have a person in our practice who meets with patients to discuss
insurance coverage and such financial problems. Despite all of
these efforts, patients must understand that the total cost of all
of these combined procedures and their specific financial respon-
sibility may not be determined until long after the procedure. If
patients are prepared for a possible financial surprise, they are
less likely to become angry and find fault with the result. The
patient coordinator and I also discuss financial responsibilities in
case of complications, hospitalization, or consultation with other
physicians.

1.8 Operating on Colleagues,

Friends, and Family
As a practice is built and a reputation is gained, colleagues,
coworkers, friends, and family will seek your services. This
is a tremendous compliment to you as a physician and to your
skills as a surgeon. Although this is flattering, the surgeon
should understand that it can also be a significant financial
drain, because this group of patients expects discounted or even
complimentary surgery. ot only do such discounts and compli-
mentary procedures generate little or no revenue to help meet
overhead and malpractice costs, but also the time spent on such
discounted procedures could have been spent on patients who
produce full revenue. Despite this, most surgeons have a sense of
obligation to discount services for this group or to provide them
selectively on a complimentary basis. our practice should have
a clear policy for such discounts and free services.
I routinely discount my surgical fee for fellow physicians and
their families, nurses, and other health care professionals. The
amount of the discount will vary, depending on the closeness of
my professional relationship with the individual in question. The
same is true in dealing with friends and family. Some colleagues
and family come in for a consultation expecting to pay full fees,
yet others come in expecting free surgery. It is somewhat embar-
rassing, if not difficult, to discuss this face-to-face with colleagues,
friends, and family. ears ago, Dr. Tom Rees shared with me a
note that he had colleagues, friends, and family read explaining
his policy for extending professional courtesy. I found the letter
most useful, and to this day I use the modified version shown in
Fig. 1.11.
Fig. 1.11 Letter presenting policy on discounted and complimentary
services.
For our office staff, the procedures are usually provided free
of charge on an individual basis, reflecting the person’s length of
service. Each practice should have a clearly delineated policy on
employee discounts. It is wise to avoid providing discounted or
free operations to patients who hold out the promise of future
referrals. These usually do not materialize once the operation has
been completed and may well raise ethical issues.
1.9 Patient Documentation
I make every effort to dictate the office notes as soon as I have
concluded the initial consultation. Although I take additional
notes while I am talking to the patient, I make every effort to
maintain eye contact with my patient rather than spending
the entire time scribbling notes or being preoccupied with the
computer and the electronic medical record. If at all possible, I
limit interruptions to those that are absolutely necessary, such
as emergencies. I put my cell phone on vibrate mode and ask
all our nurses to do the same. It is not conducive to a thorough
initial evaluation to have constant interruptions, and I will not
leave a patient while I answer a phone call unless it truly is an
emergency. It is important to sit down with the patient and focus
your attention on him or her. ou want to leave the impression
that you have plenty of time to talk. Therefore I do not look at my

11
 I Fundamentals
watch or time myself when I am with a patient. I like to have a
nurse or assistant present in the room at all times, and I feel it is
advisable to have a female nurse or assistant with me when I am
in a room with a female patient and mandatory when I examine
a female patient for breast augmentation or body contouring, not
only to put the patient at ease but also for my own protection.
Once the procedure is scheduled, the patient is given instruc-
tions in preparation for the operation. These include prescriptions
for skin preparation before chemical peels and laser resurfacing
and lists of medications and supplements to avoid taking
pre-operatively to minimize postoperative bleeding and bruising.
e encourage patients to take vitamin C. Patients are scheduled
for a preoperative visit 1 or 2 weeks before the operation. Patients
who will undergo general anesthesia need to have a physical
examination, blood test, and clearance from their primary phy-
sician before surgery is scheduled. During the preoperative visit,
the patient will meet the anesthesiologist, who performs another
preoperative evaluation. The patient also meets again with the
coordinator to review and sign the informed consent form and to
have any further questions answered. If preoperative photographs
have not already been taken, they are taken on this occasion.
During this preoperative visit, the patient talks with our financial
counselor, who goes over the fees and collects prepayment for the
full amount of the procedure, including the surgeon’s fee, facility
fee, and fees for the overnight stay and materials. If there is any
question about whether additional payments may be necessary
after the operation, such as a pathologist’s bill, this is clearly
pointed out to the patient.
The patient will be evaluating the level of service before the pro-
cedure, because it serves as an indication of how well the practice
will respond to her or his needs and concerns after the operation.
If the patient feels that the staff were not attentive enough, were
slow to respond, or were evasive before the operation, he or she
will be concerned that this may well be what they should expect
after the operation. Unfavorable preoperative experience may
justifiably lead the patient to cancel the procedure.
On the day of the operation, I review the patient’s record before
I meet with the patient to discuss the planned procedures. I
take my own finger or a cotton tip applicator and go over every
proposed incision. I then mark the patient. If he or she is accom-
panied by a family member and allows that person to remain in
the room, I ask the patient and the family member if they have
any questions and inquire whether the patient remembers the
risks, possible complications, and length of recovery. It is not
unusual for patients at the last minute in the preoperative area
to ask whether we could take off skin lesions, add an extra area
for liposuction, or even add a completely new procedure. For
that reason, and to avoid any postoperative misunderstandings, I
confirm with the patient that we have neither left out any proce-
dures nor added anything. I explain that if the patient wishes to
add extra procedures and operative time is available, there will be
an extra charge, and the patient will be billed for it. If he or she
requests excision of a skin lesion or two or a small additional area
for liposuction or fat injection, I often as a courtesy include that
without extra charge. However, I mention that the pathologist will
send a bill for examining the excised lesions.
We then proceed to the operating room. There is a special wait-
ing area for family members if they choose to wait; if not, I ask for
a phone number so that I can personally call when the operation
12
is finished and the patient is in the recovery room. I also inform
the patient and the family that if the operation is completed in less
time than I had allotted, it does not mean that I rushed through it,
and conversely, if it takes longer, it does not mean that either the
patient or I encountered a problem.
After the operation, patients either go home with a responsible
adult or stay in our recovery suites. If the patient goes home, I call
that evening to inquire whether the patient is comfortable and
whether there are any questions. If I am greeted by the answering
machine, I leave a message that I called to make sure that the
patient is home and comfortable. I ask the patient to call if there
are questions or problems. If the patient remains in our suites,
either I or someone on the team visits the patient. Two days post-
operatively, all patients receive a follow-up phone call from our
surgicenter asking them how they are doing and inquiring about
their experience with the center.
1.10 Postoperative Visits
Follow-up visits are as important as the initial consultation.
Most patients are concerned that the red carpet and VIP treat-
ment will be rolled out preoperatively so that they will sign up
for an operation, and that their postoperative care will be less
attentive, relegated to the nurses. It is important for them to have
a favorable experience in their postoperative visits. e make
every effort to usher postoperative facial patients straight into
a private waiting room or examination room to minimize their
time in our public places, such as the general waiting room. I go
in and sit and greet the patient, ask how he or she has been, and
how the recovery is progressing. I explain that the nurses will
clean the wounds, remove sutures, and change tapes, and that
our aesthetician will take care of the areas that may have been
resurfaced. I inquire whether the patient needs more medication
and explain that I will return for a more thorough examination
once the nurses have removed sutures and cleaned the wounds.
As with preoperative examinations, a nurse is present during
the postoperative examination of a breast augmentation or body
contouring patient, to put the patient at ease and for my protec-
tion. It is important to close the door, sit down, make eye contact,
and talk to the patient. I do not focus on the computer screen to
read through it or write in it. Leaving the door open, standing,
reading, and writing leaves the patient with the impression that
you breezed in for a few seconds, clicked something in the chart,
and left without examining him or her. hen I return to see the
patient, I examine every suture line and express my own opinion
about the early results and stage of recovery. I then answer ques-
tions. If the patient is at the stage in a facial procedure where
camouflage makeup can be applied, our aesthetician applies
makeup, and I see the patient after this application. For patients
who have undergone breast augmentation or body contouring
procedures and have recovered sufficiently, I go back in and see
them when they are fully dressed to make certain they are happy
with their appearance in their clothes.
Occasionally, despite my best efforts, a patient complains to the
nurse that I have not been attentive enough or spent enough time
after the operation. This is an important line of communication
between the patient and me, and I listen to the nurse and make
every effort to resolve the situation. Very often a patient who is

concerned about the result may discuss it first with the nurse or
patient coordinator for fear of offending the surgeon: I don’t want
to hurt his feelings. These communications are important and are
dealt with in a kind and understanding fashion. I explain to my
patients that I want them to be comfortable and open with me
and discuss their concerns. My feelings will not be hurt if I am told
that a patient is less than satisfied with the result. I tell patients
that my feelings would be hurt if they felt that they couldn’t com-
municate with me and chose to go elsewhere.
I rely heavily on the impressions of our nurse and patient coor-
dinator. It is crucially important to surround yourself with good
people and to listen to them. I have turned down patients based
on recommendations from these professionals and have been able
to defuse potentially unpleasant situations based on their input.
1.11 Management of Complications
and Problems
o one wants complications. I take all complications personally
and replay the entire procedure in my mind, wondering how and
why they occurred. Despite my explanations to my patients that
complications do occur, even in the best of hands, it is difficult
for me to accept that my patient has developed a complication.
Regardless of these personal feelings and the sense of disap-
pointment, it is necessary to deal with these problems and, more
important, with the patient’s anxieties, concerns, and possible
resentment. Most patients feel that something went wrong or
that something was not done properly otherwise they would
have sailed through the operation as smoothly as their friend
did, on whom your partner, your colleague, or even you operated.
I usually explain the nature of the complication to the patient.
If I have any idea why it happened, I explain that and outline
our plan to take care of it. I usually tell the patient, I am sorry
this happened; it isn’t anything you did; it isn’t anything I did.
Despite our best efforts, we have a problem. It is not the first time
I have seen it, and we know how to take care of it. I then explain
exactly what has to be done and how long it will take.
In cases of postoperative hematoma in a facelift, I reoperate
usually with the patient under local anesthesia, but general anes-
thesia is available if needed, and I explain to the patient that this
will take care of the problem. It will not affect the results, but it
will leave more bruising than expected, and the affected side of
the face (if unilateral) will lag behind the other side in recovery.
Devastating complications, such as skin slough following a
facelift, exposed breast implants, and nipple or areola loss, require
a more prolonged plan for recovery. Fortunately, these complica-
tions are extremely rare and are often associated with predispos-
ing factors such as smoking. These patients require a great deal
of attention. e naturally have an instinct to avoid unpleasant
situations and circumstances, but these are times when our
patients need us to be there for them. These patients must be seen
on an almost daily basis. If a strong bond already exists between
the patient and the surgeon before the complication develops, this
will have a positive influence on the outcome. However, if the sur-
geon’s relationship with the patient was already less than ideal,
these complications will serve to undermine the relationship
further and result in an unhappy situation for both the patient
and the physician. This is when patients become angry and seek
1 The Patient
legal advice, especially if the complication adds an additional
financial burden to the patient. It may be tempting to abandon
such a patient and to blame him or her for the complication, but
it would be unwise. If you absolutely cannot continue with the
patient, have a partner or trusted colleague assume the care at
your expense.
hen I have been able to explain the reason for the compli-
cation, I have found that patients have not only been surprised
by this explanation but also have appreciated my candor. This
communication has further improved our physician-patient rela-
tionship and the patient’s confidence in me. To do anything less
will confirm the impression that the medical profession covers
up errors.
There is no question that by offering to continue working
with the patient to correct a complication, you send a reassuring
message. I comfort patients by telling them that I have seen these
complications and know how to take care of them, and I will not
stop until we are both happy with the outcome.
1.12 e i i ed ien
Dissatisfied patients come in two varieties your own and those
of your colleagues. Despite our best efforts in preparing and
evaluating our own patients, screening them, and discussing
risks and complications and realistic expectations, we still have,
rarely, patients who are not satisfied with their outcomes. Even
though these patients may have an average or good result, they
are just not happy. This dissatisfaction may be the result of
inadequate or even poor communication between the surgeon
and patient or of patient expectations that were not met. Such
patients are extremely difficult to deal with and may never be
satisfied. They will exhaust you and test your patience and that of
everyone in your office. They also have access to the Internet and
the numerous websites that grade or evaluate doctors. They have
the freedom to say anything they want about you, your staff, and
their result. There are no checks and balances, and it is difficult,
if not impossible, to respond to these allegations or comments
once they have been posted. Although most of the time these
comments are posted anonymously, most surgeons have a good
idea who the patient may be but are bound by privacy rules from
commenting. The best way to deal with these patients is not to
operate on them, and with maturity and experience, one should
be able to identify them.
One of the most challenging problems in clinical practice is
dealing with a colleague’s dissatisfied patient. If the patient has
an identifiable problem that is correctable and the colleague
has referred the patient to you for that purpose, this represents
a relatively straightforward situation, since all three parties are
involved. However, most of the time the patient is self-referred
and would prefer that you not contact the original surgeon.
I evaluate these patients in the same manner that I evaluate any
patient. I then explain to them that the problem is correctable
and how I would do it. I also explain to them that I am flattered
and honored that they have chosen to consult with me, and I take
that as an indication of their confidence in me as a surgeon. If
the problem is a recognized and not uncommon complication or
sequela of the procedure, such as implant malposition or even lid
retraction, I explain that I have seen similar complications in my
13
 I Fundamentals
own patients. If I am familiar with the other surgeon and believe
that he or she could just as easily correct the problem, I encourage
the patient to return to the original surgeon, who may do the
revision or correction at no charge or at a discount. I explain that
I would not charge my own patients for a similar revision. If the
patient does not wish to return to the other surgeon, he or she
will usually respond, He doesn’t think there is a problem, I can’t
communicate with him, or He says there is nothing else he can
do. I then tell the individual that I would have to charge my full
fee for the revision and that it may take more than one procedure. I
do ask all patients to have copies of their records forwarded to me,
and I ask their permission to communicate with the other surgeon.
If the patient does not grant permission, then it would be a breach
of his or her privacy to obtain the files, complicating the situation
and putting me in an awkward position with my colleagues. These
are extremely delicate situations, often involving litigation. It is
paramount that the patient’s best interests be considered first and
that everything possible be done to correct the problem, even at the
risk of affecting a collegial relationship. It is important to emphasize
that complications do not necessarily indicate a deviation from the
standard of care and to refrain from inflammatory comments such
as This is the worst I have ever seen or ho did this to you
e are physicians and well-trained surgeons, highly skilled
in the procedures we perform. Communication skills, however,
were never part of our medical school or residency curriculum;
we were not taught bedside manner. Yet communication and
bedside manner are as important as our skills in the operating
room. Our patients expect more than good results; they like to be
listened to and cared for. They want a surgeon who is responsive
and who makes them feel valued and respected. Good results and
satisfied patients will do far more than any advertising program to
promote and grow a practice.
1.13 Concluding Thoughts
The practice of cosmetic medicine and aesthetic surgery is
satisfying and rewarding for the surgeon. I am excited that it
continues to evolve, and it is imperative that we adapt to these
changes so that we can provide the best for our patients. To our
patients, aesthetic treatments are not a necessity but rather are
the fulfillment of a personal goal; therefore, their experience
must be satisfying and rewarding as well. This is a partnership
that at its best works smoothly and effectively for all involved.
In this chapter I have shared my approach, but in truth it is our
approach my partners and staff are all intimately involved in
making the experience for our patients a positive one. Time spent
14
with the patient by the surgeon and the staff is time well invested.
This is especially true today, when our patients have access to all
kinds of information on the Internet. Our goal is to establish a
long-term and trusting relationship with our patients. We nur-
ture an environment in which our patients can feel that they are
among friends when they visit us in our office. Patient satisfaction
is the best form of marketing available to us. Such patients are our
best source of referrals and will themselves return if the initial
experience was one worth repeating.
Clinical Caveats
• A well-informed patient is a happy patient.
• A well-motivated patient is a happy patient.
• Eliminate postoperative financial surprises, or at least warn
the patient about them.
• Listen to your patients.
• Learn to say “no.”
• Spend time with your patients.
• Respect the patient’s privacy.
• First impressions last.
• Your website is the face of your practice to the world.
• The Internet can be a friend or foe.
Suggested Reading
1 Bennett AE, ed. Communication between Doctors and Patients. London, U :
Oxford University Press; 1976
2 Bennett G. Patients and Their Doctors: The Journey through Medical Care. London,
U : Bailli re-Tindall; 1979
3 Bird B. Talking with Patients, 2nd ed. Philadelphia, PA: B Lippincott; 1973
4 Goldwyn RM. The consultant and the unfavorable result. In: Goldwyn RM, ed.
The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Boston, MA:
Little, Brown; 1972
5 Goldwyn RM. The dissatisfied patient. In: Goldwyn RM, ed. The Unfavorable
Result in Plastic Surgery: Avoidance and Treatment, 2nd ed. Boston, MA: Little,
Brown; 1984
6 Goldwyn RM. The Patient and the Plastic Surgeon. Boston, MA: Little, Brown;
1981
7 uechel MC. Aesthetic Medicine: Growing Your Practice. St Louis, MO: uality
Medical Publishing; 2009
8 Lewis W. The Beauty Battle: The Insider’s Guide to Wrinkle Rescue and Cosmetic
Perfection from Head to Toe. Berkeley, CA: Laurel Glen Publishing; 2003
9 Lewis W. Plastic Makes Perfect. London, U : Orion Books, 2007
10 Locke MB, ahai F. Managing the cosmetic patient. In: eligan MB, ed. Plastic
Surgery, vol. 2, 4th ed. London, U : Elsevier; 2017:1–11
11 ahai F. hat not to wear and other aspects of professionalism. Aesthet Surg J
2011;31(8):977–979 PubMed
12 ahai F. Evaluating the cosmetic patient on antidepressants. Aesthet Surg J
2014;34(2):326–327 PubMed

2 Psychological Considerations in Aesthetic Surgery
David B. Sarwer and Jacqueline C. Spitzer
Abstract
Aesthetic surgeons have long been interested in the psychosocial
functioning of their patients. Early work in the area suggested
that patients seeking aesthetic surgery were psychopathological.
However, contemporary research suggests that there are rela-
tively few differences between individuals who seek aesthetic
procedures and those who do not. Patients seeking aesthetic
procedures, however, present with increased body image dis-
satisfaction compared with those who do not elect to undergo
these procedures. This can be seen as more normative than
psychopathological in most patients.
evertheless, there are several psychological considerations
of patients seeking cosmetic procedures that are relevant to
aesthetic surgeons. Because of this, a preoperative assessment of
psychosocial functioning should be conducted with a particular
focus on body dysmorphic disorder (BDD), eating disorders, and
depression. Psychosocial functioning also should be monitored
postoperatively, as patients can experience an exacerbation of
preoperative symptoms, sometimes with unfavorable results.
hile research suggests that the majority of patients are satisfied
with the result of their cosmetic procedures, these psychosocial
considerations underscore the importance of the aesthetic sur-
geon being mindful of psychosocial functioning of their patients
throughout the continuum of care.
Keywords
psychosocial functioning, body dysmorphic disorder, eating
disorders, depression, body image, quality of life
2.1 Introduction
Tens of millions of individuals around the world undergo aes-
thetic procedures each year, from noninvasive procedures to
surgery, in an effort to improve their physical appearance. Many
aesthetic surgeons and mental health professionals long have
wondered why, from a psychological perspective, patients would
take on the expense and risks of an elective procedure to improve
their appearance. The early belief was that patients who sought
aesthetic treatments were dealing with significant underlying
mental health issues. Both empirical research and contemporary
clinical impression have largely debunked that belief, although
concerns about the psychological well-being of a minority of
patients remain. Providers and patients have also speculated on
the psychological changes that occur after treatment. The vast
majority of patients report being satisfied with the results of
their procedures, and many report meaningful changes in their
physical appearance, body image, and self-esteem. However,
some patients do appear to have untoward changes in psycho-
social functioning after surgery, underscoring the important
role of evaluating the psychosocial status of patients prior to an
aesthetic treatment.
2 Psychological Considerations in Aesthetic Surgery
This chapter provides an overview of the most relevant psycho-
logical considerations of patients who undergo aesthetic surgery.
The chapter begins with an overview of the hypothesized reasons
for the growth of aesthetic surgery. ext, a brief review of the
literature on psychological characteristics of aesthetic surgery
patients is provided. The psychiatric conditions of greatest rele-
vance to aesthetic surgeons body dysmorphic disorder (BDD),
eating disorders, and depression are discussed. The final section
of the chapter describes strategies for aesthetic surgeons to evalu-
ate the psychosocial functioning of patients.
2.2 Explanations for the Growth
of Aesthetic Surgery
There are a number of potential explanations for the worldwide
growth in aesthetic surgery and minimally invasive treatments.
A number of medical advances have made many treatments
safer and have decreased postoperative recovery times. Much of
the rapid growth of minimally invasive treatments is likely the
result of decreases in the cost of these procedures, as well as
the lower risk and shorter recovery times compared with tra-
ditional surgical procedures. Aesthetic procedures, unlike many
other forms of medicine, are tailor-made for direct-to-consumer
advertising. The latest advances in the field are a regular topic of
discussion in the mass media and coverage of the entertainment
industry. As a result, aesthetic procedures have become an
element of popular culture and are commonly viewed as a step
in the journey to the physical perfection routinely portrayed in
the mass media.
The mass media and entertainment industries also impact
thoughts and behaviors related to physical appearance in other
ways. From print magazines to websites, television shows to
movies, consumers are bombarded by images of physical beauty.
Some of the images are of persons who have been blessed with
youthful and symmetrical features that naturally signal attrac-
tiveness. Most, however, have been computer–enhanced. Studies
have repeatedly shown that exposure to these images of physical
beauty increases body image dissatisfaction that, as discussed in
detail in subsequent paragraphs, is believed to be the motivational
catalyst to aesthetic treatments.
Other sociocultural factors influence beliefs about physical
appearance and, likely, beliefs about aesthetic treatments. Parents
and peers impact our sense of our appearance starting in early
childhood and through modeling of behaviors signaling the
importance of physical appearance in social interactions. Early
experiences with romantic relationships also provide feedback to
an individual on how appearance is perceived by and responded
to by others. egative feedback about one’s appearance through
teasing or bullying is no longer seen as an innocuous rite of pas-
sage of adolescents; it can color beliefs about one’s appearance
and self-worth well into adulthood and, for many individuals, may
influence the decision to pursue an aesthetic procedure.
15
 I Fundamentals

A large body of social psychological research developed over

the past 50 years has confirmed the importance of physical
2.3 Psychological Characteristics
appearance in daily life. This comprehensive body of research can of Aesthetic Surgery Patients
be summarized with two general statements:
A sizable body of research starting in the 1960s has investigated
1. Individuals who are judged to be more physically attractive are the psychosocial characteristics of persons who present for
assumed to have more positive and desirable personality char- aesthetic surgery. The first studies in this area relied heavily on
acteristics.
clinical interviews of patients and described them as having high
2. Individuals who are seen as more attractive receive preferential rates of psychopathology, including mood and anxiety disorders
treatment in a wide range of interpersonal interactions across
as well as personality disorders. All of these conditions were
the lifespan.
believed to be associated with poor postoperative psychological
hether we like to admit it or not, the evidence that our outcomes. Subsequent studies have included the use of standard-
appearance impacts our lives is compelling. ized psychometric measures rather than or in addition to clinical
A discussion of the role in physical appearance in the human interviews of prospective patients. These studies typically have
experience also has to include a consideration of Darwin’s theory of found less psychopathology. Unfortunately, both sets of studies
natural selection, perhaps the earliest scientific acknowledgment suffer from methodological problems that have made resolution
of the importance of physical appearance. According to the theory, of these conflicting findings difficult.
the goal of all species is survival through successful reproduction. In the past 20 years, advances in the use of psychometrically
Identification of a mate who can optimize the results of reproduc- validated measures have improved the quality of much of the
tion is a central part of the process. To that end, specific physical research done in this area. In particular, a number of psychomet-
characteristics have evolved to signal reproductive capability to rically sound patient-reported outcomes measures specifically
others. These characteristics, particularly those that suggest the designed for plastic surgery patients have been developed. These
potential for healthy reproduction, serve as the foundation for measures have focused on the assessment of quality of life,
what is considered attractive in another member of the species. self-esteem, and body image in patients before and after surgery.
When applied to facial appearance, the characteristics of Studies using these studies have largely found that patients typi-
youthfulness, symmetry, and averageness have been most com- cally report deficits in these areas prior to surgery.
monly associated with facial attractiveness. The development of
adult facial features at puberty for both women and men signals
reproductive potential to others. These features also may suggest 2.4 Body Image
reproductive health as expressions of normal levels of testoster-
Over the past two decades, body image has been the psycho-
one and estrogen. Clear skin, bright eyes, and lustrous hair draw
logical construct that has received the most research attention
attention to the youthful face. hile a youthful facial appearance
in the aesthetic surgery literature. Dissatisfaction with one’s
is considered attractive, an aging appearance typically is not.
facial appearance and body image is believed to be the primary
Ratings of attractiveness of males and females typically decline
motivator for both surgical and minimally invasive treatments of
with age; the relationship is stronger for women than men.
the face and body.
Symmetry of facial features across the midline also is asso-
There are several definitions of the construct. Cash and
ciated with increased ratings of attractiveness. Evolutionary
Pruzinsky defined body image as the perceptions, thoughts, and
theorists believe that the ability to develop symmetrical features
feelings associated with one’s body and bodily experience. This
in an environment full of pathogens is conferred upon only the
definition captured the multidimensional nature of body image,
healthiest of individuals. Similarly, averageness, with respect to
including both the manner in which an individual objectively
the size of individual facial characteristics, also is associated with
appears to others, but also the manner in which a body moves in
ratings of attractiveness. Composite faces made up of hundreds
time and space. These physical perceptions subsequently interact
or thousands of individual faces via computer technology (and,
with thoughts and feelings about the features of one’s appearance.
therefore, believed to represent average facial features) are
Unfortunately, this definition does not specifically highlight body
judged as more attractive than the individual faces that make
image behaviors, such as grooming habits and clothing selection,
up the composite. The most beautiful of the combined faces for
as well as more profound behaviors, such as those seen with
women reflect a petite face with a smaller-than-average mouth
aesthetic surgery. More recently, Cash and Smolak described body
and jawline, full lips, and pronounced eyes and cheekbones. Many
image as the psychological experience of embodiment. This suc-
surgical and minimally invasive treatments performed on the face
cinct description leaves the reader with a sense of the important
are undertaken to help an individual look more youthful and/or
role that body image plays in quality of life, self-esteem, and the
enhance facial symmetry.
overall human experience.
ith these elements of evolutionary theory and social psycho-
Much of our understanding of body image comes from a
logical research on appearance in mind, the popularity of aesthetic
cognitive–behavioral theoretical model, one of the dominant
treatments is not particularly surprising. hile decades ago an
theoretical models of psychology for the past several decades.
individual’s interest in improving his or her appearance may have
The model describes the perceptual, cognitive, affective, and
been seen as being symptomatic of excessive vanity, narcissism, or
behavioral aspects of body image; it also accounts for historical
other deep-seated psychopathology. Today, it also can be seen as
and proximal influences of the construct. Historical influences
a more adaptive and potentially psychologically healthy behavior,
include an individual’s physical characteristics, personality traits,
akin to other self-improvement strategies such as eating a healthy
and interpersonal experiences. Proximal influences include
diet and exercising regularly.
cognitive processing of appearance-specific information from the

16

environment that, along with more general cognitive processes,
lends meaning to situations and events.
These historical and proximal variables influence two funda-
mental body image dimensions. One is the degree of investment
in one’s appearance. Some individuals are highly invested in
their appearance (those who carefully groom themselves before
leaving the house); others are far less invested (those who are
comfortable going out in mismatched clothes or without groom-
ing). The second dimension is the degree of dissatisfaction. This
dissatisfaction is believed to fall on a continuum. Likely, very few
individuals are completely satisfied with their appearance on
a daily basis. Most individuals likely can identify features that
leave them dissatisfied. They may camouflage these features from
others (through makeup and/or clothing), but this dissatisfaction
does not routinely impact daily functioning. Others who are more
dissatisfied may exhibit more significant behavioral change in
response to their dissatisfaction. It is likely these individuals who
are most likely to seek and benefit from aesthetic procedures.
Finally, other individuals may exhibit a more extreme level of
body image dissatisfaction that may be representative of BDD or
other forms of formal psychopathology.
In general, there is consensus among thought leaders in the field
that individuals who seek and receive aesthetic procedures report
both heightened investment in their appearance as well as higher
levels of dissatisfaction. This relationship also has been supported
by research. Individuals who seek aesthetic procedures, both
surgical and nonsurgical, typically report heightened body image
dissatisfaction preoperatively. This dissatisfaction is typically
centered upon concern with the specific feature to be improved
with treatment. Thus, some degree of body image dissatisfaction
is believed to be a prerequisite to aesthetic surgery.
2.5 Formal Psychopathology
among Aesthetic Surgery
Patients
Given the number and diversity of individuals who seek aes-
thetic procedures, all of the psychiatric diagnoses can likely
be found within the patient population and a busy clinical
practice. However, three disorders BDD, eating disorders, and
depression likely warrant the greatest attention from aesthetic
surgeons and their team members.
2.5.1 Body Dysmorphic Disorder
BDD is a manifestation of extreme body image dissatisfaction. It
is defined by the American Psychiatric Association as a preoccu-
pation with a slight or imagined defect in appearance that leads
to substantial distress or impairment in social, occupational, or
other areas of functioning.
The disorder was not formally recognized until 1987.
evertheless, the aesthetic surgery and dermatology literature
has included case reports of minimal deformity, insatiable,
and dermatological nondisease patients as early as the 1960s.
These individuals sought procedures to improve slight or imag-
ined defects and were often dissatisfied with their results. hile
the incidence rate of BDD in the general population is believed to
be between 1 and 2 , a number of studies conducted throughout
2 Psychological Considerations in Aesthetic Surgery
the world have found that 5 to 15 of cosmetic surgery patients
appear to have some form of the disorder. Although persons with
BDD typically report concerns with their skin, hair, and nose, any
body part can become a source of preoccupation.
Persons with BDD frequently seek cosmetic medical treatments
as a means of improving their perceived defects. More than
three-quarters of persons with BDD report a history of aesthetic
treatments. Unfortunately, most evidence to date suggests that
aesthetic procedures are inadvisable for patients with BDD.
Most patients report being dissatisfied with the outcome of
treatment, and two large studies have found that greater than
90 of persons with BDD report either no change or a worsening
in their symptoms following aesthetic treatments. A handful of
small studies, however, have found some degree of improvement
in symptoms in patients with mild to moderate forms of BDD.
Also of note, a number of studies have documented high rates of
suicidal ideation, suicide attempts, and self-harm behaviors (e.g.,
do-it-yourself surgery) among patients with BDD. There are
also reports of patients with BDD who have threatened to sue or
physically harm aesthetic treatment providers. In light of these
issues, there is consensus that aesthetic treatments likely should
be contraindicated for persons with BDD.
2.5.2 Eating Disorders
Extreme body image dissatisfaction is a symptom of both
anorexia and bulimia nervosa. omen (and men) with both
conditions may mistakenly believe an aesthetic treatment will
improve their intense dissatisfaction with their bodies. Eating
disorders may be a particular concern for individuals who
seek body contouring procedures, including liposuction and
abdominoplasty as well as breast augmentation. Patients may
mistakenly believe that these procedures can reshape their
bodies in a way that restrictive eating and/or maladaptive com-
pensatory behaviors cannot. omen who present for cosmetic
breast augmentation are frequently below average weight and
report greater exercise compared to physically similar women
not seeking breast augmentation, both of which also may be
suggestive of eating psychopathology. Unfortunately, the study
of the relationship between eating disorders and other cosmetic
procedures has been limited to small case series.
2.5.3 Depression and Suicide
The presence of major depression or other mood disorders also
warrants particular attention. Population estimates suggest that
approximately 10 of adults are suffering with depression at any
point in time and approximately 20 are using an antidepressant
medication. Studies have suggested that the rate of usage among
aesthetic surgery patients is higher and perhaps double that of
the general population. omen seeking breast augmentation
also have been found to report a higher rate of outpatient psy-
chotherapy and psychiatric hospitalizations.
Of greater relevance, seven epidemiological studies have found
an association between cosmetic breast implants and suicide.
Across these studies, the rate of completed suicides was two to
three times higher among implant recipients than estimated rates
in the general population. Explanations of this relationship have
largely focused on the preoperative psychosocial status and func-
tioning of the women. Women who undergo breast augmentation
17
 I Fundamentals
have been shown to have a number of distinguishing demographic
characteristics. They report more lifetime sexual partners, a
greater use of oral contraceptives, and a history of terminated
pregnancies. They also are more frequent users of alcohol and
tobacco. Many of these characteristics are, in and of themselves,
risk factors for suicide.
The most likely explanation of the relationship between cos-
metic breast implants and suicide appears to be the presence
of pre-existing psychopathology prior to surgery. In one of the
epidemiological studies, women who underwent cosmetic breast
augmentation had a higher rate of previous psychiatric hospi-
talizations compared with women who received other cosmetic
procedures, as well as women who underwent breast reduction.
A history of psychiatric hospitalizations is one of the strongest
predictors of suicide among persons in the general population.
2.6 Psychosocial Status Following
Aesthetic Surgery
umerous studies have found that 80 to 90 of patients report
being satisfied with the results of an aesthetic procedure. Other
studies also have found statistically significant improvements
in body image within the first 2 years of an aesthetic surgical
procedure. In a recent systematic review, aesthetic patients also
reported improvements in quality of life and self-esteem follow-
ing both surgical and nonsurgical aesthetic procedures.
An issue that has received surprisingly little attention is the
relationship between postoperative complications and psycho-
social outcomes following aesthetic procedures. Intuitively, post-
operative satisfaction and the psychological benefits associated
with improvements in appearance may be negatively impacted
by the occurrence of a postoperative complication. At least one
study found that breast augmentation patients who experienced
postoperative complications reported less favorable changes in
body image in the first 2 years following surgery. Unfortunately,
little else is known about these relationships.
2.7 Assessment of Psychosocial
Functioning by the Aesthetic
Surgeon
Given these research findings, aesthetic surgeons are encouraged
to conduct a basic assessment of the psychosocial functioning
and status of new patients. Aesthetic surgeons, like all medical
professionals, should assess and screen for the presence of
psychopathology as part of a taking of a medical history and
completion of physical examination. The assessment should
focus on three main areas: (1) motivations and expectations, (2)
appearance and body image concerns, and (3) psychiatric status
and history.
2.7.1 Motivations and Expectations
Patients present for aesthetic procedures with a variety of moti-
vations and expectations regarding the impact of surgery on
their lives. Some may be expressed to the surgeon or treatment
team during the initial consultation; others may be unspoken.
18
hile both patients (and surgeons) may struggle to articulate or
identify specific motivations for surgery, patients with internal
motivations (e.g., desire to improve one’s self-confidence) rather
than external motivations (e.g., undergoing surgery in order to
receive a promotion) are thought to be more likely to have their
postoperative expectations met.
In assessing patients’ motivations for surgery, the surgeon may
want to begin by asking, hen did you first think about changing
your appearance Similarly, it may be instructive to ask, hat
other things have you done to improve your appearance In addi-
tion to providing important clinical information, these questions
also may reveal the presence of some obsessive or delusional
thinking, as well as bizarre or compulsive behaviors, related to
physical appearance.
Patients should be asked how romantic partners, family
members, and close friends feel about the decision to change a
physical feature. hile these individuals likely influence patients’
decision-making process, their role may not be as great as
intuitively thought. Breast augmentation patients reported that
their decision to seek surgery was influenced more by their own
feelings about their appearance than by the thoughts of their
romantic partners. evertheless, patients who seek treatment
specifically to please a current partner, or to attract a new one,
are thought to be less likely to be satisfied with their postopera-
tive outcomes. Thus, the surgeon should inquire about patients’
general expectations about how the change in appearance, which
may be rather subtle and potentially unnoticed by others, will
influence their lives.
hile there is some evidence to suggest that patients are seen
as more attractive or thought to be younger after an aesthetic
treatment, there is no current evidence suggesting that cosmetic
procedures directly impact interpersonal relationships. Therefore,
patients should be reminded that it is impossible to predict how
others will respond to their changed appearance. Some patients
may find that few people notice the change in their appearance,
while others may have the experience that everyone seems
to notice them. hile some patients may find this attention
pleasurable, others may find it uncomfortable. To assess this
issue, patients should be asked how they anticipate their lives
will be different following surgery. The experience of unmet
postoperative expectations is another possible explanation of the
relationship between cosmetic breast augmentation and suicide.
Some women may present for breast augmentation surgery with
unrealistic expectations about the effect that the procedure will
have on their romantic relationships or daily functioning. hen
these expectations are not met, they may become despondent,
depressed, and potentially suicidal.
2.7.2 Body Image Dissatisfaction and
Body Dysmorphic Disorder
The aesthetic surgeon also should assess the degree of body
image dissatisfaction and potential presence of BDD. Patients
should be able to articulate specific concerns about their appear-
ance that are readily visible to the treating surgeon, as patients
who are markedly distressed about slight defects that are not
easily apparent may be suffering from BDD. As the judgment of
an appearance defect as slight or imagined is highly subjective,
the nature of the appearance defect may be difficult to assess.

hat a lay person regards as a slight defect, well within the range
of normal, may, to the trained aesthetic surgeon, be a defect that
is observable and easily correctable. As a result, the degrees of
emotional distress and impairment, rather than the specific
nature of the defect, may be more accurate indicators of BDD.
The degree and psychosocial consequences of the patient’s
body image dissatisfaction should also be assessed. Asking about
the amount of time spent thinking about a feature or the activ-
ities missed or avoided may indicate the degree of distress and
impairment a person is experiencing and may help determine the
presence of BDD.
2.8 Psychiatric Status and History
An assessment of the patient’s psychiatric history and current
status should be included in the consultation with a new patient.
ith the exception of BDD, there is limited data on the preva-
lence of psychiatric diagnoses among persons who undergo cos-
metic procedures. The presence of a specific diagnosis, however,
may not be an absolute contraindication for cosmetic surgery.
In the absence of sound data on the relationship between psy-
chopathology and surgical outcome, appropriateness for surgery
should be assessed on a case-by-case basis.
Aesthetic surgeons (or their delegates) should ask specific
questions about current and past diagnoses and treatments (both
outpatient and inpatient). Although this information is frequently
reported on standard medical history forms, review during the
initial consultation allows for observation of the patient’s behavior,
demeanor, and ability to interact with office staff. Unfortunately,
many surgeons likely skip this psychological screening portion of
the assessment and, as a result, likely fail to identify patients who
may exhibit symptoms of relevant psychopathology.
Patients who display symptoms of psychopathology during
their initial consultation with the aesthetic surgeon, as well as
those with a history of psychopathology, may benefit from a
referral for additional assessment by a mental health professional.
Many of the early descriptions of cosmetic surgery patients are
complete with elaborate interpretations of the role of unconscious
conflicts and poor parental relationships in the decision to seek
surgery. There is no evidence, however, to suggest that such
interpretations are necessarily valid or useful in determining
patients’ appropriateness for surgery. Thus, a detailed assessment
of patients’ parental relationships and decades-old historical
experiences is unlikely to provide useful information to the refer-
ring surgeon in determining appropriateness for surgery. Rather, a
more straightforward evaluation of patients’ current functioning,
as found in the more general cognitive-behavioral assessment, is
recommended.
A trusted mental health professional can be a valuable con-
sultant to an aesthetic surgery practice. This mental health pro-
fessional should have a good understanding of the psychological
aspects of aesthetic medicine, as well as knowledge of disorders
with a body image component, such as BDD and eating disorders.
In most cases, the mental health professional will be called upon
to assess a patient’s psychological appropriateness for a procedure
at a given point in time. The mental health professional also may
be asked to join in the care of a patient postoperatively. This is
most likely to occur in situations where the patient is dissatisfied
with an objectively successful outcome or when the patient
experiences a significant postoperative complication. Aesthetic
2 Psychological Considerations in Aesthetic Surgery
surgery patients may react to a referral to a mental health profes-
sional with anger and defensiveness, believing that they will feel
better only if they look better, and therefore may refuse to go to
the consultation. To increase the likelihood that the patient will
accept the referral, it should be treated like a referral to any other
health professional. The patient should be informed of the specific
areas of concern and the reason for the referral, and this informa-
tion also should be shared with the mental health professional.
2.9 Concluding Thoughts
Aesthetic surgeons have long been interested in the psychosocial
functioning of their patients. The earliest work in this area, before
the tremendous growth of the specialty, generally suggested that
patients were highly psychopathological. As aesthetic surgical
and minimally invasive treatments have become more common,
this perception has changed. Individuals who present for pro-
cedures are not seen with the same degree of suspiciousness as
before. Furthermore, most of the more contemporary research
has suggested that there are relatively few differences between
individuals who seek aesthetic procedures and those who do
not. The most consistent difference seems to be increased body
image dissatisfaction, which is believed to be the motivation
catalyst for an aesthetic procedure.
Encouragingly, many patients report improvements in their body
image following a cosmetic treatment. However, a small yet signifi-
cant percentage of patients appear to suffer from BDD. Others likely
suffer with eating disorders or depression. All three conditions
should be assessed preoperatively. Psychosocial functioning also
should be monitored postoperatively, as patients can experience
an exacerbation of these symptoms, sometimes with dramatically
unfavorable results, such as threats of legal action, physical harm,
and suicidal behavior. These outcomes underscore the importance
of the aesthetic surgeon’s being mindful of psychosocial status and
functioning throughout the continuum of care of the patient.
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1997;17(4):230–234
57 Sarwer DB, anville HA, LaRossa D, et al. Mental health histories and psychiatric
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der. Br J Plast Surg 2003;56(6):546–551
64 oung VL, emecek R, emecek DA. The efficacy of breast augmentation: breast
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1994;94(7):958–969

3 Photographic Essentials in Aesthetic Surgery
Walter C. Lin, William Y. Hoffman, and Farzad R. Nahai
Abstract
Understanding of fundamental concepts and basic photographic
knowledge are required for accurate and reproducible medical
photography. This chapter discusses terminology and key ele-
ments with emphasis on the clinical setting, including the inter-
play between shutter speed, aperture, and ISO speed in obtaining
proper exposure, as well as appropriate selection of focal length,
acceptable lighting, metering adjustment, and control of depth
of field. Photographic standards are reviewed for various regions
of interest. Also discussed are considerations regarding digital
photography, including key differences between smartphones,
point-and-shoot, and single-lens reflex (SLR) cameras and the
impact of varying sensor size, file format, resolution, dynamic
range, and file storage. Medicolegal aspects of Health Insurance
Portability and Accountability Act (HIPAA) compliance and pri-
vacy now play critical roles in every surgeon’s practice.
Purposeful selection of focal length, exposure, and lighting
permits capture of reproducible, standardized clinical photog-
raphy. Application of advanced topics enable the surgeon to
capture studio-quality images without the need for a dedicated
photographer.
Keywords
photography, photographic standards, digital camera, SLR,
lenses, smartphone, point-and-shoot, flash, postprocessing,
HIPAA
3.1 Introduction
Photography plays a critical yet understated role in the practice of
plastic surgeons. Perhaps most important is the ability to create
standardized and reproducible photographs of the patient over
time, such that the only aspect of the photograph that changes
is the patient and nothing else. The underlying principles lay
groundwork in clinical planning, medicolegal documentation,
and patient communication. Comprehension of the underlying
fundamental concepts enables meaningful application of pho-
tography in educational and commercial marketing settings.
Although most principles of photography have remained
unchanged over the previous decades, new considerations have
arisen because of technological advances in digital photography.
The last decade has experienced exponential growth in the
quality and accessibility of camera equipment, photo processing
software, and image sharing that requires new considerations.
Image quality from mobile phones and devices nearly rivals
professional equipment from the last decade. Some modern
professional equipment is no longer prohibitively expensive and
is readily available even for surgical trainees. Virtually unlimited
digital storage space allows documentation of every aspect of
care by both the physician and the patient.
3 Photographic Essentials in Aesthetic Surgery
hereas photos were once taken sparingly due to the prohib-
itive costs of film and film development, photos are now taken
easily and often. uality photography requires careful, thoughtful
setup; however, software now enables correction of minor flaws in
lighting, exposure, and other elements of composition. Traditional
portfolios were once collected in elegant leather-bound binders,
but high-speed Internet now enables instantaneous sharing
globally, opening unprecedented possibilities for media use in
education and publication.
Because of this digital evolution, it is crucial to understand
older fundamental principles in addition to newer concepts so as
to make full use of photography in one’s practice. Skilled photog-
raphy is essential in the practice of any plastic surgeon, no matter
whether photography is provided by a third-party photographer
or by surgeons themselves. This chapter describes the essential
concepts underlying photography, lighting, and image processing,
as well as digital considerations all important elements for
creating photos suitable for documentation as well as publication.
3.2 Background
Whether referring to a camera phone, point-and-shoot, or
single-lens reflex (SLR) camera, certain concepts and consider-
ations remain universal. Conceptually, photographs are collections
of light photons reflected from the subject, which are collected
and focused through a lens and finally activate a film negative or
a digital sensor that records them. The combination of the lenses,
aperture, and shutter control the characteristic way light contacts
the sensor, determining how the subject and background are
portrayed.
The following sections detail key elements that characterize
a photograph. With understanding and practice, each element
can be altered to achieve desired and consistent results, such as
a blurred background and foreground that isolate the subject in
portrait photography, or tack-sharp photographs to highlight
clinical findings.
3.3 Basic Elements of Exposure
3.3.1 Focal Length, Shutter Speed,
Aperture, ISO Speed
Focal Length
Focal length is the distance from the optical center of the lens
to the focal point on the image sensor at which the image is
properly focused. The ratio of the sensor size to the lens focal
length determines the field of view. Longer focal lengths magnify
the image and create a narrow field of view, as experienced with
telescopes or telephoto lenses, while shorter focal lengths allow
a wide viewing angle at the expense of distortion, as with front
door peepholes or fisheye lenses.
21
 I Fundamentals

Because the ratio of the sensor size to the focal length deter-
mines field of the view, standard convention expresses focal
length in terms of 35-mm film/sensor equivalent. The field of
view of the human eye is approximated by a 40- to 50-mm lens.
Clinical photographs are best taken using portrait lenses in the
85-mm to 135-mm range.

Selecting a Lens: Zoom versus Prime Lenses

oom lenses provide versatility and convenience over a con-
tinuous range of focal lengths. However, their complex design
requires increased weight, size, and cost as well as compromises
in optical performance and aperture size. oom lenses typically
demonstrate their worst image quality at the extremes of per-
formance: at the longest or shortest focal lengths, and with the
largest and smallest apertures.
In contrast, prime lenses provide only one fixed focal length. a
The simpler design requires fewer parts, which have all been opti-
mized solely for one focal length. Overall, the result is a lighter,
smaller lens with sharper images than can be obtained with zoom
lenses at the same focal length. The lack of variable focal lengths
is easily overcome by simply walking toward or away from the
subject or changing lenses.
The choice between zoom and prime lenses is a personal pref-
erence. If nearly all photos are taken at a specific focal length, then
better results would be obtained by switching to a prime lens.

Pitfalls: Optical Distortion and

Perspective Distortion
Clinical photographs commonly suffer from distortion associ-
ated with wide-angle lenses (shorter than 40 mm) in the form of
optical distortion and perspective distortion.
Unwanted distortion is minimized in clinical photography b
by selecting medium telephoto lenses (85 mm to 135 mm) and
stepping farther from the subject. If space is limited, the distance Fig. 3.1 Optical distortion is most apparent when viewing (a) a large
between the subject and photographer must be maximized, with grid of parallel lines through a wide-angle lens, where (b) the lines
appear to be curved.
the longest focal length possible.
Also known as lens distortion or barrel distortion, optical
distortion consists of the curved appearance of straight lines
because our total field of view, including all the objects that we can
see around us, is a sphere, but the camera projects that view onto
a flat surface. Although all lenses have some amount of distortion,
the effect is more prominent in wide-angle lenses, which include
a larger portion of the total field of view (Fig. 3.1), just as a map
of a small part of the earth, such as a city neighborhood, shows
straight lines as straight, but a map of the whole earth is always
distorted in some way. Again, selection of a medium telephoto
lens minimizes the risk of distortion of clinical photographs.
In contrast to optical distortion, perspective distortion can be
avoided. Perspective distortion refers to the bulging appearance of
the subject when the subject is too close to the camera. This exag-
gerates the differences in distance between different parts of the
a b
subject; closer parts look much larger than more remote parts. In
Fig. 3.2, the same magnification is simulated in both images, but Fig. 3.2 Selection of the proper focal length minimizes perspective
Fig. 3.2b was taken at a much closer distance than Fig. 3.2a. The distortion. (a) Frontal view taken using a 90-mm lens at 1 meter
distance provides no significant distortion. (b) The same magnification
model’s face is drastically different between the two images. with a 50-mm lens requires a shorter working distance, which distorts
Distortion should be minimized by using longer focal lengths facial features (the subject’s nose and lips are proportionally much
(medium telephoto, portrait, or telephoto) and by placing the closer to the camera than her ears and neck are). The flash angle is also
exaggerated and casts harsher shadows.
subject farther from the camera. Longer focal lengths have the

22

effect of flattening the image by minimizing such distortion.
The recommended focal lengths are discussed in the Photographic
Standards section.
Shutter Speed
Shutter speed limits the length of time that light interacts with
the sensor. Film cameras use a mechanical shutter; digital
cameras typically use an electronic equivalent that activates or
samples the sensor for only a given length of time. Longer shutter
speeds can be desirable in certain settings, such as landscape
photography or astrophotography of night skies, but the image
is blurred if the subject or the camera moves while the shutter is
open. In the clinical setting, blurry photos are unusable photos.
As a general rule of thumb, shutter speeds of 1/50 second or
slower can often result in blurry photos. A shutter speed of 1/125
second or faster works well in the clinical setting.
Aperture
The aperture of the lens functions as an adjustable iris, varying the
amount of light passing to the sensor, independent of all other set-
tings. The size of the aperture is described by the f-stop number,
which is the ratio of the aperture diameter to the focal length (f) of
a b
d e
Fig. 3.3 The f-stop controls the cross-sectional area of the aperture, which controls how much of the light from the subject reaches the sensor.
Apertures are shown at (a) f/1.2, the maximum this lens allows, (b) f/1.8, (c) f/2.8, (d) f/4, (e) f/5.6, (f) f/8.
3 Photographic Essentials in Aesthetic Surgery
the lens. Each step in the familiar progression f/2, f/2.8, f/4, f/5.6,
and so on mathematically represents a change of cross-sectional
area, and will thus the amount of light gathered, by a factor of 2.
Thus, changing from one f-stop to the next (say, from f/2 to f/2.8)
decreases the aperture area by half and will thus collect only half
as much of the light, and so on and so forth with increasing f-stop
numbers. Accordingly, the camera sensor requires a shutter speed
twice as long to maintain the same exposure (Fig. 3.3).
Crucial to effectively using aperture, users must remember
the lower the numerical f-stop, the larger the aperture. More light
reaches the sensor, allowing a faster shutter speed, resulting in
an image with less risk of motion blur. Lenses with large aper-
tures, referred to as “fast lenses, require larger glass elements to
maintain the low focal length/aperture ratio, and are respectively
heavier and more expensive. Conceptually, a lens that has an f/1.0
aperture would be roughly as wide as it is long, cumbersomely
heavy, and prohibitively expensive.
In relative terms, the human eye has a focal length of about
17 mm. The pupil has a 2-mm diameter in bright light with an
equivalent f/8.3 aperture. In the dark, the pupil has an 8-mm
diameter, with an equivalent of f/2.1. Modern cameras have longer
focal lengths and wider apertures than the human eye, with the
ability to create photos that appear far brighter than reality, as
c
f
23
 I Fundamentals

with wedding photography using available light, or astronomical of opening of the faucet valve represents the aperture setting of
photographs that capture thousands of stars too faint to see with the lens, and the amount of time that the faucet runs represents
the naked eye. the shutter speed. Thus, the volume of water is determined by
As previously mentioned, lenses have worse image quality at the opening of the valve and the amount of time the faucet is
the extremes of their performance at the widest and smallest open. This is equivalent to the cross-sectional area multiplied
apertures, images will be less crisp. As a rule of thumb, most by the time, which parallels the lens aperture multiplied by the
lenses have a sweet spot for maximum image sharpness in shutter speed.
the midrange. For clinical photographs, an aperture in this middle Continuing this analogy, the sensor ISO then represents the
range around f/7 to f/11 will provide crisp images while providing a size of the water bucket. For proper exposure, the bucket requires
f fi filling exactly to the brim. If the bucket is underfilled, the sensor is
focus as well. Depth of field is a more complex but very important not activated, and the photograph is underexposed and too dark.
topic, discussed in a later section. Overfilling the bucket causes too much light to reach the sensor,
and the photograph becomes overexposed and too bright.
A small bucket represents a high-ISO, highly sensitive sensor,
Sensitivity (ISO Speed)
which requires only very little water/light to be properly exposed.
Films differ in their sensitivity to light, and so do digital sensors. A
A large bucket represents a low-ISO/low sensitivity sensor that
high-sensitivity film or sensor requires less light (fewer photons)
requires much more water/light.
to activate an individual point (pixel) in the image; a lower-sensi-
There is a tradeoff between shutter speed and aperture, as
tivity film or sensor requires more light (more photons) to get the
demonstrated in Fig. 3.4. Both frames have equivalent exposure,
same activation. For the camera to collect more photons, either
or the total amount of light collected, so the dog, the grass, the
there has to be more available light to begin with (e.g., bright sun-
sea, and the sky have the same colors and brightnesses in both.
light rather than shade), or the aperture has to be wider (lower
f-stop), or the exposure has to be longer (slower shutter speed). At
a given light level and f-stop, a more sensitive film or sensor takes
less time to collect enough light to activate it, so it is said to be
fast, just as a wider lens that allows a low f-stop is.
The International Organization for Standardization (ISO) has
determined an industry scale for the speed or sensitivity of a
film or sensor to light, replacing older different scales used in
the United States and Europe. Today the speed rating of a film or
sensor is often called simply its ISO. High ISO represents high
sensitivity, so fewer photons are required to activate the sensor,
and conversely low ISO means low sensitivity and requires more
photons. A sensor with ISO 100 requires twice as much light as a
sensor with ISO 200.
High-ISO films and sensors allow shooting in darker places, use
of higher f-stops (giving better focus, as will be discussed later),
and faster shutter speeds (for sharper views of moving subjects), a
but they tend to produce images that are grainy and noisy. If only
three or four photons are necessary to activate a given individual
point element (pixel) of the sensor, then one stray photon has a
greater chance of erroneously activating the pixel. On the other
hand, a low-ISO sensor might require a thousand photons for
activating a pixel, so it will not be affected by one stray photon.
Images taken with a low ISO are smoother, less noisy, and less
grainy, and ultimately higher-quality and more useful.
Because lower-ISO images produce less grainy images, optimal
photographs use the lowest possible ISO that still allows an accept-
able shutter speed and the desired aperture. Most cameras have
an auto ISO setting that automatically uses the lowest acceptable
setting while maintaining a usable shutter speed.

3.3.2 Exposure
Conceptually, exposure represents the cumulative light cap-
tured within a photograph, as determined by the shutter speed,
aperture, and film sensitivity (ISO). A common analogy is filling
a bucket with water from a faucet. The exposure represents the
total volume of water (volume of photons) collected. The amount
b
Fig. 3.4 Tradeoff between aperture and shutter speed, with constant
ISO. Both frames have equivalent cumulative exposure but differing
depth of field and motion blur. (a) 1/320 sec, f/8.0, ISO 100 creates a
wide depth of field and a detailed background, at the cost of motion
blur. (b) 1/8,000 sec, f/1.8, ISO 100 eliminates motion blur but has a
shallow depth of field with a blurred background.

24

Fig. 3.4a uses a small aperture of f/8.0, which requires a shutter of
1/320 sec for proper exposure at this light level and ISO speed. The
depth of field (discussed in the next section) is broad, meaning
that detail in the farthest parts of the landscape is as sharply
focused as the foreground. However, the dog’s motion makes him
look blurry at this shutter speed. Fig. 3.4b uses a large aperture of
f/1.8, which requires only 1/8,000 sec shutter for equivalent expo-
sure. The dog appears sharp despite his motion, but the depth of
field is shallow, with everything farther than the dog blurred. The
difference in the photographs is significant despite the point of
focus being the dog in both photos.
SLR cameras and some point-and-shoot cameras allow the
photographer to force the camera to maintain a certain aper-
ture ( aperture priority ) or shutter ( shutter priority ) while
automatically computing the other variables to maintain proper
exposure. Program mode allows the user to determine the
aperture and shutter, while automatically calculating ISO. Manual
mode allows the user to set shutter, aperture, and ISO, and is the
best for the user to learn the concept of exposure.
3.4 Advanced Concepts
3.4.1 Depth of Field
The f fi describes the zone in front of and behind the
focal plane where objects appear to be in focus and are acceptably
sharp (Fig. 3.5). Depth of field is determined by a combination of
aperture size, subject distance, focal length, and sensor size, but
it is most easily controlled by varying the aperture.
A conceptual understanding of depth of field helps the photog-
rapher to use it meaningfully. Objects closer than the focal plane
are focused by the lens at a spot behind the sensor, so they appear
as a blurry spot on the sensor. Objects farther than the focal plane
come into focus in front of the sensor and subsequently defocus,
so they appear as blur spots as well.
ith all camera settings equal, the size of the blur spots varies
depending on an object’s distance from the focal plane. There is a
distance in front of and behind the focal plane where the resulting
a b
Fig. 3.5 Example of shallow versus wide depth of field. (a) The large aperture of f/2.8 creates a shallow depth of field and consequently loses fine
detail in the medication labels out of the focal plane. (b) The small aperture of f/11 preserves fine detail out of the focal plane and is more useful in
clinical situations.
3 Photographic Essentials in Aesthetic Surgery
blur spots are small enough that they appear to be in focus. This
range is referred to as depth of field (Fig. 3.6).
Decreasing the aperture size will also decrease the size of the
blur spots, thus making the depth of field wider. Clinical pho-
tographs are best taken using a smaller aperture to maintain a
broad depth of field, ensuring that details across all contours of
the patient remain in focus.
In nonclinical portrait photography a narrow depth of field
can be advantageous and aesthetically pleasing, since attention
is inherently drawn toward the only object in focus the subject.
To truly create the narrowest depth of field possible, a combina-
tion of largest aperture size; shortest subject distance; longest
focal length; and largest sensor size possible would be used. In
practice the camera should be set to the largest aperture available
(the lowest f/number), which in commercially available high-end
lenses is commonly f/1.2.
However, shallow depth of field is not suitable for clinical use
because of the loss of detail out of the focal plane (Fig. 3.7). A
broad depth of field should be utilized in clinical situations,
ensuring that both the nasal tip and the helical rim of the ear
appear focused.
3.4.2 Lighting and Flash
In the clinical setting, lighting conditions are often suboptimal.
Various types of supplemental light sources compensate, includ-
ing on-camera flash, external flash, and remote flash. However,
single point sources of light create harsh shadows and highlight
contours, similar to direct sunlight. o matter the type of device,
the underlying goal remains the same: to create a broad source
of noncoherent light that illuminates the subject from multiple
angles. Such ideal sources of light provide soft illumination
without casting harsh shadows.
Classic examples of ideal light include sunlight filtering through
a white curtain (used commonly by wedding photographers),
bright overcast days, or sunlight reflecting from a broad white
wall. Studio photography recreates this effect using multiple
flashes reflecting from umbrellas.
25
 I Fundamentals

Fig. 3.6 Illustration of depth of field. Point A (blue) lies within the
focal plane and correctly focuses as a point on the sensor. Point X
(red) is behind the focal plane; light from this point is focused by the
lens and then diverges and appears out of focus. Point Y (yellow) is in
front of the focal plane, so light from it has not come into focus and
also appears out of focus on the sensor. Point Z (green) is in front of
the focal plane but within the depth of field, and it appears as a small
enough blur spot that it is considered to be in acceptable focus by the
observer.

In the clinical setting, it is not often practical to re-create studio

lighting. Ideally, a dedicated photography studio setup would be
created in the clinic, consisting of three light sources as in Fig. 3.8.
The key light provides main illumination, while the fill light illu-
minates areas missed by the key light. The back light illuminates
the back of the subject, enhancing edges and borders.
On the ward, carrying around a three-point lighting setup is
impossible. The most suitable alternatives include an on-camera
or external flash, as discussed later in the chapter. The external a
flash may be used as a bounce flash, in which the external flash
is directed upward toward the ceiling or backward toward the
wall behind the camera. The light reflects from the ceiling or wall
and acts a surrogate to a broad diffuse source of light. The built-in
on-camera flash is the simplest, most direct option.
In the operating room, lighting conditions are variable.
However, overhead lights can be used to emulate broad sources of
light (Fig. 3.9). By utilizing multiple overhead lights, it is possible
to simulate diffuse light. In Fig. 3.10, multiple overhead lights are
used to eliminate shadow and simulate a broad source of light:
one light is behind the subject, another in front, and another to
the side. Fig. 3.11 shows an example of a photo taken using mul-
tidirectional overhead operating light. Having said that, operating
room lights can cause white-out and harsh, overexposed photos
or photos with a spotlight effect (bright and overexposed in
the middle and dark on the borders), so sometimes it is best to
direct the operating room lights away from the field and adjust
the camera settings accordingly.

3.4.3 Metering
ithin the camera, light meters monitor the intensity of incom-
ing light and calculate the appropriate shutter and aperture for
proper exposure. By selectively limiting the area being sampled,
various metering modes permit more accurate exposure for a
specific region of interest.
b
Fig. 3.7 (a) This photo demonstrates an extremely shallow depth of
field, which is pleasing in portraits but should be avoided in clinical
photos due to loss of detail. (b) Although the eyes are in focus, the
eyebrows, nose, and ears all appear blurry.

26

Fig. 3.8 Three-point lighting for portrait photography consisting of a
main key light, fill light, and a back light.
Fig. 3.10 In combination, multiple overhead lights produce even
illumination from multiple directions, eliminating distracting shadow.
The default, evaluative metering, assesses the light levels across
the whole scene in order to determine correct exposure; this is
useful for travel or recreational use (Fig. 3.12a). However, proper
exposure as determined by the camera may be unsatisfactory
to the photographer. This commonly occurs in certain surgical
photos, creating photos that are too dark and lack detail of desired
anatomy. Correction requires proper exposure. Aside from man-
ually changing the shutter, aperture, and ISO, corrections can be
automated by altering the camera’s metering mode and exposure
compensation.
By changing metering to center-weighted (the center of the pho-
tograph is used to calculate exposure, regardless of focus point;
Fig. 3.12b) or spot (exposure based on the focus point; Fig. 3.12c),
the photographer instructs the camera to calculate the correct
exposure based on a smaller, more specific area of interest.
3 Photographic Essentials in Aesthetic Surgery
Fig. 3.9 Modern overhead operating room lights in fact behave as
multi-point-source light sources.
Fig. 3.11 Operating room photograph taken using three overhead
operating lights combined into natural-appearing diffuse lighting.
Exposure compensation instructs the camera to overexpose or
underexpose the photo automatically. For instance, in Fig. 3.13a,
the building and person are underexposed and the clouds are
overexposed; detail has been lost in both subjects. To visualize
detail in the underexposed building and person, exposure com-
pensation can be set to overexpose the photograph. This results in
a properly exposed building and face, at the cost of an even more
overexposed cloud (Fig. 3.13c).
In the clinical setting, wounds tend to be composed of darker
tissue (muscle, ecchymoses, and eschar for instance) and may
be located in difficult-to-illuminate areas (decubitus ulcers).
Important details can be revealed by forcing camera overexposure.
With image software postprocessing, photos are more accept-
able when they are overexposed and then darkened, as opposed
to underexposed and then lightened, as the latter results in grainy,
27
 I Fundamentals

a b c
Fig. 3.12 Red shading represents the selected region used by a camera to determine the correct exposure. (a) Evaluative metering. (b) Center-
weighted metering. (c) Spot metering.

a b c
Fig. 3.13 Exposure compensation allows detail to be revealed in regions of interest. (a) Using the default exposure setting, the building and person
are underexposed and the clouds are overexposed. (b) Setting −1 f-stop exposure compensation reveals detail within the clouds. (c) Setting +1 f-stop
makes the building detail visible and gives the person’s face a natural appearance.

noisy photographs that are less useful. In the hospital setting, it is
often helpful to set exposure compensation to 2/3 or 1 f-stop.
3.4.4 Postprocessing
Despite careful planning, in some instances the ideal exposure
is not always obtained, resulting in unusable photographs.
Fortunately, powerful programs are available to rescue such
photographs through postprocessing, referring to the process
of adjusting an already-captured image to achieve a desired
appearance, without manipulating the content of the photo.
Although powerful image manipulation software is available,
it is crucial not to create misleading appearances or enhance
results. Instead, the goal should be to correct for suboptimal
lighting conditions and/or reproduce lighting conditions to allow
comparison between photos.
The most useful and high-yield basic adjustments include white
balance and exposure correction. Sharpening and vignette correc-
tion can add subtle but significant refinement. For intraoperative
photos it is helpful to darken the highlights, lighten the shadows,
and selectively decrease red saturation to allow details within
bloody surgical wounds to be visible. Local adjustment masks can
be used to correct for suboptimal lighting and reveal detail within
shadows. Combined, postprocessing adjustments can rescue a
poor photograph as in Fig. 3.14.
When selecting postprocessing software, it is recommended to
use programs with nondestructive editing, in which the original
photo remains intact and can be restored. Editing is stored separately
in a separate file or program catalog. Using such software, a series
of adjustments can be stored as a shortcut for different lighting
situations, for instance clinic, operating room with flash, oper-
ating room without flash, and so on, and photos can be processed

28
 3 Photographic Essentials in Aesthetic Surgery

a b
Fig. 3.14 (a) Original photograph taken with suboptimal lighting conditions, resulting in uneven lighting and unnatural color. (b) Postprocessing the
raw format file allows for correction of color, exposure, and uneven lighting distribution.

a b
Fig. 3.15 Example of postprocessing. (a) The unprocessed raw image of the same scene as in Fig. 3.13, exposed at a level between those of Fig. 3.13a
and Fig. 3.13b, appears dull and washed out. (b) After postprocessing correction, the texture and detail are revealed vividly within both the building
surface and the clouds, a result that could not have been obtained with exposure compensation alone.

quickly and efficiently. hen exporting photos, it is recommended
to remove file metadata so as to remove GPS information, time/date
information, and other identifiable characteristics.
3.4.5 Compressed vs. Uncompressed
vs. Raw Format
Postprocessing provides the best results when working with
uncompressed raw format files, which are the digital equivalent
of film negatives and retain all original data. Photos are com-
pletely uncompressed and retain the most information, so
there is no data loss in shadows or highlights, as with formats
compressed for the sake of file size. ithout editing, photos
often appear washed out and faded. However, these photos
have the most potential; after processing parameters such
as exposure, white balance, contrast, and other adjustment,
these may produce the most dramatic photos once edited
(Fig. 3.15).

29
 I Fundamentals

However, if storage space is a concern, as with email or inter-

net photo sharing, compressed formats may be desirable. All
compressed formats trade convenience of file size in exchange
for loss of information that the user is less likely to notice. At the
time of print, the most common file compressed format used
is the oint Photographic Experts Group ( PEG). In this format,
information is discarded in less perceptible regions, such as fine
details in the darkest portions of shadows. PEG files are not ideal
for postprocessing, because information has been discarded and
cannot be rescued, resulting in odd artifacts. This is known as
lossy compression, where information is lost every time the file
is saved. The compression generates artifacts that distort fine
details with increasingly higher compression levels, as shown
in Fig. 3.16.
For the best photo quality and most control over file size, if photo
postprocessing is anticipated, it is optimal to shoot photos in raw
format and subsequently convert to a compressed format such
as PEG for sharing. If postprocessing is minimal or not desired,
files may conveniently be taken in PEG format with relatively low
levels of compression.
As will be discussed in more detail subsequently, the advent
of cloud storage and high-speed Internet communications and
decreasing memory and disk space costs make the need for com-
pression less of a concern.
3.5 Considerations in
Digital Photography
3.5.1 r eri i A e ing
Image Quality
Sensor Size
ith an identical megapixel resolution, a larger sensor has larger
pixels. Each pixel captures more light, resulting in less noise and a
smoother image. High-end full-frame cameras have sensors equiv-
alent to a 35-mm film frame (36 mm 24 mm in size) but conse-
quently require larger, heavier lenses and camera bodies. Many
consumer-level cameras have smaller sensors for convenience,
demonstrated by the Advanced Photo Systems (APS) sensors (14
21 mm to 16 24 mm) and Four Thirds sensors (12 17.3 mm).
Top-of-the-line digital medium format cameras have 48-mm
36-mm sensors and currently cost tens of thousands of dollars.
The ratio of a 35-mm sensor diagonal (43.3 mm) to a given cam-
era’s sensor is termed the crop factor. With identical conditions,
lenses, and settings, two differently sized sensors will produce
different photographs, as illustrated in Fig. 3.17. The smaller
sensor samples a smaller area, effectively magnifying the image

a b

c d
Fig. 3.16 Example of artifacts and loss of information detail with high Joint Photographic Experts Group (JPEG) image compression. (a,c) The 1:1
zoom shows fine details within the iris and scleral capillaries. (b,d) With unacceptably high JPEG compression, blocky artifacts distort the image.

30
 3 Photographic Essentials in Aesthetic Surgery

b c
Fig. 3.17 (a) Any camera sensor samples only a fraction of the image projected by the lens, cropping the original image. The yellow box simulates the
image captured by a full-frame 35-mm sensor, while the red box simulates a smaller image from a crop sensor. (b) The image obtained using a full
frame sensor. (c) The image obtained using a crop sensor. Note the smaller sensor captures a smaller portion of the image and has the appearance of
using a longer focal length.

with the equivalence of a new f , calculated Dynamic Range

by multiplying the original focal length by the crop factor. In a
similar fashion, the aperture and corresponding f are
calculated by multiplying the f/number by the crop factor as well.
Thus, when using an APS sensor with a 1.6x crop factor, to create
portrait photos with the appearance of an 85-mm portrait lens, a
50-mm lens should be used, since 50 mm 1.6 80 mm.
Resolution
Adequate camera sensor resolution for publication is no longer
a significant concern, as newer cameras have far greater resolu-
tion than necessary. hen decreasing resolution within camera
settings or during storage, it is recommended to store photos
at 7.6 megapixels or greater, which would allow for an
8 10 photo print at 300 pixels per inch (ppi). Higher-
resolution files, preserving finer detail, are recommended
if practical. Storage practicalities are discussed later in this
section.
Dynamic range represents the ability of a sensor to identify
information across varying levels of brightness, determining the
quantity of detailed information captured in the very brightest
and darkest areas of a scene. Outside of this detectable range,
anything brighter appears as blown out white areas, and
anything darker appears as plain black. The information in
these outer regions is not captured and cannot be rescued with
postprocessing. If the scene’s dynamic range is broader than the
camera’s dynamic range, then information will be lost in the
scene. The comparison between the dynamic range of the human
eye and that of a digital sensor is shown in Fig. 3.18. Because
of the human eye’s superior dynamic range, scenes with highly
varying brightness, such as sunsets, are far more stunning in
person than in photos.
Dynamic range depends on the quality of the sensor and the
file format. High-end camera sensors are able to distinguish light
across a broader range of light intensity. Raw, uncompressed files

31
 I Fundamentals
Fig. 3.18 Comparison of dynamic range across varying levels of brightness in the human eye versus film and digital sensors. Film and sensors are
unable to distinguish among light levels at the extremes of intensity, and information is lost and appears as pure black or pure white within the image.
also retain the detailed information in the brightest and darkest
portions, which are typically discarded with routine compression
algorithms in exchange for smaller file size.
File Storage and Backup
ith digital images, the choice of file storage balances image
quality versus file size. File format and resolution impact imme-
diate utility, as well as future usability in publication.
In general, smaller files are easier to share and store but
have worse image quality and are not useful for editing due
to the loss of data during compression. Over time, with newer
technologies that support higher and higher resolution, such
as high-definition (HD) computer monitors, compressed files
appear obsolete and dated. Larger files, on the other hand,
retain as much data as possible and are more likely to be usable
with newer resolution standards. Even though they consume
more storage space, given the combination of high-speed
Internet and unlimited, secure compliant online storage that
complies with Health Insurance Portability and Accountability
Act (HIPAA) requirements for security and confidentiality,
uncompressed or raw files are no longer prohibitive to main-
tain. Such uncompressed raw files are more likely to be updated
and usable in 10 to 20 years.
Since photos are irreplaceable, it is recommended to back
up photo databases regularly with redundancy, optimally in a
separate geographic location in the event of a natural disaster.
Commonly this may be accomplished through a rotation of mul-
tiple encrypted hard drive backups that are stored in physically
different buildings. Alternatively, online cloud storage provides
redundancy, but care must be taken to ensure HIPAA compliance
within the online service. Furthermore, the permanence and
security of online storage cannot be taken for granted, and dupli-
cate physical hard drive backup is still recommended.
32
Camera Selection: Smartphone vs.
Point-and-Shoot vs. SLR
The optimal camera choice is ultimately personal preference,
balancing portability with image quality, assuming all security
and privacy requirements are met.
Smartphones are undoubtedly the most convenient and most
ubiquitous cameras available, with acceptable image quality
for general health care needs. Although some offer the ability
to take photos in a raw uncompressed format, image sharpness
has not yet reached the level required for publication. Patient
privacy remains the primary hurdle preventing widespread use
of smartphone use. Photos should not be stored locally on the
phone; instead, some electronic medical record (EMR) services
offer smartphone apps that allow encrypted uploading directly
to the service, bypassing local storage on the phone. It is crucial
to educate health care staff regarding the dangers and pitfalls of
photo sharing and social media using unauthorized smartphone
use in the clinical setting.
The image quality of smartphones will never equal that of
stand-alone cameras in the near future, simply due to the physics
involved, with sensor size and the quality of optical elements. In
terms of image crispness and dynamic range, the major determi-
nants are sensor size and quality, giving SLR (and mirrorless SLR)
cameras the advantage. Interchangeable lenses used with SLR
cameras offer the best performance. SLR cameras will beat point-
and-shoot cameras and smartphones in virtually every aspect
except for cost, convenience, and portability.
Point-and-shoot cameras provide a practical middle ground
between smartphones and SLR cameras. For clinical use, the most
useful cameras provide modes allowing the user to manually
select the desired shutter (shutter priority), aperture (aperture
priority), or both (program mode), also with the option to
select ISO (manual mode). This allows consistent, reproducible
 3 Photographic Essentials in Aesthetic Surgery

photographs to be taken across timepoints by using the same standards, but the guiding principle is to establish a standardized
aperture setting, for instance. system that can be performed and replicated identically over
time, with the same angles, lighting, backgrounds, and content.
Across timepoints, different areas of the body should be taken
Protected Information and HIPAA Compliance
from the same angles with the same focal lengths. Lighting should
The ease of file sharing necessitates the utmost care to ensure
be consistent, ideally using multiple sources of light to avoid
patient privacy and security. Identifiable features of photos
shadowing. Color balancing should be performed at the time
include showing the full face of the patient, tattoos, or any of
of photography or with postprocessing. Distractions should be
the 19 elements of protected health information, as shown in
minimized, such as jewelry and certain clothing. In the operating
Table 3.1. Of note, it is no longer acceptable solely to mask the
room, bloodstained skin should be cleansed; clean, dry towels
eyes. It is strongly recommended to obtain consent when using
should be used to provide a uniform background; and lighting
any part of the face.
should be standardized.
Photos must be stored in a HIPAA-compliant fashion. Digital
In general, facial photographs are best taken using portrait
photos must be stored securely on encrypted hard drives. Since
lenses around 90 to 110 mm in focal length to minimize distortion.
most cameras and memory cards do not have password capability
hen this is not possible, due to equipment or small examination
or built-in encryption, it is crucial to download and delete media
rooms, it is most helpful to step as far away from the subject as
from cameras regularly and in a timely fashion lest the camera be
possible and crop the image to create a rough equivalent to using
lost or stolen. Furthermore, some file-keeping software includes
a portrait lens. Photos of the body and extremity are best taken
the patient’s name in the metadata of the photograph. In that case,
using normal lenses around 50 mm. hen using a smartphone
if the files are shared for any reason, the file name and metadata
or point-and-shoot camera, the best photos result from taking
should be cleared of any patient identifying information before
several steps farther from the subject and zooming in on the
being shared.
patient.
Patient consent must be obtained for any use outside of a sur-
gical practice for treatment, payment, or healthcare operations.
Any external use of photos in conferences, seminars, or other 3.6.1 Standard Views for Regions of
public areas requires patient consent. Photos that do not contain
Interest
identifiers do not require approval.
The following sections briefly describe defined standards for
varying body regions of interest. A reference booklet is available
from the American Society of Plastic Surgeons and Plastic Surgery
Table 3.1 Identifiable protected health information
Educational Foundation and is recommended for reference. In all
Iden i e r e ed e in rm i n
instances, distracting elements jewelry, heavy makeup, hair,
em gr i in rm i n edi in rm i n etc. should be removed. To minimize variation across time-
• Name • Date of treatment points, ideally the same location, lighting, camera position, and
• Date of birth • Fingerprints or voiceprints
patient positioning settings should be reproduced. Strategically
• Address
placed tape marks (or footprints) along the floor help expedite
• Telephone number
• Fax number positioning of the patient (Fig. 3.19a), and markings along the
• Email address wall direct the patient’s gaze. Standardized smooth, diffuse
lighting is readily available using commercially available soft-
Iden i i n num er S i in rm i n
• Social Security number • Names of relatives boxes or umbrellas, as shown in Fig. 3.19b.
• Medical record number • Name of employer Facial photographs are typically taken using a portrait or
• Account number • Website address medium telephoto lens (85 mm to 135 mm) at a 1-meter distance
• Driver’s license number • Internet address of computer or farther, aiming to include the vertex to suprasternal notch
• Credit card number (Fig. 3.20). The patient should be aligned either along the Frankfort
• Health plan beneficiary number plane (external auditory canal to the infraorbital rim) or the natural
• Vehicle/device serial number horizontal facial line (patient subjectively looks forward at eye
level) (Fig. 3.21). The entire body should be rotated for oblique and
lateral views. To standardize oblique views, it is helpful to align
the nasal tip with the anterior border of the cheek. A standardized
basal view aligns the nasal tip with the upper lid crease.
3.6 Photographic Standards in Photographs of the eyes should include from the eyebrows
Clinical Practice down to at least the upper lip to ensure inclusion of the orbitoma-
lar troughs. Aside from the typical angles, photos should include a
Although there are many ways to photograph a subject using closed-eye view, upward gaze, and downward gaze.
various lighting styles or settings, a key tenet in clinical practice asal photographs should include the eyebrows and upper lip
is standardization and reproducibility, which allows comparison as well. Additional views include a worm’s-eye view, cephalic
across timepoints. ith standardized and reproducible meth- view, and views with dynamic contraction.
ods, the only aspect of the photos changing over time is the Lip photographs should be taken in repose, with the lips resting
patient. umerous authors have published their recommended and slightly parted. Oblique views can be reproduced by lining up

33
 I Fundamentals

a b
Fig. 3.19 (a) Example of a floor diagram to direct patient positioning during photography. (b) Example of commercially available softboxes that
provide continuous neutral white light.

f g

a b c

d e h
Fig. 3.20 Standardized views of the face. (a–e) The camera is on the plane of the Frankfort horizontal. The patient must turn the entire body
rather than just the head alone. The ears are used as reference to keep the head level. (f,g) Frontal close-up views of upper and lower facial halves.
(h) Worm’s-eye view.

the junction of the philtral column and vermilion with the contra- at the side, resting on the hips, or behind the back. For oblique
lateral cheek. Pursed-lip views help in identifying vertical lip lines. views, the arms should be moved posteriorly. Lateral views may
Views of the chest and breast should include the lower neck and be standardized by ensuring that the chest/breast farther from the
extend past the subcostal margin (Fig. 3.22). Arms may be placed camera is not visible.

34

a b
Fig. 3.21 Effect of head position. (a) Frontal photograph taken in the proper plane. (b) The camera is below the Frankfort horizontal. (c) The camera
is above the Frankfort horizontal. Note the difference in the appearance of the overall height of the face, the amount of scleral show, and the
prominence of the nose and chin among other features. Note that in b and c, the angle of the face from the horizontal is less than 10°, yet it creates
obvious differences.
The lower trunk and abdomen are photographed with the legs
at hip width, with feet parallel, including the inframammary fold
and extending to the upper thigh. Distracting clothing should
be replaced with standard disposable blue underwear. A diver’s
view taken at a slightly oblique angle, with the patient stand-
ing with the torso flexed highlights the abdominal soft tissue
(Fig. 3.23).
Lower extremities are shown completely from the umbilicus to
the toes or, alternatively, for a half-view, from the umbilicus to the
patella (Fig. 3.24), or from the patella to the toes. Ideally a lengthy
background should be used to extend from the background onto
the floor in a smooth, continuous fashion. If the feet are being
highlighted, a step stage is helpful. Lateral views may be standard-
ized by ensuring the farther leg is not visible.
3.6.2 Lighting Styles
Ideal lighting consists of using standardized, reproducible broad,
soft lighting to re-create even, smooth illumination from multi-
ple angles. However, outside of the office studio, this is impracti-
cal due to the amount of equipment and time required for setup.
There are several ways to arrange the photograph according to
the desired result, with a tradeoff between studio publication
appearance versus speed and convenience.
“Standard” Flash
For most circumstances in the clinic, on the ward, and intraop-
eratively, photos are best taken using flash. Hospital and clinic
rooms are often unevenly lit with overhead light that results in
unflattering shadows across the patient’s face and body. Little
3 Photographic Essentials in Aesthetic Surgery
c
light is available, requiring high ISO sensitivity with a large
aperture to attain adequate exposure, resulting in a grainy
photo with a shallow depth of field that may also be blurry due
to inadequate shutter speed. Overhead tungsten or fluorescent
lights frequently mask accurate skin tones and color. It is not
recommended to take photos solely using ambient light unless
alternatives are not available.
To compensate for poor ambient light, the on-camera or external
flash provides reproducible lighting appearance regardless of the
ambient light, creating a more uniform photo series comparison
preoperatively and postoperatively. Flash also provides sufficient
light, allowing for lower ISO sensitivity and smaller apertures
within the f/7 to f/9 range, creating crisper images with less noise
and a broader depth of field.
ith flash photography, the position of the light source relative
to the lens affects the shadows cast upon the subject (Fig. 3.25).
ith any angled or side view, the flash should be on the side of
the lens that is closer to the patient’s anterior to avoid uneven
distracting illumination.
Bounce and Ring Flash
A more advanced technique is to direct the flash away from
the patient, reflecting light off of the ceiling or a wall, referred
to as a . This more accurately emulates a broad
source of light, decreasing the appearance of harsh shadows.
Often a shoe-mounted flash on an SLR camera is needed for this
maneuver.
are available and provide excellent high-intensity
light for macro photography. However, light is distributed so
evenly that shadows are eliminated and contours are difficult
35
 I Fundamentals
b c
d e
Fig. 3.22 (a–e) Standardized views of the breasts. Placement of the
hands on the hips for the lateral views is useful to show any postoper-
ative scars, the inframammary fold, and other features. Note that the
shoulders are aligned with the top of the photograph.
a b c
d e
Fig. 3.24 (a–e) Standardized half-view of the (upper) lower extremity.
36
a b
c d
Fig. 3.23 (a–d) Standardized views of the lower trunk and abdomen.
The diver’s view (d) highlights the abdominal soft tissue.
a b c
d e f
Fig. 3.25 The flash position relative to the lens casts differing shadows
and should be mounted on the same side of the lens as the patient’s
anterior. The top row shows a frontal view with the flash mounted to
the right (a), left (b), and above (c) the patient. Note the distracting
shadows cast with the flash mounted toward either side. The bottom
row shows a lateral view with the flash mounted toward the patient’s
posterior (d), anterior (e), and superior (f).

to discern. These flashes are useful for close-ups of detail or
difficult-to-illuminate areas, such as with dental or dermatologic
purposes, but are not typically used to photograph the body or
extremities.
3.6.3 S udi e gr y provide sufficient lighting, as in Fig. 3.11. Lights should be aimed
Certain instances call for meticulous photographs with back-
grounds completely free from distraction and evenly illuminated
details. Setup requires multiple light sources at varying angles
for elimination of harsh shadows. Backgrounds are meticulously
neat without distraction or reflection, such as with a velvet
background or a plain blue wall (Fig. 3.26).
Alternatively, the background can be eliminated completely as
in Fig. 3.27. This studio effect is accomplished by illuminating the
subject with high-intensity light while providing as little light
as possible to the background, table, and nearby elements. By
properly metering the photograph to the well-lit subject, typically
with the aid of center- or spot-metering, the background and
other elements appear far underexposed in relation and appear
Fig. 3.26 A simple blue background with evenly-distributed soft
lighting from multiple directions creates a pleasant appearance
without distracting shadows.
Fig. 3.27 An example of a textbook-style/studio-style photograph
with an absent background. This example shows medial femoral
condyle free flap anatomy prior to harvest.
3 Photographic Essentials in Aesthetic Surgery
black. This effect is best accomplished when the background and
floor are as far from the subject as possible, since less light will
reflect from the subject and provide less illumination.
Focused high-intensity light can be accomplished with external
flashes or spotlights. Operating room overhead lights function
well as spotlights and, when carefully aimed at the subject, can
to create smooth, even lighting. It is sometimes helpful to move
lights farther from the subject to allow greater diffusion of the
spotlight.
3.6.4 Intraoperative Photography
Intraoperative photography can be divided into two types:
staged and nonstaged, action shots.
ith appropriate staging, distractions are removed from the
operative field, including instruments and cables, as shown in
Fig. 3.28. Blood is wiped clean from the area. The area of inter-
est is surrounded using clean, dry operative towels to mask the
wrinkled, blood-speckled operative drapes. If flash is used, then
the operative lights should be removed from the field because of
uneven light intensity and difference in light temperature and
hue. Alternatively, operative lights may be used as spotlights
without the use of flash.
Staging of photographs can be time-consuming and disruptive
to the flow of the procedure. Alternatively, action shots taken
throughout the procedure capture key steps and fine detail with-
out repeated pauses. Results are best with telephoto lenses and
center- or spot-metering and overhead operative light, as shown
in Fig. 3.29.
3.7 Concluding Thoughts
Photography remains one of the most essential tools available
to a plastic surgeon. Mastery of fundamental principles under-
lying photographic exposure permits skillful use of advanced
concepts, allowing the eye-catching capture of crucial details.
Understanding the technological evolution in photography
permits postprocessing corrections to bring the photographs
Fig. 3.28 An example of a staged intraoperative photograph. The
operative field has been cleansed, and the tendon grafts are lined up
next to the hand.
37
 I Fundamentals
Fig. 3.29 An intraoperative “action shot” that does not disrupt the
flow of surgery. In this case, a cross-finger flap is being harvested.
The wispy, loose areolar tissue and fine capillaries are visible and not
overblown through the correct use of metering and exposure.
to true-to-life appearance for the sake of anything from plain
documentation to portfolio marketing or publication. As tech-
nology continues to evolve, novel considerations will undoubt-
edly arise, but fortunately the underlying concepts will endure
perpetually.
38
Clinical Caveats
• The most useful clinical photographs are taken in a reproduc-
ible fashion using standardized patient positioning, lighting,
and camera settings.
• Proper focal length should be chosen to minimize perspec-
tive distortion while using appropriate shutter speed and
aperture to prevent motion blur and maintain a broad depth
of field.
• The most reliable lighting is provided using external lighting
(flash or light boxes) or overhead lights arranged purposefully.
• Simple postprocessing correction of white balance and
exposure can dramatically improve the appearance and
consistency of clinical photos.
• Camera choice is a personal preference, weighing convenience
and portability versus image quality, camera size, and cost.
• All digital information should be stored in a protected, HIPAA-
compliant fashion, ideally with multiple redundant backups.
Higher-resolution files are recommended if practical.
• Adequate camera sensor resolution for publication is a lesser
concern now, as newer cameras have far greater resolution
than necessary.
• Facial photographs are best taken with a portrait lens of
around 90- to 110-mm focal length to minimize distortion.
• When using a smartphone or point-and-shoot camera, the
best results are achieved by stepping back from the subject
and zooming in.
Suggested Reading
1 American Society of Plastic Surgeons. Photographic Standards in Plastic Surgery.
Arlington Heights, IL: Plastic Surgery Educational Foundation; 2006
2 Hoffman . Photography in plastic surgery. In: Hentz VR, Mathes S , eds. Plastic
Surgery. 2nd ed. Philadelphia, PA: Elsevier; 2006:151–165
3 inney BM. Photography in plastic surgery. In: eligan PC, arren R , eds. Plastic
Surgery. Vol. 1: Principles. 3rd ed. ew ork, : Elsevier Health Sciences; 2012

4 Patient Safety in Aesthetic Surgery
Christopher A. Tokin, Christodoulos Kaoutzanis, Kent K. “Kye” Higdon, and James C. Grotting
Abstract
Patient safety in aesthetic surgery is a dynamic and complex
topic that is a core concern for any cosmetic practice. It rep-
resents a complex interaction between balancing medical risk
factors, minimizing morbidity, preventing medical errors, and
optimizing patient care. In this chapter we review guidelines
and recommendations set forth by major professional societies
and review the literature specific to aesthetic surgical patients.
Understanding patient-specific risk factors that increase mor-
bidity enables surgeons to perform risk stratification appropri-
ately. Reviewing guidelines related to prevention and treatment
of common surgical morbidities enables improved quality and
optimal outcomes.
Keywords
plastic surgery, aesthetic surgery, cosmetic surgery, patient
safety
4.1 Introduction
Patient safety represents a complex interaction between bal-
ancing medical risk factors, minimizing morbidity, preventing
medical errors, and optimizing patient care. Every plastic
surgeon must be adept at appropriate patient selection and
risk management and be well-versed in guidelines and policies
that enhance patient safety. Many of these guidelines and rec-
ommendations are not taught and are not specific to aesthetic
surgery. e collect methodology from other medical disciplines
to create evidence-based guidelines so as to manage risk
effectively, especially in this special subset of patients in whom
elective procedures are being performed. Recently, several large
databases have become available for collection of outcome data
specific to the aesthetic surgery population. This has allowed
more accurate identification of important risk factors applicable
to these patients and this specific subset of procedures. It is with
this continued enthusiasm that we can optimize patient safety
in aesthetic surgery.
The landmark report To Err is Human: Building a Safer Health
System, issued by the Institute of Medicine in 1999, identified
preventable medical errors as an obstacle to patient safety. This
report estimated that approximately 44,000 to 98,000 Americans
died annually secondary to preventable medical errors, costing
the health care system over 79 billion. It defined medical error as
“the failure to complete a planned action as intended or the use of
a wrong plan to achieve an aim, and it concluded that more than
half of surgical adverse events are preventable. It was in response
to this that the patient safety movement was founded. Large
public health agencies such as the Centers for Disease Control and
Prevention (CDC), orld Health Organization ( HO), Centers for
ien S e y in Ae e i Surgery
Medicare and Medicaid Services took on the task of improving
quality and safety in health care.
The amount of information regarding patient safety is stag-
gering. Luckily, the national plastic surgery professional associa-
tions the American Society for Aesthetic Plastic Surgery (ASAPS)
and the American Society of Plastic Surgeons (ASPS) have created
easily accessible documents and consensus statements regarding
the most important patient safety initiatives. It is these guidelines,
as well as the evidence available to support their adoption in
aesthetic surgery, that we will review in this chapter.
4.2 Patient Selection:
Risk Management
In order to optimize outcomes and minimize risk, appropriate
patient selection is imperative. During the initial consultation,
it is important to recognize the patient’s behavior and identify
warning signs that may affect ultimate patient satisfaction (such
as fixed psychological or social problems or defensive manner-
isms). At the same time, it is the surgeon’s responsibility to assess
the suitability for ambulatory plastic surgery. This involves
a complete history and physical exam, including important
patient-specific risk factors such as age, gender, body mass index
(BMI), smoking status, and other complicating medical factors
that could affect morbidity. Most of these factors will each be
discussed separately later in the chapter. The preoperative con-
sult must also include strategies to enhance the perioperative
process, including documented informed consent, adequate
photo documentation, a review of postoperative expectations,
compliance with postoperative instructions, and a pregnancy
test on female patients of childbearing age.
4.3 Patient Selection:
Patient-Related Risk Factors
A complete preoperative history and physical exam can easily
identify patient-specific risk factors that can increase the risk
of intraoperative adverse events and postoperative complica-
tions. Identifying these risk factors as they relate to aesthetic
procedures and quantifying how they impact adverse events
are important. In 2009, the ASPS Patient Safety Committee
published evidence-based guidelines regarding patient selection
and procedures in ambulatory surgery. It has made recommen-
dations and graded them based on the strength of the supporting
data (Table 4.1). In subsequent years, our group has had the
opportunity to publish extensively on how many of these patient
characteristics and comorbidities specifically affect the aesthetic
surgical patient and how they relate to complications following
specific aesthetic procedures.
39
 I Fundamentals
Table 4.1 Scale for grading recommendations
Grade Descriptor u i ying e iden e
A Strong recommendation Level I evidence or consistent findings from
multiple studies of levels II, III, or IV
B Recommendation Level II, III, or IV evidence and findings are
generally consistent
C Option Level II, III, or IV evidence, but findings are
inconsistent
D Option Level V: little or no systematic empirical
evidence
Data from American Society of Plastic Surgery, Grading Recommendations, available at www.plasticsurgery.org.
4.3.1 Age
Adults over the age of 65 represent approximately 13 of the
current population in the United States, and the number of
elderly people seeking aesthetic procedures is increasing. There
has been conflicting evidence that older age contributes to
intraoperative or postoperative risk in the ambulatory surgery
setting. Increasing age is often associated with increased comor-
bidities, but age alone should not constitute a contraindication to
ambulatory surgery. In one of our previous studies that used the
CosmetAssureTM database to assess age as an independent risk
factor for postoperative complications, we found a major com-
plication rate of 2.2 in octogenarians, a number comparable
to younger cohorts. Other studies have shown that individuals
older than 65 years were 1.4 times more likely to experience an
intraoperative event and 2.0 times more likely to experience an
intraoperative cardiovascular event; however, this risk is depen-
dent on the patient’s overall health, the presence and severity of
cardiovascular disease, and the nature of the surgical procedure.
In conclusion, while age may increase the presence of comorbid
conditions, age alone does not appear to be an independent risk
factor in cosmetic surgery when these factors are controlled for.
4.3.2 Gender
Gender-based disparities in surgical outcomes have long been
documented across several disciplines. It has been shown that
men are more likely to have higher morbidity and mortality
following operative treatment of hip fractures, higher incidence
of pneumonia after blunt trauma, and increased peripheral
neurovascular complications secondary to diabetes. et the
surgical literature evaluating clinical outcomes of cosmetic
surgery in men is limited. Our group has recently shown that
men demonstrate a similar overall complication rate compared
to women. However, when specific complications were analyzed,
men appeared to have significantly higher hematoma rates but
a lower incidence of surgical site infections. This was especially
true for facelift procedures in men versus women (1.4 vs 0.5 ).
This has been supported by other large-volume studies that
suggest that the relative risk of hematoma in male patients is as
40
Im i i n r r i e
Clinicians should follow a strong recommendation unless a clear
and compelling rationale for an alternative approach is present
Generally, clinicians should follow a recommendation but
should remain alert to new information and sensitive to patient
preferences
Physicians should be flexible in their decision making regarding
appropriate practice, although they may set bounds on
alternatives; patient preference should have a substantial
influencing role
Clinicians should consider all options in their decision making and
be alert to new published evidence that clarifies the balance of
benefit versus harm; patient preference should have a substantial
influencing role
high as 3.86 compared with females. On multivariate analysis,
independent predictors of major complications in men include
BMI greater than 25 kg/m2 (relative risk RR 1.05; p 0.01),
procedures performed in hospital-based settings as opposed
to office-based procedures (RR 3.47; p 0.01), and combined
procedures (RR 2.56; p 0.01). In conclusion, aesthetic surgery
in men is safe, with low complication rates comparable to those
in women. Care must be taken to achieve excellent hemostasis,
as men have a higher risk of hematoma. Modifiable predictors
of complications to consider are BMI and combined procedures.
4.3.3 Body Mass Index
early 70 of adults in the United States are overweight or obese
(BMI greater than 25 kg/m2), and this constitutes over a third of
patients seeking cosmetic surgical procedures. Obesity is not just
an epidemic of the current era; more important, it is associated
with cardiovascular disease, diabetes, hypertension, obstructive
sleep apnea, and increased infections. Studies have also shown
that obesity correlates with failed regional anesthetic block,
unplanned hospital admissions, and respiratory complications.
Our group has shown that not only does obesity increase com-
plication rates, but these rates also increase with increasing BMI
(Fig. 4.1). Specifically, surgical site infections, venous throm-
boembolism (VTE), and pulmonary dysfunction were twice as
common among overweight patients. Complications following
abdominal and body contouring procedures, or combinations
of breast and body procedures, were also significantly higher.
On multivariate analysis, we found that being overweight (BMI
25–29.9 kg/m2) and obese (BMI 30 kg/m2) were independent
risk factors of any complication, especially surgical site infection
and VTE. Mechanisms by which obesity affects surgical morbid-
ity and mortality are not entirely clear. However, the proinflam-
matory state is promoted by extra adipose tissue and may foster
an environment that makes patients susceptible to injury in
times of stress. Local wound complications in obesity have also
been well documented. Reviews of abdominoplasty and breast
reduction patients have found higher rates of wound dehiscence
and seroma. Obesity and venous thromboembolism also have a
known relationship. In the Caprini risk assessment model, which

Fig. 4.1 Major complications stratified by body mass index (BMI)
category. VTE: venous thromboembolism.
has been validated for use in plastic and reconstructive surgery,
BMI greater than 25 represents an independent risk factor and
may be used as a factor when considering pharmacologic VTE
prophylaxis. In conclusion, BMI has a direct and proportional
relationship to the incidence of both minor and major complica-
tions following aesthetic surgery.
4.3.4 Smoking
All patients should be asked about their smoking history as
well as their exposure to second-hand smoke. Smoking is a
well-established risk factor for atherosclerotic disease and has
been shown to increase the overall risk of complications in
plastic surgery. Smoking can lead to increased production and
activation of fibrinogen and has been associated with VTE. It also
alters the microcirculation and can compromise flap survival.
Many plastic surgeons do not offer certain aesthetic procedures
to smokers, and the ASPS evidence-based recommendations
encourage smoking cessation anywhere from 24 hours to 6 to
8 weeks before surgery (Grade B Recommendation) and up to
7 days following surgery (Grade D Recommendation). The CDC
recommends smoking cessation at least 4 weeks before surgery.
Patient compliance with smoking cessation can be ensured by
blood, urine, or saliva test and is encouraged.
4.3.5 American Society of
Anesthesiologists Status
The American Society of Anesthesiologists (ASA) status has been
accepted as the standard for assessing preoperative condition
(Table 4.2). Patients should be assigned an ASA classification, and
this should be used for risk stratification. Large, hospital-based
ambulatory surgery studies have shown that ASA II or III was
a predictive factor for unanticipated hospital admission that
increased the risk over twofold. Other retrospective studies have
shown that risk significantly increased between ASA class II and
III. Many cosmetic surgeons feel that a patient with an ASA class
ien S e y in Ae e i Surgery
Table 4.2 American Society of Anesthesiologists physical status
classification
Class e ri i n u
ASA I Normal, healthy
ASA II Mild systemic disease
ASA III Severe systemic disease
ASA IV Severe systemic disease that is a constant threat to life
ASA V Not expected to survive without the operation
ASA VI Organ donor
Data from the American Society of Anesthesiologists, available at https://www.
asahq.org/standards-and-guidelines/asa-physical-status-classification-system.
of IV is not suitable to undergo elective cosmetic surgery. This is
in line with ASPS evidence-based recommendations, which state
that patients categorized as ASA class I to III can be considered
for ambulatory surgery (Grade B Recommendation).
4.3.6 Diabetes Mellitus
Diabetes mellitus is a common chronic disease affecting 9 , or
29 million, of the U.S. population and is considered a risk factor
for a variety of perioperative adverse events. Diabetics are nearly
twice as likely to be overweight or obese as nondiabetic patients
and are at higher risk of infection due to impaired immune func-
tion secondary to hyperglycemia. Studies have demonstrated
decreased granulocyte function and microbicidal action in
diabetics. Complications from hyperglycemia can be reduced
with improved glycemic control; however, optimal perioperative
glucose targets have not been established, and highly intensive
insulin regimens are associated with minimal benefits and the
risk of hypoglycemia.
Our group has shown that in aesthetic surgery patients, dia-
betics have significantly more complications than nondiabetics
(3.1 vs 1.9 , p 0.01), especially in body cases, most notably
abdominoplasty (Fig. 4.2). Diabetics were also more likely to have
wound infections and pulmonary complications. In conclusion, a
preoperative diagnosis of diabetes mellitus is an independent risk
factor for complications in the aesthetic surgery patient. It is pru-
dent to set the right expectations in the preoperative period by
notifying diabetic patients of their increased risk of complications,
reviewing and optimizing their hemoglobin A1c, and ensuring
adequate glucose control in the perioperative period.
4.3.7 Obstructive Sleep Apnea and
Obstructive Lung Disease
The significance of obstructive sleep apnea in the ambulatory
surgery setting is unclear, largely because it is difficult to sep-
arate the effects of surgery from the consequence of apnea. In
addition, the diagnosis of obstructive sleep apnea often coincides
with other comorbidities, such as obesity, hypertension, and dia-
betes. However, retrospective studies comparing patients with
obstructive sleep apnea to those without, controlling for other
comorbid conditions, have shown no difference in the rate of
unplanned hospital admissions. evertheless, the ASA guidelines
41
 I Fundamentals
Fig. 4.2 Major complications in diabetic versus nondiabetic patients
following aesthetic surgery on different body regions. Breast proce-
dures include augmentation, mastopexy, reduction, and gynecomastia
correction. Body procedures include buttock lift, calf implant, labi-
aplasty, lower body lift, thigh lift, brachioplasty, and upper body lift.
Face procedures include blepharoplasty, brow lift, cheek implant, chin
augmentation, facelift, facial resurfacing, hair replacement, otoplasty,
and rhinoplasty. Numbers in red indicate statistical significance with p
< 0.05.
state that patients with prior diagnosis of obstructive sleep
apnea have an increased risk for respiratory depression and may
require longer postoperative monitoring. Respiratory depression
is more prominent with general anesthesia and postoperative
opioid use. For this reason, the ASPS evidence-based recommen-
dations reflect the ASA guidelines and state that patients with
a diagnosis of obstructive sleep apnea are at increased risk of
perioperative complications and are generally not appropriate
candidates for procedures in free-standing outpatient settings
(Grade D recommendation). In addition, systemic opioids should
be avoided, continuous supplemental oxygen should be strongly
considered, and continuous positive airway pressure (CPAP)
machines should be utilized.
ith regard to obstructive lung disease, patients may be
considered appropriate in the ambulatory setting if they are free
from symptoms and have optimal lung function documented
preoperatively. If patients have symptoms, elective surgery
should be postponed, and patients should be free from steroid
therapy for at least 6 months prior to elective surgery (Grade D
recommendation).
4.3.8 Cardiovascular Conditions
There is evidence in the literature indicating that patients
affected by various cardiovascular conditions, such as heart
disease, stroke, or hypertension, are at increased risk for
intraoperative hemorrhage and postoperative complications in
the ambulatory setting. According to the American College of
Cardiology guidelines, patients with active cardiac conditions
should be treated and cleared prior to undergoing elective sur-
gery. However, those with remote/prior myocardial infarction
( 6 months), ew ork Heart Association class I heart failure,
and asymptomatic valvular disease can be considered for ambu-
latory surgery. Patients with cardiovascular conditions are often
42
on anticoagulation. hile some studies have shown that contin-
ued aspirin use (75–300 mg) before surgery is an independent
risk factor for intraoperative and postoperative bleeding, the
increase in bleeding duration and severity is small. Risks and
benefits are likely patient-specific and directly related to the
procedure at hand and should be discussed with the patient pre-
operatively. Patients on other anticoagulation therapies, such as
warfarin or clopidogrel, are likely at higher bleeding risk. Many
of these patients can be safely bridged on some form of heparin
therapy, but these decisions should be made in conjunction with
a cardiologist, as stopping anticoagulation for any period of time
may be unsafe in this specific patient subset.
4.4 Patient Selection:
Postoperative Complications
Patient-specific risk factors, in combination with certain aes-
thetic procedures or groups of aesthetic procedures, may put
patients at increased risk of particular postoperative complica-
tions, the most common being surgical site infection, hematoma,
and life-threatening VTE. Our group has been able to use a
large, prospectively maintained insurance database of aesthetic
surgery patients to gather outcome data to assist in identifying
particular subgroups at risk. In this way, we hope to assist plastic
surgeons with patient selection and informed consent.
4.5 Surgical Site Infection
Surgical site infections represent one of the most common post-
operative complications in patients undergoing aesthetic surgery,
and while overall incidence is low, the potential outcome for the
cosmetic patient can be devastating. The role of perioperative
antibiotics in preventing surgical site infection is clear, and they
are utilized to target the most likely contaminant. Most often, a
first-generation cephalosporin is used, given anywhere from 30
to 60 minutes before incision is made. Alternative antibiotics are
chosen based on risk factors and patient allergies.
It is important to understand the incidence and risk factors for
major surgical site infections, in order to be able to risk-stratify
patients, as well as prepare to intervene when necessary. Our group,
again using the large, prospectively maintained CosmetAssureTM
database of exclusively aesthetic surgery patients, found the
incidence of major surgical site infections requiring emergency
room visit, hospital admission, or reoperation to be low (0.46 ).
ound infections were more likely in smokers, who had a 61
increase in risk compared to nonsmokers. These findings have
been duplicated among multiple surgical specialties. Smoking
can affect the microenvironment of the tissue through nicotine’s
vasoconstrictive and hypoxic effect and potentially compromise
all phases of wound healing. In randomized controlled trials,
smoking cessation for at least 4 weeks prior to surgery was asso-
ciated with reduced infectious complications, potentially due to
improvement in inflammatory cell and host defense functions.
Diabetes mellitus has inconsistently been reported as a risk
factor specific for surgical site infections, but our group found
that diabetes increased the risk for major wound infections in
cosmetic surgery patients by 58 . hile it is unclear whether
 ien S e y in Ae e i Surgery

this is related to perioperative glucose control, we continue to contouring procedures. Male gender had a relative risk of 1.98 for
recommend obtaining a hemoglobin A1c as part of the medical major hematoma in our analysis.
clearance (ideally less than 7 ). hile cosmetic surgery can safely Combined procedures and breast procedures were additional
be performed on diabetics, patients should be warned of their independent predictors for hematoma development. However,
increased risk for complications, especially in body procedures, as BMI, smoking, and diabetes, which are risk factors for overall
mentioned previously. complications, did not show significance with the development of
Trunk and extremity procedures were an independent risk hematoma specifically.
factor for major surgical site infections on multivariate analysis; in
fact, trunk and extremity procedures were the strongest predictor
of wound infections of any independent risk factor, with a relative
4.5.2 Venous Thromboembolism
risk of 2.42. Of note, in our analysis, the majority of patients (68 ) VTE, including both deep venous thrombosis (DVT) and pulmo-
underwent a combined procedure. Combined procedures had nary embolism (PE), remains one of the most feared complica-
a relative risk of 1.88, which was statistically significant. Even tions in all of medicine. In the postsurgical patient, the period
though the increase in complication rate in combined procedures of highest risk for fatal PE is within the first 3 to 7 postoperative
is less than the sum of the complication rates of each procedure days, with the estimated 28-day mortality for a first episode of
done separately, it still requires careful consideration. There was VTE being 11 . The American Association for Accreditation of
a trend toward a higher surgical site infection rate with each Ambulatory Surgery Facilities (AAAASF) reported that between
additional region added to the operation (Table 4.3). It should anuary 2001 and une 2006, there were 23 deaths among approx-
be noted that our group did not control for operative time, which imately 1 million outpatient aesthetic surgery procedures, 134 of
has been shown in numerous other studies to be an independent which resulted from PE (57 ). The procedure with the highest
variable associated with increased surgical site infections and is rate of postoperative mortality was abdominoplasty, followed by
logically lengthened with combination procedures. facelift surgery in combination with other procedures.
In 2008, the release of a report by the Surgeon General’s office
identified VTE as one of the leading public health problems. It
Table 4.3 Incidence of surgical site infections among different stated that 20 of people with PE die, and postoperative surgical
procedure combinations per body region(s), stratified by gender patients are at highest risk up to 3 months following surgery. In
Body region(s) Surgical site Surgical site Surgical site response, the ASPS created the Venous Thromboembolism Task
in e i n in e i n in e i n Force to assist plastic surgeons in implementing best practices
m e em e for VTE prevention. Among these was endorsement of the 2005
Face 34 (0.2%) 5 (0.2%) 29 (0.2%) Caprini Risk Assessment Scale, which has been validated for use in
Breast 143 (0.2%) 1 (0.1%) 142 (0.3%) plastic surgery patients and is now the most commonly used tool
in cosmetic surgery to assess a patient’s VTE risk profile (Fig. 4.3).
Body 266 (0.8%) 14 (0.5%) 252 (0.9%)
In the Caprini model, VTE risk factors are assigned points, and the
Face + Breast 5 (0.4%) 0 5 (0.4%) points are added to assess overall risk. The ASPS follows with rec-
Face + Body 15 (0.6%) 2 (0.7%) 15 (0.6%) ommendations on anticoagulation strategies based on the Caprini
Breast + Body 132 (1.0%) 2 (0.3%) 130 (1.0%) score (Fig. 4.3). Most notably, a score as low as 3 is considered
an indication for use of postoperative chemical chemoprophylaxis
Face + Breast + Body 4 (0.9%) 1 (5.9%) 3 (0.7%)
(Grade B recommendation), and a score of 7 or more should be
an indication to strongly consider using extended postoperative
chemical prophylaxis (Fig. 4.4). This is in accordance with the
American College of Chest Physicians (ACCP) recommendations
that all surgical patients receive mechanical and chemoprophy-
4.5.1 Hematoma laxis for venous thromboembolism unless they are undergoing a
Hematoma is another very common complication in aesthetic minor procedure or have a high risk of bleeding. The variety of
surgery patients. In a previous study of 129,007 patients under- procedures and what defines minor surgery in the aesthetic
going cosmetic procedures, multivariate analysis showed age, surgical patient make studying VTE in this population especially
male gender, combined procedures, and procedures performed difficult.
on the breast to be independent risk factors for developing major One of our previous studies examined 129,007 aesthetic surgi-
hematomas requiring emergency room visit, hospital admission, cal patients and found the rate of major VTE to be 0.09 . Age and
or reoperation. hile our group has shown that aesthetic surgery BMI were found to be the only significant patient characteristics
is safe in the elderly, the data shows that advancing age can be an that were predictors for VTE. Smoking and diabetes were also
independent risk factor for hematoma development. This could evaluated but not found to be risk factors. This is inline with the
be related to undiagnosed or untreated hypertension, or higher Caprini model, which assigns both age and BMI one point but does
ASA class, which was not specifically looked at by the study. not include smoking or the diagnosis of diabetes in their model.
Gender has also been previously identified as a risk factor for In multivariate logistic regression analysis, body procedures and
the development of postoperative hematoma in different plastic combined procedures were found to increase the risk of VTE most
surgery populations, specifically breast surgery, facelift, and body significantly (Fig. 4.5). The ACCP data and the Caprini model do not

43
 I Fundamentals
Fig. 4.3 American Society of Plastic Surgeons thrombosis risk factor assessment, adopted from the 2005 Caprini Risk Assessment Model.
look specifically at plastic surgery procedures. However, smaller
studies have shown that abdominoplasty specifically, as well as all
body procedures, increases the risk of VTE significantly, compared
with procedures performed on other body locations such as breast
and face. e have also shown that face procedures, breast proce-
dures, or combining face and breast procedures confers an overall
low risk of VTE. However, body procedures, or any combinations
that include body procedures, impose greater risk. In conclusion,
while the overall incidence of VTE in cosmetic procedures is rel-
atively low, the risk increases with BMI and age, as well as with
combined procedures involving trunk and extremities.
44
4.6 Safety of Combining
Aesthetic Procedures
Combining procedures is common practice in aesthetic surgery,
not only because it reduces cost and improves efficiency but
also because multiple procedures may be needed for a more
balanced overall result or because patients desire multiple areas
to be addressed. Our group has shown that because the inci-
dence of major complications is relatively low in the aesthetic
surgical patient, the cumulative risk of multiple procedures is
 ien S e y in Ae e i Surgery

ASPS VTE Task Force

Risk Assessment and Prevention Recommendations
Approved by the ASPS Executive Committee in July 2011

Step 1: Risk Stratification

Patient Population Recommendation

In-patient adult aesthetic and reconstructive plastic surgery who
undergo general anesthesia
Should complete a 2005 Caprini RAM risk factor assessment tool
in order to stratify patients into a VTE risk category based on their
individual risk factors. Grade B
Or
Should complete a VTE risk assessment tool comparable to the
2005 Caprini RAM in order to stratify patients into a VTE risk category
based on their individual risk factors. Grade D

Out-patient adult aesthetic and reconstructive plastic surgery who
undergo general anesthesia
Should consider completing a 2005 Caprini RAM risk factor assessment
tool in order to stratify patients into a VTE risk category
based on their individual risk factors. Grade B
Or
Should consider completing a VTE risk assessment tool comparable
to the 2005 Caprini RAM in order to stratify patients into a VTE risk
category based on their individual risk factors. Grade D

Step 2: Prevention

The scores Based apply to the 2005 Caprini RAM

2005 Caprini
Patient Population Recommendations and were not intended for use with alternative VTE risk
RAM Score
assessment tools

Elective Surgery Patients Should consider utilizing risk reduction strategies such as limiting
(when the procedure is OR times, weight reduction, discontinuing hormone replacement
scheduled in advance and therapy, and early postoperative mobilization. Grade C
7 or more
is not performed to treat
an emergency or urgent
condition)

Patients undergoing one 3 to 6

of the following major
procedures when performed
under general anesthesia
lasting more than 60 minutes:

• Body contouring, 3 or more Should consider the option to utilize mechanical prophylaxis
• Abdominoplasty, throughout the duration of chemical prophylaxis for non-ambulatory
• Breast reconstruction, patients. Grade D
• Lower extremity procedures,
• Head/neck cancer procedures 7 or more Should strongly consider the option to use extended LMWH
postoperative prophylaxis. Grade B

Fig. 4.4 ASPS Venothromboembolism (VTE) Task Force risk assessment and prevention recommendations (based on 2005 Caprini Risk Assessment
Model).

often acceptable, and not directly additive. e have shown, as

mentioned in prior sections of this chapter, that certain patient
characteristics, such as elevated BMI, can increase the risk of
both individual and combined procedures. e have also shown
that the risk of these complications in combined procedures
increases when the trunk and extremities are involved. ow that
we have been able to define these additive risks, they should be
adequately disclosed to our patients as part of our preoperative
discussion and informed consent.
4.7 S e y ffi e- ed
Procedures
Over the past decade, there has been a dramatic rise in office-
based surgery across surgical subspecialties, particularly in aes-
thetic surgery. According to the American Society of Aesthetic
Plastic Surgery (ASAPS), there was over a 5 increase in office-
based cosmetic procedures from 56.3 to 61.9 from 2014 to

45
 I Fundamentals

hypothermia, and being prepared to manage crisis situations,

most notably malignant hyperthermia.

4.8.1 Communication at Fault

In 2006, the oint Commission reported that 70 of all sentinel
events in health care were caused by communication failures.
ow communication failures are largely touted as being the
most common, and likely most modifiable, preventable cause of
medical error. Communication errors likely involve verbal com-
munication between two people but can also include ambiguity
about delegation of responsibility.
Fig. 4.5 Venous thromboembolism (VTE) in single versus combined
procedures (p < 0.05).
4.8.2 Crew Resource Management
and Checklists
2015. Guidelines and regulation to assist with safety exist in only
Crew resource management, adopted first in the aviation indus-
31 states, and regulations often vary from state to state. As part
try, has been shown to improve performance, safety, commu-
of the regulatory process, some states require accreditation from
nication, and morale as well as to decrease incidents related to
one of the three accreditation agencies: the oint Commission on
crew error. The concept was designed after the industry realized
Accreditation of Healthcare Organizations ( CAHO, often referred
that anywhere from 50 to 80 of significant aviation incidents
to simply as the oint Commission), the American Association
were caused by human rather than mechanical error. The Federal
for Accreditation of Ambulatory Surgery Facilities (AAASF), and
Aviation Administration defines crew resource management
the Accreditation Association for Ambulatory Healthcare. Much
as an active process by crew members to identify significant
of the published literature regarding the safety of office-based
threats to an operation, communicate them to a person in charge,
surgery is limited to surveys, single-practice/surgeon retrospec-
and to develop, communicate, and carry out a plan to avoid or
tive reviews, or noncosmetic literature. Using the CosmetAssure
mitigate each threat.
database, our group looked at over 129,000 patients (183,914
Adopting from successful safety practices in the aviation indus-
procedures), 57.4 of whom had procedures done at ambulatory
try, the oint Commission and HO have developed a universal
surgery centers (ASCs), 26.7 at hospitals, and 15.9 at office-
protocol and surgical checklist to assist hospitals and organiza-
based surgery suites (OBSS). Complication rates were lowest
tions improve system-based practices and patient safety (Fig. 4.6).
at OBSS (1.3 ), as compared with ASCs and hospitals (1.9 and
The Safe Surgery Saves Lives Challenge, which included adop-
2.4 , respectively). On multivariate analysis, there was a lower
tion of the HO surgical checklist, was prospectively studied and
risk of developing a complication in an OBSS compared to an ASC
showed a significant decrease in death rate from 1.5 to 0.8 , and
(RR 0.67, 95 confidence interval CI 0.59–0.77, p 0.01). These
in complication rate from 11 to 7 , after implementing use of
results are in line with other published studies that conclude
the checklist.
that office-based surgery by board-certified or eligible plastic
surgeons is safe and of relatively low risk. The most common
complications were hematoma and infection. It should be noted 4.8.3 Patient Positioning
that patients with significant comorbidities, generally reflected
Patient safety regarding positioning cannot be overlooked.
in ASA, may be preferentially treated in the hospital setting,
Advanced age, extremes of body habitus, poor nutritional status,
possibly contributing to higher complication rates observed in
pulmonary or cardiovascular disease, or preexisting limitations
hospitals; however, it is generally noted that most patients with
in movement can predispose patients to injury. An extensive
higher ASA classifications (III, IV) may not be suitable candidates
review of intraoperative patient positions is beyond the scope of
for elective cosmetic surgery at all. This study adds validity to
this chapter; however, the most noteworthy goal with regard to
other published studies and suggests that procedures performed
patient positioning is prevention of pressure ulcers, which have a
in OBSS are generally safe. This is especially true in the setting of
surprising incidence of 4.6 to 26 . The ASPS has identified six fac-
appropriate accreditation and sound clinical judgment.
tors that may prevent the formation of pressure ulcers: preventing
hypotension or local hypoperfusion, padding pressure points to
4.8 Perioperative Considerations prevent local pressure in excess of 32 mm Hg, padding pressure
points with layers; reducing operative time to 90 to 120 minutes,
Any conversation regarding perioperative patient safety would preventing skin moisture buildup (i.e., skin preparation or irriga-
not be complete without discussing the importance of com- tion) and reducing shear and friction forces during transfer.
munication in the operating room and the adoption of crew
resource management as a method to improve communication,
reduce errors, and improve patient safety. In addition, important
4.8.4 Skin Preparation/Scrub
issues regarding perioperative patient safety include appropriate It is clear that antiseptic technique in the operating room has
patient positioning, adequate skin preparation, prevention of been one of the single greatest patient safety maneuvers. Skin

46

Fig. 4.6 World Health Organization (WHO) Surgical Safety Checklist.
preparation, hand antisepsis, and other barriers (such as dedi-
cated operating room clothing, masks, and caps) are meant to
minimize surgical site infections as well as to decrease exposure
to the surgeon and operating room staff.
A recent review of hand antisepsis techniques suggested that
rubbing with an alcohol-based solution is more effective than
scrubbing. While scrubbing eliminates transient bacteria, it
removes the stratum corneum and can cause excoriation and
colonization. Like hand scrubs, an ideal skin preparation solution
is broad-spectrum, safe, and easy to use. Commonly used tech-
niques are an iodine soap scrub followed by a paint; alcohol-based
preparations with either iodophor or chlorhexidine; or a simple
soap-and-water preparation. The CDC and the Association of
periOperative Registered urses also recommend the avoidance
of shaving operative sites, showering or use of a surgical wash
prior to antiseptic skin preparation, and the need to allow
alcohol-based preparations to dry to prevent operating room fires.
4.8.5 Importance of Normothermia
Hypothermia is defined as a drop in core body temperature
below 36.5 C. Regional and general anesthesia can affect the
body’s ability to regulate core body temperature. Therefore, it is
important that resources be available to assist in heating the cold
patient, such as forced-air warming blankets and fluid warmers
ien S e y in Ae e i Surgery
for intravenous and irrigation fluids. Many studies involving
surgical patients have shown that hypothermia correlates with
adverse outcomes, including wound infections and bleeding,
as well as more serious cardiac events. For this reason, ASPS
has developed evidence-based recommendations regarding
hypothermia that include protocols for hypothermia prevention
during general or regional anesthesia. These include actively
prewarming patients, monitoring core body temperature
throughout the procedure, active intraoperative warming with
forced-air heater or resistive-heating blankets, minimizing repo-
sitioning, warm intravenous and irrigation fluids, and aggressive
treatment of postoperative shivering with heat or other pharma-
cologic interventions (Grade B recommendations). In addition,
procedures that do not have all of these strategies available
should be limited to 1 to 2 hours in duration and involve no more
than 20 of the body surface area.
4.8.6 Management of Malignant
Hyperthermia
Malignant hyperthermia is an inherited genetic disorder that
causes a hypermetabolic reaction to potent volatile anesthetic
gases and the depolarizing muscle relaxant succinylcholine.
It is important in the discussion on patient safety because it
represents a preventable and treatable cause of surgical patient
47
 I Fundamentals
mortality. Understanding the disease, how to appropriately
identify and screen patients at risk, and how to treat malignant
hyperthermia crisis can save lives.
The incidence of malignant hyperthermia episodes is thought
to be between 1 in 5,000 and 1 in 100,000 anesthetic encounters.
Malignant hyperthermia is inherited in an autosomal dominant
pattern with variable penetrance and has been linked to the
ryanodine receptor type 1 gene, as well as the gene that codes
for the alpha subunit of the dihydropyridine receptor. Because of
this known mode of inheritance, preoperative family history is of
utmost importance. The patient’s medical history intake should
also inquire about other myopathies and inherited muscular
dystrophies that can influence anesthetic choice. Common vola-
tile inhaled anesthetics as well as succinylcholine can trigger the
clinical condition that results from abnormal release of calcium
by muscle cells, ultimately resulting in hyperthermia, hypercap-
nia, hyperphosphatemia, and metabolic acidosis. Patients who
are at risk should be referred to the Malignant Hyperthermia
Association of the United States for further testing, which could
include genetic testing or the gold standard caffeine–halothane
contracture test. The latter involves a muscle biopsy and must be
performed in an accredited facility.
hile guidelines regarding patient selection and facility
requirements have been established by multiple anesthesia
and surgical societies, both ASAPS and ASPS require that their
members operate only in accredited or licensed facilities for
all procedures that involve more than local anesthesia. Office-
based surgical centers should have reviewed state and national
guidelines and should be prepared with appropriate monitoring
equipment and treatment drugs (which include dantrolene, dex-
trose 50 , antiarrhythmics, calcium chloride, sodium bicarbonate,
insulin, furosemide, and adequate ice), as well as an established
malignant hyperthermia emergency protocol.
Nontriggering agents must be used in all susceptible and
suspect patients. However, it should be noted that malignant
hyperthermia can also be triggered by nontriggering agents in
less than 1 of susceptible patients. Treatment protocols have
been created by the Malignant Hyperthermia Association of the
United States, and a hotline is available 24 hours a day, 365 days
a year. Although specific treatment strategies are outside the
scope of this chapter, some salient points will be reviewed. hile
malignant hyperthermia can be clinically difficult to diagnose,
a herald sign may be a rising end-tidal carbon dioxide level.
Skeletal muscle spasm, trismus, tachycardia, acidosis, hyper-
thermia, and hyperkalemia are other important signs. Treatment
involves discontinuing the offending agent and arranging for
immediate transfer of the patient to the hospital. Administration
of dantrolene sodium stabilizes the ryanodine receptor and is one
of the most critical parts of early resuscitation. It is important
to remember that dantrolene must be reconstituted in injectable
saline prior to administration.
In conclusion, the aesthetic surgery patient undergoing office
procedures with deep sedation or general anesthesia may be at
risk for developing malignant hyperthermia, and patients should
be adequately screened preoperatively. All facilities should be
ready to manage this clinical crisis if encountered. Susceptible
individuals identified preoperatively are not candidates for office-
based surgery.
48
4.9 Anesthetic Considerations in
Aesthetic Surgery
A complete review of anesthetic considerations in office based
aesthetic surgery is beyond the scope of this chapter. However,
the performance of safe anesthesia (whether that is general,
regional, or local), knowledge regarding common postanesthetic
complications (e.g., postoperative nausea and vomiting), as well
as familiarity with treatment strategies for more serious compli-
cations (i.e., local anesthetic systemic toxicity) are imperative in
any safe and successful aesthetic practice.
4.9.1 Nil per Os
It is common practice to have patients consume nothing by
mouth (nil per os, PO) for 8 hours prior to surgery. This recom-
mendation originated from a paper by Mendelson in 1946 that
noted a higher incidence of pulmonary aspiration in obstetric
patients undergoing general anesthesia. This recommendation
was partially revised 50 years later by the American Society of
Anesthesiologists Task Force on Preoperative Fasting, which now
recommends a period of fasting for 8 hours after a meal of fried
or fatty foods but allows a period of 6 hours for milk or a light
meal and 2 hours from clear liquids.
4.9.2 Postoperative Nausea and Vomiting
Postoperative nausea and vomiting (PO V) are a major concern
for patients and are more pronounced after general anesthesia.
This event can affect upward of 70 of the patient population,
with young women and nonsmokers, or those with a history of
PO V, at highest risk. ot only can PO V reduce surgical satis-
faction rates, but it also can impact patient safety with regard
to increasing recovery time and possibly causing unplanned
hospital admissions. The use of narcotics and nitrous oxide has
been associated with increased rate of PO V. Depending on
the situation, many anesthesiologists try to minimize or even
avoid the use of narcotics in favor of improved local anesthesia
and non-narcotic analgesics, such as ketorolac and ketamine.
Other agents can prevent or treat PO V include ondansetron
(5-hydroxytryptamine 5-HT antagonist), dexamethasone
(steroid), scopolamine (tropane alkaloid), and metoclopramide
(dopamine and 5-HT antagonist). Combination therapy targets
different pathways to prevent and/or significantly ameliorate
PO V for many individuals.
4.9.3 Local Anesthetic Systemic Toxicity
The use of local anesthetics is commonplace and usually encour-
aged in aesthetic surgery. Local anesthetics are often mixed
with epinephrine, which allows increased dosing and improved
hemostasis. Aesthetic surgeons must be aware of maximum
local anesthetic dosing, populations at risk (e.g., extremes of
age and pregnancy), as well as rare complications associated
with overdose. Local anesthetic systemic toxicity (LAST) is
a life-threatening complication of local anesthetic overdose
that can cause central nervous system and cardiovascular
 ien S e y in Ae e i Surgery

compromise. The clinical presentation is variable and can occur
hours after injection. Systemic effects are related to sodium
channel blockade and can present with symptoms of perioral
numbness, metallic taste, mental status changes, or seizure.
Cardiovascular symptoms begin with tachycardia and hyperten-
sion, but this ultimately degrades into bradycardia, hypotension,
ventricular arrhythmias, and ultimately asystole with loss of
vascular tone.
Management of LAST is consistent with guidelines and check-
lists published by the American Society of Regional Anesthesia
and Pain Management and includes stopping the injection and
calling for help. The Association of Anaesthetists of Great Britain
and Ireland (AAGBI) have also created safety guidelines that
summarize common recommendations for treatment (Fig. 4.7).
Advanced cardiac life support is instituted, and intravenous lipid
emulsion therapy is initiated. Twenty percent lipid emulsion ther-
apy is administered at a bolus dose by weight and then continued

Fig. 4.7 The Association of Anaesthetists of Great Britain and Ireland (AAGBI) safety guidelines regarding management of severe local anesthetic
toxicity. (Source: The Association of Anaesthetists of Great Britain and Ireland [AAGBI])

49
 I Fundamentals
as an infusion. It is believed that the lipid emulsion binds to the
local anesthetic and removes it from affected tissues; however, the
mechanism is likely multifactorial. In addition to lipids, benzodi-
azepines can be used to suppress seizure activity, and airway man-
agement and circulatory support should be primary objectives.
4.10 Concluding Thoughts
The quality of the surgical care that we deliver as aesthetic sur-
geons is inherently intertwined with optimized patient safety.
There are inherent risks to all surgical procedures. Understanding
these risks as they relate to patient characteristics, procedures,
and outcomes, and using this knowledge to optimize the envi-
ronment in which we practice aesthetic surgery, are of utmost
importance.
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3 American Society of Plastic Surgeons. Operating Room Safety. https://www.plas-
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5 Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of
adverse events in day-case surgery. Br J Anaesth 1999;83(2):262–270
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in the overweight patient: analysis of 127,961 patients. Aesthet Surg J
2016;36(6):718–729
11 Gupta V, inocour , Shi H, Shack RB, Grotting C, Higdon . Preoperative risk
factors and complication rates in facelift: analysis of 11,300 patients. Aesthet Surg
J 2016;36(1):1–13
12 Gupta V, Parikh R, guyen L, et al. Is office-based surgery safe Comparing
outcomes of 183,914 aesthetic surgical procedures across different types of
accredited facilities. Aesthet Surg J 2017;37(2):226–235
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17 Horton B, Reece EM, Broughton G II, anis E, Thornton F, Rohrich R . Patient
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18 Iverson RE; ASPS Task Force on Patient Safety in Office-Based Surgery Facilities.
Patient safety in office-based surgery facilities: I. Procedures in the office-based
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21 aoutzanis C, Gupta V, inocour , Shack B, Grotting C, Higdon . Incidence
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129,007 patients. Aesthet Surg J 2017;37(1):89–99
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32 guyen L, Gupta V, Afshari A, Shack RB, Grotting C, Higdon . Incidence and
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ing patient safety in plastic surgery. Plast Reconstr Surg 2017;140(6):812e–817e
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plasty: risk factors, complication rates, and safety of combined procedures. Plast
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38 inocour , Gupta V, aoutzanis C, et al. Venous thromboembolism in the cos-
metic patient: analysis of 129,207 patients. Aesthet Surg J 2017;37(3):337–349
39 orld Health Organization. Patient Safety. http://www.who.int/patientsafe-
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40 eslev M, Gupta V, inocour , Shack RB, Grotting C, Higdon . Safety of
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41 eslev M, Gupta V, inocour , Shack RB, Grotting C, Higdon . Safety of cos-
metic surgery in adolescent patients. Aesthet Surg J 2017;37(9):1051–1059

5 Sedation and Anesthesia for Aesthetic Surgery
Aaron M. Kearney, Sergey Y. Turin, and Sammy Sinno
Abstract
Sedation and anesthesia for aesthetic surgery are crucial topics
for the surgeon to understand in order to optimize the patient
experience. General anesthesia provides total anesthesia and a
lack of awareness, but it incurs higher costs and risks complica-
tions ranging from mild airway irritation to malignant hyper-
thermia. Monitored anesthesia care and lighter levels of sedation
may be used to promote a more rapid recovery but come with
their own risk of aspiration due to an unsecured airway, incom-
plete amnesia and analgesia, and possibly increased difficulty
for the surgeon should the patient be inadequately anesthetized.
Ultimately, the method of anesthesia for a procedure should be
chosen by the patient, surgeon, and anesthesiologist together
and guided by the nature of the procedure, medical comorbid-
ities of the patient if any, and capabilities of the chosen facility.
In this chapter, we discuss principles for ensuring the safety of
patients undergoing aesthetic surgery, choosing an appropriate
anesthetic modality, minimizing the associated risks of anes-
thesia, and managing postoperative complications related to
anesthesia in aesthetic surgery patients.
Keywords
aesthetic surgery, anesthesia, general anesthesia, monitored
anesthesia care, local anesthesia
5.1 Preoperative Evaluation
A simple method for screening patients prior to undergoing
sedation or general anesthesia is the Rule of Threes, consisting
of the patient’s (1) acute history, (2) chronic history, and (3)
physical examination.
hen taking a patient’s acute history, the surgeon should
inquire about the patient’s exercise tolerance (e.g., how many
blocks or flights of stairs the patient can walk or climb before
becoming short of breath), history of present illness (e.g., any
major organ system abnormalities, including cardiac, pulmonary,
renal, and neurologic as well as a history of sleep apnea), prior
problems with anesthesia or intubation, and last visit to a primary
care physician. Items in the patient history that suggest difficult
airway anatomy include prior problems with anesthesia; snoring
or sleep apnea; advanced rheumatoid arthritis; and chromosomal
abnormalities. Exercise tolerance correlates with a patient’s car-
diac reserve and is commonly described in metabolic equivalents
(METs). Patients able to perform at least 4 METs without becoming
short of breath have been shown to have improved perioperative
outcomes. Examples of 4 METs include walking 5 city blocks or up
one flight of stairs.
The chronic history should include a patient’s medications,
allergies, social history, and family history of problems with
anesthesia.
Sed i n nd Ane e i r Ae e i Surgery
The physical exam pertinent to patients undergoing sedation or
anesthesia should include a careful examination of the patient’s
airway, heart, and lungs. The oropharynx is assessed and graded
using the Mallampati classification, which is a predictor of the ease
of orotracheal intubation (Table 5.1). Aside from a high (III or IV)
Mallampati score, exam findings that may suggest a difficult intu-
bation include obesity, a short neck with limited neck extension,
decreased hyoid–mental distance ( 3 cm), cervical spine disease,
syndromic facial features, mouth opening 3 cm, and mandibular
anomalies. These findings, if present, should be noted, as they will
be relevant if endotracheal intubation is required.
Table 5.1 Mallampati classification
I Faucial pillars, soft palate, uvula, and tonsillar pillars visualized
II Faucial pillars, soft palate, and uvula visualized
III Soft palate and base of uvula visualized
IV Only soft palate visualized
After performing a history and physical examination, the
surgeon must determine whether further preoperative testing
is necessary prior to proceeding with the planned surgery. Little
high-level evidence is available to guide preoperative testing,
and current practices are based on guidance from the American
Society of Anesthesiologists (ASA), which is largely based on sur-
veys of anesthesiologists. In general, an electrocardiogram may be
considered in patients with cardiac risk factors, a chest X-ray may
be obtained in patients with pulmonary disease, and a complete
blood count may be obtained in patients with anemia. Coagulation
studies may be obtained in patients with a history of bleeding or
those on anticoagulation. All women of childbearing age should
have a urine pregnancy test prior to undergoing anesthesia.
Patients are commonly stratified according to the ASA classifi-
cation, which provides a global assessment of a patient’s risk of
morbidity (Table 5.2). Patients in low risk categories (ASA I or II)
can be evaluated in the preoperative area on the day of surgery
by the anesthesiologist. For patients with recent hospitalizations,
body mass index (BMI) 30, ASA III or greater, anticipated difficult
airway, or cardiopulmonary or other significant comorbidities,
evaluation by an anesthesiologist should be conducted prior to
the day of surgery.
hile most patients presenting for aesthetic surgery tend to
be in good overall health and present few challenges in terms
of preoperative workup or anesthesia, an important exception
is patients presenting for body contouring after massive weight
loss. Patients who have undergone previous surgery altering their
gastrointestinal (GI) tract are at a high risk of nutritional and vita-
min deficiencies as well as comorbidities concomitant with their
51
 I Fundamentals

Table 5.2 American Society of Anesthesiologists (ASA) classification disorders and thrombophilia, one can refer to the review by Haeck
of patients et al. Herbal supplements should also be discontinued days to
ASA class Medical condition weeks prior to surgery, as these can affect platelet function. It is
I Healthy, no medical conditions prudent to consult with the prescribing physician when cessation
of antiplatelet or anticoagulant agents may be needed for surgery
II Mild systemic disease
or if there is any question regarding medications for any cardio-
III Severe systemic disease with functional limitation vascular or pulmonary disease.
IV Severe systemic disease that is a constant threat to life
V Moribund patient who will not survive without operation 5.1.2 Prophylaxis and Anxiolysis
VI Organ donor

Postoperative Nausea and Vomiting

obesity. The combination of the risk factors present in this patient
population and the risks of large body contouring surgeries, such
as a higher deep venous thrombosis (DVT) rate, make this by far
the highest-risk cohort in aesthetic surgery. These patients should
undergo a thorough nutrition and medical evaluation prior to sur-
gery and be assessed by the anesthesiologist well ahead of time to
optimize any risk factors.
5.1.1 Preoperative Home Medication
Management
In general, patients should take their home medications the
morning of surgery to maintain steady-state serum levels.
Exceptions to this rule include antiplatelet and anticoagulant
agents, oral hypoglycemic medications, monoamine oxidase
inhibitors (e.g., phenelzine), and herbal supplements.
Antiplatelet agents (e.g., aspirin) should be discontinued 7 days
prior to surgery. Patients on warfarin prior to surgery should be
transitioned to low-molecular-weight heparin by their primary
care physician or other provider who manages their anticoag-
ulation. Patients on novel oral anticoagulants (e.g., apixaban
Eliquis , rivaroxaban Xarelto ) should hold their anticoagulation
for four half-lives prior to surgery (commonly a total of 48 hours).
Patients with bleeding disorders may require replacement of
clotting factors prior to surgery. For a detailed review of bleeding
Postoperative nausea and vomiting (PO V) is an unpleasant expe-
rience for patients undergoing aesthetic surgery. It also increases
the risk of surgical complications (including wound dehiscence,
hematoma, aspiration, and electrolyte abnormalities).
The three most important risk factors for PO V are female
sex, nonsmoking status, and a history of motion sickness or prior
PO V. One simplified risk stratification system for predicting
PO V utilizes these three factors plus the use of postoperative
opioids. This risk stratification applies to patients undergoing
general anesthesia using inhalational anesthetics. Patients with
no risk factors have a 10 risk for PO V. Patients with one risk
factor have a 20 risk of PO V. Each additional risk factor adds a
20 risk of PO V, for a maximum risk of 80 in patients who have
all four risk factors.
Four proven interventions to reduce the risk of PO V are
administration of ondansetron ofran , intraoperative dexameth-
asone 4 mg intravenous (IV), droperidol, and total intravenous
anesthesia (due to propofol’s antiemetic activity). Each of these
interventions reduces the risk by approximately one-fourth, and
they work through independent mechanisms. The surgeon may
wish to avoid droperidol because of its relatively short half-life
and controversial effect on the –T interval of the cardiac cycle.
Additional antiemetics include anticholinergics (e.g., transdermal
scopolamine), benzamides (e.g., metoclopramide Reglan 25–50
mg), and substance P receptor antagonists (e.g., aprepitant 125 mg
orally PO ). A suggested algorithm for prevention and treatment
of PO V is given in Table 5.3.

Table 5.3 Prevention and treatment of postoperative nausea and vomiting (PONV)
Condition re men
One risk factor Dexamethasone 4 mg IV
Two risk factors Dexamethasone 4 mg IV + ondansetron (Zofran) 4 mg IV
Three risk factors Dexamethasone 4 mg IV + ondansetron 4 mg IV + total intravenous anesthesia
Four risk factors dexamethasone 4 mg IV + ondansetron 4 mg IV + total intravenous anesthesia + aprepitant 125 mg PO
Postoperative adjuncts Ondansetron 4–8 mg every 8 hours IV or ODT
Prochlorperazine (Compazine) 10 mg every 6 hours IV or PO
Metoclopramide (Reglan) 20 mg every 8 hours IV or PO
Trimethobenzamide (Tigan) 300 mg every 6 hours PO or 200 mg every 6 hours IM
Droperidol 1.25 mg IV
Scopolamine transdermal patch every 72 hours
Dexamethasone IV: after induction
Ondansetron IV: 30 min before end of case
Aprepitant PO: given in PACU
Droperidol: second line, Food and Drug Administration (FDA) black box warning for –T interval prolongation in cardiac cycle
Abbreviations: IM, intramuscular; IV, intravenous; ODT, orally disintegrating tablet; PO, orally; PACU, postanesthesia care unit.
Adapted from Apfel C. Postoperative and postdischarge nausea and vomiting: risk assessment and treatment strategies. Anesthesiology News 2008(October 29).

52

Anxiety
Many patients benefit from anxiolysis prior to entering the
operating room. Anxiolytics can improve the anxious patient’s
surgical experience and allow earlier onset of amnesia. Common
medications used for this purpose include diazepam (Valium)
10 to 20 mg PO on the morning of surgery, and midazolam
(Versed) 2 to 4 mg IV prior to entering the operating room.
Hypertension
Patients undergoing procedures for which hypertension is
especially detrimental (e.g., rhytidectomy) may be started on
an antihypertensive preoperatively. The goal of preoperative
prophylaxis is to decrease the risk that surgical stress, local
anesthetic infiltration, and patient awareness will increase blood
pressure. Clonidine is commonly used for this purpose, often
given as 0.1 to 0.2 mg PO the morning of surgery, and it may be
continued twice daily in the perioperative period to reduce the
risk of hematoma due to hypertension (see Chapter 56). otably,
postoperative analgesia is another key to avoiding hypertension
due to poorly controlled pain.
5.2 Methods of Anesthesia
The decision of which method of anesthesia to use for a given
procedure depends on the patient’s medical history, inva-
siveness and length of the planned procedure, capabilities of
the facility, and the preferences of the patient, surgeon, and
anesthesiologist.
5.2.1 General Anesthesia
General anesthesia achieves unconsciousness and analgesia
through intravenous and inhaled agents. Respiratory support
is required through either endotracheal intubation (ETT) or
laryngeal mask airway (LMA) with a ventilator. Endotracheal
intubation provides more definitive airway control with less
risk for aspiration, but with a higher risk of postoperative cough,
hoarseness, and sore throat (Table 5.4), with the opposite being
true for LMA. The positioning, type and duration of procedure,
and ease of intubation (should it be needed) are all factors that
are considered in the LMA vs. ETT decision. For each patient, the
airway management method should be discussed and agreed
upon with the anesthesia staff.
Table 5.4 Airway management in general anesthesia
Method Ad n ge
Endotracheal intubation (ETT) Greatest airway control (e.g., during position changes)
Better for cases in high aspiration risk, maintenance
of airway patency, pulmonary toilet, maintaining
oxygenation
Laryngeal mask airway (LMA) Minimal cardiovascular response during insertion
Fewer postoperative complications
Reusable device (more cost-effective)
Useful in rhinoplasty to act as mechanical barrier for blood
entry down gastrointestinal tract
Sed i n nd Ane e i r Ae e i Surgery
5.2.2 Monitored Anesthesia Care
For patients undergoing less invasive procedures, or those in
whom general anesthesia is less desirable, a lighter level of seda-
tion can be provided with monitored anesthesia care (MAC). This
provides a deep level of anesthesia, often using infusions such
as propofol that are carefully titrated by anesthesia personnel to
maintain the patient’s spontaneous respirations.
The advantages of MAC include fewer postoperative side
effects from anesthesia (e.g., hoarseness and cough as intubation
is avoided), more rapid recovery, lower risk of PO V (if propofol
is used instead of inhalational anesthetics), and lower cost. This
method of anesthesia is ideal for patients undergoing shorter
procedures (less than 3 hours) with good airways and baseline
pulmonary status. The use of MAC provides a comfortable level
of sedation for patients undergoing tumescent liposuction who
wish to avoid general anesthesia. The disadvantages of MAC
include the skill necessary to titrate the sedative medications
carefully, to avoid respiratory depression but provide adequate
sedation, and the lack of definitive airway control should the
patient be unable to maintain spontaneous ventilation. Patients
undergoing MAC should be informed that they may have some
awareness of the procedure and that conversion to general
endotracheal intubation is possible if there is any concern about
maintaining the airway.
5.2.3 Sedation
Procedural sedation can range from minimal sedation, in which
the patient has mild anxiolysis but responds normally to verbal
stimulus, to deep sedation, in which a repeated painful stimulus
is required to elicit a purposeful response (Table 5.5). Moderate,
or conscious, sedation is commonly used for office-based
procedures. During conscious sedation, the patient maintains
spontaneous ventilation and is able to respond purposefully
to verbal and tactile stimuli. Common medication regimens
used for conscious sedation include a combination of a sedative
(typically a benzodiazepine) and an opioid, such as midazolam
and fentanyl. Benzodiazepine hypersensitivity and a history of
acute-angle glaucoma are absolute contraindications to using
midazolam. Common dosing regimens for conscious sedation
are listed in Table 5.6. Conscious sedation is often adminis-
tered without the presence of anesthesia personnel, leaving
the surgeon responsible for ensuring an appropriate level of
sedation. In these cases it is helpful to monitor the patient’s
i d n ge
Higher incidence of postoperative cough, hoarseness, sore
throat
Does not protect against aspiration, gastroesophageal
reflux, or upper airway bleeding
53
 I Fundamentals

Table 5.5 Types of sedation and anesthesia

y e ne e i ed i n e ni i n
General anesthesia Loss of consciousness, unarousable even to deep painful stimulus
Deep sedation Responds purposefully to repeated/painful stimulus; respiratory support may be required
Moderate (conscious) sedation Responds purposefully to verbal or tactile stimulus; spontaneous ventilation maintained
Minimal sedation Anxiolysis, but responds normally and has a clear airway
Monitored anesthesia care (MAC) Sedation provided by anesthesiologist, can include conversion to general anesthesia
Adapted from Smith I, Skues M, Philip BK. Ambulatory (Outpatient) Anesthesia. St. Louis, MO: WB Saunders; 2015.

Table 5.6 Conscious sedation protocols

Medication Class Dosing
Initiation agents
Diazepam Benzodiazepine 10–50 mg preoperatively
Midazolam Benzodiazepine 0.5–1 mg IV every 5–10 minutes
or
0.01 mg/kg preoperatively, then 0.01 mg/kg bolus followed by
continuous infusion at 0.08 mg/kg/h
Ketamine Dissociative anesthetic 200–750 mcg/kg bolus, followed by 5–20 mcg/kg/min infusion
Fentanyl Opioid 25–50 mcg every 5–10 min per patient alertness
or
0.7 mcg/kg single dose preop
Reversal agents
Flumazenil Benzodiazepine antagonist 0.2 mg in incremental doses up to max of 1 mg
Naloxone Opioid antagonist 0.1–0.2 mg every 2–3 min up to adequate reversal
Adapted from Mustoe TA, Buck DW 2nd, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg
2010;126(4):165e–176e; Cinnella G, Meola S, Portincasa A, et al, Sedation analgesia during office-based plastic surgery procedures: comparison of two opioid
regimens. Plast Reconstr Surg 2007;119(7):2263–2270.

pulse oximetry continuously and avoid the use of supplemental
oxygen. The need for supplemental oxygen is an indicator of an
inappropriately deep level of sedation in the absence of anes-
thesia personnel. Anesthesiology guidelines provide guidance
for nonanesthesiologists providing conscious sedation; these
are reviewed in Table 5.7.
5.2.4 Local Anesthesia
Local anesthetics are used as an adjunct in patients under gen-
eral anesthesia, MAC, and conscious sedation or as a stand-alone
analgesic regimen for smaller procedures. Several of the more
commonly used local anesthetics are listed in Table 5.8.
Local Anesthetics
Local anesthetics function by crossing the membrane and
blocking sodium channels to stabilize the membrane of periph-
eral nerve axons, thereby preventing depolarization and nerve
conduction through pain fibers. There are two classes of local
anesthetics: esters and amides. Esters are hydrolyzed by plasma
pseudocholinesterases, have shorter half-lives, and are more
likely than amides to produce an allergic reaction. Amides are
metabolized in the liver and have less potential to cause an
allergic reaction but are more likely to accumulate and cause
systemic toxicity. In patients who have had an allergic reaction
to an ester, an amide may be used for local anesthesia, and vice
versa. A useful memory aid is that the amide local anesthetics

Table 5.7 Recommendations for patient monitoring during conscious sedation

• An additional staff member is recommended, whose primary responsibility is to monitor the level of sedation.
• The patient’s response to verbal commands should be verified every 5 minutes. For patients unable to give a verbal response, a “thumbs up” can
suffice to ensure that the level of sedation is not excessively deep.
• Pulse oximetry, capnography, and heart rate should be monitored continuously. Blood pressure should be measured every 5 minutes, and patients
with significant cardiovascular disease should be monitored with a continuous electrocardiogram.
• It is recommended that someone with the ability to establish airway access and institute positive pressure ventilation be present. It is also
recommended that emergency equipment be available in locations where conscious sedation is provided.
Adapted from Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on
Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental
Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018;128(3):437–479.

54
 Sed i n nd Ane e i r Ae e i Surgery

Table 5.8 Commonly used local anesthetics (doses based on 70-kg adult)
Name imum d e i u ur i n i u imum d e i ur i n i e ine rine
epinephrine epinephrine epinephrine
Esters
Procaine (1–2%) 400 mg 10–30 min 7 mg/kg, max 600 mg 30–40 min
Chloroprocaine 11 mg/kg, max 800 mg 15–30 min 14 mg/kg, max 1,000 mg
Amides
Lidocaine (1–2%) 4.5 mg/kg, max 300 mg 30–60 min 7 mg/kg, max 500 mg 120–360 min
Mepivacaine (1-2%) 300 mg 30–90 min 7 mg/kg, 500 mg 60–120 min
Bupivacaine 0.25% 2.5 mg/kg, max 175 mg 120–140 min 2.5–4 mg/kg, max 225–400 140–180 min
mg
Prilocaine 8 mg/kg, max 500–600 mg 30–90 min
Data from elman M, Ceradini DJ. Anesthesia in aesthetic surgery. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. New ork, N : Elsevier
Limited; 2009:27–35; Mustoe TA, Buck DW 2nd, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg
2010;126(4):165e–176e.

have two i’s in the name (e.g., lidocaine is an amide whereas
procaine is an ester).
The pain of injection is the major source of patient discomfort
when local anesthetics are used, and minimizing this pain can
drastically improve the patient experience. Lalonde and col-
leagues have written extensively on this topic; some of the key
points are summarized here:
• Epinephrine:
Use local anesthetics mixed with 1:100,000–1:800,000
epinephrine. Epinephrine provides local vasoconstriction,
which increases the duration of action, reduces bleeding
(and therefore bruising), and allows for higher dosages by
slowing systemic uptake.
• Buffering:
Lidocaine, bupivacaine, and other local anesthetic solutions
are acidic as drawn up from the vial, which contributes to
the discomfort of injection.
To increase patient comfort, buffer the solution 10:1 with
8.4 sodium bicarbonate to reduce the acidity of the injec-
tion solution to a more physiologic pH; e.g., add 1 mL of
bicarbonate buffer to 10 mL of injectable lidocaine.
• Warm the local anesthetic to room temperature using the
palm of your hand.
• Use the smallest-diameter needle feasible (27–30-gauge).
• Switch needles to a fresh needle if one becomes blunt.
• Distract the patient by having them look away. Tactile dis-
traction can be provided by pinching the surrounding skin or
cooling it with ice.
• Preanesthetize the skin using topical anesthetic creams such
as eutectic mixture of local anesthesia (EMLA); a mix of 2.5
prilocaine and 2.5 lidocaine can provide topical anesthesia
prior to injection. ote that EMLA requires 90 to 120 minutes
to reach its maximal effect.
• Insert the needle perpendicular to the skin; an oblique angle
will cross more nerve fibers, causing more pain.
• Stabilize the syringe with your nondominant hand to mini-
mize needle movement.
• Inject subdermally, not intradermally.
• Inject a small bleb of local anesthetic immediately after punc-
turing the skin, then pause for a few seconds before slowly
advancing the needle and injecting more.
• Inject into the subcutaneous fat if there is an open wound.
• eep a wheal of local anesthesia 10 mm ahead of the needle tip
when advancing the needle.
• Only reinsert the needle within 1 cm of the blanched skin
border.
• Have patients score their pain with injection on a scale of
1 to 10, and learn from your own experience.
Local anesthesia can be especially useful for head and neck
procedures. Almost the entirety of the facial skin and a significant
portion of intraoral mucosa can be anesthetized using small
amounts of local anesthetic deposited around the nerves of the
face. Landmarks for local nerve blocks of the face have been well
described by ide and Swift (Table 5.9).
Tumescence
Tumescence solutions are dilute mixtures of local anesthetics
and epinephrine that reduce pain and significantly reduce
blood loss. They are commonly used during liposuction, which
facilitates the safe removal of large volumes of fat in one setting,
but are also widely used in body contouring, breast surgery, and
other aesthetic procedures. The exact composition may vary, but
typically 2 to 4 mg of epinephrine and 500 to 1,000 mg of lido-
caine are mixed in 1 L of normal saline. Sodium bicarbonate can
be added as 5 mL of 1 mEq/mL sodium bicarbonate for every 1 L
of normal saline to reduce the acidity of the solution. Lidocaine
injected as part of a tumescent solution has been demonstrated
to be safe in doses as high as 35 to 55 mg/kg. Systemic lidocaine
levels peak approximately 12 hours after tumescent injection in
most areas of the body. In the head and neck, plasma levels of
lidocaine peak sooner, approximately 6 hours after infiltration.
For this reason, it is recommended that in cases where both areas
are to be infiltrated with tumescence, the head and neck should
be infiltrated before other areas to reduce the risk of the plasma

55
 I Fundamentals

Table 5.9 Sensory blockade of the face

er e
Supraorbital and
supratrochlear (V1)
External nasal (V1)
Zygomaticotemporal (V1)
Zygomaticofacial (V1)
Infraorbital (V2)
Mental (V3)
Mandibular division of
trigeminal nerve (V3)
Great auricular (C2–3)
Adapted from ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998;101(3):840–851; ide BM, Swift R. Addendum to “How to block and tackle
the face.” Plast Reconstr Surg 1998;101(7):2018.
ndm r r in e i n
Palpate supraorbital notch, distract brow laterally, insert needle in middle third of brow pointed toward supraorbital
notch; inject at notch, above notch, and at nasal bone.
Note that periorbital ecchymosis may occur.
Palpate lower ends of nasal bone and inject just below nasal bone, 5–10 mm lateral to midline. Use 1–2 mL per side.
Palpate zygomaticofrontal suture, insert needle 5 mm inferior to the junction of the lateral orbital rim at or below the
lateral canthus. Advance behind lateral orbital rim to 10 mm below the lateral canthus. Inject local while withdrawing
needle.
1–2 cm lateral to junction of infraorbital rim and lateral orbital rim.
Palpate junction of infraorbital rim and lateral orbital rim by palpation. Inject 1–2 cm lateral to this point. Use 2 mL.
Approach intraorally or percutaneously between the alar base and nasolabial fold, aiming toward medial limbus. Advance
until foramen entered or bony contact made (then “walk up” to foramen). Use 1–2 mL per side.
Distract lip over 2nd mandibular premolar, visualize submucosal nerve. Use 1–2 mL. For lower chin, advance
supraperiosteally to lower border of mandible and withdraw while injecting 2–3 mL.
Spinal needle is placed through the sigmoid notch, 1 cm posterior to the pterygoid plate.
Palpate sigmoid notch externally, 2.5 cm anterior to tragus as the patient opens and closes the mouth. Inject small
amount of superficial anesthetic; advance spinal needle perpendicular to face until pterygoid plate is contacted
(approximately 4 cm deep); almost completely withdraw needle, readvance to a point 1 cm posterior to prior point of
contact at the same depth, aspirate, and inject. Use 3–4 mL per side.
6.5 cm inferior to external acoustic meatus over the middle of the sternocleidomastoid; inject on muscle fascia.

concentration curves being superimposed, raising the risk of
toxicity. To decrease the risk of lidocaine toxicity, the surgeon
has the option of decreasing the amount of tumescent solution
used or using general anesthesia and omitting lidocaine from the
tumescent solution. Bupivacaine should be avoided in tumescent
solutions, as it has a longer half-life and its toxicity is more difficult
to reverse should systemic toxicity occur. For patients intolerant
to lidocaine, prilocaine may be safely substituted when dosed
at 8 to 15 mg/kg. Patients should be observed for 12 hours after
infiltration with prilocaine solutions to monitor for methemo-
globinemia. Signs would include central nervous system abnor-
malities (headache, confusion, seizures), cardiac abnormalities
(chest pain, arrhythmias), and cyanosis. Epinephrine solutions
should be avoided in patients with pheochromocytoma or signif-
icant cardiac or vascular disease. Halothane should be avoided
in patients undergoing tumescent anesthesia, as it increases
the risk of cardiac arrhythmias. Epidural and spinal anesthesia
should also be avoided in patients undergoing tumescent lipo-
suction, as these anesthetic modalities can result in hypotension,
confounding the fluid resuscitation protocols and increasing the
potential for systemic fluid overload postoperatively.
5.2.5 ffi e- ed Ane e i
Office-based surgery has become an important component of
practice for plastic surgeons. Procedures carried out in the office
have been shown to have lower rates of overall complications,
hematoma, and infection than those carried out at ambulatory
surgical centers and hospitals, with similar rates of venous
thromboembolism. Procedures considered appropriate for office-
based surgical centers include breast augmentation, liposuction,
rhytidectomy, blepharoplasty, rhinoplasty, and laser resurfacing.
Anesthesia administered in offices ranges from local anesthe-
sia alone to general anesthesia. In 2002, the American Society
of Plastic Surgeons Task Force on Patient Safety in Office-Based
Surgery Facilities provided recommendations on the nature of
facilities in which procedures should be performed. Specifically,
it recommended the following:
Plastic surgery performed under anesthesia, other than minor
local anesthesia and/or minimal oral tranquilization, should be
performed in a surgical facility that meets at least one of the
following criteria:
• Accredited by a national or state-recognized accrediting
agency/organization such as the American Association for
Accreditation of Ambulatory Surgical Facilities (AAAASF),
the Accreditation Association for Ambulatory Health Care
(AAAHC), or the oint Commission on Accreditation of
Healthcare Organizations ( CAHO).
• Certified to participate in the Medicare program under Title
XVIII
• Licensed by the state in which the facility is located
Patient selection for office-based surgery is important. State
regulations differ regarding requirements for in-office surgical
facilities. In general, an office-based surgical facility should
have adequate preoperative evaluation, informed consent for
surgery and anesthesia, age- and size-appropriate resuscitation
equipment available, positive pressure ventilation ability with a
well-maintained ventilator, difficult airway algorithm equipment,
defibrillation equipment, oxygen, suction, backup generator, and
intraoperative and postoperative monitoring equipment.
In general, procedures over 6 hours in length or those finishing
after 3 pm should be undertaken in an ambulatory surgery center
or hospital to allow adequate time for recovery. The American
Society of Plastic Surgeons agrees that ASA class I or II patients
are good candidates for office-based surgery using any method of
anesthesia, while ASA III patients should be given no more than

56

local anesthesia with sedation in an office setting, and ASA IV
patients should be given only local anesthesia with no sedation
in an office-based setting. Additionally, patients with labile or
poorly controlled diabetes mellitus, seizure history, susceptibility
to malignant hyperthermia, morbid obesity, or obstructive sleep
apnea, and those without escorts home, are not candidates for
office-based sedation and should be given no more than local
anesthesia if undergoing in-office procedures.
5.3 Technical Considerations
5.3.1 Thermoregulation
Patients undergoing long procedures involving exposure of
their trunk can be especially prone to intraoperative hypother-
mia. Hypothermia can have deleterious effects on the body,
including increased risk for surgical site infection, impaired
wound healing, altered coagulation, and increased cardiac
stress. Therefore, it is important to take measures intraoper-
atively to maintain normothermia. These can include mini-
mizing exposure of nonsurgical sites, airwarming blankets,
administering warmed intravenous fluids, and increasing the
operating room temperature if necessary. Forced-air warming
is likely not beneficial in procedures that are shorter than 60 to
90 minutes.
5.3.2 Fluid Management
Careful attention should be paid to fluid management, partic-
ularly during large-volume liposuction where fluid shifts can
occur. It is important to maintain euvolemia to maintain the
body’s electrolyte balance and optimize oxygen delivery to the
issues. Fluid resuscitation regimens following large-volume
liposuction are subject to debate; however, it is generally
agreed that some intravenous fluid should be administered
if more than 1 or 2 liters of lipoaspirate are removed in one
setting. Additionally, it is recommended that patients with
greater than 5 L of total aspirate removed be observed in a
facility overnight. It is estimated that up to 70 of tumescent
solution used in liposuction becomes intravascular and is not
aspirated. In standard liposuction cases, patients should be
administered maintenance intravenous fluids while under
anesthesia, and it should be expected that 70 of the tumes-
cent will become intravascular. In large-volume liposuction
cases with over 5 L of aspirate, 0.25 mL of intravenous fluid for
every 1 mL of aspirate should be infused as a bolus at the end
of the case.
5.3.3 Patient Positioning
Careful attention must be paid to adequate positioning of the
patient so as to avoid pressure-induced skin injury and neu-
ropathy. Particular points of consideration include the cubital
tunnel, axilla (especially in lateral position), and heels. Correct
positioning is a patient safety issue, and justification cannot be
made for neglecting it: nerve injury is only second to death in
causes of settled liability claims related to anesthesia.
Sed i n nd Ane e i r Ae e i Surgery
5.4 Postoperative Management
There are three phases of recovery from anesthesia. Phase 1
starts in the operating room when the anesthetic agents are
stopped and continues in the postanesthesia care unit (PACU).
Motor function, spontaneous ventilation, and airway protective
reflexes return, and vital signs are closely monitored.
Phase 2 typically takes place in the PACU or secondary recovery
area, where the patient’s vital signs can still be monitored and the
patient is observed for pain, nausea, vomiting, and bleeding. The
patient’s ability to ambulate is assessed, and he or she is evaluated
for discharge home. This typically occurs during the 1 to 2 hours
following surgery. Ability to tolerate oral intake is not a typical
discharge requirement, and it has not been shown to correlate
with PO V.
During phase 3, the patient’s body returns to its baseline phys-
iology. This portion of recovery typically occurs at the patient’s
home following ambulatory surgery.
5.4.1 Complications
Postoperative Nausea and Vomiting
PO V is the most common complication following anesthesia. It
occurs in 20 to 30 of patients in the general population and in
up to 70 to 80 of high-risk individuals. Eighty percent of PO V
occurs within 48 hours from surgery, but 65 of these patients do
not have symptoms until leaving the surgery facility. The use of
volatile anesthetics, nitrous oxide, and intraoperative and post-
operative opioids, as well as longer surgical duration, increase
the risk of PO V. In plastic surgery, PO V is more common in
patients undergoing breast augmentation.
The best way to avoid PO V is to administer prophylaxis to
patients at high risk. This can include anticholinergics, serotonin
antagonists, and steroids, as mentioned previously. Additionally,
an anesthesia plan can be tailored to avoid agents more likely to
provoke PO V, such as inhalational agents.
Ondansetron, scopolamine, and prochlorperazine are the main-
stays of treatment for PO V. These can be administered in the
recovery unit. For patients who are otherwise meeting criteria for
discharge except for persistent PO V, ondansetron oral dissolving
tablets can be prescribed for continued PO V control at home.
Hoarseness, Cough (Airway Irritation)
Hoarseness and cough are more likely to occur following endo-
tracheal intubation and occur due to airway irritation. These
symptoms almost always resolve spontaneously within hours
after surgery. Topical anesthetic lozenges can be used for symp-
tomatic relief.
Local Anesthetic Systemic Toxicity
Local anesthetic systemic toxicity (LAST) is a rare but potentially
fatal complication of local anesthesia. It occurs when plasma
levels of local anesthetic exceed the toxicity threshold and cause
physiologic derangement. Central nervous system symptoms
precede signs of cardiac dysfunction. The earliest symptoms
57
 I Fundamentals
include tinnitus, perioral paresthesias, and restlessness. This can
be followed by seizures, respiratory arrest, and cardiac depres-
sion. Treatment is instituted using basic life support principles
(the ABCs: airway, breathing, circulation) and advanced cardiac
life support as necessary. Additionally, intravenous lipid emul-
sion therapy is begun as soon as feasible. Any frequent user of
local anesthetics should be familiar with the treatment of LAST.
For reference, the user is referred to the free LipidRescue algo-
rithm, available from the American Society for Aesthetic Plastic
Surgery.
Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare, life-threatening com-
plication of general anesthesia that occurs following the admin-
istration of succinylcholine or volatile agents. Signs include
rapid-onset tachycardia, acidosis, hypercarbia, muscle rigidity,
and fever. MH may be difficult to diagnose intraoperatively, as
there are several possible causes for this clinical scenario. Two
particular signs that should alert the surgeon to the diagnosis of
MH are a rise in end-tidal CO2 associated with masseter spasm or
trismus. The treatment for MH is cessation of offending agents,
administration of dantrolene (a muscle relaxant), cooling as
necessary, and frequent vital sign and electrolyte/metabolite
monitoring. Every surgical facility using succinylcholine or
volatile agents should have dantrolene available for this reason.
MH is inherited in an autosomal dominant fashion with variable
penetrance, with most cases linked to a mutation in the RYR1
gene. Anesthetics appropriate for patients susceptible to MH
include propofol, opiates, and nondepolarizing muscle relaxants.
Patients with muscle disorders or paraplegia should not be given
succinylcholine, either, as this can trigger a life-threatening
rhabdomyolysis and hyperkalemia similar to MH. Procedures
with sedation in patients susceptible to MH should be under-
taken in an accredited ambulatory surgery center or hospital.
Patients with suspected susceptibility to MH can be referred to
the Malignant Hyperthermia Association of the United States for
testing, which is undertaken through a surgical muscle biopsy
and caffeine-halothane contracture test (gold standard) or RYR1
mutation screening (less sensitive).
Benzodiazepine or Opioid Overdose
Any procedure involving sedation requires a careful titration
of medications to ensure adequate analgesia and anxiolysis
while permitting adequate spontaneous respiration. During
the administration of sedation, it is important to monitor the
patient’s level of sedation periodically (e.g., every 5 minutes)
by eliciting a response to verbal stimulus or, if the patient is
unable to talk, eliciting a motor response such as a thumbs up.
Excess doses of benzodiazepines or opioids lead to respiratory
depression with hypoventilation or even respiratory arrest. In
this emergency it is important to provide artificial respiration
(i.e., bag-valve mask) and immediately institute reversal of the
relevant sedative agents. The American Society for Aesthetic
Plastic Surgery has published a quick-reference guide to the
dosing of flumazenil and naloxone for benzodiazepine and opioid
reversal, respectively.
58
5.5 Concluding Thoughts
Effective anesthesia allows patients to undergo aesthetic surgery
safely so as to restore or improve their body image. Modern-day
anesthesia services are overall very safe, with a low risk profile,
in part due to thoughtful preoperative evaluations by surgeons
and anesthesiologists. A variety of anesthetic modalities exist,
ranging from general anesthesia to monitored anesthesia care,
conscious sedation, and local anesthesia alone. This chapter
provides a framework to assist the surgeon in choosing an
appropriate anesthetic plan in concert with an anesthesiologist,
in managing the patient’s perioperative symptoms that may
be related to anesthetic medications, and in being cognizant of
potential adverse effects related to anesthesia. It is our hope that
this will assist the reader in providing an optimal experience for
patients undergoing aesthetic surgery.
Clinical Caveats
• ASA classification is a global assessment that classifies
patients according to medical fitness.
• In general, patients should take their home medications the
morning of surgery to maintain steady-state levels.
• Risk factors for PONV include female, nonsmoker, past history
of PONV, history of motion sickness, young age, migraine
history.
• Other than procedures performed using local and mild oral
tranquilization, surgery should be carried out in an accredited
facility.
• Conscious sedation commonly uses midazolam for sedation
and fentanyl for analgesia.
• Amides contain the letter I in the prefix of the generic name.
• To avoid pain, insert needle perpendicular to skin, use small
needles (27- or 30-gauge), and inject and advance slowly.
Suggested Reading
1 American Society for Aesthetic Plastic Surgery. LipidRescue . 2019. https://
www.surgery.org/professionals/patient-safety/lipidrescue 25E2 2584 25A2-
Accessed September 22, 2019
2 Apfel C. Postoperative and postdischarge nausea and vomiting: risk assessment
and treatment strategies. Anesthesiol News 2008(October 29). https://www.anes-
thesiologynews.com/Review-Articles/Article/10-08/Postoperative-and-Postdis-
charge- ausea-and-Vomiting-Risk-Assessment-and-Treatment-Strategies/11751
Accessed September 22, 2019
3 Cinnella G, Meola S, Portincasa A, et al. Sedation analgesia during office-based
plastic surgery procedures: comparison of two opioid regimens. Plast Reconstr
Surg 2007;119(7):2263–2270
4 Haeck, P. C., et al. (2009). Evidence-Based Patient Safety Advisory: Blood Dyscra-
sias. Plastic and Reconstructive Surgery 124(4S):82S-95S
5 Mustoe TA, Buck D 2nd, Lalonde DH. The safe management of anesthesia,
sedation, and pain in plastic surgery. Plast Reconstr Surg 2010;126(4):165e–176e
6 Practice guidelines for moderate procedural sedation and analgesia 2018: A
report by the American Society of Anesthesiologists Task Force on Moderate
Procedural Sedation and Analgesia, the American Association of Oral and Maxil-
lofacial Surgeons, American College of Radiology, American Dental Association,
American Society of Dentist Anesthesiologists, and Society of Interventional
Radiology. Anesthesiology 2018;128(3):437–479
7 Rubin P, Xie , Davidson C, Rosow CE, Chang , May r. Rapid absorption
of tumescent lidocaine above the clavicles: a prospective clinical study. Plast
Reconstr Surg 2005;115(6):1744–1751
 Sed i n nd Ane e i r Ae e i Surgery

8 Scarborough DA, Herron B, han A, Bisaccia E. Experience with more than 5,000
cases in which monitored anesthesia care was used for liposuction surgery.
Aesthetic Plast Surg 2003;27(6):474–480
9 Shafer DM, Opperman S. Postoperative Nausea and Vomiting. ew ork, : DS, alden L, eds. Aesthetic Plastic Surgery. Elsevier Limited; 2009:27–35
Elsevier Limited; 2009
10 Shermak MA. Pearls and perils of caring for the postbariatric body contouring
patient. Plast Reconstr Surg 2012;130(4):585e–596e
11 Smith I, Skues M, Philip B . Ambulatory (Outpatient) Anesthesia. St. Louis, MO:
B Saunders; 2015
12 Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia
injection. Plast Reconstr Surg 2013;132(3):675–684
13 elman M, Ceradini D . Anesthesia in aesthetic surgery. In: Aston S , Steinbrech
14 hou , et al. Malignant Hyperthermia and Muscle-Related Disorders. St. Louis,
MO: B Saunders; 2015:1
15 ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg
1998;101(3):840–851
16 ide BM, Swift R. Addendum to How to block and tackle the face. Plast Reconstr
Surg 1998;101(7):2018

59
 Part II
Business Basics

II

6 y er Ae ei edi ine in n Ae
Practice?
Ali A. ureshi, Renato Saltz, and W. Grant Stevens
Abstract
Aesthetic surgeons may wonder, hy offer aesthetic medicine
in an aesthetic surgical practice The answered is based on
the Five Ps of aesthetic medicine: patient acquisition, patient
retention, patient optimization, patient education, and patient
conversion. Aesthetic medicine accounted for over 2 billion in
2017 and continues to grow with newer demographics such as
men and younger patients seeking services. The explosion in
new nonsurgical technologies and treatments, combined with
patients’ demands for quick, effective solutions to look refreshed,
has compelled plastic surgeons to incorporate aesthetic medi-
cine. e will explore in this chapter how aesthetic medicine is
a core part of aesthetic plastic surgery, can help grow a prac-
tice, and above all, can lead to better results for our patients.
Specifically we look at the 747 effect and how to build a practice
with patients for life. ew paradigm shifts, such as outcome
optimization with pre- and postsurgical skin treatments and the
subscription model of aesthetic services, are also explored.
Keywords
aesthetic medicine, nonsurgical, noninvasive, cryolipolysis,
injectables, lasers, facials, skin treatment, subscription model,
patient optimization, practice management
6.1 Introduction
Aesthetic surgeons have long debated the value of offering com-
prehensive aesthetic medical services as a part of their surgical
practices. aysayers question the value of nonsurgical services to
their practice and patients. onsurgical aesthetic services may be
viewed as a disruptive technology, forcing aesthetic surgeons to
reassess and re-evaluate how to incorporate these services into
their surgical practices. Competition from nonplastic surgeons
and industrywide competition have also been disruptive forces,
leading to change and blurring the divisions between cosmetic
procedures and aesthetic surgery. Our personal experience and a
growing body of evidence demonstrate a number of compelling
reasons it would behoove aesthetic plastic surgeons to offer these
services. These five Ps of aesthetic medicine are all centered
on patient care (Fig. 6.1): patient acquisition, patient retention,
patient optimization, patient education, and patient conversion.
The globalization of beauty, changing demographics and cul-
tural preferences, and advances in technology are shaping and
transforming the aesthetic marketplace. Cosmetic medicine offers
exciting options for practices to grow and expand. The growth in
nonsurgical and aesthetic medical consumption has been expo-
nential; it accounted for nearly 2 billion in 2017, according to the
y er Ae ei edi ine in n Ae e i Surgi r i e
e i Surgi
Fig. 6.1 The five Ps of aesthetic medicine.
American Society for Aesthetic Plastic Surgery (ASAPS) Cosmetic
Surgery Data Bank. ust from 2012 to 2017, injectables saw a 40
increase while skin rejuvenation saw a 30 increase in utilization.
Even more impressive, nonsurgical fat reduction increased over
200 in the same time period. More than ever, men have been
seeking nonsurgical aesthetic treatments, accounting for 10 of
services in 2017. The top five nonsurgical procedures in 2017
were neurotoxin, filler, nonsurgical fat reduction, hair removal,
and chemical peel. Areas with major growth have included
microablative skin resurfacing and nonsurgical skin tightening
procedures. The International Society of Aesthetic Plastic Surgery
(ISAPS) has also seen exponential growth in nonsurgical proce-
dures, demonstrating that the demand for such services is truly a
global phenomenon.
These numbers demonstrate not only the magnitude of demand,
but also the distribution and type of nonsurgical aesthetic ser-
vices patients seek. Patients continue to seek quick and effective
solutions in order to look young and refreshed. The services they
seek range from laser therapies to cryolipolysis to ultrasound skin
tightening to peels and facials. The breadth of aesthetic services
cannot be underestimated. It is this diversity of services that can
enable a surgical practice to incorporate nonsurgical aesthetic
services selectively to complement the surgeries they offer or spe-
cialize in. This will, in turn, appeal to a broader range of patients
over a long term, leading to patients for life.
A landmark study in 2007 from the Cosmetic Medicine Task
Force of the ASAPS and American Society of Plastic Surgery
(ASPS) highlighted prevailing perceptions and trends in cosmetic
medicine. The task force was established to address the disruption
caused by noncore providers entering the aesthetic field, the
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 II Business Basics
growing popularity of nonsurgical procedures, and emergence of
medical-grade spas. The study found that the public considered
injectables low-risk procedures and that these patients were more
price-sensitive and likely to seek providers of any specialty with
a lower price point. Patients were found to be just as likely to see
noncore providers as to see plastic surgeons for these services. The
most significant finding was what is now called the 747 effect.
hen surveyed women were asked whom they would choose
to perform their cosmetic surgery, 93 would choose a plastic
surgeon and 7 would choose a noncore doctor or dermatologist.
Only 25 would choose a plastic surgeon to perform a minimally
invasive procedure (laser, injectables, peels, microdermabrasion,
etc.) and of patients who had a positive experience with a non-
invasive procedure with a nonplastic surgeon (either a dermatol-
ogist or noncore physician), 47 would stay with the nonplastic
surgeon for a cosmetic surgery as well. Similar surveys performed
by the Sociedade Brasileira de Cirurgia Plastica (SBCP) in Brazil,
the second-largest cosmetic surgery market in the world, had very
similar findings.
The Cosmetic Medicine Task Force conclusion was obvious:
demand for our surgical procedures could be in jeopardy if aes-
thetic plastic surgeons do not capture new patients early in their
experiences with aesthetic medicine. Indeed, the impact of such
sentiments could drastically affect the flow of patients into the
operating rooms. In order to preserve aesthetic plastic surgery,
aesthetic surgeons must be willing to incorporate disruptive
technologies such as nonsurgical procedures and aesthetic
medicine into their practices. Aesthetic medicine and nonsurgical
procedures need to be incorporated into the training of residents
and fellows in plastic surgery and our daily practices, or plastic
surgeons may not remain relevant as the specialty of aesthetics.
6.2 Patient Acquisition
Cryolipolysis is an ideal example of how a nonsurgical aesthetic
service leads to patient acquisition. ith nonsurgical fat reduc-
tion seeing one of the largest periods of growth since 2012,
this service offers a unique opportunity for practice growth.
Stevens et al describe their clinical and business experience with
cryolipolysis in 2013. Of over 500 new patients to the practice,
66 came specifically seeking cryolipolysis with CoolSculpting
(Allergan, Dublin, Ireland), and 62 had never had an aesthetic
procedure. This provided an opportunity to introduce patients
to other offerings within the practice: injectables, skin care, laser
hair removal, and even surgical procedures performed by the
aesthetic plastic surgeons in the practice. Forty percent of these
patients actually came back to the practice to avail themselves of
other aesthetic treatments. These same patients had previously
never had aesthetic surgery at the practice, let alone a nonsur-
gical treatment. Interestingly, 95 of patients had never had an
injectable treatment, with either neurotoxin or soft tissue filler,
and the practice found that the service most commonly used by
returning cryolipolysis patients was for injectables.
The study also found that offering nonsurgical procedures
expanded the male demographics of the practice. After a targeted
marketing campaign specifically tailored for men, nearly 42 of
all cryolipolysis clients were men. This demonstrates that non-
surgical aesthetic services bring patients into a surgical practice
64
that they may have otherwise never considered. This can be a very
powerful tool for new practices seeking to establish themselves or
mature practices that seek to expand their demographic, as the
case may be with male clientele.
In a study by urkjian et al examining the impact of economic
factors on facial aesthetic surgery, an overwhelming majority of
patients preferred treatments that have a long-lasting effect over
those with shorter duration. Only physician’s training and exper-
tise with the treatment superseded this as a treatment decision
driver. Further, over half of respondents said that their decision to
have an aesthetic facial treatment was affected by the economy. It
is important for aesthetic practices to offer diverse services with
a range of price points for new patient acquisition. The study also
suggests that well-trained aesthetic surgeons should consider
offering nonsurgical treatments, as one of the most important
factors for patients choosing to have a treatment is the physician’s
training and background. Plastic surgeons have a unique opportu-
nity to offer these services.
A new paradigm shift in nonsurgical aesthetic services is cur-
rently under way, with a subscription aesthetic services model
that also helps with patient acquisition. This model has been suc-
cessful in other industries. Apple (Cupertino, CA) saw a doubling
in sales of its iPhones when it started a monthly payment service;
there is increasing momentum for a similar subscription model
in aesthetics. Previous studies have demonstrated that cost can
be a barrier when drawing a wider audience into aesthetics, and
this model may be an affordable option that will increase patient
acquisition.
6.3 Patient Retention
Given that it costs five times as much to acquire a new customer
as to retain an existing one, building loyalty is paramount to any
business. Creating a loyal aesthetics customer, however, is not an
easy task, as many patients prefer to shop around for hot deals
rather than return to the same practice for repeat treatments.
The growth in nonsurgical procedures and the aesthetic med-
icine industry might not translate to increases in revenue for
individual practices that are unable to retain their patients. It is
not that the patients are no longer seeking treatment it is that
they are going elsewhere.
As many other physicians and nonphysicians increasingly
become involved in aesthetic medicine, it is important that aes-
thetic surgical patients be retained in the practice. As previously
mentioned, the 2007 seminal study by the Cosmetic Medicine
Task Force found that 47 of patients would be willing to return
to someone other than a plastic surgeon for an invasive aesthetic
procedure based on a prior positive noninvasive treatment with
that provider. This could bode poorly for aesthetic surgeons as we
try to maintain high quality and excellent outcomes in aesthetic
surgery. Maintaining patients in a practice will lead to multiple
encounters and potential procedures over the course of their
lifetime. For example, we found with cryolipolysis that 40 of new
patients who were seen remained in the practice for up to 4 years
after their treatments, which was the longest follow-up available
from the study at the time.
The subscription model of aesthetic services is a unique way to
deliver ongoing aesthetic services to patients and retain patients.

Instead of patients’ waiting for the effects of their neurotoxin or
filler to wear out before seeking treatment again, subscription
services enable patients to maintain their results. In our practice,
prior to implementing a subscription model, neurotoxin patients
were coming, on average, 2.1 times per year, waiting for the effects
of the neurotoxin to diminish and then often having difficulty
making time for themselves to come in for a treatment. Since we
implemented a subscription model for aesthetic services, patients
now maintain their neurotoxin results and come in more often, on
average 3.7 times per year. This has dramatically improved patient
retention, as these patients are no longer seeking treatments
elsewhere or seeking a lower price point each time they need a
treatment.
6.4 Patient Optimization
Aesthetic surgeons pride themselves in their surgical outcomes
and want their patients to look as good as they can. Presurgical
treatments with skin care, facials, and proper cosmeceuticals
can prepare a patient for an optimal surgical outcome particular
in facial aesthetic surgery. Interestingly, the concept of patient
optimization for improved surgical outcomes is not a new con-
cept. The use of tretinoin or hydroquinone prior to laser therapy,
or weight loss before an abdominoplasty, are just a few examples
of plastic surgery dogma in patient optimization. The use of
noninvasive devices to enhance a facial surgical outcome is an
extension of that same philosophy.
In our practice, the use of noninvasive aesthetic services to
enhance surgical outcomes is called the icing on the cake.
This includes laser resurfacing, microneedling, nonsurgical skin
tightening, fillers, neuromodulators, skin care, facials and bio-
logically-active cosmeceuticals. Aesthetic medical services and
products optimize the appearance of our surgical patients, and
this optimization leads to higher patient satisfaction as well as
practice growth.
Increasingly, pretreatment and priming of the skin before
surgery and noninvasive treatments with medical-grade skin care
products is taking place. The thought is that, just as one would
perform surgical d bridement before doing a flap, medical-grade
skin products cleanse the skin and prepare it for undergoing the
knife and being manipulated. For example, skin care products can
be used a few weeks in advance of a facelift so that the skin is
primed and ready to go for the healing process. e anticipate
this to be a rapidly growing trend and could be the next paradigm
shift in patient optimization. It is a sort of refining the sugar
before baking the cake and icing it.
Patient optimization with noninvasive technologies is not
limited to facial aesthetic surgery. They have a role even in breast
and body surgery with scar management, for example. Different
devices that focus on lymphatic massage can also be adjuncts for
patients who have had liposuction or other body contouring sur-
geries. Appropriately selected nonsurgical vaginal rejuvenation
devices can also be used as adjunct procedures when treating
labiaplasty patients with sexual dysfunction or distress, which
can be prevalent in plastic surgery patients. The subscription
model for aesthetic services has improved patient optimization,
with patients visiting the practice more often, utilizing more
products with less time between visits and better results.
y er Ae ei edi ine in n Ae e i Surgi r i e
hen the philosophy of the practice is deliver the optimal
outcome for the patient, the surgeon and the practice must use
more than just the scalpel; adjunct technologies must be used to
deliver that result and complement what happens in the operat-
ing room.
6.5 Patient Education
hen patients are treated with nonsurgical modalities, they are
often in the office for extended periods of time, which can be a
couple of hours. This time may include preprocedure numbing or
postprocedure massage, depending on the nature of the treat-
ment. Unlike in the operating room under a general anesthetic,
patients using nonsurgical aesthetic services are awake. This
means there is an opportunity to engage patients and educate
them about aesthetic services that the practice offers.
This one-on-one time between staff and patients is invaluable.
It is a true teaching moment and can be a costly missed opportu-
nity for patient and surgeon. Patients can be exposed to videos
or before-and-after photo books of surgical and nonsurgical
procedures. These visual cues often lead to questions that staff
can answer and, in our experience, has been a real opportunity to
dispel myths about surgery and outcomes. Many of our patients
who receive nonsurgical services ultimately go on to become
surgical patients because they have learned to trust the surgeon
and the practice and feel empowered with the aesthetic medicine
education they got in the office.
Simple interventions such as surveys can actually help both
retain and educate patients about nonsurgical procedures. In a
pilot study performed in the ortheast, 17 practices administered
a Cosmetic Interest uestionnaire (CI ), which simply asked
patients whether they were interested in a list of possible nonsur-
gical treatments. Staff would then follow through with any areas
that patients said they were interested in and provide information
such as before and after photographs. Patients were educated
and questions about procedures were addressed. A total of 2,673
surveys were administered, and almost 60 (n 1,586) had an
inquiry. This led to almost 20 new cosmetic appointments for
nonsurgical procedures.
6.6 Patient Conversion
It is this conversion of a nonsurgical patient to a surgical patient
that is the lifeblood of an aesthetic surgical practice. A recent
study performed confirmed that there was a 40 retention in
nonsurgical patients, and the revenue stream was 400 greater
than the original nonsurgical revenue stream. Most of this
revenue was from surgical procedures. As aesthetic surgeons,
our goals are happy patients and also doing more surgery. The
conversion to surgical patients is key and follows the educational
process.
A single-surgeon experience reported by Richards et al with
injectables and facial aesthetic surgery identified over 15 con-
version of aesthetic-na ve new patients, who came to a practice
for injectables and converted to surgical patients at an average
of 19 months. On average, patients had three injectable sessions
before converting to a surgical procedure at this practice, which
included facelift, upper blepharoplasties, and brow lifts. Other
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 II Business Basics
studies have also shown that patients who ultimately went on to
have a facelift had previously undergone multiple noninvasive
aesthetic procedures.
6.7 Concluding Thoughts
For aesthetic plastic surgeons to continue providing high-vol-
ume and high-quality surgical care, practices must be willing
to incorporate aesthetic medicine. The diversity of treatments,
procedures, and price points enables practices to tailor a set of
services to meet their clientele. hether with the scalpel or with
the needle, the goal is to achieve the best result possible for each
patient and help patients achieve their aesthetic ideals.
66
Suggested Reading
1 D’Amico RA, Saltz R, Rohrich R , et al. Risks and opportunities for plastic surgeons
in a widening cosmetic medicine market: future demand, consumer preferences,
and trends in practitioners’ services. Plast Reconstr Surg 2008;121(5):1787–1792
doi: 10.1097/PRS.0b013e31816c3c49
2 urkjian T , enkel M, Sykes M, Duffy SC. Impact of the current econ-
omy on facial aesthetic surgery. Aesthet Surg J 2011;31(7):770–774 doi:
10.1177/1090820X11417124
3 Saltz R. Cosmetic Medicine and Aesthetic Surgery: Strategies for Success. St. Louis,
MO: uality Medical Publishing; 2009
4 Stevens G, Pietrzak L , Spring MA. Broad overview of a clinical and commer-
cial experience with CoolSculpting. Aesthet Surg J 2013;33(6):835–846 doi:
10.1177/1090820X13494757
5 Richards BG, Schleicher F, D’Souza GF, Isakov R, ins E. The role of injectables
in aesthetic surgery: financial implications. Aesthet Surg J 2017;37(9):1039–1043
doi: 10.1093/asj/sjx136
 im rre i n nd ien e en i n A er n i
7 Optimal Correction and Patient Retention: A Personal
Philosophical and Practical Approach to Your Nonsurgical
Practice
A. Jay Burns
Abstract
Historically, surgical practices including plastic surgery focused on
optimizing clinical outcomes. Talking about optimizing the busi-
ness side and profits were taboo. Today, things are changing rap-
idly for many, if not most, plastic surgeons as they look for ways to
both optimize profits and enhance secondary, passive income. This
chapter directly addresses ways to achieve these financial goals
while, unflinchingly and appropriately, maintaining a priority on
optimizing patient outcomes and satisfaction. A comprehensive
patient consultation focuses on full correction in scope. ot only
is the surgery discussed, but a long-term, comprehensive surgical
and nonsurgical plan to full correction is also discussed in detail.
It is incumbent on the surgeon to understand all of the nonsurgical
options and to be able to provide them to surgical patients with
expertise and confidence. These options are highlighted.
Optimally, the patient leaves the office with a comprehensive
aesthetic plan. However, obstacles the patient must overcome
in remaining loyal to such a plan are the financial costs and dis-
tractions of a busy lifestyle. Such obstacles and the methods to
overcome them are discussed. Specifically, the author will focus
heavily on the role of aesthetic subscriptions as a model to opti-
mize patient loyalty and retention and to overcome the hurdles
discussed. Data will be given proving the validity of this approach
in many practices as well as his own.
Keywords
full correction, comprehensive long term aesthetic plan, sub-
scription economy, aesthetic subscriptions, patient loyalty,
patient retention
7.1 Introduction
As a physician who identifies first and foremost as a surgeon,
I have spent a significant portion of my career in a parallel
universe of nonsurgical approaches to aesthetic concerns. This
chapter would have never been included in a reputable textbook
when I began my career over 30 years ago, because nonsurgical
techniques were ignored at best and deemed disreputable at
worst. Thankfully, we have come a long way since then, and most
successful aesthetic surgeons now understand the value of their
nonsurgical practice.
I feel honored to contribute to such a prestigious textbook and
take the responsibility very seriously. However, I must make it
clear this chapter is a wholly personal perspective. Such personal
bias will differ from others’ reasonable opinions, but there are no
substantial studies to prove a best approach, so I simply present
i nd r i A r ur n urgi r i e
mine, which, without argument, has proven both beneficial to my
patients and successful for my business.
My opinions are based on general and plastic surgery training,
as well as over 30 years of running a surgical and nonsurgical
practice. During this time, I have also had an academic career in a
teaching institution and been fortunate to be involved in research,
Food and Drug Administration (FDA) studies, and many scientific
advisory boards, which have helped introduce innovative technol-
ogies such as lasers, radiofrequency, ultrasound, and cryolipolysis
to market. Therefore, while certain opinions on management and
business decisions will be personal, many more will be based on
scientific research and data.
I have a gift from one of my best friends from medical school,
which I often ponder over. It is a framed quotation from Sir
illiam Osler that reads:
ou are in this profession as a calling, not a business; as a call-
ing which exacts at you at every turn self-sacrifice, devotion, love,
and tenderness to your fellow man. Once you get down to a purely
business level, your influence is gone and the true light of your life
is dimmed. ou must work in the missionary spirit, with a breadth
of charity that raises you far above the petty jealousies of life.
I feel strongly that, as physicians, our calling is a privilege and a
responsibility. I am not here to place a relative moral value on aes-
thetic plastic surgery, but if our focus is to put our patients’ wishes
above our own, then I believe we can abide by Osler’s famous
challenge, and if our surgery practice and business is successful and
efficient, it is no sin. hether we are treating patients for coronary
blockage, cancer, psychiatric illness, or the visible signs of aging,
I believe we can deliver care with the patients’ best interests at
heart optimizing quality and results in the safest manner possible.
I truly believe that both objectives excellent patient care and a
successful business can be achieved with integrity, and the aim
of this chapter is to make that point to you and hopefully help
you achieve those goals. By putting patients first and offering a
quality, comprehensive program with long-term optimal results,
I know that every aesthetic physician can achieve happy patients
and a thriving business.
7.2 Consult with a Purpose
Ask yourself this: If you provided your patients with the best
experience and quality results, every time, why would they
even think about going anywhere else I believe that, as plastic
surgeons, we are uniquely trained to offer a full complement of
treatments to aesthetic patients. Therefore, we should always
provide, in addition to the best surgical solutions, the most tech-
nically advanced nonsurgical services and treatments as well as
scientifically proven skin care and sun protection.
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 II Business Basics
This all starts with a comprehensive consultation . . . with a
purpose.
My initial consult always addresses every available option to
the patient, regardless of the patient’s primary focus. The purpose
for this is to optimize my chances of retaining a satisfied patient
for life. I listen carefully to their desires, biases, fears, and expecta-
tions, and if their expectations are reasonable, I move forward to
create a win–win for us both. And, by the way, if their expecta-
tions are anything short of reasonable, I have found that it is best
to avoid a doctor–patient relationship of any kind.
e all understand that patients are most satisfied when they
are fully corrected. The key, however, is to educate them on how to
achieve this reasonably and logically. They must understand we are
talking about optimal results, while never implying perfection. I find
that an educational approach always leads to the most satisfied and
loyal patients, and I go about it by explaining facial aging in four ways:
1. Gravity: The results of gravity are manifested by certain physical
findings, including neck laxity, jowls, marionette lines, nasolabial
folds, and droopy eyebrows. I realize there are varying opinions
on the value of addressing only the skin, versus the fascial lay-
ers when discussing the results of gravity, but I like to inform the
patient that skin is an elastic layer, which, when young and tight,
shows benefits, but over time will relax and reveal signs of aging.
Gravity is also a major player when it comes to laxity of the platys-
ma. I point out that nonsurgical skin tightening will not address
platysmal issues and that any pure skin tightening procedures,
regardless of the approach, yield only temporary results, because
skin will always relax to a resting tension of 32 mm Hg. If asked, I
also advise that although nonsurgical skin tightening approaches
work to a lesser and more variable extent than surgery, they do
have the least morbidity and have no need for general anesthesia.
2. Dynamic Lines: Dynamic lines can be addressed surgically in
the forehead, but the growth in effective neuromodulator usage
and techniques have been impressive in recent years. Botulinum
toxin injections remained the top nonsurgical procedure in the
United States in 2017, with 1,548,236 procedures carried out
nationwide. Compare this to the top surgical procedure, breast
augmentation at 333,392 procedures, and you can see that neu-
romodulators continue to outpace all other aesthetic procedures.
I point out to my patients that neuromodulators are excellent
alternatives to surgery for frown lines and frontalis lines, as long
as significant brow ptosis is not present. euromodulators are
also the treatment of choice for crow’s feet rhytids in my practice.
3. Actinic Damage: Actinic skin damage plays a significant part of
the aging process, and if it is neglected, surgical results and patient
satisfaction are negatively impacted. For example, if the percep-
tion of skin age lags behind the perception of gravitational and
dynamic age post facelift, there will be disharmony, and the face
will appear awkward and unnatural. So, a plan to optimize skin to
a more youthful appearance is key to my surgical consultation. In
experienced hands, any resurfacing technique, such as dermabra-
sion or a series of chemical peels, can be utilized to a satisfactory
endpoint, but my preferred technique is laser resurfacing.
4. Volume Loss: hen it comes to treating volume loss, there are
many good uses of fat injection, either as an isolated procedure
or in conjunction with other rejuvenating procedures. I have no
problem with this approach, but I believe that dermal fillers play
a stronger and more popular role due to their ease of use and lack
of general anesthesia and fat harvesting. o matter what your
preference is for volume restoration, the consultation is a golden
opportunity to discuss the idea of full correction. I usually state
that if there are any remaining volume issues postoperatively,
68
we can discuss fillers as both a finishing touch and/or a solu-
tion for future volume loss.
I realize every surgeon has his or her own approach to the con-
sultation process, but I’ve found significant success in painting this
large picture to give patients a plan for achieving full correction.
Most patients are not aware of all the possibilities available, and the
comprehensive consult serves a purpose, not only to educate them
but to inform them that you can personally provide those services
with excellence, optimizing their outcome and experience. However,
I am always respectful of any plan they choose, as long as they are
aware of the implications of those choices; therefore, we cover risks,
benefits, and expectations. As a cosmetic surgeon, I have a respon-
sibility to help them optimize safety, but also to point out that safe,
viable options may fall short of full correction and possibly high
expectations. Ultimately, patients must decide on their individual
plan based on personal goals, biases, fears, financial considerations,
recovery time and overall risk-to-reward ratio. My job is to explain
each option clearly and fully, so they can make an educated choice.
If they leave the consult with an effective personalized plan and a
long-term maintenance program that enhances their surgical out-
comes, skin health, and appearance, I know my job is done.
7.3 ering e m re en i e
Aesthetic Plan at Your Practice
hile my nonsurgical consultation occasionally takes place
in my surgical office, it is most often carried out by physician
extenders located in our skin care and laser/technology center.
This is because our aestheticians and nurses are taught to offer a
comprehensive skin care plan that ties in with our practice goal
of full correction for all patients.
In my opinion, the ideal aesthetics practice should be able to
offer a wide array of surgical and non surgical services that would
anticipate the large majority of patient’s concerns. Although
difficult early in practice it, comprehensive aesthetics care should
always be the end goal.
Before I describe my thoughts regarding this comprehensive
package, I’d like to point out one approach you should always avoid.
Do not make a technology purchase, then push all patients to that
technology, regardless of their needs and wishes. This is a financially
driven approach that is understandable but not optimal and perhaps
a little short-sighted. If you must compromise, understandably, on
limited technology do not compound the problem by overselling
this treatment to some of your patients who will not benefit opti-
mally from it. Again, this financial prioritization is tempting, but is
short sighted, creating disappointed patients. Many spas fail due to
poor technology choices, as a result of inferior knowledge and/or
lack of proper funding. a ve approach to management is especially
problematic in struggling spas. All of these potential issues must be
kept in mind and avoided if you want to provide quality treatments
and service to the patient. Remember, it is imperative to maintain
your clarity of purpose if you want a successful business.
In an ideal situation, after IPL purchase you would begin to add
devices and services that address each patient issue more specif-
ically to optimize the result. Examples might be to add a technol-
ogy that addresses pore size and texture more aggressively, body
contouring, and skin tightening.
 im rre i n nd ien e en i n A er n i
It is beyond the scope of this chapter to describe an in-depth com-
prehensive approach to every aging condition you will encounter.
However, to serve as a limited example, if you are to start out with
one piece of technology, an intense pulsed-light (IPL) device would
be a reasonable choice in many offices, especially if the majority of
your patients are skin types II and III. At a practice with a majority
of ethnic patients, light-based technology is more challenging due
to the melanin content encountered and resultant potential hypo-
and hyperpigmentation issues. Other energy-based devices might
be a better option, but I would encourage you to do your homework
attending Continuing Medical Education (CME) courses, reviewing
the literature, and asking experts as to the proper choice for you.
So, why do I choose IPL Simple. An IPL device treats many
patients’ nonsurgical concerns, such as texture, pore size, vascular
issues, and dyschromia. Even laser hair removal can be addressed,
although there are better devices for that specific issue. However,
it is an excellent initial tool that will aid you in achieving your
patients’ goals to full correction. There are also many excellent
technology platforms that can be purchased with an IPL module
in place, leaving room for other laser and/or alternative energy
technology additions to the platform as your practice grows.
In an ideal technology and skin care center, you would also have
a set of devices that address your patients’ nonsurgical concerns
specifically, such as redness of the skin, dyschromia, texture, and
pore size, as well as mild to moderate wrinkles and mild skin
laxity. If you are prepared to invest the time and financial resources
to acquire sufficient knowledge and energy technologies, you can
confidently carry out a comprehensive long-term plan that will
optimize the patient’s aesthetic appearance.
In my office, such a comprehensive skin care assessment is
aided by photographic analysis. This can be carried out with
simple photographs, but it is aided greatly by modern technology
and software programs that show patients the full extent of their
damage through ultraviolet photography and digital filters. In
many programs, a qualitative and quantitative assessment can
also be rendered to place objective measurements on skin quality.
This is a great tool for patients, because it enables them to see
visible results and gain even more confidence in their progress
and, ultimately, in your skills as their physician.
7.4 The Full Correction Goal
The purpose of your doctor-patient relationship and treatment
plan should be crystal clear from the outset. ou are not there to
sell them the latest technology or to promote the most popular
trend but rather to determine a comprehensive long-term treat-
ment plan with which to optimize their skin health and appear-
ance for life. A helpful analogy to offer the patient is to compare
skin health to physical health. obody would go to the gym once
or twice a month and truly expect to optimize their overall health
and fitness. That takes discipline and commitment something
also required to achieve optimal skin and full correction.
I like to show my patients photographs of others who have com-
mitted to a comprehensive skin care plan and had better-quality
skin than they did when they started.
I point out a very important study by Dr. Patrick H. Bitter r., a
board-certified dermatologist and founder of Advanced Aesthetic
Dermatology, that shows how patients who committed to three
i nd r i A r ur n urgi r i e
BroadBand Light Therapy (BBL) treatments a year for 3 years
genetically changed their skin to a more youthful D A expression.
BBL uses a broad band (560–1,200 nm) of noncoherent light waves
that are absorbed by the skin, and it is very popular for skin reju-
venation. After administering a regular, consistent course of BBL
treatments to a number of aged female volunteers with moderate
to severe photodamage, Dr. Bitter and his associates discovered
that the skin showed significant improvements in clinical ratings
of both intrinsic and extrinsic skin aging. An increase in epidermal
thickness was also noted. In short, this course of BBL treatments
was proven to restore the gene expression pattern of photoaged
and intrinsically aged human skin to resemble that of young skin.
Another of Dr. Bitter’s studies shows how patients who com-
mitted to at least one BBL treatment a year over a period of 5 to
11 years notably delayed the long-term effects of skin aging. The
study proved that although participants’ skin aged a median of 9
years over the course of the treatments, their treated skin appeared
to have aged only a median of 2 years or less. This indicates that
patients who maintain a regular annual or biannual course of IPL
treatments such as BBL can delay and even reverse the visible
signs of aging, including skin laxity, photodamage, telangiectases,
and fine lines and wrinkles.
Such dramatic findings make it clear to patients that it is never
too late to start treating the skin but that it takes commitment to
achieve the results they desire.
Again, details of the various full correction options are beyond
the scope of this chapter, and excellent physicians can, and will,
vary greatly in their approach. In general, daily sunscreen is a
given in every plan. However, an exact skin care regimen must be
designed based on a comprehensive skin analysis. The practitioner
must evaluate the patient’s skin type and qualitative skin issues,
as well as the patient’s concerns and commitment. Based on the
information gathered, an individualized, long-term plan can be
designed and delivered.
I strongly believe that if we, as aesthetic surgeons, maintain an
open mind and a commitment to skin care and all nonsurgical
technology, we can provide the most comprehensive and complete
set of aesthetic solutions available. e are uniquely qualified to
deliver every need of the aesthetic patient, but we must present all
of these options confidently and clearly to the patient in the initial
consultation. We should be able to recommend the best sunscreen,
the most beneficial skin care, the latest laser or alternative energy
technology, and the most effective surgical services. Then, and
only then, can we be the equivalent of a full-service bank that
provides comprehensive, quality service and eliminates the need
for a patient ever to consider going elsewhere. If this environment
is provided, then I return to my original premise that if we provide
the best treatments and outcomes we will be rewarded with satis-
fied and loyal patients . . . and a very successful business.
ow, the last piece of the puzzle is to recognize the patients’
challenges when it comes to staying on their prescribed plan.
They may be dedicated and willing, but what obstacles do they
face, and are there ways to help these patients minimize such hur-
dles I have personally discovered options that greatly enhance
patient retention and loyalty. These options also enable many of
my patients to stay on plan and finally get the results they are
striving for. The business rewards financially have been equally as
satisfying. In the remainder of this chapter, I will review current
trends, options, and results seen nationally and in my practice.
69
 II Business Basics

7.5 The Patient Retention Table 7.1

2016
Research on < 10,000 neuromodulator patients in 2015 and

Conundrum um er nnu er en ge neur m du r

neur m du r re men patients
A question that frustrates almost every physician in the aesthetic
1 47%
space is this: why don’t patients stick to their prescribed aes-
thetic schedule e can deliver a perfect consult and spend all 2 26%
the time in the world curating a carefully constructed injectable, 3 15%
laser and/or skin care plan for our patients, but getting them to 4 or more 12%
comply is an almost impossible task. Many cosmetic physicians
believe they have a loyal aesthetic clientele and a highly prof-
itable business. The actual loyalty percentages vary, but when Table 7.2 Data from Dallas Plastic Surgery (2016/2017) demonstrating
the number of neuromodulator treatments the average patient receives
looked at objectively, data prove that no practice has the patient
annually
retention desired, with data showing the average U.S. neuro-
um er nnu er en ge neur m du r
modulator patient receives treatment only 1.4 times a year. In
neur m du r re men patients
my practice, it remains a challenge (Table 7.1, Table 7.2).
1 36%
ot long ago, I realized that fewer than 50 of my patients were
following their schedule for injectables, and I knew that with this 2 20%
lack of compliance, their results would suffer and ultimately so 3 17%
would my business (Fig. 7.1). While new customers are para-
4 or more 26%
mount to any successful company, these repeat customers are the
absolute essence. ot only does it cost around seven times more
to acquire a new customer than it does to retain one (an average Interestingly, of the 30 million people in the U. S. who con-
of 800– 1,000 per patient), but repeat customers also spend up sider getting aesthetic procedures, only 10 of them follow
to 33 more on services and treatments. through with an actual treatment. This is obviously a frustrating

My Toxin Results

Baseline* Epi-Elite Members Growth

Compliance

1.73 3.09 79%

treatments/year treatments/year

Transaction Value

$.327 $441 35%

avg spend/treatment avg spend/treatment

Annual Revenue per Patient

$.521 $.1,604 $.1,083

annually annually

Dr. Burns Data. n = 786 baseline (pre-subscription) patients vs. EpiElite membership patients, n = 359. 2016. 2018.

Fig. 7.1 The information in the figure indicates my own personal experience implementing aesthetic memberships in my practice. Increased number
of visits per year in addition to greater spend per visit increased my yearly revenue per patient on toxins alone by over 1,000 per year.

70
 im rre i n nd ien e en i n A er n i
and challenging statistic for all of us interested in this patient
population.
So why are customers notoriously difficult to both acquire
and retain in the aesthetic industry Unsurprisingly, financial
challenges are the most significant barrier. In recent studies, over
two-thirds of consumers who were interested in aesthetics but
had yet to try a treatment stated that cost was the main obstacle
stopping them from trying a procedure. And while we are all
acutely aware that countless miracle creams from the drugstore
work out to be far less effective and way more financially costly in
the long term, it’s not so easy to convey this to the consumer when
asking for 500 for a 20-minute injectable session.
Regular aesthetic patients are also price shoppers when it comes
to dermal fillers and neuromodulators. Rather than staying loyal
to one injector, many will look around for deep seasonal discounts
or the best local deal often without a thought for who will be
administering their treatment. This cost-saving approach is often
shortsighted and potentially dangerous, as such treatments are
best delivered in experienced and talented hands. However, if we
can offer these treatments in a way that reduces financial barriers
and provides other opportunities for patients to stay under our
care, it will be a win–win for both the patient and the practitioner.
Fortunately, I believe our industry has an exciting new solution
to acquiring and retaining patients: aesthetic subscriptions.
7.6 What Is An Aesthetic
Subscription?
I’m certain you’re aware how the subscription model is being
executed successfully across virtually all industries at this time.
From the way we watch television ( etflix) to how we shop
(Amazon Prime), it’s clear that leveraging some kind of subscrip-
tion business model is the most effective way to win and retain
new customers while increasing the average value of existing
ones. Aesthetics is no exception.
Simply put, by offering and selling a subscription membership
to one of your patients, you create a loyal, long-term relationship
and better results that equate to both increasing and recurring
revenue.
At the time of this writing, subscription memberships are just
entering the world of aesthetic medicine, so my experience is per-
tinent, as I am one of the first to utilize such a model. I decided to
beta-test the impact subscriptions would make on my aesthetics
practice, with a primary focus on injectable subscriptions. There
are several types of subscriptions, as I mentioned previously, but
I chose a platform that structured their aesthetic subscriptions
similarly to Apple’s offering of the new iPhone. hat this means
is that a patient does not get as much Botox as they want for a set
price; but instead they pay for the cost of their treatment over
time. It made sense, since like Apple, I was trying to get consumers
to commit to a luxury purchase over an extended period time, so
by making payments easier for consumers along with a one-time
buying decision, I felt that patient loyalty would be increased. My
decision was heavily influenced by retention data on over 50,000
injectables patients from leading aesthetic practices in the San
i nd r i A r ur n urgi r i e
Francisco Bay area. hat the investigators found was that the
average neuromodulator patient was being treated only 1.4 times
per year, while the average filler patient was being treated just 1.1
times a year. They were also able to show that 73 of patients do
not follow their prescribed treatment schedule.
Initial reporting on 35 practices from a beta test of an aes-
thetics subscription software platform showed impressive and
consistent results from the 3,000 patients who had signed up
for a neuromodulator or filler subscription. For neuromodulators,
aesthetic subscription patient retention had increased from the
average 1.4 treatments per year to 2.9 treatments per year, and
filler retention from 1.1 treatments per year to 1.6 treatments
a year. The researchers were also able to demonstrate that the
aesthetics subscription patient spent an average of 31 more on
their neuromodulator or filler each treatment and was 72 more
likely to cross-sell to other services in the practice.
As stated previously, based on these pilot data, I recently imple-
mented a personalized membership program in my own practice.
This program centers on the subscription model just described.
By empowering my patients to take control of their aesthetic
treatments, and offering them a service that allowed them to pay
for these treatments in affordable monthly installments, the busi-
ness was transformed almost immediately. I had a 79 growth in
patient compliance and an increase in annual recurring revenue of
over 1,000 per patient. In the first seven months, I signed up 377
members to a membership program (EpiElite) powered by the
subscription software. This equated to an annual lift of 381,524
in practice revenue based on a 12-month run rate.
In our model, the setup is relatively simple and was totally
customized to my practice, pricing, and marketing requirements.
Current software enables us to create aesthetic plans for our
members so they can maintain their aesthetic goals through
affordable monthly payments. It also enables us to prescribe and
personalize the brand of treatment, frequency, and the number
of units, and more important, it gives us the flexibility to change
a patient’s plan according to their concerns over time. I believe
this personalization is the absolute key to optimized results and
success in aesthetic subscriptions. It certainly has been in our
practice, as our patient satisfaction and revenues suggest.
Our current software solution has seamlessly integrated into
our working day, and there is a mobile app for patients, so they
can follow their aesthetic journey. Let me once again remind you
that the other major challenge to patient retention and staying
on plan, besides cost, is busyness. The mobile app tied to the
software solution for aesthetic subscription memberships also
sends reminders of their plan and their appointment schedule.
This app can be customized to receive texts about the advantages
of membership, specials, and individualized touches from the
physician or their service provider.
Our subscription program has significantly strengthened our
relationships with patients and simultaneously increased prac-
tice loyalty by providing members with a personalized beauty
plan that is dynamic, affordable, convenient, and extremely
results-driven. This means our patients see visible results and
keep returning to our practice (rather than just any practice) to
maintain their aesthetic goals.
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 II Business Basics
7.7 e ree ene
Implementing an Aesthetic
Subscription Program at Your
Practice
7.7.1 Consistency Means Better Results
and Better Retention
Utilizing a subscription model gives patients stability and con-
sistency with their treatments and procedures, making it much
easier for them to stick with their recommended plan. It’s been
proven that aesthetic subscribers visit the office twice as often
as regular patients, so you can expect them to stay much more
closely aligned to their plan. To put this into perspective, 24 out
of my first 25 subscription members returned for their follow-up
toxin treatment in less than 100 days. hen you compare that to
the baseline of 50 returning in that same period, it is a signifi-
cant impact to the practice.
7.7.2 Patient Satisfaction Means
a Bigger Spend
Members who enjoy a positive experience with their subscription
program are far more likely to spend extra dollars at the practice
than nonmember patients. As an example, studies have shown
that 72 of patients enrolled in a subscription membership for
dermal fillers will also sign up for neuromodulators, proving that
implementing a subscription model promotes full correction
due to the lower upfront cost implications. Being a member of
a practice also triggers customers to buy into a broader selec-
tion of procedures, treatments, or skin care products that may
previously have gone ignored. I do not want this discussion to
center purely on the financial ramifications, as I have empha-
sized that results are the primary focus. However, if subscription
memberships encourage patients to try other excellent services,
their results and satisfaction are enhanced. fi -
tages and results are intimately tied together, and this cannot be
overlooked.
7.7.3 Easy Monthly Payments Mean
Expansion of Your Practice with
New Patients
As previously mentioned, price is the main obstacle for intro-
ducing aesthetics to a wider audience, so by implementing a
subscription program, reducing up-front costs to the patient,
and offering member-only prices, you automatically make
aesthetics more desirable to a wider audience. Instead of paying
500 every time they visit the practice for their fillers and toxin,
for example, patients can split these payments over the year. The
current average patient, especially millennials, buy with a pref-
erence for the subscription model. They have proven that they
72
much prefer a charge of 150 per month over a larger lump sum
in most cases. e also reward our members by offering reward
treatments at 6 months and/or a year in exchange for their loy-
alty, which has proven to be a huge incentive when transitioning
patients into members. e also offer some member advantages
in our particular practice to incentivize membership enrollment
and retention, but many successful practices offering aesthetics
subscriptions choose not to offer any additional incentive other
than the financial ease provided by the subscription itself.
7.8 Advantages I Did Not Expect
hen I implemented aesthetic subscriptions in my office, I was
unapologetically driven by the need to drive patient retention,
loyalty, and profits. However, I must list some further advantages
that cannot be overlooked.
7.8.1 Barrier to Patient Transfer
Subscription memberships keep patients more loyal. They are
less likely to transfer to another practice that does not provide
subscription services. This barrier is not 100 effective, but if
an aesthetician or nurse leaves the practice for any reason, they
cannot transfer the advantages of the membership program you
provide in your office. In speaking with other physicians who
have implemented an aesthetic subscription program in their
office, I have discovered that most find this ability to protect your
patient base from departing staff members invaluable.
7.8.2 The Value of Data
The facts speak for themselves: few tools have offered me
more customer data than my aesthetics subscription platform.
ot only did it make me aware of my actual retention and the
need to improve it, but also I now have access to valuable key
performance indicators in my practice, such as patient spend
per treatment, retention, cross-sell, and other data into which I
previously had little visibility.
7.8.3 Building Practice Value and
Providing Enhanced Exit Strategies
A dilemma for every physician is how to value his or her practice,
especially when trying to add a partner or sell it. Blue sky is elu-
sive to define and difficult to agree on. By bringing subscriptions
into your practice, not only do you realize immediate revenue
increases, but you secure an increased future revenue stream.
This increased stream is the reason subscription businesses are
generally valued higher than nonsubscription businesses ( etflix
is valued today at 10 its revenue, while Blockbuster at its height
in 2004 was only valued at 1 revenue). As a physician looking
forward to my own exit at some point in the future, I hope to
capitalize on this additional intangible benefit that subscription
has brought to my practice value.
 im rre i n nd ien e en i n A er n i
7.9 The Future for Aesthetic
Subscriptions
It’s clear that aesthetic subscriptions have already proven suc-
cessful for practices and patients around the country, including
my own. All signs indicate that the subscription model is not
only here to stay but also here to increase due to an extremely
fast-growing consumer group, millennials, as mentioned
previously.
Born roughly between 1980 and 2000, millennials are
forward-thinking, are comfortable with technology, and provide
the biggest portion of consumer spend of any demographic group
in history. Contrary to what some believe, millennials are far
more concerned with aging than their older counterparts and
have already proven keen to adopt a subscription model for their
aesthetic treatments data from the largest subscription model
company in existence at the time of this writing show clearly
that over a quarter of beauty members are aged between 18 and
38. I have a well-established facial rejuvenation practice and no
doubt target a large group of aging patients over 50 years old.
However, as a result of knowledge about millennial trends, we are
now targeting the 35-year-old mother of two looking to get her
confidence back. She, after all, is a millennial.
Further studies show that over 80 of potential millennial
customers are willing to spend money on improving their appear-
ance, compared to just 46 of the over-50s. That portends well for
future subscription membership programs.
Something else to consider: these figures should only grow
when it comes to the next generation in line: post-millennials.
Surrounded by technology from the day they were born, postmil-
lennials have grown up with smartphones, apps, and social media,
making it an understatement to say that the subscription model to
anyone born after 1995 will feel totally normal across most, if not
all of their lifestyle choices.
In summary, I want to emphasize that I remain a surgeon first
and foremost, as I have tried to make clear. However, we must not
forget that 90 of aesthetic patients will never opt for surgery.
i nd r i A r ur n urgi r i e
This is why I have tried to define in this chapter how you can
continue to be an excellent surgeon but still respect patients who
desire other options. I believe that if you do that, you can provide
excellent care to every single patient who enters your practice.
I have also tried to give you real experiences and data from new
business models that are bursting onto the scene and disrupting
the industry by both enhancing patient satisfaction in your
nonsurgical business and enhancing passive income. Consumer
data are utilized mightily in every industry today, and their value
will soon be fully realized in our aesthetic practices, bringing
focused, logical, and efficient strategies for marketing and patient
retention.
I am proof positive that you can teach an old dog new tricks. As
a result, my patients are achieving improved results with greater
overall satisfaction. My practice value and current income are on
the rise, and I have had more enjoyment in my practice than ever
before.
Suggested Reading
1 Bitter P r, Posner . Retrospective evaluation of the long-term antiaging effects of
BroadBand Light therapy. Cutis 2013;26(2):34–40
2 Chang AL, Bitter PH r, u , Lin M, Rapicavoli A, Chang H . Rejuvenation of
gene expression pattern of aged human skin by BroadBand Light treatment: a
pilot study. J Invest Dermatol 2013;133(2):394–402
3 Gurdus L. Allergan CEO sees more millennials and men turning to aesthetic
medical treatments. C BC.com; 2017. https://www.cnbc.com/2017/08/07/aller-
gan-ceo-more-millennials-men-turning-to-aesthetic-treatments.html. Accessed
September 23, 2019
4 Haroun A. Retention is the new acquisition: exploring the overlooked approach
to more aesthetic procedures patients. BrandingMD; 2017. http://www.
brandingmd.co/retention-is-the-new-acquisition-exploring-the-overlooked-ap-
proach-to-more-aesthetic-procedures-patients. Accessed September 23, 2019
5 Harress C. The sad end of Blockbuster Video: The onetime 5 billion company
is being liquidated as competition from online giants etflix and Hulu prove all
too much for the iconic brand. International Business Times; 2013. https://www.
ibtimes.com/sad-end-blockbuster-video-onetime-5-billion-company-being-liq-
uidated-competition-1496962. Accessed September 23, 2019
6 etflix Annual Earnings Report. 2017. https://www.netflixinvestor.com/
financials/annual-reports-and-proxies/default.aspx
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 II Business Basics
8 The Spa and the Law
Michael S. Byrd
Abstract
hile medical spas (MedSpas) are gaining increasing popular-
ity, they also introduce increasingly complex regulatory and
legal issues, requiring a new way of thinking and a compliant
structural foundation. This chapter will not only highlight many
of the common compliance issues facing MedSpas and their
owners but also shed light on how to become compliant. The
compliance risks for a MedSpa tend to reside with the physician.
The consequences of running an illegal medical spa range from
fines all the way to losing a medical license. hen the stakes
are this high, no room exists for educated guesses. Opening and
operating safe and compliant MedSpas requires guidance and
careful navigation of this regulatory minefield. State laws and
licensing board rules governing the practitioners in a MedSpa
often offer confusing (sometimes contradicting) information.
This chapter will expand on these risks and offer solutions to the
most common issues facing MedSpas today.
Keywords
MedSpas, medical spas, ownership, delegation, supervision, plas-
tic surgeon, nurse practitioner, aesthetician, physician assistant
8.1 Introduction
The explosion of the noninvasive medical aesthetic market
directly impacts the business of plastic surgery. This market,
where a practice is commonly branded as a medical spa or
MedSpa, challenges both the noninvasive services offered
by an aesthetic practice and the market for surgical services.
Technological advances increasingly make a MedSpa treatment
an attractive alternative to surgery. Health care reform and
decreasing reimbursements increasingly draws noncore physi-
cians and others to the cash-based MedSpa model. The influx of
private money by investment bankers and angel investors into
the MedSpa market fuels this explosion.
The data behind this MedSpa market growth is compelling. The
number of MedSpas has increased by more than 20 annually. In
2016 alone, 11,674,754 nonsurgical procedures were performed,
and of that, 4,597,886 botulinum toxin type A treatments were
conducted, according to the American Society for Aesthetic Plastic
Surgery. This number represents a 75.5 increase from 2011.
ot only has the number of botulinum toxin injections risen;
hyaluronic acid injections have increased by 106.9 , chemical
peels have increased by 60.4 , and nonsurgical skin tightening
treatments have increased by 76.9 .
As in so many other industries, the state and federal lawmakers
are far behind the advances in the MedSpa market. It will take
years to know how the various professional boards and state
74
statutes will govern MedSpas. In the meantime, existing law
causes an overwhelming percentage of MedSpas to be noncompli-
ant. Because of the training and typical staffing of a plastic surgery
practice, plastic surgeons sit on a unique compliance advantage to
not only survive the influx of MedSpa competition but also thrive.
8.2 The Big Three: Compliance
Issues to Owning and
Operating a MedSpa
Because a MedSpa is a fusion of health care and retail, patients,
providers, and investors have a fundamental disconnect from
the need for compliance. Beneath the fast, noninvasive, relatively
painless experience found often in a retail setting lies an import-
ant truth: most MedSpa treatments are the practice of medicine.
In diagnosing the source of noncompliance of MedSpas, three big
traps exist. The traps can be found in the ownership structure of
the MedSpa and the staffing for treatment of MedSpa patients.
8.2.1 Who Can Own a MedSpa?
In most states, only physicians (and sometimes other health care
professionals) are legally allowed to own MedSpas. The legal
doctrine, called the corporate practice of medicine, is enacted
to prevent nonphysicians from employing physicians to offer
medical services. States that have strong corporate practice of
medicine rules include ew ork, Texas, and California.
This raises the obvious question as to how nonphysicians can
own a MedSpa. The answer is an old model found in health care
and in the business of plastic surgery (historically for different
purposes): the management services organization (MSO) model.
The Management Services Organization Model
The MSO model allows physicians and nonphysicians alike to
effectively own a MedSpa. The MSO model splits the business
and clinical aspects of a MedSpa into two different entities. The
MSO is the business entity that provides management services to
the clinical entity. Ownership of the clinical entity must follow
the applicable state law governing ownership of a professional
entity that provides medical services. The MSO, however, may be
owned by anyone. The cord that tethers the two entities together
is a management services agreement (MSA). The MSA outsources
the business aspects of the MedSpa to the MSO and typically
drives the economics of the MedSpa to the MSO entity. Examples
of the services provided by an MSO include leasing of space and
equipment, licensing of intellectual property, marketing, human
resources, accounting, billing, and payroll (Fig. 8.1).

MSO
Ownership Ownership
$$$
$$$
Doctors Non-Doctors
Fig. 8.1 The MSO model. This figure depicts the structure of a MedSpa medical entity partnered with a management services organization (MSO)
business entity through a management services agreement (MSA). The various arrows and boxes give a thorough explanation not only of how the
model is structured, but also of how to handle the flow of money from patients to physicians to billing legally.
Why Do the Ownership Rules Matter to
Aesthetic Surgeons?
The impact of the ownership requirements of a MedSpa to an
aesthetic surgeon depends on the nature of the relationship
between the surgeon and the MedSpa. The three most common
scenarios for a surgeon to be involved with a MedSpa are as fol-
lows: (1) the surgeon owns a MedSpa ancillary to the physician’s
surgical practice, (2) the surgeon owns a MedSpa with a mid-
level provider or a business partner, or (3) the surgeon serves as
a medical director for a MedSpa.
The situation posing the most potential risk to an aesthetic
surgeon is serving as a medical director for a MedSpa. The
surgeon, in this arrangement, is asked to serve in a limited role
to supervise and delegate treatments to the actual providers of
MedSpa services, while typically receiving not much more than
a monthly stipend. Surgeons often find value in this by hoping
their name awareness will generate new surgical patients from
the MedSpa. Many surgeons sign on as medical directors with
eS nd e
Patient
MedSpa
$$$ Services
$$$
MedSpa
MSA
$$$ Ownership
Doctors
little inquiry into the structure of the MedSpa. If the MedSpa is
not compliant with the ownership rules of the applicable state,
the surgeon may unwittingly be supervising a medical practice
that is not authorized to practice medicine.
The second common scenario for aesthetic surgeon involve-
ment within a MedSpa is co-ownership with a nonphysician.
Depending on state law, this arrangement may not comply with
the ownership rules governing medical practices. The MSO model
then becomes the compliant model for the surgeon to continue
the MedSpa in this co-ownership arrangement.
Finally, many aesthetic surgeons have a MedSpa as a part of
their surgical practice. This is the ideal position for aesthetic
surgeons, as the MedSpa will comply with the ownership rules
of any state in this scenario. Increasingly, aesthetic surgeons are
nevertheless choosing to adopt the MSO model. By adjusting
the legal model, the aesthetic surgeon has now positioned the
MedSpa to be acquired in the future by either a successor surgeon
or a nonphysician-owned MSO. The market for potential buyers
then expands exponentially.
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 II Business Basics
8.2.2 Who Can Diagnose for Nonsurgical
Cosmetic Treatments?
ust like any traditional medical treatment, any MedSpa proce-
dures that constitute the practice of medicine require an initial
diagnosis. The definition for the practice of medicine is typically
broad in most states and encompasses many of the common
MedSpa treatments. For example, injectables, lasers, micronee-
dling, dermablading, body contouring (e.g., CoolSculpting),
medical-grade chemical peels, and microdermabrasion most
often fall within the definition of the practice of medicine. In any
medical practice, including an aesthetic practice, the physician
may provide the initial exam and diagnosis.
Typically, physician assistants (PAs) may also perform the initial
exam and diagnosis. However, the requirements vary by state,
so it remains important to understand the nuances. Most states
allow a PA to diagnose but require the supervising physician and
the PA to have the appropriate training in aesthetics. The key then
becomes planning for appropriate training when bringing in a PA
from another specialty.
Similarly, a nurse practitioner ( P) and advanced practice
registered nurse (APR ) will usually be able to provide the initial
exam and diagnosis. The scope of practice and other boundaries
for Ps and APR s vary widely from state to state. In some states
an P or APR will have more autonomy than a PA. On the other
hand, some states have requirements that Ps or APR s may
diagnose only in the specialty for which they are certified. This
creates a risk, because currently no aesthetics certification exists.
Those states typically relegate the P’s or APR ’s scope of practice
in a MedSpa to that of a registered nurse (R ).
In most states, it would be beyond the scope of practice for an
R or a licensed practical nurse (LP ) to engage in the diagnosis
phase of treatment. This becomes a problem for MedSpas, because
it is common for an R to see and treat patients in the facility
without the patient ever coming into contact with a physician or
mid-level practitioner (Table 8.1).
In a recent survey by the American Med Spa Association, 37 of
responders admitted that either they do not perform a good faith
examination prior to a patient’s first treatment or the exam is not
performed by a physician, PA, or P. Good faith examination is a
term used in California, but it simply refers to performance of an
appropriate medical exam before prescribing, dispensing, or fur-
nishing a dangerous medication, which would include botulinum
Table 8.1 Common treatments offered by MedSpas and which ones constitute medical treatments
edi A nmedi
Microdermabrasion penetrating the epidermis
Physician-grade chemical peels (e.g., glycolic)
Laser treatment (intense pulsed light IPL devices, etc.)
Treatments to remove scars, blemishes, wrinkles, pigmentation
Injectables (e.g., botulinum toxin)
Adapted from ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998;101(3):840–851; ide BM, Swift R. Addendum to “How to block and tackle
the face.” Plast Reconstr Surg 1998;101(7):2018.
76
toxin A or fillers prescribed for a patient. Other terms used for
this exam and diagnosis include initial exam or initial consult.
This response rate indicates a broader issue of noncompliance,
because physicians, or the mid-level practitioners to whom they
can properly delegate the task, often do not perform an initial
patient examination or prescribe treatment plans for MedSpa
patients. And while the semantics may differ, all states have some
requirement that a physician must prescribe a course of treatment
before rendering services.
8.2.3 Who Can Provide Treatment?
hile an initial exam must be provided by either a physician or
a mid-level practitioner to be compliant, many types of licensed
professionals can provide a variety of treatments in a MedSpa.
The exact scope of practice for any type of practitioner is going
to depend on state-specific laws and regulations, and it typically
varies based on education and experience. Aside from physi-
cians, PAs, Ps, R s, and aestheticians (usually spelled this way
to distinguish them from medical aestheticians, who usually
work in hospitals and concentrate on reconstructive care) are
the main practitioners in a MedSpa setting. The providers who
have authority to diagnose (MDs, PAs, Ps, and APR s) may also
provide treatment. Additional providers, depending on the state,
include master aestheticians, laser techs, medical assistants, and
even patient coordinators.
Registered Nurses
Like many practitioners, the scope of practice for an R will
depend on the state where he or she holds a license. The board of
nursing for each state regulates specific action for R s. However,
in a medical practice setting, the scope of practice will rely heav-
ily on delegation. Generally speaking an R will have little inde-
pendent authority but can receive various delegations for those
procedures. Some states, such as ew ersey, currently limit an
R ’s ability to inject and fire a laser. Most states, however, will
allow the traditional MedSpa services to be delegated to an R .
Aestheticians
Unlike other licensed professionals, aestheticians in most states
are unable to perform any tasks that are categorized as the prac-
tice of medicine. While unable to perform medical treatments,
e ei i n
Microdermabrasion for cosmetic treatment (only outermost layer of skin or
stratum corneum)
Aesthetician-grade chemical peels/exfoliation (superficial/epidermis; not
medium-depth/grade)
Hair removal by tweezing, depilatories, waxing (electrolysis limited to
licensed electrologists)
Deep-cleaning facials and skin care (cleaning pores, sloughing off dead
surface cells via commercially available products)
Laser hair removal (when applicable)

aestheticians are able to administer a variety of cosmetic treat-
ments. Aestheticians are usually licensed and regulated by the
state board of cosmetology and must undergo a state-specified
training program. Some national programs exist, but by and
large this is a state regulation. hile not yet commonplace,
some states have implemented a new Master Aesthetician
license. The master aesthetician completes training beyond that
of the aesthetician license and expands their scope of practice.
hile expanding aestheticians’ training and knowledge into
areas such as pharmacology, medical terminology, and pre- and
postoperative care, these programs still do not give aestheticians
carte blanche to operate outside their state-mandated scope.
Some states, such as Utah and Virginia, along with the District
of Columbia, have expanded the aesthetician practice to include
more education and, in some instances, more treatment oppor-
tunities. Employing aestheticians or master aestheticians is legal
so long as they are not operating outside their scope of practice.
Ensuring that they are administering only limited treatments
not constituting the practice of medicine will help maintain
compliance and avoid enforcement actions. As a word of caution,
aestheticians are commonly operating outside their scope of
practice in MedSpa settings. Typical noninvasive cosmetic treat-
ments seem like a natural extension of traditional aesthetician
services, leading physicians and aestheticians to provide medical
services unwittingly.
Medical Assistants and “Unlicensed Persons”
Last, some states have laws and regulations for medical assis-
tants, while others are completely silent on the matter. Medical
assistants are unlicensed, although sometimes certified, indi-
viduals who may work in a medical setting. Medical assistants
typically assist with administrative duties or perform some
clinical duties such as taking medical history and assisting a
physician. Typically medical assistants are not qualified under
state law to receive delegations, but there are some instances
when that might not be the case. Some state laws allow dele-
gation to unlicensed persons. In these instances, a physician
(or an autonomous NP) can delegate to an unlicensed person as
long as that person is qualified. However, there is substantial
risk associated with this type of practice. Ultimately, as with any
delegation or practice, the physician will hold the liability on
behalf of those who receive the delegation orders. ith that in
mind, best practices are to delegate medical treatments to those
who are licensed professionals and trained to perform the task
at hand.
Enforcement
A common question that arises with compliance issues is how
the medical board, or any regulatory body, would become aware
of a compliance issue. Stated more bluntly, the question is typi-
cally some variation of How is everyone else doing it and getting
away with it hile random audit of a practice is typically a
low risk, tangible ways to come under the enforcement spotlight
exist. The most frequent sources of enforcement initiatives are
(1) patients, (2) competitors, and (3) disgruntled ex-employees.
Once the enforcement spotlight is turned on a practice, exposure
becomes real.
eS nd e
8.3 Remaining Compliance Issues
8.3.1 Commissions
hile the law varies significantly, payment of commissions to
staff can create significant risk in many states. In a survey of
MedSpas by the American Med Spa Association, 31 of those
who responded pay commissions for the performance of certain
medical treatments. For example, the providers commonly
receive an hourly wage plus a certain percentage of revenues
for treatments provided, products sold, and even treatments
provided by other providers. The amount paid ranges from 5
of sales net of product cost to 25 of gross sales. Many MedSpas
create a business problem by essentially paying all the profits to
the providers. More important, commissions in some cases are
illegal.
Commissions fall within a veritable minefield of regulations
that intersect to make what otherwise would be a benign form
of compensation (when properly structured) into a payment that
can range from unprofessional conduct to illegal. Common law
legal doctrines that prevent fee splitting of medical revenues vary
from state to state. States such as ew ork and Illinois prohibit
fee splitting. Other states create regulatory risk for commissions
through their corporate practice of medicine doctrine, antikick-
back laws, and antireferral laws.
The simplest answer in navigating this regulatory minefield is
to avoid commissions. The best practices of MedSpas are to pay
a bonus for specified performance metrics or pay discretionary
bonuses. A discretionary bonus is the simplest approach, as
it avoids the pitfalls with creating complicated metrics. This
approach requires trust between the provider and the MedSpa
that the MedSpa will fairly compensate for performance. The
performance metric approach sounds great in theory but is
challenging to create. The idea behind this approach is to create
performance goals that tie into the overall goals of the MedSpa.
Common performance metrics include team revenue targets,
individual revenue targets, efficiency targets, and patient satisfac-
tion benchmarks.
8.3.2 The Health Insurance Portability
and Accountability Act
hile the Health Insurance Portability and Accountability Act
(HIPAA) is familiar to physicians, the breadth of issues that must
be considered with patient privacy and security is elusive. A
common question posed by MedSpa owners is I have heard that
HIPAA does not apply to a MedSpa because it does not take insur-
ance; is that true hile the law, of course, is more complicated
than this, there is a good rule of thumb that the federal HIPAA
law may not apply for a cash-only business. However, three big
caveats to this rule of thumb exist: (1) most states have a state-
level HIPAA law covering patient privacy that apply to MedSpas,
(2) many MedSpas are actually a part of a surgical practice that
does bill insurance and is therefore subject to HIPAA, and (3)
most states recognize some civil level of patient protection for
violations of patient privacy, which may result in a direct lawsuit
from a patient to the MedSpa.
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 II Business Basics
hen HIPAA does apply to a MedSpa, the real consideration
is the evolution of patient privacy and security laws. The Health
Information Technology for Economic and Clinical Health Act
(HITECH) was signed into law in 2009 by President Obama as
part of the health care reform. This act established privacy and
security measures and expanded HIPAA in five ways: (1) business
associates are now directly governed by HIPAA rules, (2) there
is a new notification of breaches requirement, (3) there are new
restrictions on certain disclosures, (4) there is an alteration of the
disclosure standard, and (5) new accounting rights of patients
have been provided.
Because of the importance on protecting patient privacy and
information, HITECH requires that organizations implement com-
pliance plans to describe and outline privacy policies. All covered
entities are required to have privacy policies and security policies
to protect sensitive patient information. Compliance plans have
seven elements: (1) written privacy and security policies and
standards of conduct, (2) designation of a compliance officer and
compliance committee, (3) workforce training and education,
(4) effective lines of communication, (5) issuing disciplinary
guidelines, (6) internal monitoring and auditing, and (7) timely
responses to detected breaches and corrective mechanisms.
A MedSpa must first determine whether HIPAA applies to the
MedSpa and understand the scope of patient privacy regulation in
the applicable state. From there, a MedSpa may design and build
an appropriate plan to protect patient privacy.
8.4 Emerging Trends in the
MedSpa Industry
8.4.1 Private Equity
Investment from private equity funds, hedge funds, and oppor-
tunistic businesses has been an accelerant to the explosion
of the MedSpa market. Private equity brings great economic
opportunity for MedSpas and aesthetic providers. The drawback
to this influx of private equity capital is a lack of sophistication
regarding the principles for compliance. Consequently, the lack
of compliance in the MedSpa space is high and will ultimately
draw increased enforcement and scrutiny from the medical
boards, nursing boards, and other governmental bodies. Like it or
not, private equity is a new reality for MedSpas and for those in
the aesthetic sector. A look into the dental sector will shed light
on the impact (good and bad) of private equity in health care.
The common thread between MedSpas and dental practices in
the private equity world is that they tend to operate like a retail
store from a business perspective and like a health care practice
from a regulatory compliance perspective. In the dental market,
this looks like a branded chain of dental offices typically found
in retail real estate space. Similarly, MedSpas tend to be branded
as retail elective health care services. The regulatory hurdles are
similar for the management of dental and medical practices, and
the legal solutions to these regulatory hurdles are structurally the
same.
From a compliance perspective, private equity accesses the
dental provider market in a similar manner to the MedSpa market.
Dental service organizations (DSOs) and MSOs share similar busi-
ness and legal compliance characteristics. DSOs are management
78
organizations in the business of providing all back-office business
management services to dental practices. MSOs, by contrast,
provide similar business services to medical practices, including
MedSpas. Because the DSOs have been around longer, they serve
as a great example for the infusion of private equity into MedSpas.
hile the private equity world is just starting to enter into
the MedSpa field, the development of the dental private equity
market is instructive for those physicians who want to use private
equity as a MedSpa exit strategy. Because private equity investors
are typically growth-oriented rather than value-oriented, it is
important to be clear that the business strategy is in alignment
with private equity strategy. Moreover, the founding physicians
must be able to articulate clearly a vision for the next 3 to 5
years. They must also be able to communicate the competitive
advantage over the competition clearly, and the MedSpa must be
compliant from a regulatory standpoint. Compliance includes the
legal structure from a corporate practice perspective as well as
patient privacy and staff delegation. Last, the service organization
must be able to articulate a strategy for attracting and keeping
clinicians.
Businesses in the younger and emerging MedSpa market would
be wise to pay attention to the trends and developments in the
DSO market. Private equity is coming into the MedSpa market,
presenting unique opportunities to surgeons to expand the
potential audience of buyers of a MedSpa. If the MedSpa house
is not in order from either a regulatory or business perspective,
private equity will flee.
8.4.2 Autonomy of Nurse Practitioners
A current trend across several states has been to expand the
authority and autonomy of an P. Because Ps have earned
either a master’s degree or a doctoral degree in nursing, they are
able to work in a variety of specialties. This impacts MedSpas
in a few ways. First, in some states this allows P ownership,
which expands competition and potentially eliminates the need
for physician involvement. Second, in some states, the aesthetic
surgeon may staff the MedSpa with an autonomous P and sub-
stantially reduce the need for clinical oversight, thus allowing
the surgeon to spend clinical time operating and focus on the
business side of the MedSpa. Although Ps may be autonomous in
a particular state, states differ as to whether an P can then own
a MedSpa. For example, an P with 3,600 hours of experience
in ew ork obtains autonomy but is prohibited from owning
a MedSpa. On the other hand, an P in ashington may own a
MedSpa outright. hether a physician is staffing a MedSpa or
agreeing to partner with an P, understanding an P’s autonomy
and ability to own are imperative from a compliance perspective.
The wave of P independence in some states may also create
opportunity for the physician in staffing a MedSpa. However,
while many states have opened up legislation to allow for P
independence, sometimes this independence is tied to the NP’s
particular specialty. For example, an P who specializes in neona-
tal care might not be completely autonomous in adult care. More
important, some state licensing boards are hesitant to pronounce
Ps autonomous in aesthetic medicine. Aesthetic medicine is not
currently a recognized specialty for advanced education; conse-
quently, some states take the position that an P is limited to the
scope of practice of an R in aesthetic medicine.
 eS nd e

8.4.3 New Tax Reform new deduction. This new law and the pending regulations merit
monitoring, as new strategies may surface to refine the business
In December 2017, Congress passed the Tax Cuts and obs Act structure of MedSpas in a tax-advantageous manner.
(TC A), which is causing big changes for the business community.
At the heart of the bill is a new scheme that will reduce the
personal income tax rate for owners of pass-through entities. 8.5 Concluding Thoughts
These entities, typically partnerships, sole proprietorships and
MedSpas directly and indirectly impact the business of aesthetic
subchapter S corporations, will receive a 20 deduction on their
surgery. Aesthetic surgeons face important business decisions as
taxable income. However, for specified service trades (which
to how and when to incorporate a nonaesthetic cosmetic service
includes health care professionals), the deduction applies only
strategy into their business. The heart of the risk for the MedSpa
for those who fall below a threshold. The threshold for a single
market lies in health care compliance. hile some smaller
filer is 207,500, and the threshold for married joint filers is
MedSpas may continue to operate in a noncompliant structure,
415,000. hile a taxpayer loses the full deduction at 207,500,
the dual benefit of operating a compliant MedSpa is that (1) the
the deduction begins to be phased out at 157,500. In a profitable
risk for the MedSpa is substantially reduced and (2) the opportu-
MedSpa, this could be an issue.
nity for a successful sale of the MedSpa is increased.
Because regulations indicating how the new tax law will be
enforced have not been issued, Certified Public Accountants
(CPAs) and tax attorneys are left to speculate on strategies that
may work to fit within this deduction. Some speculate that MSO Suggested Reading
owners may be able to work around the service trade limitation.
1 Adatto BE, Byrd MS. Legal and regulatory issues in the medical spa industry. Mod
Additionally, there is a thought that separating product sales into a Aesthet 2017;(Suppl 2: May– une):8–9
separate entity may create a benefit as a nonservice entity for this 2 Thiersch AR. The medical spa boom. Mod Aesthet 2017;(Suppl 2: May– une):5–6

79
 II Business Basics
9 Social Media
Anthony Youn
Abstract
How does a plastic surgeon effectively navigate the world of
social media etworks such as Facebook and ouTube have
become a go-to source of information for cosmetic surgery
patients. A majority of our patients use social media every day,
and recent studies are documenting its rising impact on the plas-
tic surgeon–patient relationship. Facebook, Instagram, Snapchat,
Twitter, and ouTube have emerged as the most prominent and
influential social media networks for plastic surgeons. But how
does a doctor choose which outlet to use and how to benefit
maximally from the time and effort that he or she invests The
first step is to determine which social media network matches
your ideal patient, or avatar. Then, match the network to the
surgeon’s interests: live video text articles This chapter shares
practical tips and advice to pick the best social media networks
for a practice and use each network effectively and efficiently.
Keywords
social media, Facebook, Instagram, Snapchat, Twitter, ouTube
9.1 Introduction
The methods plastic surgeons use to interact with prospective
patients are constantly changing. In the 1990s, print still ruled.
Plastic surgeons bought ads in the Yellow Pages, newspapers,
and magazines. In the 2000s, we discovered the power of the
Internet and began creating websites with extensive before-
and-after photo galleries. Today, social media have emerged as
the quickest growing factor in the interactions between plastic
surgeons and patients.
In fact, recent studies reveal that more and more patients are
being influenced by social media to undergo cosmetic procedures,
and they’re utilizing social media to interact with their doctors
in ways never before imagined. It’s also become a way for plastic
surgeons to educate and court prospective patients. So, in this
chapter I’ll describe the most prominent social media networks,
break down which ones you want to consider participating with,
and recommend how to maximize your time with them.
If you’re a novice in the world of social media, the dozens of
options of networks can be daunting. hich social media channel
should you spend your efforts on Facebook Instagram ouTube
Twitter This is the first major question you need to answer.
The best way to determine which social media network to pick
is to first decide who is your avatar. our avatar is whom you
would consider as your ideal patient. ould your avatar be male
or female hat age would your avatar be hat socioeconomic
group would he or she belong to hat are your avatar’s primary
concerns and interests
80
Choosing your avatar can help you choose which social media
channel is ideal for you. For example, if your favorite surgery to
perform is breast augmentation, then your avatar is likely to be
a woman in her 20s or 30s. If your preferred procedure is facelift,
then your avatar may be a woman in her 50s. Or maybe gyneco-
mastia surgery is your primary focus Then your avatar may be a
man in his 30s.
Once you determine your avatar, then pick the social media
channel that your avatar gravitates to. Go where your patients are.
9.2 The Main Social Channels
9.2.1 Facebook
Currently, Facebook is by far the most popular social media
network in the world, with over 2 billion users worldwide. Its
massive reach extends across all age groups, with over 70 of
Internet users between the ages of 18 and 65 using this network.
Its users are both male and female, with women making up 52 .
Of all the social media channels, Facebook has the most varied
content. ou can post photos, videos, links to articles, and even
create live video (Facebook Live). So if your avatar matches
Facebook’s demographic and you like to share a wide variety of
content, then Facebook may be the optimal network for you.
9.2.2 YouTube
ouTube is the second most popular social media network, with
over 1 billion users. It’s basically a repository for videos, allowing
users to create their own channels. Videos can range in length
from just a few minutes to a half hour or longer. ouTube isn’t as
social as the other networks, as it doesn’t allow for you to share
thoughts or photos, limiting the interaction and community feel
to it. Its demographic is extremely wide, however, and some
people are even using ouTube as a search engine, taking the
place of Google.
9.2.3 Instagram
Instagram is the most rapidly growing social media channel,
with approximately 800 million users and counting. It’s a very
visual medium where users can post photos and videos (up to
60 seconds long) in their main feed. Followers can like and
comment on these posts. Instagram users can also post stories,
short videos of 15 seconds or less that disappear after 24 hours.
It’s believed the stories feature was added in order to compete
with Snapchat. Instagram users trend younger than Facebook,
with 59 of Internet users between the ages of 18 and 29 active
on the network but only 33 of 30- to 49-year-olds using it. Its
users skew female, with 58 women.

9.2.4 Snapchat
Snapchat began as an app that allowed users to send rapidly
disappearing photos to each other. This was initially very pop-
ular with teenagers, who used it to send hidden messages and
photos to their friends. Then Snapchat added the stories feature,
and the network exploded in popularity. Plastic surgeons who
were early adopters, such as Dr. Miami (Michael Salzhauer) and
Dr. Matthew Schulman, quickly accumulated audiences in the
millions as they snapped their day’s surgeries, often in explicit
detail. Snapchat remains very popular among the younger crowd,
with 400 million users, the majority of them under the age of 24.
Although millions of men are active on Snapchat, its users skew
female, making up 70 of its user base. Snapchat’s growth has
become fairly stagnant over the past couple years, eclipsed by
Instagram.
9.2.5 Twitter
Twitter allows its users to post short messages, or tweets, of
280 characters or fewer. These can include text, photos, links,
and short videos. Unlike the other channels, Twitter users some-
times tweet dozens of times per day. Its demographic is wide and
has a 53:47 male-to-female audience. Although Twitter has 317
million users worldwide, its growth has also stagnated in recent
years.
9.3 Some Smaller Networks
9.3.1 Pinterest
Pinterest has 150 million users, most of whom are female, with
an average age of 40. It allows users to create small graphics
called pins, which are then placed onto a virtual bulletin board.
These graphics can include recipes, quotes, and images. Although
some plastic surgeons have Pinterest accounts, as of this writing
no plastic surgeons have fully taken advantage of this network.
9.3.2 Reddit
Reddit users skew young and male, with an average age in
their twenties. It’s basically a huge bulletin board of interesting
stories, videos, and images, which users can up-rate or down-
rate, depending on how interesting they think the posts are. The
posts can be grouped into separate channels depending on the
subject matter for example, Plastic Surgery, Announcements,
TodayILearned. Although the least known among the major
social channels, it boasts 125 million users.
9.3.3 LinkedIn
LinkedIn is a professional networking site with 106 million users.
It’s a social channel that enables users to network with friends,
coworkers, and others in industry to make connections, obtain
jobs, and promote what’s happening with your work. It’s not a
place for doctors to court patients, and it should be used in a
professional fashion only.
9 Social Media
Google Plus, Vine, tumblr, Periscope,
and MySpace
Google Plus, Vine, tumblr, Periscope, and MySpace are dead.
Social media channels notoriously come and go. One day a
medium is hot with millions of users, and a mere year later no
one uses it anymore. This is the nature of online marketing and
communication in today’s world. So don’t put all your eggs into
one social media basket. Today’s hot channel may be in tomor-
row’s digital dustbin.
9.4 Tips for Using Each
Social Channel
9.4.1 Facebook Tips
Every plastic surgeon or practice should have a Facebook business
page separate from the owner’s personal page. Business pages
enable you to access analytics to see how your page is perform-
ing, purchase ads, and promote posts. The business page can be
centered on your actual business or on yourself. For example, I
have a Facebook page for my practice, oun Plastic Surgery, and
a separate Facebook page for me as a public figure. If you haven’t
yet used Facebook for your business, then I recommend creating
a page for your plastic surgery practice first.
Facebook allows a very wide range of posts, so if you like to share
a wide variety of items, from before-and-after photos to short
videos of you performing surgery or injections to links to online
articles, and even images with famous inspirational quotes, then
this is the best network for you. It skews a bit older, so if your prac-
tice is more mature consisting of facelifts, blepharoplasty, and
laser treatments then it will match your avatar well. If, however,
your practice skews younger with more breast augmentation,
liposuction, and Brazilian butt lift (BBL) surgeries then Facebook
probably shouldn’t be where you spend your resources. Look to
Instagram and Snapchat instead.
If you don’t like taking photos or videos of yourself or your
patients and would rather write articles and share links to other
content, then Facebook is a better fit for you than Instagram or
Snapchat, which require considerable amounts of video to be
successful. However, over the past several years Facebook has
pivoted toward live video and even added Facebook stories to its
feed. So now it’s basically become a one-stop shop for all sorts of
sharable items.
Currently, the most effective way to use Facebook is by going
live. By creating live video, you can take advantage of more organic
reach than any other type of post. hat types of live videos should
you create I recommend starting simple. For my first Facebook
Live video, I pointed my iPhone camera at myself and discussed
the popular facial fillers in my office. I had a box of each of them
and pointed the camera at each box while I discussed which ones
I used and why.
If you haven’t done a Facebook Live, then I strongly recommend
you try it. It’s a real rush. ou can see the number of people
who are watching you during your broadcast, and you can even
read and reply to their questions live our followers will post
81
 II Business Basics
comments and questions which you can read on a separate device
during the live broadcast. For example, you can go live from your
phone and read the comments and questions on your iPad. This
is a great way to interact with prospective patients, show your
personality, and even promote specials in your office.
If you want to take it to the next step, then try broadcasting a
live treatment. This can really enable your followers to virtually
step into your office and see a procedure they are interested in.
e’ve had great success with broadcasting live procedures on
Facebook, as it demystifies the treatment for the viewers and can
make them more apt to call for an appointment. I recommend
starting with a noninvasive treatment first, such as a chemical
peel or laser treatment, prior to proceeding to more invasive
procedures such as filler and surgery.
So what do you do after you make a Facebook Live video Post
it to your feed to get hundreds or thousands more viewers and
organic reach. ou may also consider boosting the post: paying
Facebook to show it to more people. ou can boost a post for as
little as 1 to as much as you want to spend. If you boost a post, I
recommend that you boost only posts that have some popularity
already. The posts with more engagement get better results when
boosted, so your paid reach can actually increase your organic
reach. I also recommend boosting posts that can make you money.
For example, it doesn’t make sense for you to pay 20 to boost a
post about a fun movie you watched over the weekend, since there
is no direct monetary benefit. But a post about your new toxin and
filler office special That makes more sense
So how would you do this It’s actually quite easy. Once you
click that you’d like to boost a post, Facebook will prompt you to
target an audience. Audiences can be targeted in terms of gender,
geographic area, and interests. This allows you to very specifically
choose the type of users you want to see your post. For example,
let’s say I have a toxin and filler special I’d like to advertise. Since
we perform these injectable treatments on both men and women,
I’d choose both genders. I’d select Metro Detroit as the geographic
area to target. In regards to interest, I may choose people who have
indicated that they are interested in uvederm (Allergan, Dublin,
Ireland), Botox (Allergan, Dublin, Ireland), and cosmetic surgery.
This allows me to target very specifically the types of people I’d
like to see my ad and pay only for those people.
9.4.2 YouTube Tips
Every plastic surgery practice should have a ouTube channel.
It’s a perfect place to post promotional videos, such as an intro-
duction to your practice and videos showing minimally invasive
treatments, surgical procedures, and even consultations. Unlike
Facebook videos, ouTube videos are often viewed for months
to years after they are posted, and successful videos can garner
hundreds of thousands of views.
Also, unlike Facebook videos, ouTube videos can be monetized
with ads. ust click the button monetization when editing the
video and choose which type of ad you are ok with and ouTube
will pay you when people view these ads. Some experts believe
that your organic reach is higher for videos that are monetized
with ads, since there is a financial incentive for ouTube to
show your video with ads more than a non-monetized video.
82
Unfortunately, ads featuring graphic content such as live surgery
are usually exempt from ad placement.
If you create a ouTube channel for your business, I recommend
that you separate your individual videos into appropriate play-
lists. These playlists can have separate names, such as Surgery
Videos and Online Consultation Videos, allowing viewers easier
navigation when they get to your site. If they open your channel
and the videos are all haphazardly arranged, they’re more likely to
click and exit away without watching anything.
I also recommend creating a professional-looking video that
introduces you and your practice. This video should be pinned to
the front of your channel so any new visitor sees this video first.
ou may also want to embed this video on the front page of your
website as well.
I also recommend that you embed relevant videos in your
website procedure pages. For example, under my website page for
breast augmentation, I have embedded a video of me explaining
the differences between various types of breast implants. Surveys
show that most people would rather watch a video than read an
article, so having both available on your website is ideal. ou can
also embed a video of you performing the actual surgery so that
the process is demystified for potential patients.
Any videos you post in ouTube can be easily shared on your
Facebook page. ust click share on your video’s page, then click
the Facebook icon to place the video in a post on your Facebook
page. ou can also share ouTube video links on Twitter as well.
9.4.3 Instagram Tips
Instagram is all about the image, making it the obvious top choice
for many plastic surgeons. Those users who are most successful
on this network consistently post attractive images and videos.
Although you don’t need to hire a professional photographer or
videographer, make sure any images you post are visually appeal-
ing and in harmony with your brand. Use a similar color palette
when posting static images about you and your plastic surgery
practice. This brings a sense of familiarity to your page. ou don’t
want the colors to be haphazard or inconsistent from day to day.
Currently, you can post on Instagram in two ways: as a regular
post and as a story. Regular posts consist of a photo or video up
to 60 seconds long. ou can also post multiple photos and video
in one post if you’d like to share several images or videos on one
post. These show up in the main, scrolling feed of the user who
follows you.
Attractive before-and-after photos typically get good engage-
ment on Instagram. Many plastic surgeons (including myself)
have had great response from intraoperative videos as well. Static
images that are obviously advertisements don’t typically do as
well, nor do selfie photos or selfie videos unless you’re a celebrity
or extremely attractive.
In very short time, Instagram stories have outgrown Snapchat
stories. These reside at the top of the app as a bar with a row of cir-
cles, each one representing a different person’s stories. Instagram
stories last up to 15 seconds long and are a great place for you to
share video clips from inside the office and operating room. These
stories stay for 24 hours, after which they are erased. However,
you can choose to highlight certain stories keep them on display

when anyone visits your profile page. These highlighted stories
can be separated into categories that you create, such as breast
augmentation, facelift, or Botox.
eep in mind that nudity is not allowed on either Instagram or
Facebook, so make sure to cover nipples and private parts; other-
wise you risk getting banned by the networks. Instagram stories
allow you to pin items over these sensitive areas digitally, or you
can just cover them at the time of filming. Adherent nipple covers
can be purchased online.
As with Facebook, you can pay Instagram to boost your posts
and show it to more people than your organic reach allows. This
may be worth it for really important posts, especially those which
you can monetize. These Instagram ads are actually created using
the Facebook ads manager program.
9.4.4 Snapchat Tips
If you’re not a millennial, Snapchat can be very difficult and
counterintuitive to use. It was probably engineered that way to
keep older people from being active on the app and making it less
cool to the younger crowd. Upon opening the app, you see the
video camera portion of the app. Swiping in the different direc-
tions (up, down, left, and right) brings you to different screens,
such as your friend list, your previous snaps, the discover page,
and more. As on Facebook, you can friend other users, but
unlike Facebook and Instagram, Snapchat doesn’t have an easy-
to-use, general search page. This makes it more difficult to find
people you might know or want to follow. For this reason, many
users find that their followers on Snapchat are more engaged
with their posts than, say, Facebook followers.
One main benefit to Snapchat for plastic surgeons is that it is
the only major social media network that allows you to post nude
photos and videos. This can be especially helpful for surgeons
who do a lot of breast and genital surgery. Unlike Facebook and
Instagram, Snapchat doesn’t allow longer-form videos, however.
Its stories only allow ten-second clips (unlike Instagram, which
allows 15 seconds), but it’s very easy for users to post dozens of
these short clips together, which is what most plastic surgeons
who are active on this network do. A recent update from 2017
increased the allowable length of recordings. Snapchat allows
you to record continuously for a full 60 seconds. Then Snapchat
automatically clips it into 10-second clips for upload. This is
all done automatically and when viewing the snap videos, it’s
virtually seamless. This was a huge change that makes recording
surgical procedures much simpler than on Instagram. Also, you
can upload video clips of up to 60 seconds from your camera roll
as well. Snapchat allows you to edit these videos (add captions,
add filters, etc.) within its platform.
Snapchat’s younger audience is interested in procedures rel-
evant to their demographic, such as breast augmentation, BBL,
and liposuction. Practices with older patients might not find
this network as valuable. ou’ll get best results if you cater to
Snapchat’s younger interests, trying to be a bit creative with your
posts without being unprofessional.
Prior to investing a lot of time and money in Snapchat, make sure
to gauge the current climate for this outlet. Ever since Facebook
bought Instagram, forecasters have been predicting the demise of
9 Social Media
Snapchat. It hasn’t happened yet, but some people believe that the
future isn’t so bright.
9.4.5 Twitter Tips
My good friend, and the person whom I consider the ueen of
Twitter, Dr. Heather Furnas (Santa Rosa, California), has stated
in our many talks together that Twitter is not for getting new
patients. Although she has amassed over 120,000 followers, she
doesn’t find that it’s effective in obtaining new patient leads.
Instead, Twitter has become a very valuable outlet for network-
ing with other plastic surgeons.
A few years ago, Dr. Olivier Branford (London, United ingdom)
started a movement to use #plasticsurgery as a way for plastic
surgeons to network by sharing the latest news, tips, and research.
Now there are hundreds of plastic surgeons throughout the
United States and the rest of the world who use this hashtag to
communicate with each other, building an online community of
collegial plastic surgeons. New research is shared on Twitter from
The Aesthetic Surgery Journal, Plastic and Reconstructive Surgery,
and others, with plastic surgeons commenting on the findings and
learning and supporting each other.
Do you want to get involved One way to join the conversation
is to retweet and comment on posts by other plastic surgeons and
the journals while using #plasticsurgery. Although you’re unlikely
to get new patients from doing this, you can make new friends with
your colleagues and peers. ou can get even more attention and
engagement from your peers by tagging them on posts and images,
essentially giving them a heads-up that your tweet is something
for them to pay attention to. ou can tag up to ten users per post, so
this can be a quick and effective way to spread the word.
9.5 Code of Conduct
The ethical use of social media by plastic surgeons is currently a
hot topic. Stories of cosmetic and plastic surgeons acting inappro-
priately in the operating room abound, including dancing while
performing surgery, poking fun at patients and/or their body
parts, and making crude jokes. The two main plastic surgery
societies, The American Society for Aesthetic Plastic Surgery
(ASAPS) and the American Society of Plastic Surgeons (ASPS),
have both made changes to their ethics and bylaws to address
the growing concern about unethical behavior on social media.
Although often it is the most controversial and provocative posts
that draw the most attention and views, surgeons must always
remember that we serve our patients first, not our social media
followers.
Please see Fig. 9.1 for the ASAPS Suggested Social Media
Guidelines. This is a great resource to gauge the ethical standards
of your social media activities.
9.6 Patient Privacy Issues
One final, but extremely important note: Make sure always to
obtain consent from your patients prior to featuring them on
social media. Be very cognizant of patient identifiers that might
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 II Business Basics

9.7 The Future of Social Media

Social media represent a constantly changing and evolving
avenue for interacting with and educating our patients. They
may soon surpass traditional advertising as the preferred way
to promote our practices to new patients. By keeping up to date
with the current and future trends in social media, you can be
sure to maximize this incredibly powerful tool.

Glossary of Terms
• Avatar: our ideal patient in terms of gender, age, occupa-
tion, interests
• Engagement: Followers interacting with your social media
network via liking, commenting, or sharing
• Organic reach: The number of people who view your post
organically, without having to pay for it. Organic reach for
most networks, especially Facebook, has dwindled over the
years, causing some to proclaim “organic reach is dead.”
• Stories: Short videos measuring 10 to 15 seconds long, which
disappear after 24 hours
• Tag: To attach a user’s name to a post
• Tweet: A post on Twitter, up to 280 characters; can also
contain photos and short video

Suggested Reading
Fig. 9.1 ASAPS Suggested Social Media Guidelines. (© American
Society for Aesthetic Plastic Surgery, all rights reserved. Used with
permission.)
not be as obvious, such as tattoos (cover them up), patient names
on charts and photos, and bystanders in your videos. HIPAA rules
apply with social media, and training your staff to be aware of
this is definitely recommended.
ou may also want to consider obtaining a cyber insurance
policy. Check with your insurance carrier if your insurance covers
you for breaches of confidentiality or other liability associated
with your social media. If not, then you might want to look into a
separate cyber policy that covers you for it.
1 American Academy of Facial Plastic and Reconstructive Surgery. Social Media
Continues to Influence Facial Plastic Surgery Requests. 2017. https://www.aafprs.
org/media/press-release/20170616.html. Accessed September 23, 2019
2 Gould D , azarian S. Social media return on investment: how much is it worth
to my practice Aesthet Surg J 2018;38(5):565–574
3 Gould D , Grant Stevens , azarian S. A primer on social media for plastic
surgeons: what do I need to know about social media and how can it help my
practice Aesthet Surg J 2017;37(5):614–619
4 Lewis . Aesthetic Clinic Marketing in the Digital Age. Boca Raton, FL: CRC Press;
2018
5 Pho , Gay S. Establishing, Managing, and Protecting Your Online Reputation: A So-
cial Media Guide for Physicians and Medical Practices. Phoenix, MD: Greenbranch
Publishing; 2013
6 Sorice SC, Li A , Gilstrap , Canales FL, Furnas H . Social media and the plastic
surgery patient. Plast Reconstr Surg 2017;140(5):1047–1056
7 Spredfast 2018 Social Audience Guide. https://www.spredfast.com/
social-media-tips/social-media-demographics-current. Published 2018. Ac-
cessed May 13, 2018

84

10 Hiring and Training a Superstar Patient-Care Coordinator
Karen A. Zupko
Abstract
More than just about any role in an aesthetic practice, the
patient care coordinator (PCC) can be a strong marketing asset
or a big marketing liability. This chapter discusses the success
characteristics and skills, best practices for hiring and training,
and ideas for rewarding the PCC without alienating the rest of
the staff. Included are insights from practice leaders who have
successfully recruited and retained high-performing PCCs.
Keywords
hiring, training, recruitment, incentive, motivating, patient care
coordinator, practice building, sales, customer service
10.1 Introduction
More than just about any role in an aesthetic practice, the patient
care coordinator (PCC) is a strong marketing asset or a big mar-
keting liability. An effective PCC can build the surgeon’s value
and credibility with enthusiasm, cultivate long-term patient
relationships, and improve the patient acceptance rate (PAR).
Because the person you hire can enhance or fracture the patient
consultation experience, as well as be a significant influence in the
patient’s decision to schedule surgery or not, I strongly advise aes-
thetic surgeons not to fill this role too quickly. Instead you must fill
it with the right individual. Doing so may take a little more time,
but if the process is completed thoroughly and correctly, the result
will be worth the wait.
This chapter discusses the characteristics and skills of suc-
cessful PCCs, best practices for hiring and training, and ideas for
incentivizing. Included are insights from practice leaders who
have successfully recruited and retained high-performing PCCs.
10.2 Superstar Characteristics
and Skills
Before you even begin your recruitment effort, do you know
what kind of person you are looking for Do you know which
characteristics make for a PCC superstar Hiring someone with
the right talent and aptitude at the outset increases the likeli-
hood that the employee will be successful, stay motivated, and
stick with you for many years,
e asked multiple practice leaders what they feel are the char-
acteristics of their superstar PCCs. Excellent communication skills
and the ability to relate to others are at the top of the list. They
know how to build relationships and are engaging in a way that
makes patients feel they are important and well cared for.
Rapport building is an essential part of the PCC’s job. Her or
his role is to become the patient’s best friend forever (BFF), the
nonclinical confidant to whom the patient can ask questions that
10 Hiring and Training a Superstar Patient-Care Coordinator
might be too embarrassing to ask the surgeon. An effective PCC
becomes a bridge between the surgeon and the patient’s support
team. She or he can be the one who will listen when a patient
says she has no encouragement from her adult children or spouse.
She or he helps patients find solutions to childcare during early
postop. To achieve this successfully, the PCC must be able to facil-
itate conversation.
The PCC also must be intuitive, sensing when someone is
hesitating and able to probe to find out the real reasons why.
Despite what many surgeons believe, most of the time a patient
does not schedule, it’s not about the fee. Maybe a patient hasn’t
discussed surgery with a spouse or feels pushed. Great PCCs know
how to read people and tailor the consultation conversation in a
way that the patient can understand, handing these nonfinancial
roadblocks with aplomb. They must be good listeners, which I
would add is an essential skill not only for understanding patient
concerns but also for handling objections.
Great PCCs are genuine. Patients can see right through a cha-
rade intended only to sell them something. Finding a PCC who is
genuine ensures she or he doesn’t come off as pushy or phony.
Genuine people know how to convey confidently to patients that
they truly believe in the practice, the surgeon, and the results
patients will get if they choose to schedule their procedure with
the practice. It builds patient trust. Don’t underestimate the deep
sense of connection that can occur when a patient feels genuinely
heard and understood.
Practice leaders also describe their long-term superstars as
compassionate, empathetic, and nonjudgmental. They recognize
the worth of others and can sense when a patient is fearful or
insecure. They know how to provide assurance that things are
going to be okay. Their empathy may be enhanced if they, too,
have had that procedure and had some of the same concerns.
Finally, a medical background is a nice to have but not a
requirement. Few aesthetic practices these days require the PCC
to have a licensed practical nurse (LP ) or registered nurse (R )
certification. Certainly, a clinically trained person can capably
answer medical questions, but after working with thousands of
PCCs over the past several decades, I can say with certainty that
service skills are more important to this role than answering
questions about drains and dressings. Moreover, Box 10.1 explains
why I believe surgeons must use caution when hiring from other
aesthetic offices.
Additional essential skills for this role include the following:
1. Ability to ask for the sale: The PCC role is a sales and service po-
sition. Assessing patient needs, providing estimates, scheduling
consultations and surgeries, and following up with patients
who have not scheduled are sales responsibilities. Glossing over
this fact will lead you to hire someone who may be personable,
bright, and organized but who will not fill the surgery sched-
ule. If you are serious about hiring a superstar, you must look
for someone who either has sales or service experience or has a
propensity for sales and can learn. That means hiring someone
85
 II Business Basics
who is comfortable handling objections, closing, and asking
patients for large sums of money.
2. fi This is a fast-paced, intense
job. If your PCC can’t speedily enter data, she will never get her
quotes, emails, follow-up letters, and practice management sys-
tem tasks completed. Hire a hunter and pecker at your own peril.
3. Comfort using Internet applications and social media: A signifi-
cant amount of aesthetic marketing and communications hap-
pens online. PCCs must understand the importance and use of
social media, online ratings, email, and web inquiry forms.
4. Ability to write in complete sentences: The last thing you want
is a poor first impression when a potential patient receives a
response to emails and web forms. Ask for a writing sample to
evaluate each person’s skills in this area.
5. Top-notch organizational and project management abilities: Each
surgical case is its own little project with many steps, forms, and
customer touch points not to mention the project of your next
Facebook posts, website relaunch, or spring VIP event. A PCC
must be able to stay organized and on top of every one. eeping
all these plates spinning takes organization and tenacity.
Box 10.1
Think Outside the Botox
Our firm has recruited many hundreds of patient care coordina-
tors. I can tell you with confidence that “She worked for another
plastic surgeon” or “She looks the part” should not be at the
top of your list of reasons to hire someone for this role. We’ve
seen plenty of PCCs who “look right” but lack the sales ability,
customer service, technology proficiency, and strategic thinking
required to be successful in this role.
Handling the service experience and patient needs in an aes-
thetic practice requires skill and sophistication. The PCC must be
adept at assessing patient needs and buying style, convey your
value proposition, quote fees with grace, overcome objections,
and offer personalized service. These abilities do not come
naturally to everyone, and the baggage and lack of training that
comes from working in a previous plastic surgeon’s office can be
a challenge to correct.
Some staff can be retrained, but others may be congenitally
unable to change their behavior or style to meet your expec-
tations. This is particularly important to understand when an
applicant arrives with a competing aesthetic surgeon’s name
on her résumé. Don’t assume the person was trained or has the
right skill set for your practice just because of having worked in
another practice. Other practices’ standards don’t necessarily
equal yours.
10.3 Hiring Process Part 1:
Organize, Search, and Curate
e break the hiring process into two primary parts. Part 1,
shown in Fig. 10.1, includes all the steps in the process up to
narrowing the candidate pool to two or three finalists. Part 2
includes assessment of those final candidates before deciding to
make an offer to one of them.
86
10.3.1 Step 1: Develop a Position
Description
To describe the job or write an ad, it’s essential that you put the
role’s responsibilities in writing. The description should clarify
the title, and reporting relationship and give a summary, as well
as list the qualifications and experience you require and the tasks.
e find that categorizing tasks by key areas of the job makes
organization easier. Box 10.2 contains an excerpt of a PCC role
description. Early-stage aesthetic practices can combine this role
with an office manager role until the practice builds its patient
volume, at which time the PCC must become a full-time role.
Box 10.2
Excerpt of a Patient Care Coordinator Role Description
Position: Patient Care Coordinator
Responsible to: Surgeon or Practice Administrator
Job summary: Speaks with potential patients by phone, counsels
all aesthetic patients about costs of surgery and other treatments,
and coordinates scheduling and follow-up. Reviews marketing
and productivity data and conducts meaningful report review
and analysis. Initiates and/or implements marketing programs to
increase aesthetic surgery revenues and patient base.
Education: Associate’s or bachelor’s degree preferred
u i i n nd e erien e
• Three to five years of work experience, with increased
responsibility, in high-end retail, hospitality, or other service
industry, or an elective surgery practice
• Sales experience required: preparing estimates, discussing
details, and closing the sale
• Proficiency with Internet applications and Microsoft Office
applications
• Proven ability to handle upscale clientele
• Excellent writing and communication skills; ability to build
long-term relationships
• Experience discussing financial arrangements and asking for
money
• Neat, professional appearance
Responsibilities include, but are not limited to, those in the
following lists.
Relationships with Potential Patients
• Appropriately discusses aesthetic consultations, procedures,
and skin care services with prospective patients over the
phone; encourages them to schedule and executes a follow-up
system for those who don’t schedule immediately
• Schedules aesthetic patients into the computer system; asks
them how they heard about the practice and enters required
demographics
• Schedules all appointments into the computer; keeps a can-
cellation list and calls patients if their appointment can be
rescheduled to an earlier time
• Sends information to prospective patients and tracks activity
in the database
 10 Hiring and Training a Superstar Patient-Care Coordinator

Hiring process part 1: organize, search, and curate

5. Interview 6. Conduct
1. Develop a 4. Conduct a 3–5 second
2. Put the 3. Review
position phone candidates interviews
word out résumés
description screen in person or with 2–3
via video call candidates

Fig. 10.1 Hiring process part 1: Organize, search, and curate.

Surgery Counseling, Scheduling, and Follow-Up • Initiates and/or implements practice enhancement programs
tracks revenue and discusses progress with the surgeon
• Greets aestheticHiring process
patients, part 2:possible,
when assess final
atcandidates
the frontand make an offer
desk • Coordinates seminars arranges room, food, information to be
• Discusses fees and financial policies with aesthetic patients distributed then follows up with attendees on the phone or
after their consultation provides written information and in writing
answers patient questions • Participates in handling requests from the practice website;
• Tracks information about patients who scheduled surgery and checks and responds to email messages that come from the
9. Check
those who didn’t schedule surgery
7. Administer 8. Assess site within guidelines 11. Conduct a
references 10. Send offer
a workstyle essential background
• Schedules all surgeries coordinates patient preoperative
analysis skills
and social letter
check
paperwork, history and physicals (H P), examinations, andsites
lab work and confirms written consent for procedures
Other Essentials
• Collects surgical scheduling deposits and posts transactions
into the computer system • Meets with the surgeon monthly to review reports and mar-
• Takes and/or ensures patient photos placed in the record after keting program results
consultation and surgery • Maintains proficiency with imaging software and Internet
• Screens patient phone calls postoperatively, advising the applications
patient or deciding whether a telephone conversation or • Maintains patient confidentiality by following the Health
appointment with the surgeon is necessary Insurance Portability and Accountability Act (HIPAA)
Compliance Plan
• Attends American Society for Aesthetic and Plastic Surgery
(ASAPS) and American Society of Plastic Surgeons (ASPS)
Practice Enhancement and Marketing
training, or other educational courses as requested
• Ensures that all information about aesthetic patients is entered
into computer system
10.3.2 Step 2: Put the Word Out
• Generates monthly reports for surgeon and team
• Calculates the practice’s Patient Acceptance Rate (PAR) of There are two ways to announce that you’re looking: (1) word
consultations to surgeries of mouth, through your personal professional network, and (2)
placing an ad. e find that the most efficient option for finding
• Ensures that marketing information capture tools are under-
the right person is the former, but invariably you’ll need to do
stood and used by all staff and that staff are trained properly
both. Savvy managers and surgeons begin their search by telling
in using marketing collateral
colleagues, employees, and their personal network, as well as
• Maintains the database of patients who have had surgery and posting the opportunity on LinkedIn, since that is an extended
who haven’t, and targets specific mailings about other services
network that links with your network’s networks highly
and the skin care program
efficient.
• Maintains and updates the patient brochure, outlining infor- Placing an ad in the local classifieds and on job websites invites
mation about the surgeon, skin care, and the entire practice a flood of r sum s for you to wade through, many of which won’t

87
 II Business Basics
be a fit. ust as I advise clients that it is much better to have fewer
consults with the right surgical candidates than to blast through
a torrent of appointments only to find that only half of them are
actually potential patients, a similar principle applies in hiring.
So before you write an ad and post it for the masses, start with a
word-of-mouth, inner-circle approach.
Practice leaders we interviewed shared these tips for ways
they’ve procured their superstars:
• Post the job internally and ask employees whether they know
anyone who is looking.
• Reach out to skin care product, implant, injectibles, and
patient financing company representatives who know you and
your market and may be looking or know someone who is.
• Consider people in upscale salons, high-end spas and hotels,
and gourmet restaurants.
• Talk to your personal shopper, personal chef, or that amazing
associate at Tiffany or eiman Marcus who knows you by
name.
• Tell your friends you have an open position, and describe the
characteristics you are looking for.
• Ask the folks at the hospital and ambulatory surgery center
whether they know anyone looking.
ext, post an ad on your practice website and social media sites,
as well as the online job sites Monster, Indeed, CareerBuilder,
GlassDoor, and Craigslist. Include in the ad a summary of the
role, key requirements, and benefits, as well as who would make
a good candidate. Box 10.3 is a sample you can customize to your
needs.
Box 10.3
Sample Job Ad for a Patient Care Coordinator
Patient Care Coordinator for Prestigious Aesthetic Surgeon
Our high-profile practice is looking for a sales-oriented and
style-conscious professional who moves at a fast pace, can
manage multiple projects simultaneously, and delivers superb
customer service to patients. If you have experience in luxury
retail, five-star hospitality, or an aesthetic surgery, dermatology,
or spa environment, we’d love to hear from you.
As part of our team, you will counsel patients who are con-
sidering aesthetic surgery procedures. Experience handling an
upscale clientele, providing service quotes, asking for payment,
and building long-term customer relationships are all required.
Use of our state-of-the-art practice management system and
social media will be central to your success. Professionalism,
poise under pressure, and penchant for detail are essential.
Experience in aesthetic surgery, dermatology, or another
elective surgical specialty, along with strong customer service
and effective writing and communication skills, are all pluses.
Preferred candidates who have been in managerial positions
at a surgical or aesthetic dental practice that cater to clients
accustomed to luxury will be strongly considered. A bachelor’s
degree is required.
88
For this full-time position, we offer a competitive salary with
bonus potential, health benefits, retirement, and a variety of
other perks. We conduct background, credit, and reference
checks, and assess skills. With your r sum , please include a
cover letter detailing why your experience qualifies you for this
role. Email to: hiring highprofileaesthetics.com
10.3.3 Step 3: Review Résumés
ou’re going to receive a lot of r sum s for this job position.
Think of cover letters and r sum s as a method to rule out
unqualified candidates so that you’ll have fewer to screen by
phone. The following r sum missteps should immediately rule
out an applicant:
• ero sales or service experience
• othing that indicates the person has ever worked with an
upscale clientele
• o degree, if you specified that one is required
• Typos, misspellings, poor grammar
• An email address or phone number that is clearly through the
person’s current employer
• A personal e-mail address that has unseemly connotations
A candidate’s failure to provide a salary range/need in response
to an ad that specifically requested it may not rule the candidate
out immediately, but salary needs/ranges should be discussed to
determine whether you are both in the same ballpark.
Be aware, however, of your state and city employment laws
about salary history. To fight the issue of wage discrimination
and the gender pay gap, cities, states, and territories around
the United States are banning employers from asking for a job
candidate’s pay history. As of May 2018, Oregon, Massachusetts,
Delaware, and California, as well as Philadelphia and ew ork
City, have disallowed questions about salary history for private
and public companies. ew Orleans and Pittsburgh have similar
ordinances for city agencies. Do your homework about what you
can and cannot ask.
10.3.4 Step 4: Conduct a Phone Screen
hen our firm recruits in other specialties, we often make
the first conversation with a potential candidate a video call.
Aesthetics is different. The PCC is going to spend a great deal
of time on the phone, engaging patients in conversation and
encouraging them to schedule an appointment or surgery. As
endra Cook, Operations Director at Columbus Aesthetic
Plastic Surgery in Upper Arlington, Ohio, put it, it’s like being a
judge on the television show The Voice. This seems to run counter
to the idea of a video call; clarifying text might be needed. allows
you to focus on energy and tone as well as whether or not they
have the right phone skills.
As Cook rightly explains, the person may have relevant sales
experience on paper, but is the person engaging on the phone
Can she or he keep the phone conversation going That’s what
I’m looking for and what will warrant an in-person interview, she
explains. This person is going to be asking people to pay 20,000.

If they can’t do that on the phone, they won’t be able to do it in
person.
anit Pike, Practice Administrator of Charlotte Plastic Surgery in
Charlotte, orth Carolina, adds, If the person doesn’t give good
phone,’ they don’t get an interview. Effective phone screening
can really save you from scheduling in-person interviews with
people you are never going to hire. Ask a few basic questions on
the phone, and you’ll quickly know whether the person has the
answer or experience or not. If they don’t, you politely thank
them for their time and tell them you’ll be back in touch if you
decide to schedule an interview, Pike advises.
The following are a few options for phone screening questions:
• I’m curious why you are interested in this job. Tell me what
attracted you.
• Give some detail about your sales experience at company
on the r sum . Describe the customer base. hat were you
selling How were you successful
• How do you handle pricing objections
• hen customers didn’t buy on the first round, what was your
follow-up plan
• Tell me two or three things you learned from our website (If
they didn’t visit in anticipation of the call, that’s an indicator
of poor initiative.)
10.3.5 Step 5: Interview Three to Five Can-
didates In Person or by Video Call
If your phone screening has been effective, you’ll only need to
interview three to five candidates individually, in person or by
video call. The surgeon, practice manager, and at least one other
staff person should interview each candidate. Don’t conduct
interviews with all three in the first interview. Some practices
arrange for one or two of these interviews to be completed on
the same day, while others conduct first interviews to screen
candidates for the surgeon to interview only the final two.
Prior to the start of each interview, ask each candidate to com-
plete and sign an application. This important step confirms that
candidates understand their own employment history, secures
a handwriting sample for neatness and readability, and provides
a signature attesting to the accuracy and truth of everything
candidates have listed on their applications. If you don’t have an
application with an accuracy attestation statement, contact an
attorney to obtain one that complies with the laws in your state.
Many application forms ask candidates to provide the names of
several references. If yours does not, ask candidates to provide
them.
The goal of the first interview is to determine whether the
person is a cultural fit, can demonstrate she or he has the key
characteristics discussed at the beginning of this chapter, and
provide assurance that he or she does have the skills and expe-
rience for the role. Let the candidate do most of the talking during
the interview. To do this, ask open-ended questions, as opposed to
questions that can be answered yes or no. Open-ended questions
encourage the responder to speak at length. They begin with
words such as Describe . . . ; Tell me about . . . ; or How . . .
uestions that begin with are, is, and will typically represent
closed-ended questions, which to do not facilitate the goal of
10 Hiring and Training a Superstar Patient-Care Coordinator
getting the applicant to talk. Box 10.4 offers seven questions that
we find work very well to understand the candidate beyond just
skills and experience.
Box 10.4
Interview Questions That Work
1. What do you know about us? “They’ve got to arrive knowing
something about your practice,” says Pike. “If they don’t,
they haven’t done their homework,” which indicates a lack
of curiosity and initiative.
2. What do you do when you need to accomplish something (for
a project, a patient, a boss), but no one has told you how?
This question provides insight into problem-solving skills,
initiative, and tenacity.
3. If your last manager or supervisor were sitting here, how would
he or she describe you? What words would he or she use? How
about a coworker? Getting the candidate to move out of first
person and into the mind of others provides an interesting
perspective.
4. Tell me about a hard time you had at work (you and your
boss; you and a customer; an experience that went badly) and
how you handled it. Listen for introspective responses and
an ability for the candidate to be honest. If the candidate
has “never” had a hard time, it indicates a lack of ability to
self-assess.
5. What do you read to keep up with the aesthetic practice (or
high-end service) profession? Ask for specific publications. If
a candidate isn’t reading, his or her knowledge is probably
stale.
6. What have you tried, in any sphere of life, that didn’t work out?
What did you learn? You’ll get a sense of how comfortable
the candidate is with dealing with failure by asking this ques-
tion. A candidate who has never failed either hasn’t tried to
grow or is not being honest.
7. In order to be successful here, what do you need from me? No
one you hire will be perfect. Pike says she ends the interview
with this question because “I like to know what I can do to
support their success. The PCC’s success is our practice’s
success.”
It’s important to ascertain how well the person will be with
patients, and in service and sales. Cook uses patient scenarios to
find out how the candidate would handle them. She also suggests
asking about time management and prioritization, providing
candidates with a sample to-do list and asking what they would
address first, second, and so on. Following are scenarios that our
firm uses during recruitment:
1. The fee quote to achieve the facial rejuvenation recommended
by the surgeon is 19,500. The patient says, ow, that’s a lot.
hat is your response, and how might that conversation go
2. The surgeon is running 30 minutes late in the operating room
(OR), and afternoon consult patients have started to arrive. One
has already been waiting for 10 minutes. How would you com-
municate the delay to patients already in the reception room as
well as those on their way
89
 II Business Basics

3. hen you open the office in the morning, one of your regular
patients is waiting. I know it’s my fault for not calling to sched-
ule, she says. But could Dr. onderful fit me in for a quick
injection Please The schedule is already overbooked.
Ask questions that get at the candidate’s service sense. hat
has the candidate done to successfully resolve a customer com-
plaint hat specific things has the candidate done to build rela-
tionships with upscale clientele Asking the candidate to handle
scenarios can give you a sense of the person’s service orientation,
confidence, and ability to think on his or her feet. Expect those
who have worked in high-end retail or with upscale brands to
have reasonable responses, based on their customer service and
sales experience.
As part of the interview, pay attention to the following:
• Do the candidate’s handshake, posture, and facial expression
exhibit confidence and a positive, can-do attitude
• Is the candidate capable of keeping the conversation flowing in
a way that is engaging
• Can the person maintain eye contact
• Is the candidate able to explain her or his work history in a way
that aligns withHiring
the rprocess
sum part 1: organize, search, and curate
Do not discount the importance of decorum. In an age where so
many are fascinated with their mobile devices, etiquette is often
overlooked in practice hiring. But it is not lost on your high-end
patients, who expect a certain level of personalized attention and
correct behavior.
1. Develop a
ou may be surprised 2. Put the things 3.
the unprofessional Review
that some
position
word out résumés
people say in interviews. Do your best not to appear wide-eyed
description
with disbelief and simply take the odd things people say and do
as an opportunity to pare down the candidate pool closer to a
final decision. And keep in mind that certain questions and topics
of discussion are illegal during the selection process. Do not ask
candidates anything regarding marital status or plans, parental
status or plans, race, ancestry, age, religion, political affiliation,
sexual orientation, veteran status, or disability.
10.3.6 Step 6: Conduct Second Interviews
with Two or Three Candidates
At the end of the first round of interviews, you should expect to
have two or three excellent candidates to bring back for a second
interview. Some practices ask that these candidates shadow the
front desk for a few hours as part of that second meeting. Others
set up peer-to-peer interviews with more members of the staff.
Still others do both. All of these are efforts to have the maximum
number of staff spend time with candidates and opportunities for
candidates to learn more about you as you learn more about them.
10.4 Hiring Process Part 2:
Assess Final Candidates
nd e n er
After a second interview, you may well have been able to pare
your choices. hether your final pool is one, two, or three at this
point you’ve ascertained a cultural fit, and candidates will have
met with nearly all staff. ou feel they have the right skills and
experience. In the final steps, you’ll assess their workstyle and
skills and conduct reference checks. See Fig. 10.2 for a list of all
steps in this second part of the hiring process.
ote: Depending on scheduling and everyone’s availability,
sometimes the workstyle analysis and skills assessment may
happen during the second interview or between the first and the
5. Interview 6. Conduct
second. The point is not that each step must occur sequentially
4. Conduct a 3–5 second
onlyphone
that all the steps are completed interviews
before an offer is made.
candidates
screen in person or with 2–3
via video call candidates
10.4.1 Step 7: Administer a Workstyle
Analysis
The abilities of a PCC to read people, communicate well, and
build relationships are important characteristics discussed earlier.
A workstyle analysis, such as Proception2 (Maximum Potential, St.
Paul, M ), is a low-cost and strikingly accurate way to determine
whether the candidate has those abilities innately, as well as which
other effective team building, communications, and workplace
strengths and weaknesses they would bring to your practice.

Hiring process part 2: assess final candidates and make an offer

9. Check
7. Administer 8. Assess 11. Conduct a
references 10. Send offer
a workstyle essential background
and social letter
analysis skills check
sites

Fig. 10.2 Hiring process part 2: Assess final candidates and make an offer.

90

Proception2 is based on the Dominance, Influence, Steadiness,
Conscientiousness (DISC) theory, a neutral and observable
language first developed by psychologist illiam Marston.
The instrument is used worldwide, and has been validated. It
measures behavior and emotion; it does not measure intelligence,
values, skills or education, and it is not a personality test. The
profile provides practical insight into a person’s interpersonal,
decision-making, data management, and other skills.
Our firm has used Proception2 in consultation and recruitment
projects for more than 30 years. For less than 100, you’ll be
amazed at what you can learn about a candidate. The assessment
is striking in its ability to accurately predict the workstyle and
communication preferences of candidates.
e recommend that the final candidates take the online,
26-question assessment. The result is a comprehensive profile
report that can be used not only for insight, but to conduct
additional conversations with candidates, as well as determine
training needs.
10.4.2 Step 8: Assess Essential Skills
It’s one thing to ask a candidate whether he or she can write fol-
low-up letters and effective email thank-you notes. It’s another
to actually read what the candidate has written and determine
this for yourself.
Ask final candidates to perform a few skills tests:
• Writing: Ask for several samples, for example:
1. A follow-up email to a patient who was quoted a Mommy
Makeover but decided not to schedule
2. An email response to an inquiry on your website about breast
augmentation and laser services
Assess for the ability to construct sentences using correct gram-
mar and punctuation.
• Keyboarding: As discussed previously, an important skill is to
operate quickly on the keyboard. Test how fast the candidates
type.
• f Test candidates’ proficiency on your word pro-
cessing (e.g., Microsoft ord), email (e.g., Microsoft Outlook),
and spreadsheet (e.g., Microsoft Excel) software.
Total Testing (http://www.totaltesting.com) offers more than 800
online tests. Our firm has found particular utility with the Microsoft
Office assessments, which distinguish the Excel and ord whizzes
from candidates who would need additional training.
10.4.3 Step 9: Check References and
Social Sites
ou are in the home stretch with your final candidates. ow it’s
time to check the references. e are often asked whether, in these
litigious times, a former employer or boss will provide much
other than the person’s name, position held, and employment
dates. In most cases, you will find that this is not the case. Most
former employers will be open to answering your questions. For
PCCs who will have managerial responsibilities in their role, we
ask for two references of people they have supervised.
10 Hiring and Training a Superstar Patient-Care Coordinator
In addition to reference checks, it’s quite beneficial to review
candidates’ public online presence. As long as the information you
review is posted publicly, it is legal and acceptable to ask Google
about the candidates, as well as search for them on Facebook,
Twitter, Instagram, and other social sites to review their public
posts. Do not send them a friend request, however. And regard-
less of what you see in their public profile, interviewing and hiring
decisions cannot be based on race, color, religion, sex, or national
origin. Consult with an attorney for additional details.
10.4.4 S e Send n er e er
ith everything complete, it’s time to summarize and make the
offer. e highly advise that this be done in writing; however, in
those states that are at-will, be clear in the letter that it is not
a contract. Box 10.5 is an example of the information to cover
in your letter. The sample may be customized and used in your
hiring efforts.
Box 10.5
S m e er e er
[Put on Practice Letterhead or Insert Graphic of Logo]
Date
Name
Address / Email
Dear ,
I am pleased to offer you the position of Patient Care
Coordinator. The job description for this role is attached, and
the offer described below is contingent on the results of a back-
ground check. Details about our medical insurance and employee
policies will be provided to you in our employee handbook.
This letter summarizes the benefits that are offered and is not
a contract, as your state is an employment-at-will state.
The Patient Care Coordinator role is a full-time, non-exempt
position, with an annual salary of . Benefits include
medical insurance, 14 days of PTO, a 40% discount on skin care
products, a surgery benefit (available after two years of service),
and a first-year training stipend of 1,500. After 120 days, you will
have an opportunity to participate in a compensation bonus for
the entire team. You will also receive on-the-job training over the
next several months.
All staff are hired on a 90-day probationary basis. During this
period both you and the practice can assess whether it is a good
fit.
As we discussed, your start date will be . Please
arrive by 9:00 am.
Going forward, your performance is reviewed annually on
or around your hire anniversary date. Raises are merit-based,
contingent on performance.
I’m very enthusiastic about the skills you bring to my practice.
I look forward to having you on board!
Sincerely,
Shannon
Shannon Surgeon, MD, FACS
91
 II Business Basics

Box 10.6
e e I em In ude in ur rien i n n
I em rge d e r e m e ed
m ei n
1. Establish performance goals and initial projects that need attention. Setting expectations is
vital to the new person’s success. Establish some short-term and long-term goals for the
person and the position and put them in writing.
2. Review the practice website in detail. The entire team must know it like the back of their
hand so they can direct patients to use it and explain what’s there.
3. Review the surgeon’s curriculum vitae CV . All staff must be able to explain the scope of your
training, the medical school you attended, and where you completed your fellowship.
4. Review all the practice’s social media and online rating site listings. Schedule time with the
surgeon and the manager to discuss findings within the first 2 weeks.
5. Review the websites of the surgeon’s top ve competitors. It’s essential that the PCC have
intelligence about the other options in the market.
6. Review social media and physician rating site listings for the surgeon’s top ve competitors.
Look at RealSelf, elp , and Vitals.
7. Read ASAPS and ASPS printed and online materials. Schedule time to discuss which proce-
dures you perform most often and point out any differences in your patient care.
8. Schedule a welcome lunch with the manager and physician. This is a good opportunity to get
to know your new employee personally and to review topics such as expected behaviors,
practice culture, and the characteristics of your patient mix.
9. Attend technology training. Ideally, schedule training directly with vendor to optimize the
new employee’s knowledge of the system.
10. Shadow 5 to 10 aesthetic consultations. Make sure staff thoroughly understand the consul-
tation process so they can accurately explain it to patients.
11. Observe surgery and postop care. Seeing patients in the OR and in the exam room postop-
eratively will give your team the “big picture” of the patient experience.
12. Read Seth Godin’s Purple Cow, a book about differentiating yourself based on your uniqueness,
or another book on customer service or marketing. Discuss learnings in an upcoming staff
meeting.

10.4.5 Step 11: Conduct a Background 10.5 Orientation and Training

Check
Background checks enable physicians to avoid potentially disas-
trous hires of people who seemed great or looked the part but
clearly weren’t. A background check provides relevant, detailed
facts that typically aren’t uncovered during a standard reference
check, and it is an important risk mitigation step when it comes
to HIPAA requirements around privacy and data security. Theft
of a patient’s identification can result in hefty fines and attorney
fees. Our insistence that practices perform background checks
has uncovered information such as the following:
1. Felony charges
2. Universities listed on r sum s that the candidate never attended
3. Degrees and certifications the candidate never earned
4. Six-figure credit card debt for a candidate who was to manage
an aesthetic practice
TrustedEmployees (trustedemployees.com) is a cost-effective
background screening company that provides a report of a per-
son’s criminal and credit history, work, education, and identity
verification, and more. ou’ll need the candidate’s Social Security
number and signed authorization to execute the search.
ith the hiring process behind you, it’s time to make sure your
new superstar is a success. Orientation and training are vital to
making that happen.
Rushing the new employee orientation process can be a costly
mistake. If your practice provides a week of training that focuses
primarily on completing paperwork, obtaining office keys, and
observing coworkers as they do their jobs and use the computer
system, the PCC is being set up to fail.
Training must be comprehensive and intense. The new PCC must
learn everything from the surgeon’s style and computer software
to the nuances of scheduling surgery and preparing quotes, and an
overview of your practice culture too.
Plan on 3 to 4 weeks of training before you put the PCC in front
of a patient on her or his own.
Savvy practice leaders agree that a focus on culture is an
important first step. Interviewing is like dating. hile you can be
blissfully happy while dating, the decision to live together might
make you miserable. At Charlotte Plastic Surgery, a new PCC shad-
ows the surgeon, a scrub tech, the front desk staff, and the clinical
staff in the first week, all of whom are asked for feedback about
whether they feel the new hire is a good fit. The person could be

92

the best coordinator in the world, but if they don’t fit into your
culture, it’s a dead end, says Pike.
Observing the roles and tasks of every member of the practice
or MedSpa team is essential. Our surgical patients receive an
allowance in the spa, so the PCC has to know all those services
and products cold, shares Roxanne Housley, Executive Director
at Maxwell Aesthetics in Tucson, Arizona. They must also spend
time listening to the front desk staff on the phone, observing
consults, and observing follow-up visits with the surgeon.
Housley also advises allotting significant time for the new PCC
to spend with the surgeon during the first few weeks and months.
The PCC needs to hear things directly from the doctor in order
to learn the doctor’s medical philosophy and style. Housley says
that frequent, 10-minute meetings after consult days and surger-
ies help cement the relationship between the surgeon and PCC
early on.
Pike and Housley avoid a common mistake we observe in aes-
thetic offices: skipping orientation and sufficient shadowing and
moving right to training. Think of orientation as pretraining;
the foundational elements that will make your new PCC’s training
even more effective.
Box 10.6 contains 12 items to include in the PCC’s orientation
plan. e recommend that every new employee you hire not only
the PCC complete many, if not all, of the items. The more deeply
the new PCC understands the practice culture and services, the
surgeon’s style, and the patient mix, the better the PCC will serve
as a marketing ambassador. The orientation items need not all be
completed before training begins; in most practices, the two are
done concurrently.
It’s worth emphasizing that technology training provided
directly by the vendor not from a coworker is much more
effective. our PCC will learn more effectively and may even bring
back ideas about features and reports that are currently unused.
o matter how dire your need, you cannot cut the orientation
or training process short, warns Cook. Columbus Aesthetic
Plastic Surgery learned this the hard way, through experience. So
Cook used the lessons to develop a 4-week, comprehensive train-
ing plan, summarized in Box 10.7. It’s divided into three chunks:
culture, software training, and business operations. At the end
of the training Cook conducts an evaluation. If the new PCC isn’t
100 ready, training continues for another week. Everyone learns
differently, Cook says. e make sure they are confident before
they are on their own.
Box 10.7
New PCC Training at Columbus Aesthetic & Plastic Surgery
Week 1: Culture immersion: The new PCC gets oriented to
everything about the culture of the practice. She or he reviews
the website thoroughly, shadows front desk and call center staff,
observes clinic workflow, and receives an overview the consul-
tation process, from first phone call to scheduling surgery. This
week is mostly about understanding the brand and the patient
experience at every touch point in the process.
Week 2: Software training: The PCC continues with shadow-
ing and learning processes, but this week is focused primarily on
learning the software from an internal trainer, who provides an
attestation that the new employee has successfully passed the
10 Hiring and Training a Superstar Patient-Care Coordinator
training. “If your PCC can’t maneuver in the software before they
ever see a patient, you are going to sacrifice the patient experi-
ence,” Cook insists. “There is no way they will be confident and
sure. You are setting them up to fail at scheduling the patient.”
Week 3: Business operations: The primary focus of the week
is surgeon shadowing. The new PCC sits in on consultations and
follow-up visits with the surgeons. She or he also sits in with the
other PCCs to learn how to have patient conversations about
the quote and how to schedule surgery. She or he continues to
practice what was learned in software training and work with
other team members to learn the procedures of the PCC role.
Week 4: Evaluation: Before the new PCC can see her or his
first patient, Cook administers an assessment and conducts
role-playing scenarios. Cook, the surgeons, and staff must feel
confident that the PCC can answer questions correctly and is
ready to see patients. If the new employee does not feel 100%
ready, Cook addresses the hesitations and challenges and will
extend training another week.
10.6 Measuring and Rewarding
Success
“Employees respect what managers inspect.”
My associates and I have been saying this for more than 30
years, and it is still true. A PCC who knows that she or he is being
measured based on a standard goal, task, or metric is much more
apt to focus on being on top of his or her game.
Although it is important to track and monitor your PAR, it’s
unfair to use this metric as the sole measuring stick for PCC
performance. The reason is that there are many other influencers
on whether or not a patient schedules surgery. Among them are
patient interaction with the surgeon, whether the appointment
schedule was on time, and the mood of the nurse that day. one
of these are within the PCC’s control.
The issue here is fairness. For a reward system to be effective,
it must reward not only the PCC but also the other team mem-
bers who contribute to converting callers to patients, building
the spa business, check-in consults with a smile, or removing
stitches oh, so gently. All of this is part of the patient’s experi-
ence (Box 10.8).
Box 10.8
Should I Pay the PCC a Sales Commission?
No. Not only can commissions balkanize other staff against a PCC
who gets a bonus when they do not; commissions for this role
are a violation of the state medical practice act in some states.
Don’t do it.
For instance, Cook has developed protocols and tasks on which
she measures the practice’s PCCs. All patient leads are entered
into the customer relationship management (CRM) system so we
can track, she explains. Among the performance items monitored
by the practice are the following:
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 II Business Basics
• as the patient contacted within 2 hours of the call or email
inquiry
• as the correct, practice-approved verbiage emailed
• How many phone/Internet leads converted to a consultation
Our benchmark is that 60 of our inquiries come in for a
consultation, Cook explains. If a PCC falls below, we provide
coaching.
Effective measurement includes a variety of qualitative and
quantitative data. Synthesizing it provides a broad picture of PCC
performance. For example:
• How many hours of OR block time are scheduled
• Is the PCC hitting key task metrics such as sending follow-up
emails within protocol time frames
• Is their performance free of patient complaints
• How well does the surgeon feel the PCC is performing
Pike believes that a key to retaining sales people is offering a
bonus. But because everyone in the practice contributes to the
surgery schedule being filled, as well as the bottom line, it’s not
only the PCCs who benefit. e give a quarterly bonus if the
practice makes money. It’s not based on individual performance;
it’s based on the practice as a whole. This system has gone over
well for the practice, Pike says.
Maxwell Aesthetics implemented something similar. Everyone
who is involved in the first call all the way through to the PCC and
94
the medical assistants receives a quarterly bonus. It’s based solely
on net income, Housley explains. e have a preset percentage
for the bonus and multiply that by each quarter’s net income.
Then we allocate the amount to everyone based on the hours they
worked during that quarter. Everybody gets something, even those
who work part-time. It’s easy to administer and staff are thrilled.
Cook’s group provides a combination of financial and nonfinan-
cial bonuses for example, a monetary bonus for the PCC team and
gift cards, certificates, and team competitions where the reward is
free lunch for the team. The practice gives accolades for the best
month ever and works hard to make sure everyone knows that
his or her contributions count.
The knowledge that you value an employee’s opinion can be its
own reward. At the end of the day, saying thank you means a lot to
a team that is loyal and that has your best interests in mind. It can
be energizing and motivating for the PCC and others on your team
if you simply stop by their desk and tell them you’ve noticed that
surgeries are up and that you appreciate their hard work. Try it.
You’ll see.
Suggested Reading
1 Cain A, Pelisson A, Gal S. 9 places in the US where job candidates may never
have to answer the dreaded salary question again. Business Insider, April 10,
2018. http://www.businessinsider.com/places-where-salary-question-banned-
us-2017-10. Accessed May 30, 2018
2 upko . 10 non-financial reasons patients don’t schedule. Aesthet Soc News
2016(Spring):65–66

11 Evidence-Based Pricing Strategies That Work
Karen A. Zupko
Abstract
In aesthetic plastic surgery practices, price is the least under-
stood of the four marketing Ps. Instead of setting fees and cre-
ating offers using proven business methods that align with the
practice brand, most aesthetic practices do what everyone else
is doing. Then they acquiesce to patient pleas for discounts when
they fear the surgery schedule won’t fill. Using evidence-based
pricing strategies is a more effective way to establish fees that
reflect the value of the service and experience you deliver and
proactively build loyalty and revenue. This chapter discusses
how to use evidence-based pricing to increase revenue while
enhancing and maintaining the credibility of the practice brand.
Keywords
price, pricing, fee schedule, packaged price, discounts, special
offers, luxury brand, premium, value, differentiate, unique, mar-
keting strategy, patient experience
11.1 Introduction
Every day, plastic surgeons make evidence-based decisions while
treating and caring for patients. et most fail to apply research-
driven management principles when it comes handling one of
their most important business decisions: pricing procedures and
services. Instead, many surgeons set their fees on hunches or let
emotions fuel their decisions.
This chapter explains the essentials of evidence-based pricing
strategies and how they can be used to establish, offer, and dis-
count aesthetic surgery and nonsurgical services fees. It addresses
various uses of these strategies by luxury and retail brands and
why aesthetic practices should adopt one or more of these strate-
gies instead of charging based on competition, or worse: charging
less than competitors in hopes that will garner more surgical or
nonsurgical patients.
The primary concepts covered are
• Premium pricing
• Strategic discounting
• Special offers
• Bundled pricing
• The power of nine
11.2 Premium Pricing
The Cosmopolitan and Planet Hollywood hotels are located
across the street from each other on the Las Vegas Strip. In May
2018, the rate for a double-occupancy room for a mid- uly 2018
visit to The Cosmo, as it’s known, started at 330 per night.
Planet Hollywood’s started at 143.
iden e- ed ri ing S r egie r
One could argue that both hotels are offering the same product
because they have similar features. Both have identical placement
on The Strip. Both have casinos, restaurants, workout facilities,
meeting room space, and sleeping rooms, of course. Both are high-
rise hotels with views.
So what’s the difference The difference is that the Cosmo has
differentiated itself as a unique luxury resort hotel and casino like
no other in the heart of Las Vegas, and it can command a higher
price because of it. Comparing the two hotels’ websites conveys
this. The Cosmo’s website is chic and sexy, with high-quality pho-
tography that positions the hotel’s interior design, restaurants,
rooms, and clubs as hot and modern. People in the photos are styl-
ishly dressed and are shown doing exciting things. The marketing
copy tells you to Plan on o Regrets. Anyone who ever hoped to
hang out with the beautiful people would want to stay in a place
that looks like The Cosmo.
Conversely, Planet Hollywood’s home page looks like a dis-
count travel aggregator site, boasting deals and wasting prime
home page real estate to promote Hotel Highlights instead of
indicating anything about the experience you’ll have as a guest.
On the highlights list: in-room i-Fi, self-check-in, pool access,
and fitness center. Really These are highlights ou could say
the same for La uinta. That’s because these highlights are in
fact, commodities, which BusinessDictionary.com defines as
reasonably interchangeable goods or materials that are sold
freely as an article of commerce. Planet Hollywood is a decent
commodity hotel offered on the Las Vegas Strip, and it has priced
itself accordingly.
I doubt that, after all their years spent in training and fellow-
ship, many aesthetic surgeons consider themselves reasonably
interchangeable. et many price themselves as if they are. They
price themselves like everybody else. Our firm advises surgeons
to rethink this mindset and instead differentiate their practice
and the patient experience as a premium brand. Doing so requires
that, before you even think about your fees, you step back and ask
yourself: hat is my Unique Service Proposition (USP) hat
makes my practice unique hat would I like to be known for
hat kind of experience do we deliver to patients and potential
patients Differentiating your brand is essential when considering
what to charge.
In his book Purple Cow, marketing guru Seth Godin talks about
teasing out what makes you product or service remarkable. To
paraphrase Godin, most cows (your competitors) are brown.
A purple cow would really stand out in a sea of brown cows. It
would be remarkable. And according to Godin, Something
remarkable is worth talking about. orth noticing. Exceptional.
ew. Interesting. It’s a Purple Cow. Boring stuff is invisible. It’s a
brown cow.”
hen ay ewelers offers diamond rings for 489, does Tiffany
rush to match the price ope. hen Dunkin’ Donuts and
McDonald’s duke it out to see who can sell the most espresso-based
beverages and fancy coffee drinks, does Starbucks jump in the ring
95
 II Business Basics

and cut the cost of a grande latte o. Starbucks doesn’t have to,
because it has redefined coffee consumption and is in a class all by
itself. The company is now selling reserve whiskey-barrel-aged
coffee for 10 a cup, with great success.
It’s remarkable products like this, coupled with the memora-
ble Starbucks store experience (music, smells, ambience), that
McDonald’s or Dunkin’ Donuts will never be able to deliver.
Dunkin’ Donuts and McDonald’s don’t have that kind of pricing
ability, because selling lattes and cappuccinos cannot change
how consumers perceive their brands. either chain will ever be
considered upscale, no matter how many trendy items they add.
Premium brands target different customers than their lower
price–driven counterparts do, and there are plenty of consumers
who are willing to pay a premium price for these brands. Research
conducted by Michael Silverstein and eil Fiske, formerly of
Boston Consulting Group, shows that, in dozens of categories,
luxury brands sell at huge premiums over conventional goods.
Their findings show that people are willing to pay a little more
if they feel they are getting a unique value. The aesthetic surgeon
who understands how to differentiate him- or herself from the
pack will win with these consumers.
Premium brands know they are remarkable. They can articulate
their value proposition because they know what differentiates
them from the herd. And, most important, premium brands
recognize that they are not everyone’s gourmet grocer, coffee
purveyor, or clothing store. ot everyone will appreciate and pay
for the value and experience they offer; and that’s okay. Aesthetic
surgeons must adopt a similar philosophy.
As you think about what makes you remarkable, realize that
you don’t have to spend tens of thousands of dollars on marketing
or build a Taj Mahal. ou just have to do three things:
1. Don’t be like everybody else. For example, don’t send canned
thank-you notes post consultation. Use scenting throughout the
reception and exam room areas. Be on time.
2. Deliver memorable experiences, which create a higher price toler-
ance. One practice we visited uses dimmer switches in the exam
room to make patients feel more confident, and decorates the
rooms using beautiful furniture and framed mirrors that you
would expect to find in a lovely home. A movable swing arm
was used to enable patients to self-register into the imaging sys-
tem, using a tablet computer.
3. Articulate why you are remarkable, and train your team to
demonstrate and deliver it.
Pricing power comes with differentiation. ou can deliver
luxury, such as a luxurious spa or facility experience, or cloth
robes instead of paper. ou can deliver unique services, such
as healthy, organic meals delivered for a week after surgery,
a black car service that transports patients to/from their first
postop visit, or special events only for men. ou can deliver
convenience that no one else does, such as office hours outside
of the typical 9 a.m. to 5 p.m., which are appreciated by working
women, or upscale overnight stay suites in your facility, or a
hotel partnership, both of which are staffed with your own
overnight nurses.
hatever you choose, make it memorable and make it remark-
able. Box 11.1 provides guidance on how to identify your differen-
tiators. Being remarkable is powerful. If you are not like everyone
else, you won’t have to charge like everybody else.
Box 11.1
remium ri ing e uire i eren i i n
What’s Your Unique Service Proposition (USP)?
Define what makes your practice different. Hint: It’s not that you
are board certified. ou’ve got to do a lot better than that to
price yourself at a premium.
1. Sit down with your team and create a list of everything that
makes you unique and different from your competitors. Once
it’s all down on paper, pare it back to a Top 5 list.
2. Ask three to ve happy patients what they believe makes you
fabulous. What do they believe makes you valuable and
worth it? Modify the Top 5 to include words and phrases
you heard from patients. Add any of the differentiators that
patients valued, if they were not on the Top 5 list.
3. Synthesize what you’ve learned into a written “talk sheet.” Use
it to create short, scripted responses that staff can use on
the phone with potential patients and that the patient care
coordinator can use to handle the objection “that’s expen-
sive” when discussing surgery options.
4. Be OK with patients choosing someone other than you. If you
price yourself at a premium, not everyone will be able to
afford your services. That’s OK. In a world of plenty, there
are many who appreciate your unique value and have the
means to pay for it. You must accept that you are not every-
one’s plastic surgeon. ou may end up doing fewer cases, for
more revenue overall.
11.3 Strategic Discounting
Strategic discounting can build loyalty and repeat visits. However,
it requires practices to think strategically about offering the right
type of discount, at the right time, for the right reason.
Reactionary discounting caving in to patients when they ask
for a lower fee during the quote review delivers no long-term
benefit to the practice, and in fact, it can tarnish your brand.
hen practices rush to offer discounts and compete on price,
they often look desperate. Haphazard or let’s make a deal
discounting can backfire and make it difficult to recoup your rep-
utation. When word gets out that Dr. Wonderful drops the price
15 if you just ask, transaction buyers will start to fill the schedule.
Dr. Paul ang of orthwestern University’s ellogg School of
Business is widely known for identifying buyer types. Two of these
classifications are particularly relevant for aesthetic surgeons:
transaction buyers and relationship buyers. e’ve summarized
some of the relevant descriptors of these buyer types in Table 11.1.
Transaction buyers are primarily motivated by price. These are
the patients who come into your office with three quotes in hand
from other surgeons, demanding that you match the lowest one.
Transaction buyers are not loyal. They came for the price, and
they’ll leave for a price. Their psychology is I want to get the
best deal. It doesn’t matter how differentiated your value or how
fantastic the patient experience. This is lost on them. A good piece
of advice is never to price match their best offer from another
office. ord of mouth and mouse will spread that you can be

96
 iden e- ed ri ing S r egie r

Table 11.1 Transaction buyers vs. relationship buyers 2. Make specific “consultation” and “promotion” categories.
For instance, an adjustment for Consultation—Breast,
r n i n uyer e i n i uyer
Consultation—Face, or Promo—Spring Laser.
• Price-driven • Seek “trust” in you 3. Charge the full fee, then use the adjustment category to
• No loyalty • Want friendly, reliable services apply the discount.
• Pride themselves on getting the and products
4. Generate and review an “Adjustments Report” each quarter
“best deal” • Feel shopping and comparing
• Less profitable/fewer repeat are a waste of time to review the totals.
customers • Appreciate those who
recognize and value them

In addition to reviewing the amount of the discounts, evalu-

coerced, and the floodgates will open with the transaction buyer’s
friends.
Offering free consultations is a good way to attract transaction
buyers. hen the consult is free, there’s no risk for patients to
see you for a second opinion after they’ve already scheduled
surgery elsewhere. And who can blame them hy not verify
the recommendation of another surgeon when the consult is free,
free, free These patients don’t, and won’t, appreciate the value
associated with the overall patient experience you and your team
have worked so hard to create. To them it’s a free opportunity to
ask a reasonably interchangeable surgeon a bunch of questions
and perhaps get an additional set of images. And if the consult is
free, many patients reason, hy not ask for a discount on the
surgery
Relationship buyers, on the other hand, are patients who genu-
inely like you and your services. They refer to you as their plastic
surgeon. our staff knows more than just their names. They know
about their vacation plans, which child just graduated, and the
patient’s most recent work promotion. These patients value
good service and reliability. They believe that shopping around
is a waste of time, so relationship buyers will not be swayed by
bargains. They may likely become long-time patients, who will
continue to invest in and trust you to keep them looking terrific.
Even better, they’ll recommend you to their relationship buyer
friends.
Strategic discounts that effectively build your practice and
attract relationship buyers have a few important characteristics:
1. , which keeps you and the staff in the driver’s
seat instead of reacting to a patient’s discount request
2. fi fi as
opposed to offering a discount to everyone, for any procedure
3. fi , such as to introduce a
new aesthetician or pay for a technology that hasn’t had quite
the uptick you had hoped
4. Used with discretion, because exclusives work better than
giving discounts to everyone; be selective and don’t blast out
special offers to everyone in the email database or post them to
Facebook
Box 11.2
How to Track and Evaluate Strategic Discounts
1. In the practice management system, create an “adjustment”
category for each type of discount you offer—for instance,
consultation, multiple procedure, skin care services,
promotion.
ate the composition of the group who took advantage of the
discounts. ere they new patients or established patients Did
they schedule something else, after their discounted service Take
a look at the Lifetime Value report, available in most aesthetic
practice management systems. Is the discounting strategy effec-
tive in building a valuable, loyal patient relationship, or were most
recipients of the discount transaction buyers
Following are a few examples of strategic discounts that work.
Remember also to track and evaluate the discounts you offer. Box
11.2 explains how.
• Occupational discounts: Offer teachers a special discount if
they schedule in uly or August, when their seasonal break
makes recovery time a nonissue, or offer a flight attendant dis-
count if you live in the hub city for a major airline. In Atlanta,
Dallas, and Chicago, it’s easy to see why a surgeon would offer
a strategic discount for Delta, American, and United flight
attendants, respectively. It makes them feel special. Several
clients also offer discounts to active military personnel or their
family.
•
Consider the offer of a discounted fee when a patient schedules
an abdominoplasty and two or three areas of liposuction. It
makes sense because you generate an additional hour or two
of surgical fees with only slightly more time pre- and postop-
erative. e commonly see practices offer anywhere between
5 and 25 off the second and third procedure, with 10 being
the median. ever reduce the price on the primary or most
expensive procedure.
• Splurge cards: These discount cards are given after the patient
has had a procedure or spends a certain amount on services in
the spa. It gives them an incentive to splurge on themselves
again, this time at a 10 or 20 discount. For example, send a
splurge card to patients who have had a series of neurotoxin
services, encouraging them to consider scheduling a peel or
other facial service at a discount.
• Birthday discounts: People appreciate being remembered on
their birthday, which is why this discount can be more effec-
tive than the offered-to-everyone discounts. Mail or email a
certificate for a 75 credit toward fillers or laser services, for
example, and make the offer valid for up to 60 days after the
patient’s birthday.
• Introductory discounts for a new laser: Promote the bene-
fits of a new piece of equipment you purchased by offering a
limited time discount on a package. It can boost appointments
and help you recover the costs more quickly.

97
 II Business Basics

11.4 S e i er year during the doldrums season. hen patients in spring and
early summer ask for a discount or express their wish to pay less,
A special offer is a strategy is whereby you make special, offer a limited-time special price if they schedule their proce-
limited-time offers designed to reach specific business goals. In dure no later than une 30 for a date of surgery that is between
luxury brands, targeting a special offer to a specific group makes August 15 and September 15. The patient care coordinator can
it even more exclusive. For example, ordstrom offers sales explain that as when Dr. onderful’s otherwise busy schedule
only a few times each year, whereas at Macy’s nearly every item has more openings.
seems to be perpetually on sale. hen used correctly, special Finally, consider developing special offers for procedures that
offers can increase the profitability of your practice and amplify have a high margin. As an example, an upper lid blepharoplasty,
your brand. performed in the special procedure room, paired with the right
Special offers come in a variety of forms. For example, similar aesthetician services, for a bundled price may be very profitable.
to the birthday discount mentioned previously, consider the It’s an easy age-reducing treatment with a short recovery time
offer of exclusive vouchers to a targeted patient group. Perhaps that can be promoted as a limited offer during a specific time
target your best referring patients or those who attend a special period.
VIP event, or have a Mommy Makeover in September after the
kids are back at school. Science shows that vouchers can increase
happiness. A study by Dr. Paul . ak, professor of neuroeconomics 11.5 Bundled Pricing
at Claremont Graduate University, showed that coupon recipients
Bundled pricing occurs when several items or services are sold
who received a 10 voucher experienced a 14 rise in oxytocin
as one item, at one combined price. It goes by name names,
levels, an 8 decrease in the stress hormone adrenocorticotropin,
including package price, collection, or gift set. ou’ve seen the
and a 27 reduction in respiration compared with those who did
promotions at department makeup store counters: Buy our new
not receive one and self-reported that they were happier than
perfume and get a free Plum Power lipstick, concealer, and blush
those who did not.
in a convenient travel bag.
In some cases you may be able to leverage special incentives
The travel industry often uses bundled pricing. A 7-day trip
from skin care or injectible companies or patient financing
marketed on an airline vacation site includes business airfare,
companies. Combining efforts can create a significant success. For
hotel, car rental, and spa gift certificate for one amount, including
instance, CareCredit, the healthcare credit card company, offered
taxes and fees. It makes the vacation easy to budget for, which
a special offer to new cardholders in the spring of 2018. hen a
speeds a person’s decision making. o additional charges or
new customer applied for a CareCredit card and spent 1,000 with
surprises are lurking behind the price tag. The beauty of this
a practice, the patient received a 100 credit on his or her next
approach is that the consumer cannot see which business partner
statement, which could be used toward a future service at the
or partners lowered their usual fees nothing is itemized so all
practice. Having 100 to spend in your practice or spa is almost
discounting is opaque.
guaranteed to garner additional revenue to the bottom line. So
The reason bundled pricing is so effective is because it addresses
practices that aligned their spring promotions with CareCredit’s
an interesting problem that many people suffer from: consumer
special offer were able to, in effect, benefit from the offer of a 100
innumeracy. Research reveals that percentage off discounts
credit without actually paying for it.
are less enticing to people than getting something extra or free,
Always make sure that the special offers you create are advanta-
because most people are lousy at fractions. Deals such as 10 , 13 ,
geous to the practice and not just a loss leader a pricing strategy
or 17 off confuse them because they can’t do the complicated
in which a product is sold at a price below its market cost to stim-
math in their heads that is required to determine the real value of
ulate other sales of more profitable goods or services. In a luxury
the discount. So, when you offer 13 off a syringe of Restylane,
brand like aesthetic surgery, this isn’t necessary for driving revenue.
you’ve put the patient into hyperperplex. And, since most people
A client in the est designs brilliant VIP events, inviting select
don’t have an anchor price for a syringe of any injectable in
patient groups. Breasts and Bras was held at a local lingerie
mind, even if they could do the math, they don’t have anything
boutique and featured the surgeon discussing all breast surgery
to compare the discount with in order to determine whether it’s
options, after which guests enjoyed drinks and light snacks and
good or bad. According to the research, a complimentary bag of
had the opportunity to shop for beautiful bras. An event at the
goodies, a gift set, or a bonus something extra entices a sale
practice featured Pilates and Plastic Surgery, and the surgeon as
more effectively than getting it at a discount. So, swap your per-
well as the president of the neighboring upscale Pilates studio
cent off deals with giving patients something extra or free. It’s
talked about healthy weight and healthy bodies. At these events
easier for the staff to explain, too.
as well as others, attendees always leave with a special offer that
Another psychological reason for the effectiveness of packaged
no one but them receives. It’s different each time but is typically
pricing is the human preference for getting a deal and the fact
something like a 75 credit in the MedSpa or a dollar figure credit
that it’s easier for people to justify a single price for a bucket of
toward a procedure.
products or services than purchase multiple things individually.
Every practice, in every geography, has a doldrums season, a
Advantages of this strategy for aesthetic practices include the
time when everything seems to slow to a near halt. For most, it’s
following:
August and September. A special offer can help reach the goal of
increasing the number of scheduled surgeries over the previous 1. fi Fewer prices and fewer questions make it
easier to decide.

98

2. The psychological cost of purchasing all the items is lowered. Buy-
ers feel as if they are getting a deal.
3. It makes for easier accounting, in many cases. There is no need to
track or report individual product sales tax. The patient sees one
simple fee. Of course, on the back end of your practice man-
agement system is where each individual line item is properly
posted and sales tax for products and/or garments is calculated.
So while the patient sees one opaque fee, the practice’s revenue
reports retain their accuracy, and the products sold as part of
the package are properly removed from the system’s inventory
count.
4. It builds the overall value of what the patient is buying. For exam-
ple, staff may explain to patients, Our fee includes incision line
reduction gel and a garment because Dr. onderful believes
these are important to your recovery and outcome.
A simple way to incorporate the strategy of bundled pricing into
your practice is to offer a single fee for certain surgical procedures.
Antiaging packages for injectibles and laser services lend them-
selves well to bundled pricing too. In terms of procedures, bundled
pricing is very effective for breast augmentation, which is typically
bought by a price-sensitive, younger patient demographic. Fig. 11.1
shows how one client provides the quote for augmentation. otice
how it delineates everything that is included, providing potential
patients with an all-inclusive fee for 7,200. (Pain medications are
excluded from the bundled price because they vary due to patient
safety and preference.) Mommy Makeover and abdominoplasty
also lend themselves well to packaged pricing, as well as packages
provided in the MedSpa laser, injectibles, or bundling skin care
products with treatment packages.
Another aesthetic surgeon uses the bundled price concept to
add a bonus to all surgical procedures. Patients receive a spa
allowance that varies in value with the cost of the surgery. Patients
choose to purchase the services they desire.
The way you bundle your services is up to you, based on your
creativity and your market needs. The point is to bundle items or
services that increase the overall perceived value of the purchase
and make it simpler for the patient to say yes. e recommend
that if you do decide to try bundled pricing, you start with breast
augmentation.
11.6 The Power of Nine
hy is it that so many retail items are priced at 99, 8.99,
79.99 Because this psychological pricing strategy has been
proven to increase sales, according to multiple studies.
A classic example is an experiment conducted by MIT and
the University of Chicago. A women’s clothing item was tested
at three price levels: 35, 39, and 44. Interestingly, the price
at which the item sold best was 39. The same study also found
that prices ending in 9 sold better than even their lower-priced
counterparts by an average of more than 24 . This is one of eight
studies dissected in the book Priceless, all of which concluded that
the power of 9 does work to increase sales.
To implement this strategy, simply change the last number in
your procedure fees to a 9: 4,999, 3,599, etc. For instance, you
could modify the previously discussed 7,200 bundled price for
breast augmentation to 7,199. The power of 9 also works beauti-
fully in the MedSpa with products and nonsurgical services.
iden e- ed ri ing S r egie r
Example of packaged pricing as a way to simplfy surgery quotes.
The one fee—breast augmentation
Estimate of surgical fees
Sam Wonderful, MD
Description Item price
Breast augmentation silicone One simple fee. $7,200.00
Our fee is all-inclusive and includes Dr.
Wonderful’s fee, implants, operating room,
anesthesia, garments, incision line reduction gel,
and all pre- and post-operative visits.
Subtotal: $7,200.00
Tax: $0.00
In some states, using a bundled approach means you don’t charge sales tax
Quote $7,200.00
Fig. 11.1 Example of packaged pricing as a way to simplify surgery
quotes. (Please note: Fees are for illustrative purposes only.)
11.7 Concluding Thoughts
hen pricing your services, focus less on what competitors are
charging and more on creating perceived value for patients.
Differentiate your practice and make the experience memo-
rable. Implement retail-tested strategies such as premium and
packaged pricing, and be thoughtful and selective about special
pricing and discounts. The goal of effective pricing is to build
patient loyalty over time, not to get a one-time patient onto the
schedule.
Author’s Note
The American Society for Aesthetic Plastic Surgery (ASAPS; http://
www.surgery.org) and the American Society of Plastic Surgeons
(ASPS; http://www.plasticsurgery.org) both conduct annual fee
surveys of their members’ surgical and nonsurgical fees. These
data can be particularly useful if you are just starting practice.
The survey results are available on each society’s website.
Suggested Reading
1
2
Godin S. Purple Cow. ew ork, : Portfolio Publishing; 2003: 3
line D. Coffee wars: McDonald’s, Dunkin’ Donuts fight on price. USA Today, une
28, 2017. USAToday.com/story/money/personalfinance/2017/06/27/when-it-
comes-to-coffee-price-isn’t-everything/103224458/. Accessed September 24,
2019
3 Silverstein M, Fiske , Butman . Trading Up. ew ork, : Penguin Random
House; 2008
4 upko . Going from free to fee consultations. es, you can. Here’s how. Aesthet
Soc News 2017(October 4):56–57
5 Alexander V, Tripp S, ak P . Preliminary evidence for the neurophysiologic
effects of online coupons: changes in oxytocin, stress, and mood. Psychol Market
2015;32(9):977–986
6 upko . Evidence based pricing strategies for plastic surgeons winning the
price wars. Aesthet Soc News 2018(March 26):99–100
7 The psychology of discounting. Something doesn’t add up. The Economist, une
30, 2012. https://www.economist.com/node/21557801. Accessed September
24, 2019
8 Anderson ET, Simester DI. Effects of 9 price endings on retail sales: evidence
from field experience. Quant Mark Econ 2003;1(1):93–110 https://link.springer.
com/article/10.1023 2FA 3A1023581927405. Accessed May 24, 2018
99
 Part III
Nonsurgical
Cosmetic
Treatments

III

12 Clinical Decision Making for Nonsurgical Cosmetic
Treatments
Mikaela Kislevitz, Foad Nahai, and Jeffrey M. Kenkel
Abstract
onsurgical office-based cosmetic treatments are becoming
more mainstream. These treatments can provide patients
alternative options to surgery. It is important to understand that
nonsurgical cosmetic treatments do not provide the same out-
come as surgery. All options of treatment and realistic outcomes
should be reviewed with the patient.
Keywords
nonsurgical cosmetic treatment, facials, fillers, chemical peels,
toxins, injectables, laser, rhytids
12.1 Introduction
Today, nonsurgical and less invasive, office-based procedures
and treatments are the mainstay of therapy for our patients.
According to the American Society for Aesthetic Plastic Surgery
(ASAPS), nonsurgical procedures increased by a total of 4.2 in
2017. The most significant increases in nonsurgical procedures
in 2017 included microablative skin resurfacing (up 99.5 ), full-
field ablative skin resurfacing (up 29.2 ), nonsurgical fat reduc-
tion (up 24.7 ), chemical peel (up 15.9 ), and nonsurgical skin
tightening (up 15.1 ). hile they have not replaced surgery, their
consistency and lack of significant recovery time requirements
have appeal for many of our patients. ith the emphasis on a
youthful facial appearance and an appealing, slim figure, much
younger patients are consulting us about facial rejuvenation and
body contouring.
Cosmetic treatments are nonsurgical treatments that require
minimal or almost no downtime, returning our patients to the
acts of daily living without delay. Many of these treatments can
be delegated to an aesthetic technologist, nurse, and/or physician
assistant (PA). e feel that most treatments should be performed in
a clinical environment under the supervision of a physician. hile
facials, lighter peels, and microdermabrasion may be performed by
an appropriately trained aesthetician in a nonclinical setting, we
believe that their training, experience, and the identity of a physician
Table 12.1 Nonsurgical treatments in order of increasing invasiveness
nin i e inim y in i e
Spa treatments Light-based treatments
Facials Microdermabrasion
External ultrasonography Fruit acid peels
Nonablative lasers
Sclerotherapy
Transcutaneous skin tightening
Abbreviation: TCA, trichloroacetic acid.
ini e i i n ing r n urgi me i re men
to contact in case of a problem should be transparent to the patient.
More invasive procedures, such as injections of toxins and fillers,
and invasive laser treatments should be performed in a clinical
setting, such as a physician’s office or outpatient center, rather than
at a spa or beauty salon. These are procedures and require a medical
environment to ensure the patient’s safety. Although injectables
and other technology-based procedures are safe in the hands of
trained technologists, nurses, and PAs, a physician should evaluate
the patient, make decisions concerning treatment, and be available
while these procedures are being performed.
These office-based and less invasive procedures keep patients
cycling in a practice. It is not uncommon to see some patients con-
vert from these procedures into surgical ones. Research has shown
that patients who are satisfied with their cosmetic treatments are
likely to return to the same surgeon for surgical procedures as the
aging process continues. It is a rare aesthetic practice that does
not offer the full range of cosmetic treatments.
12.2 Cosmetic Treatments
Options for office-based cosmetic treatments (such as those
listed in Table 12.1) are constantly increasing. Our patients are
tuned in to these treatments, heightened by direct-to-consumer
marketing. In many cases, claims are being made without
well-controlled studies or any objective data. It is imperative for
us as physicians to stay abreast of the dissemination of this type
of information to our patients so that we are adequately prepared
to discuss them and answer questions regarding these products
and devices. hile great advancements have been made in the
nonsurgical arena, they are still not a replacement for surgery,
nor do they approach the type of results and longevity achieved
with surgery. That being said, patients understand this and are
willing to accept a lesser result and even the need for multiple
treatments. Most important, we need to choose treatments that
can achieve a certain result in a predictable fashion. This is a
constantly evolving field that requires treating physicians to stay
informed. Outcomes and safety help differentiate us from many
other providers and it behooves us to familiarize ourselves with
mode of action, safety limits, risks, and limitations.
der e y in i e
Injectables
Ablative lasers
Peels: TCA, croton oil
Dermabrasion
103
 III Nonsurgical Cosmetic Treatments
12.3 Choosing the Right Option:
ffi e- ed Surgi
Procedures
In the first edition of this book, this section was titled Choosing
the Right Option: The eedle or the nife. It is no longer a
question of needle or knife; these are not competing but rather
complementary treatment methods. e also have to recognize
that many patients have made up their mind that surgery is not
on the options list. Despite this, we routinely review what a
surgical procedure can accomplish. This often serves as a frame
of reference as they begin to consider nonsurgical options.
Choosing a nonsurgical option in a patient who clearly needs
surgery to achieve the desired goal leads to a dissatisfied patient
who often can be difficult to manage. On occasion, saying no
is the best for the patient. e have seen some of these patients
come back later on and move forward with surgery.
It’s not unusual for young people who are nowhere near ready
for a facelift to come in to discuss a facelift, while individuals
with advanced facial aging who are no longer candidates for
cosmetic treatments frequently ask for nonsurgical treatments.
ounger patients often benefit from skin care, light peels, toxin,
and injectables, if needed, while strongly advising patients to
wait for the appropriate time to undergo a surgical procedure. To
an older patient who is a candidate for surgical rejuvenation but
comes in to discuss cosmetic treatments, I recommend surgical
treatment as the first choice and discuss cosmetic treatments as a
a
b
Fig. 12.1 (a) Anterior, (b) right and left oblique views pre (left) and
post (right) intense pulsed-light (IPL) treatment (five total treatments).
104
less effective alternative and perhaps a better adjunct to a surgical
procedure rather than the primary treatment.
The choice between cosmetic treatments and open surgical
procedures should be an informed decision, and all options,
including expectations of them, should be discussed during initial
consultation. The patient must clearly understand what outcomes
are anticipated with both surgical and nonsurgical treatments
and should also understand how many treatments would be
required and what the longevity of the procedures are (Fig. 12.1;
Fig. 12.2; Fig. 12.3; Fig. 12.4).
12.4 Face
Most women undergoing noninvasive facial cosmetic treatments
are seeking improvement of their facial skin. It is important
to note the degree of skin pigmentation and redness and the
nature of each. Is it superficial or deep, and what does it consist
of The texture, thickness, and quality of the skin are deter-
mined. Finally, static and dynamic lines are assessed. Having a
systematic approach to the analysis of the skin ensures that all
aspects of the evaluation are reviewed, allowing a more detailed,
patient-specific recommendation. These evaluations are usually
performed by the physician and aesthetician together.
Classification systems such as the one for rhytids given in Table
12.2 may be useful to describe the patient and objectively assess
their progress following intervention.
Pigmentation, a darkening of the skin, results from an increased
production of melanin. Increased pigmentation in the epidermal
layer appears light brown, whereas hyperpigmentation in the
dermal layer can appear blue–gray. Increased vascularity can
contribute to a bluish pigmentation.
The texture of one’s skin can be smooth or rough. Extremely
coarse textures characterize individuals with rough skin surfaces
including deep creases, wrinkles, and loss of skin laxity. Visually
smoother skin would be consistent with an improvement in
texture.
12.4.1 Rhytids
Grade I: No Rhytids at Rest or on Animation
Grade I patients (Fig. 12.5) require only preventive and main-
tenance skin care. The importance of sunblock is stressed, the
cornerstone of prevention. In most cases, it is too early for any
Fig. 12.2 Patient pre (left) and post (right) filler and botulinum toxin.
Restylane was injected to the lower eyelid/tear trough bilaterally. The
crow’s feet and glabella were injected with botulinum toxin.
 ini e i i n ing r n urgi me i re men

a a

b b
Fig. 12.4 (a) Anterior and (b) lateral views pre (left) and 9 months post
(right) erbium:yttrium aluminum garnet (Er:YAG) laser treatment.

Table 12.2 Classification system for rhytids

Grade I No rhytids at rest or on animation
Grade II Superficial rhytids on animation only
Grade III Deep rhytids on animation only
Grade IV Superficial rhytids at rest, deep on animation
Grade V Deep rhytids at rest, deeper on animation

for patients to understand that these preventive measures will

c
not eliminate the aging of their skin but may delay or help avoid
Fig. 12.3 (a) Anterior, (b) lateral, and (c) oblique patient views pre some of the sequelae of the aging process.
(left) and 4 months post (right) Ulthera skin tightening to the lower
face and submental area.

surgical or invasive procedures, and the patient’s best interests
would be served by preventive measures, including tretinoins
and glycolic acid peels, if needed, but most of all we discuss skin
health: avoiding environmental toxins, such as smoking and
secondhand smoke, and taking precautions about sun exposure.
Patients are also advised on general antiaging measures, includ-
ing diet, exercise, and the use of antioxidants. It is important
Gr de Su er i y id n y n Anim i n
For each successive grade, most if not all of the treatments of the
preceding grade are applicable, along with specific treatments
for the current grade. Superficial animation lines are best treated
by directly targeting the underlying muscle function. By elim-
inating muscle function, especially in the glabella, forehead,
and crows’ feet, the lines are minimized. Additionally, the brow
shape and position can be altered and improved (Fig. 12.6).

105
 III Nonsurgical Cosmetic Treatments
Grade III: Deep Rhytids on Animation
In grade III patients (Fig. 12.7), for the glabella, forehead, and
crow’s feet, toxins are the best agents to soften their appearance.
Adjunct treatments may be required to have a greater impact on
these areas.
Options may include some of the following:
• Intradermal fillers
• Dermal ablation with peeling agents, ablative lasers, or
dermabrasion
Perioral lines and wrinkles deserve further discussion. Dynamic
lines in this area are responsive to botulinum toxin. It is import-
ant for patients to realize that the results may last only 2 to 2.5
months. Additionally, it may be more difficult for these patients to
drink out of a straw or to whistle. Spot treatment of the lines with
dermal fillers is also an option for patients not wanting a longer
downtime period. Many of these patients are concerned about
filling and plumping of their lips, so this should be approached
cautiously. That being said, most women would rather accept
more limited improvement and the need for repeat treatments
Fig. 12.5 Grade I rhytid condition.
Fig. 12.7 Grade III rhytids.
106
than the excess downtime associated with more aggressive abla-
tive treatments.
Gr de Su er i y id e nd ee
on Animation
The recommendations for grade IV patients (Fig. 12.8) are essen-
tially the same as those for grade III patients. hen considering
ablative treatments, it is often helpful to diminish the dynamic
nature of the area with a toxin in appropriately designated areas.
This may allow better healing and dermal line fill. Additional sur-
gical procedures of the face and periorbita are often considered.
Grade V: Deep Rhytids at Rest and Deeper on
Animation
Grade V patients are the best candidates for perioral adminis-
tration of toxins, but, as in grades III and IV, toxins alone are not
sufficient. These patients clearly need a multimodal approach,
as any single treatment alone will have limited improvement.
Fig. 12.6 Grade II rhytids.
Fig. 12.8 Grade IV rhytids.

Surgical facial rejuvenation procedures help address these lines
by shifting the underlying superficial musculoaponeurotic
system (SMAS)/fascia and skin, helping soften the appearance
of the lines. Most of these patients benefit from ablative resur-
facing, which may be performed in combination with surgical
intervention or in a staged procedure (Fig. 12.9).
12.4.2 Nasolabial Folds and Marionette
Grooves
hile surgery is a very good option for treating deep nasolabial
fold and marionette lines, injectable fillers have become the
mainstay of treatment for many patients due to the ease of
treatment and quick recovery. These areas are often one of the
earlier signs of aging noticed by patients, with glabella frown
lines pushing them to seek treatment. Complaints of looking old,
tired, and even angry are common. e have learned that even
when surgery is chosen, these areas often need either fat or filler
to complement the surgical procedure. It is hard to compete with
the predictability and ease of office-based filler injections.
Unlike facial rhytids, which reflect the insertion of the muscles of
facial expression into the skin, nasolabial folds and marionette grooves
reflect not only muscle insertion and muscle pull but also adhesions
of the dermis to the fascial layers of the face. Established nasolabial
folds and marionette grooves are resistant to superficial and even
deep ablative skin procedures. However, muscular manipulation
with toxins and superficial and deep injections of filler materials can
be very effective in ameliorating these folds. The deeper the fold, the
deeper the level of injection and the more viscous the material. In
addition to dermal and subdermal injections, filler materials may also
be placed within the subcutaneous tissues. Many surgical options are
also available, including various rhytidectomy procedures as well as
local excisions. Recommendations are made based on the grading of
the folds according to the system shown in Table 12.3.
Grade I: Visible Folds on Animation
The majority of patients with this presentation need nothing
more than reassurance. Nasolabial folds with animation are
Fig. 12.9 Grade V rhytids.
ini e i i n ing r n urgi me i re men
Table 12.3 Classification of nasolabial folds and marionette grooves
Grade I Visible folds on animation
Grade II Visible folds at rest
Grade III Visible folds at rest and deepening of folds on animation
Grade IV Deep folds at rest and deeper on animation
Grade V Overhanging folds
normal and are part of human expression. Fillers injected der-
mally to obliterate dynamic lines may be noticeable and promi-
nent in repose. e discourage the use of injectable products for
this type of fold (Fig. 12.10).
Grade II: Visible Folds at Rest
For grade II patients (Fig. 12.11), dermally injected fillers may
be the best option to soften their appearance. Typically, a small
amount of product is needed superficially. It is important to inject
evenly. hen lower-viscosity products are used, care should be
given to how aggressively one massages the area treated, as it
may dissipate the product, losing its effect.
Grade III: Visible Folds at Rest and Deepening
of Folds on Animation
Grade III patients (Fig. 12.12) require the injection of a filler
product at different levels. Deeper injections help fill its depth,
but often a dermal injection is required to soften the fold better.
Fat may be used as an alternative to injectable fillers. hile fat
is less predictable than off-the-shelf filler products, it nicely
complements a surgical procedure and may be preferred by
some patients.
Toxin injections of the depressor anguli oris for the marionette
grooves are helpful in some patients. Toxins in the lip elevators
(the levator labii superioris and the levator labii superioris
Fig. 12.10 Grade I nasolabial fold.
107
 III Nonsurgical Cosmetic Treatments
Fig. 12.11 Grade II nasolabial folds.
alaeque nasi) should be approached with caution, as animation
can be affected.
Grade IV: Deep Folds at Rest and Deeper on
Animation
The recommendations are similar to those described for grade
III. Surgical intervention, specifically midface lift with fat trans-
fer, should be considered (Fig. 12.13).
Grade V: Overhanging Folds
The recommendations of filler injections and toxin remain the
same for this grade (Fig. 12.14). As far as surgical interventions,
I add the option of direct excision as an alternative to a midface
lift. Should the patient choose to undergo a midface lift, the
direct placement of autologous dermis fat graft or SMAS fat graft
is an alternative to autologous fat injections. Most individuals in
grades IV and V are more suitable candidates for rhytidectomy
procedures, with injectable fillers as an adjunct.
12.4.3 Periorbital Region
The periorbital region improves predictably with nonsurgical
options. Proper analysis enables one to manipulate the area, also
Fig. 12.13 Grade IV nasolabial folds and marionette grooves.
108
Fig. 12.12 Grade III nasolabial folds and marionette grooves.
correcting asymmetries and elevating the brow. The mainstay
of treatment includes the use of botulinum toxin along with
both superficial and deep filler injections to diminish volume
loss along the orbital rim and tear trough, as well as their use
to help correct upper lid and brow volume deficiencies and to
help improve static lines. These products are very predictable
and, in the case of the fillers, often last over a year. These
products cannot address skin laxity, crepelike skin, or fat her-
niation. Other adjuncts, including surgical excision and ablative
resurfacing, may be required in order to address these specific
issues. Administration of injectable products in this area should
be performed with a thorough understanding of the underlying
anatomy, including the vasculature. Significant complications,
including tissue loss and even blindness, have been reported.
12.4.4 Neck
The neck is a more challenging area to treat with nonsurgi-
cal devices and products. The following areas may require
intervention:
• Skin
• Medial platysmal bands
• Fat
• Salivary glands
• Anterior belly of the digastric
Fig. 12.14 Grade V nasolabial folds and marionette grooves.
 ini e i i n ing r n urgi me i re men

The skin of the neck may be thin and lax. It is important to
understand that neck skin has about 10 of the glandular struc-
tures of facial skin, significantly decreasing its healing capacity
following injury. For that reason, caution and conservatism should
be used when treating the neck with ablative devices. There are a
number of skin tightening procedures available using laser, light,
radiofrequency, and microneedling. In some cases, a combination
of several modalities can be used. Appropriate expectations must
be established with these devices (Fig. 12.15; Fig. 12.16).
Fat in the neck can be addressed in many ways. The gold stan-
dard remains liposuction, which can be performed in the office
under a local anesthetic. It requires one treatment and produces
predictable results. Alternatives do exist, including cryoadipolysis,
deoxycholic acid, and heat-based technologies,

a a

b b

c c
Fig. 12.15 (a) Anterior, (b) lateral, (c) oblique views pre (left) and 3 Fig. 12.16 (a) Anterior, (b) lateral, (c) oblique views (left) pre and (right)
months post (right) Ulthera after one treatment. 1 year status post office-based neck liposuction.

109
 III Nonsurgical Cosmetic Treatments
It is beyond the scope of this chapter to elaborate on nonsurgi-
cal means to address platysmal banding and prominent salivary
glands (see Chapter 21).
12.5 Concluding Thoughts
Facial rejuvenation with office-based products and devices
is now commonly performed on a wide range of ages. Early
changes and late changes from the aging process can be delayed
or reversed. Toxins and fillers lead the way. There are more and
more treatment options for our patients, allowing the physician
to tailor treatment plans to the patient’s specific needs. Most
of these treatments have little downtime and produce predict-
able results. These procedures not only keep patients with our
practices but nicely complement the surgical procedures we
perform.
Clinical Caveats
• Patients have an increasing number of options for office-based
cosmetic treatments. These treatments can provide great
benefit for appropriate candidates but are not a replacement
for surgery.
• Utilize a systematic approach to determine which nonsurgical
office-based cosmetic treatments should be administered.
• Referring to the classification of rhytids can help in objectively
assessing outcomes of interventions.
• Injectables are usually the first-line treatment for deep naso-
labial folds and marionette lines.
• The neck region is a challenging area to target with office-
based cosmetic treatments.
110
Suggested Reading
1 Achauer BM. Lasers in plastic surgery: current practice. Plast Reconstr Surg
1997;99(5):1442–1450
2 Alam M. ho is qualified to perform laser surgery and in what setting Semin
Plast Surg 2007;21(3):193–200
3 Alster TS, Lupton R. Lasers in dermatology. An overview of types and indica-
tions. Am J Clin Dermatol 2001;2(5):291–303
4 Atiyeh BS, Dibo SA. onsurgical nonablative treatment of aging skin: radiofre-
quency technologies between aggressive marketing and evidence-based efficacy.
Aesthetic Plast Surg 2009;33(3):283–294
5 Bass LS. Injectable filler techniques for facial rejuvenation, volumization, and
augmentation. Facial Plast Surg Clin North Am 2015;23(4):479–488
6 Carruthers , Fagien S, Matarasso SL; Botox Consensus Group. Consensus
recommendations on the use of botulinum toxin type A in facial aesthetics. Plast
Reconstr Surg 2004; 114(6, Suppl)1S–22S
7 Cosmetic Surgery ational Data Bank statistics. Aesthet Surg J
2017;37(Suppl 2):1–29
8 D’Amico RA, Saltz R, Rohrich R , et al. Risks and opportunities for plastic surgeons
in a widening cosmetic medicine market: future demand, consumer preferences,
and trends in practitioners’ services. Plast Reconstr Surg 2008;121(5):1787–1792
9 Day D , Littler CM, Swift R , Gottlieb S. The wrinkle severity rating scale: a
validation study. Am J Clin Dermatol 2004;5(1):49–52
10 Fitzpatrick RE, Rostan EF, Marchell . Collagen tightening induced by carbon
dioxide laser versus erbium: AG laser. Lasers Surg Med 2000;27(5):395–403
11 Honigman R, Castle D . Aging and cosmetic enhancement. Clin Interv Aging
2006;1(2):115–119
12 arimipour D , arimipour G, Orringer S. Microdermabrasion: an
evidence-based review. Plast Reconstr Surg 2010;125(1):372–377
13 im EH, im C, Lee ES, ang H . The vascular characteristics of melasma. J
Dermatol Sci 2007;46(2):111–116
14 Matarasso A, Glassman M. Effective use of Botox for lateral canthal rhytids.
Aesthet Surg J 2001;21(1):61–63
15 McCullough L, elly M. Prevention and treatment of skin aging. Ann N Y Acad
Sci 2006;1067:323–331
16 Rohrich R , Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane)
in facial cosmetic surgery: review and technical considerations. Plast Reconstr
Surg 2007; 120(6, Suppl)41S–54S
17 ielke H, lber L, iest L, Rzany B. Risk profiles of different injectable fillers:
results from the Injectable Filler Safety Study (IFS Study). Dermatol Surg
2008;34(3):326–335
 er- e-
13 Over-the-Counter Skin Care and Nutraceutical Basics for
the Aesthetic Surgeon
Mary P. Lupo and Katharine Saussy
Abstract
Skin care is a basic step in the improvement and maintenance
of healthy, beautiful skin. There is a plethora of choices on the
market, which can be overwhelming for the patient. Many
physicians retail cosmeceuticals from their offices. It is optimal,
however, to have at least some knowledge about less expensive,
mass-marketed, over-the-counter products, their ingredients,
and their best uses. Skin care protocols are needed to target the
treatment of different symptoms of skin aging and maintain
improvement postprocedure. This chapter discusses key compo-
nents of skin care protocols from the perspective of the cosmetic
physician.
Keywords
over the counter (OTC), recommended daily allowance (RDA),
antiaging, skin care regimen, sunscreen, cleansing, moisturizing,
cosmeceuticals, nutraceuticals, dyspigmentation
13.1 Introduction
Proper skin care is an essential component of both health and
beauty. The skin plays a vital role as the first line of our body’s
defenses. It is constantly exposed to internal and external
influences, which ultimately lead to visual and physical changes,
hastening skin aging. For the aesthetic surgeon, patients often
present with specific concerns. These concerns of irregular pig-
mentation, coarse texture, fine lines, deeper folds, and laxity can
be the result of both intrinsic (chronological) aging and extrinsic
aging. External influences, including but not limited to lack of
adequate cleansing, ultraviolet radiation, tobacco and chemical
exposures, lack of exercise, stress, hormonal dysfunction, and
insufficient nutrition are a few of the most common factors
leading to damaged skin. Internally, increased production of free
radicals, oxidative stress, and inflammation lead to quickened
collagen and elastic fiber reduction, cell damage, and cell death.
These intrinsic factors also result in the signs and symptoms of
aging skin.
Over-the-counter (OTC) skin care can be overwhelming for the
patient, as the products available for purchase are vast. In turn, the
extensive OTC options to choose from can be challenging for the
aesthetic surgeon to have a comprehensive understanding of all
available products. In this chapter, we review common OTC skin
cosmeceuticals and oral nutraceuticals, recommended practices,
and suggested ingredients for pigment, inflammation, redness,
and scar reduction.
un er S in re nd u r eu i i r e Ae e i Surge n
13.2 OTC Skin Cosmeceuticals and
Oral Nutraceuticals
OTC skin cosmeceuticals and oral nutraceuticals are thought to
play key roles in antiaging, maintaining youthful and healthy
skin, and treating damaged skin. Cosmeceuticals consist of
products that have more than a superficial benefit to the skin
but do not quite reach to the level of pharmaceutical changes.
If the manufacturer claims physiologic changes, more rigorous
testing is required. utraceuticals are naturally derived dietary
components thought to have benefits medically as well as nutri-
tionally. It is critical to mention that few OTC cosmeceuticals
and oral nutraceuticals have been extensively investigated or
validated by significant clinical trials. Most are not regulated by
the U.S. Food and Drug Administration (FDA), and not all have
recommended dietary allowances (RDA) set by the Food and
utrition Board of the Institute of Medicine. This discordance
places the responsibility on the aesthetic physician to research
and recommend products appropriately based on the physician’s
clinical expertise.
In this section, we discuss what we believe to be the most
important components of a comprehensive skin care regimen for
the aesthetic surgeon to recommend to patients. To understand
which type of product to recommend in order to slow the appear-
ance of aging, maintain improvement from aesthetic procedures,
and treat aging skin, we review the mechanisms in which skin is
damaged and best aesthetic practices. As you will find, many of
the cosmeceuticals and nutraceuticals mentioned in this chapter
have many functions in the skin and human body. Some of these
agents fall under multiple categories and will not be repeatedly
discussed. hether addressing a specific concern, tailoring for a
procedure, or creating a daily routine, these components all play
a role in a comprehensive skin care regimen and can be applied to
any aesthetic patient.
13.2.1 Skin Cleansing
hen creating a comprehensive skin care regimen for the
aesthetic patient, it is essential to start with skin cleansing. The
number of available OTC facial cleansing products is vast, making
skin cleansing the first step to tackle when recommending
products.
There are multiple types of cleansers, each with a different com-
position and pH. Surfactants are the main active component in a
cleanser, with the ability to reduce surface tension, allowing the
cleanser to remove substances that do not readily mix with water
such as makeup, dirt, and sebum and offer a fresh facial canvas
and better absorption of active ingredients. The skin’s natural pH
is around 5.5. Ideally, the closer the pH of the cleanser is to the
111
 III Nonsurgical Cosmetic Treatments
skin’s natural pH, the more tolerated. In regard to facial cleansers,
one of the most popular types of cleansers is a synthetic detergent
(syndet), non-soap-based, that creates a neutral to mildly acidic
pH environment (pH 5.5–7). This composition is optimal, as it
decreases the amount of protein denaturation, which can then
cause a reduction of intercellular lipids. Loss of epidermal lipids
compromises the skin barrier. This compromise from cleansers
with a higher pH can result in irritation, pruritus, tightness, ery-
thema, and dryness as the skin loses its ability to retain moisture.
Various ingredients can be added into cleansers such as natural
oils, exfoliating materials, topical vitamins, antibacterial agents,
fragrances, and moisturizers (hydrators/occlusive/emollients).
Micellar cleansers are one of the most popular cleansers rec-
ommended by aesthetic physicians, as they delicately cleanse the
skin and they are suitable for all skin types. Micellar cleansers
are considered mild surfactants, containing molecules with a
hydrophilic head and hydrophobic tail. These surfactant mole-
cules arrange to form clusters, referred to as micelles. These more
or less spherical micelles arrange themselves in such a way that
when applied to the skin, the hydrophobic tail gently removes
makeup, dirt, sebum, leaving the face cleansed without disrupting
the epidermal lipid layer.
For sensitive skin patients and those more susceptible to contact
allergens, it is imperative to review the ingredients in these prod-
ucts carefully. Patients with dry and/or sensitive skin should focus
on facial cleansers that contain micellar properties, or ones with
added oils and moisturizers to help support the stratum corneum’s
epidermal barrier. Patients with oily and/or less sensitive skin
can usually tolerate foaming cleansers. Patients with acne-prone
and oily skin can use benzoyl peroxide washes. It is important to
inform patients that benzoyl peroxide can be drying and irritating
to delicate facial skin. Benzoyl peroxide is generally well tolerated
on the chest and back, even if not also tolerated on the face. Benzoyl
peroxide is also notorious for bleaching towels, so recommend use
of white towels when using benzoyl peroxide–containing products.
All aesthetic patients should be advised to cleanse the skin
every morning and evening, as this allows the skin to be properly
cleansed of external factors residing on the surface, and washing
the skin serves as a vehicle for better penetration of later steps in
the regimen.
13.2.2 Skin Moisturizing and Barrier
Repair: Hydrators, Occlusives, and
Emollients
As the skin serves as a barrier to what it defends inside, it is
essential to provide additional protection by adequately mois-
turizing the skin. Adequate moisturization supports the stratum
corneum’s ability to hold on to water within the dermis and
epidermis. When the epidermal barrier is disrupted, signs and
symptoms of skin dehydration become a common concern for
the aesthetic patient. Patients often want to discuss moisturizers
when the skin shows signs of dryness, roughness, scaling, or irri-
tation. Regardless of skin type or aesthetic concern, all patients
should be advised to moisturize the skin appropriately as a part
of their daily skin care regimen.
Moisturizers come in multiple vehicles, such as lotions,
creams, ointments, gels, and serums. The components needed
112
in a moisturizer can be tailored to a specific skin type (oily, dry,
combination, sensitive, etc.). In general, it is best to recommend
moisturizers with the properties of being noncomedogenic, hypo-
allergenic, and fragrance free. Moisturizers are most commonly
either a lotion or cream. Lotions are compounded as oil-in-water
emulsions, while creams are compounded as water-in-oil emul-
sions, the main differences being the amount of lipid composition
and thickness of product.
Moisturizers, regardless of vehicle used, are intended to assist
in hydrating the skin, serve as an additional barrier to extrinsic
factors, and support the intrinsic properties of the skin. During
patient counseling, it is recommended to apply twice daily after
properly cleansing the face for best results. In patients with dry
and sensitive skin, it is imperative to implement at least twice
daily moisturization to the entire body. More frequent applica-
tion of moisturizers reduces epidermal lipid loss, which helps
prevent inflammation resulting from skin dehydration. hen
showering, advise patients to pat dry and apply moisturizer to
damp skin within minutes of bathing since lipids and water are
lost during bathing, leaving the skin feeling tight and even drier.
The benefits of shorter showers, utilizing more tepid to cool water
temperatures, should be mentioned. There are various types of
moisturizers to consider.
Hydrators/Humectants
Hydrators/humectants are products that increase water reten-
tion by drawing water into the skin through water-soluble,
absorptive properties. This allows the stratum corneum to
appropriately swell and retain water from viable epidermal
and dermal layers, as well as external exposures when in high
humidity. Examples of humectants are hyaluronic acid, glycerin,
alpha-hydroxyl acids, and sorbitol.
Hyaluronic acid (HA) is currently the most common humec-
tant. It has gained in popularity lately for its innate humectant
and hypoallergenic properties. HA is a glycosaminoglycan found
in the skin’s extracellular matrix (ECM). HA’s ability to enhance
tissue hydration is seen in its capacity to bind and retain water.
HA has been reported to bind water nearly one thousand times
its volume. As we age, the concentration of HA is significantly
reduced, leading to signs of aged skin such as loss of elasticity,
dehydration, and atrophy. HA has been claimed to improve fine
lines and wrinkles. This ability is the result of HA’s absorptive
properties by drawing water into the stratum corneum, allowing
viable layers to swell, giving the appearance of a reduction in fine
lines and a more even skin texture. Humectants work best in more
humid environments, where water can be captured extrinsically.
Occlusives
Occlusives are products that serve to decrease transepidermal
water loss by creating a hydrophobic layer on the skin surface.
These oily products have strong hydrophobic properties that
repel water from being lost to the outside environment; as
such, these are ideal in low-humidity climates. Petrolatum is a
commonly used ingredient in occlusive products. Petrolatum
consists of a synthetic substance that mimics the work of the
skin’s intercellular lipids, thereby decreasing transepidermal
 er- e- un er S in
water loss. Mineral oil is a thinner, less greasy occlusive used for
its same properties as petrolatum. It is also a commonly added
ingredient to moisturizers to ease the spread on the skin surface
during application. Other commonly used occlusives are olive
oil, coconut oil, silicone, paraffin, and ceramides. Occlusives
are considered the optimal family of products to use after skin
resurfacing to speed re-epithelialization and protect from sec-
ondary infection. It is important to note that acne-prone patients
undergoing resurfacing for acne scars will most likely get an
acne outbreak as a result of this occlusive therapy and be advised
as such preoperatively.
Emollients
Emollients serve as fillers between desquamating corneocytes
and keratinocytes in order to hydrate the skin and increase
cohesion between cells. Emollients adequately hydrate the skin
while also improving skin texture with increased appearance
and smoothness. Emollients are frequently found in thick topical
agents such as those used for atopic dermatitis patients, as the
epidermal barrier is more easily disrupted than normal skin.
Many topical products have emollient properties as well as
humectant and occlusive properties. Common emollients are
shea butter, collagen, and elastin. Common combination hydra-
tors are products such as petrolatum and mineral oil.
13.2.3 Exfoliation and Cell Renewal
Alpha-Hydroxy and Beta-Hydroxy Acids
Alpha hydroxy acids (AHAs) and beta-hydroxy acids (BHAs) are
in many OTC products used for acne, antiaging, and dyspigmen-
tation, as well as when preparing the skin for procedures. AHAs
and BHAs exfoliate the skin, creating an environment to allow
for deeper penetration and support a more homogeneous skin
surface by thinning the stratum corneum. AHAs are typically
water-soluble and work by decreasing intercellular adhesion,
allowing the bonds between dead skin cells to dissolve on the
skin surface. BHAs are commonly oil-soluble, so they penetrate
deeper beneath the skin’s surface, desquamating the stratum
corneum. In specific preparation for procedures, AHA- and
BHA-containing products are often used in combination with a
procedure such as a chemical peel for enhanced results. During
patient counseling, it is recommended that patients use moistur-
izers containing AHAs and BHAs for 2 to 3 weeks prior to certain
procedures in order to decrease the risk of postinflammatory
hyperpigmentation and promote a more even skin surface. This
pretreatment step may reduce acne flare in resurfacing patients.
Retinoids
Topical retinoids are one of the most commonly recommended
product for the aesthetic patient. Topical retinoids are acknowl-
edged for their highly efficacious abilities such as increasing
dermal thickness, healing, and re-epithelization, while also
decreasing the risk of hyperpigmentation and acne. Retinoids
are also celebrated for reducing appearance of fine lines and
wrinkles. Topical retinoids accelerate skin cell turnover, normal-
ize follicular hyperkeratosis, reduce inflammation, and inhibit
re nd u r eu i i r e Ae e i Surge n
melanogenesis by a few proposed mechanisms, such as inhibit-
ing the transfer of melanin from melanosomes to keratinocytes.
These properties make topical retinoids highly effective for
patients when targeting aging, dyspigmentation, and acne and
in pre- and postprocedure patients.
For the pre- and postprocedure patient, a minimum of 2 weeks
prior to procedure has been found to be beneficial. In the ideal
setting, applying topical retinoids nightly for 3 months prior to
the procedure is desired. In the preprocedure setting, topical ret-
inoids are intended to accelerate re-epithelization and decrease
melanin production. Discontinue topical retinoids 1 week prior
to procedure. Patients using retinoids prior to a procedure such
as a chemical peel can discontinue use 5 to 7 days prior to and
after the procedure to decrease risk of irritation. Caution should
be used if the retinoid is not discontinued a week before the
procedure, as it will make the procedure more aggressive than
the clinician might have intended or might be prepared to handle.
For the acne and antiaging patient, it is recommended to apply a
pea-sized amount of the topical retinoid to the entire face nightly.
For patients with dry or sensitive skin, recommend the patient
to start every other night and increase to nightly as tolerated. For
sensitive skin patients using topical retinoids, it might be benefi-
cial to discuss the short-contact application technique, allowing
the topical retinoid to be applied to cleansed skin for 2 minutes
to 2 hours, then rinsed off the skin. Increase length of application
time as tolerated. Patients can also be advised to mix the topical
retinoid with a moisturizer in order to decrease initial irritation
when adding this step into a daily regimen.
It is noteworthy to counsel the patient on the side effects such
as dryness, flakiness, and possible irritation during the first few
weeks of using topical retinoids. It is key to discuss a quality mois-
turizer for patients. It is crucial to advise patients to discontinue
topical retinoids in patients who are pregnant, trying to become
pregnant, or breastfeeding, as topical retinoids have not been
validated as safe to use in these circumstances.
13.2.4 Photoprotection: Sun Protection
Factor, Antioxidants, Ultraviolet
Radiation Defenses
Chemical and Physical Sun Protection Factor
It is of the utmost importance to stress daily sunscreen use to all
patients. There is a common misperception that sunscreen is to
be used when there is direct, visible sunlight, when exposed for
an extended amount of time, or during distinct events such as
sunbathing on the beach. What patients might not understand
is the significant and cumulative exposure they receive when
near a window, walking to and from locations by foot, driving or
riding in the car, on cloudy/rainy days, and during nonpeak sun-
light hours as well as the importance of reapplication throughout
the day.
Patients often express dislike for sunscreens due to their
texture, smell, or appearance when applied. There are countless
sunscreen-containing products on the market. It is recommended
to review major differences in specific products such as differences
in vehicle (cream, lotion, stick, spray), in texture (thin or thick),
and in appearance (tinted or nontinted). Having specific products
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to recommend on a sheet of paper or having products available
for sale in the office are recommended ways to increase use of
daily sunscreen. The goal is to help your patients find sunscreen
products that they will consistently use for best results.
Ultraviolet (UV) light can be broken down into three different
categories (UVA, UVB, and UVC); however, only two are pertinent
to discuss in this chapter. UVA (320 to 400 nm) and UVB (280 to 320
nm) are important to discuss with patients, as these wavelengths
are harmful to the skin, while the shorter UVC wavelengths are
filtered out in the stratosphere. UVA wavelengths are commonly
described as the photo-damaging rays, while UVB wavelengths are
notorious for causing sunburns. To review, sun protection factor
(SPF) refers to protection from UVB radiation. The higher the SPF,
the greater the UVB radiation needed to develop the minimum
erythema dose (MED) after adequate sunscreen application. SPF
30 stops (1 1/30) 100 approximately 97 of UVB rays, while
SPF 50 blocks (1 1/50) 100 98 of UVB rays.
There are two broad categories of sunscreens chemical and
physical which differ in how they process UV light. Chemical
sunscreens work by absorbing the UV radiation and release it as
heat, while the majority of physical sunscreens instead reflect the
UV light. Chemical sunscreens commonly consist of compounds
such as octocrylene, octisalate, octinoxate, avobenzone, and
homosalate. Physical sunscreens most commonly consist of zinc
oxide or titanium dioxide. Chemical sunscreens vary in their
UV radiation coverage, specifically targeting UVA, UVB, or broad
spectrum (UVA/UVB) filters. Chemical sunscreens are more
common for causing contact and irritant dermatitis, particularly
in patients with rosacea and atopic dermatitis. For patients with
various contact allergies or sensitive skin, it might be beneficial to
recommend a physical blocker. Physical sunscreens are primarily
better tolerated by patients, with a decrease incidence of reported
sensations such as burning, stinging, erythema, or contact derma-
titis. However, physical sunscreens are often reported as thicker
by patients and noted to leave visible residue when used in excess,
so compliance can suffer as a result.
During patient counseling, review recommended practices with
your patient, including when to apply sunscreen, how often to
reapply, and key words when searching for a product. It is crucial
for your patient to understand the importance of daily sunscreen
use with SPF 30 or higher. Sunscreens should be applied at least
15 minutes prior to sun exposure, with reapplication every 2
hours at baseline, and every hour when in water or excessively
sweating. Sunscreens should generally be water resistant and
should be broad spectrum in coverage, meaning that they protect
against both UVA and UVB exposure. It is also relevant to mention
that although many makeup products have SPFs, it is important
to wear a sunscreen on its own, over other steps in the skin care
regimen but under makeup. To reiterate, the best sunscreen for
your patients is a sunscreen they are willing to consistently and
appropriately apply.
Vitamin C
Vitamin C, also known as ascorbic acid or ascorbate, is a
water-soluble compound with major antioxidant and free radi-
cal scavenging properties that play a vital role in defending the
skin, cell membranes, and D A from oxidative and free radical
damage. Previous studies report that vitamin C can reduce the
114
skin’s malondialdehyde concentration, a marker of oxidative
stress. Vitamin C is an electron donor and a vital cofactor in col-
lagen hydroxylation, which supports the growth of intracellular
and extracellular collagen production. Most recently, studies
have reported that vitamin C is able to decrease UVB-induced
oxidative damage and UV radiation–induced skin neoplasms in
mice. Studies also note that vitamin C is capable of protecting
keratinocytes from UVA-induced lipid peroxidation. Topical
vitamin C agents, such as products containing 5 to 20 ascorbic
acid, have been reported to improve pigment and are commonly
a part of a daily regimen for their skin-brightening effects.
For ascorbic acid to be stable, it has to be kept at an acidic pH,
which encourages a greater potential for skin irritation, espe-
cially if other topical products are used in addition to vitamin C.
Derivatives of ascorbic acid, including tetrahexyldecyl ascorbate
(fat-soluble), magnesium ascorbyl phosphate (water-soluble), and
ascorbyl palmitate (fat-soluble), are stable at neutral pHs and are
better tolerated by patients.
Vitamin C must be ingested by humans or applied topically. In
vivo, vitamin C is oxidized to dehydroxyascorbic acid, which is
then transported into cells by glucose transporters. Once inside
the cell, dehydroxyascorbic acid is reduced to ascorbic acid and
so can be used by the cell. Oral vitamin C supplementation has
been proven to be effective in increasing skin and plasma content.
ell-known dietary sources of vitamin C consist of fruits such as
strawberries, oranges, and grapefruits as well as vegetables such
as Brussels sprouts, broccoli, and peppers. RDA for oral vitamin C
is 90 mg/day for men and 75 mg/day for women.
Vitamin E
Vitamin E is a fat-soluble compound that is most commonly
found as alpha-tocopherol ( T), which is its biologically active
form in human metabolism. T defends against UVB damage by
inhibiting the formation of reactive oxygen species and free rad-
icals, which in turn stabilizes the membranes of cells, decreasing
the amount of apoptotic cells. UV radiation counteracts vitamin
E by decreasing the T concentration in the skin when exposed.
Vitamin E, along with vitamin C, has been shown to increase
the MED when taken orally. Oral supplementation of vitamin
E is most popularly found in nuts and seeds such as peanuts,
almonds, walnuts, pistachios, and sunflower and sesame seeds.
The RDA is 15 mg/day orally for men and women.
Zinc
inc is an essential mineral and cofactor that serves to defend
against lipid peroxidation, UV-induced cytotoxicity, and oxi-
dative stress. The highest concentrations of zinc in the skin are
found within the epidermis, as zinc supports keratinocyte differ-
entiation and epidermal proliferation. Of note, zinc is involved in
wound healing and has anti-inflammatory properties by decreas-
ing proinflammatory markers within keratinocytes as well as
nitric oxide. Topical zinc is noted to support re-epithelization
by activating matrix metallopeptidases (MMPs), which prompts
keratinocyte migration. Proteins such as red meat and seafood,
whole grains, and fortified foods are rich in zinc. The RDA for
oral zinc is 11 mg/day for men and 8 mg/day for women. For the
 er- e- un er S in
purposes of wound healing specifically, suggested daily supple-
mentation is 15 to 30 mg/day.
Selenium
Selenium is an essential mineral that most commonly exists as
selenomethionine in humans. Selenium assists enzymes: gluta-
thione peroxidases and thioredoxin reductases. Through these
reactions, harmful by-products such as lipid hydroperoxides,
hydrogen peroxide, and peroxynitrite are removed, which pro-
tects against oxidative damage to D A and enhances cell mem-
brane stabilization through D A synthesis and repair. Foods rich
in selenium are meat and seafood. The RDA of oral selenium is 55
mcg/day for men and women.
N-Acetylcysteine
-Acetylcysteine is a crucial amino acid that acts as a precursor
for glutathione. Glutathione serves as the major endogenous
intracellular antioxidant in the body. As we age, the synthesis of
glutathione production slows, which poses the risk of increased
oxidative stress, leading to oxidative stress and ultimately aging.
A previous study evaluated the significance of cysteine and
glycine oral supplementation. The study reported that prior to
supplementation, older individuals were found to have signifi-
cantly lower levels of intracellular glutathione than younger
individuals. The subjects were evaluated 2 weeks after taking
daily oral supplementation and found to have a significant
increase in concentrations of red blood cell glycine, cysteine, and
glutathione. They also reported a decrease in oxidative stress
and oxidative damage. Various studies have suggested ranges
from 1,000 mg to 3,000 mg orally a day.
N-Acetylglucosamine
-acetylglucosamine ( AG) is another vital amino acid, serving
as the precursor to hyaluronic acid. It has multiple crucial roles
in the human body, one of which is its role in the skin. AG is
reported to have properties in the skin such as aiding in wound
healing, increasing hydration of the skin, improving fine lines and
wrinkles, reducing dyspigmentation, and stabilizing structural
integrity of the skin. Further studies are needed for oral supple-
mentation recommendations. Topical products containing AG
have been found to improve pigmentation as well as strengthen
the dermal–epidermal junction.
Carotenoids (Beta-Carotene, Lutein,
Zeaxanthin, Lycopene)
Carotenoids are fat-soluble plant pigments that mammals are
unable to synthesize, so that humans must consume them by a
well-balanced diet or through supplementation. Carotenoids are
known for scavenging reactive oxygen species, which defends
the skin against oxidative stress. Oxidative stress and UV
exposure cause a decrease in carotenoid concentrations in the
skin. Beta-carotene, lycopene, lutein, and zeaxanthin are four
common dietary carotenoids.
Beta-carotene increases the MED, protecting against sunburn and
photosuppression of the immune system. It also serves by halting
free radical and singlet oxygen–induced lipid peroxidation, thus
re nd u r eu i i r e Ae e i Surge n
defending against cell damage. Green leafy vegetables and yellow
and orange fruits are packed with beta-carotene. Beta-carotene
gives rise to vitamin A. The RDA of dietary all-trans-beta-carotene
is 10,800 mcg/day for men and 8,400 mcg/day for women. The
RDA for oral supplemental all-trans-beta-carotene is 1,800 mcg/
day for men and 1,400 mcg/day for women.
Lutein and zeaxanthin are carotenoids found in the skin working
as antioxidants against free radical damage and protecting against
UV radiation damage. Studies report that both lutein and zeaxan-
thin increase the mean MED, inhibit MMPs (which slows ECM
degradation), decrease lipid peroxidation, defend keratinocytes
from UV photoaging, and improve skin tone, luminance, and color.
Both oral supplementation and topical application have been
studied to show these skin effects. Eggs, green leafy vegetables,
and oral supplements are required in adequate amounts, as the
body cannot endogenously produce lutein and zeaxanthin. Studies
suggest 2 mg/day of zeaxanthin and 6 to 10 mg/day of lutein.
Lycopene is the last major carotenoid we mention. It serves
a crucial role as a singlet oxygen quencher, which decreases
UV-induced erythema, and slows the breakdown of collagen by
inhibiting the activity of MMP-1. It has been shown to decrease
the severity of skin roughness when greater amounts are found
in the skin. There is no RDA for lycopene; however, foods with
higher levels of the carotenoid include tomatoes, watermelons,
and grapefruits.
13.2.5 Collagen and Dermal Repair
Collagen and dermal repair has been a huge focus as of late.
Various cosmeceuticals and oral nutraceuticals fall into this
category that have already been discussed elsewhere. Peptides,
growth factors, collagen supplements, retinoids, vitamins, and
minerals are promoted for their rejuvenation properties.
Peptides
Peptides, which are short-chain sequences of amino acids, are
capable of encouraging the production of collagen, increasing
skin hydration, and lessening skin wrinkling through various
mechanisms depending on the specific type of peptide contained
in the product. Signal peptides exhibit their effects by enhanc-
ing new collagen production and inhibiting the destruction of
existing collagen. europeptides work by specifically targeting
different aspects of the neuromuscular junction ( M ), which
clinically results in improvement in fine lines and wrinkles, as
they lessen the contractions of facial muscles. Finally, carrier
peptides play a role in collagen regeneration and wound healing
by stabilizing and delivering known essential elements, such as
copper, to the skin. Cosmeceutical peptides are recommended
in addition to topical retinoids. Topical peptides are especially
recommended after procedures to help further increase collagen
production with lasting results. These peptides are applied daily,
along with sunscreen if used in the morning, or with retinoids if
applied at night.
Copper
Copper is an essential trace mineral that has many roles in
the human body. Copper is vital in the proliferation of dermal
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fibroblasts, stimulating the production of collagen and elastin by
fibroblasts. It maintains collagen-crosslinking properties, serv-
ing a vital role in collagen building and wound repair by enhanc-
ing fibroblast and keratinocyte production. It also functions as
a cofactor with lysyl oxidase and tyrosinase during enzymatic
reactions. During the lysyl oxidase enzymatic reaction, collagen
is crosslinked, which is necessary for building and maintaining
the ECM. Copper also has antioxidant properties, serving as a
cofactor in antioxidant reactions protecting against free-radical
production, lipid peroxidation, and membrane damage. Among
these roles, copper’s wound-healing properties (by enhancing
angiogenesis and promoting and stabilizing the skin’s ECM)
prove to be most key when focusing on postprocedure scar
prevention/reduction. Topical copper is also reported to have
anti-inflammatory and antibacterial properties, which help in
wound healing in damaged skin. Meat, seafood, grains, nuts, and
seeds are popular dietary sources of copper. hen consumed
orally, the RDA is 900 mcg/day for men and women.
13.2.6 Pigment Reduction
Heterogeneous skin pigmentation is undesired by the aesthetic
patient, as it is a primary sign of aging skin and skin damage.
Pigment reduction is a common request, whether the patient is
postprocedure, post-trauma, or has accumulations of unwanted
melanin from factors such as chronic UV radiation exposure or
hormonal/pharmacologic causes.
Pigment-modifying products are successful in reducing melanin
production by inhibiting the main enzyme, tyrosinase, respon-
sible for creating pigment. There are multiple mechanisms by
which pigment reduction can be accomplished, including simply
inhibiting tyrosinase from working, inhibiting the production of
the enzyme itself, reducing the transfer of melanin from mela-
nosomes to keratinocytes, or interrupting any part of the process
that assists in melanogenesis. Regardless of the pigment-reducing
product used, it is key to inform patients that multiple treatment
types may be needed and to inform patients of the consequences
of re-exposure to the underlying cause of pigment production.
Often patients who are continuously exposed to UV radiation will
exhibit repigmentation after treatment, as UV light is a known
stimulator of melanogenesis. Broad-spectrum UV protection is
crucial for many reasons, this being one of them. There are oral
and topical products available to modify pigment, including AHAs
and BHAs, kojic acid, vitamin C, vitamin E, niacinamide (vitamin
B3), hydroquinone (H ), oral tranexamic acid (TXA), azelaic acid,
polyphenols, and fatty acids. Here we will review a few of the
most common products that have not been mentioned previously.
Kojic Acid
ojic acid is a hydrophilic product that is derivative of various
fungi. It limits melanin production by inhibiting the binding
of copper to tyrosinase. ojic acid is commonly found in OTC
skin-lightening lotions, creams, serums, and pads.
Niacinamide
iacinamide, vitamin B3, is a water-soluble vitamin that
inhibits the transfer of melanin to keratinocytes. Previous
studies reported that niacinamide also supports skin hydration,
decreases transepidermal water loss, increases skin elasticity,
softens fine lines and wrinkles, and improves the appearance of
hyperpigmented macules.
Hydroquinone
H inhibits the production of pigment, melanogenesis, by inhib-
iting tyrosinase and is reported to have melanocyte cytotoxic
effects. As mentioned previously, tyrosinase is the main enzyme
responsible for creating pigment. Hydroquinone remains the
topical gold standard for pigment reduction. The amount of the
active component in a product typically ranges from 2 to 4 but
can be as high as 8 in some agents. Recent studies have shown
no significant benefit in percentages greater than 2 to 4 H . H
can cause skin irritation and postinflammatory hyperpigmenta-
tion at higher doses, so it is commonly compounded with topical
steroids. Improvement in pigment is commonly seen between 4
and 6 weeks, with reports of stabilizing results in 3 to 4 months.
However, newer products on the market are promoting H skin
brighteners that can be used year-round. It is recommended that
patients use the skin-brightening product twice daily for best
results.
Oral Tranexamic Acid
TXA is an oral agent used for pigment reduction. In 1979, Sadako
reported the use of TXA for melasma. TXA works by inhibiting
tyrosinase activity through various mechanisms involving
the plasminogen/plasmin conversion and interaction between
keratinocytes and melanocytes. Suggested dosing for treating
melasma ranges from 250 mg twice daily to 1,500 mg daily for 8
to 12 weeks. Caution must be exercised in patients with a history
of blood clots.
13.2.7 n mm i n edne nd
Scar Reduction
hether a patient is postprocedure or dealing with inflamma-
tion and redness from other etiologies, there are multiple oral
and topical products to recommend. These products commonly
have antioxidant and anti-inflammatory properties while also
hydrating the skin. Commonly recommended products that
assist in lowering the erythema and inflammation include oral
and topical vitamin C, oral and topical vitamin E, hyaluronic
acid (humectant), ceramides, niacinamide (vitamin B3), and oral
and topical polyphenols. Vitamin C, vitamin E, and hyaluronic
acid have been mentioned previously. Here we discuss some in
further detail.
Topical and Oral Polyphenols
Polyphenols, such as curcumin and epigallocatechin gallate
(EGCG), are secondary metabolites of plants with reported
anti-inflammatory, antioxidant, and anticarcinogenic proper-
ties. Curcumin is a chemical compound found in the turmeric
spice. Curcumin is well known for its anti-inflammatory proper-
ties by hindering proinflammatory cytokines (prostaglandin E2,
interleukins 6 and 12, MMPs, tumor necrosis factor–alpha, and

116
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cyclooxygenase COX -2). Curcumin is also capable of hindering
lipid peroxidation, reducing reactive oxygen species (ROS)
production, scavenging free oxygen radicals, and diminishing
c-reactive protein levels, which highlight curcumin’s antioxidant
abilities. Reported studies suggest 2 to 8 g/kg daily for oral sup-
plementation of curcumin.
EGCG is found in green tea and is reported to be the most
potent tea polyphenol. EGCG and other tea polyphenols have
anti-inflammatory and antioxidant properties. ECGC also has
the ability to hinder proinflammatory cytokines, similarly to
curcumin. ECGC is able to reduce the amount of UV radiation–
induced D A damage, minimize the amount of ROS and free radi-
cals produced, and hinder lipid peroxidation in the skin. EGCG has
effect both topically and orally. Topically, ECGC has been shown
to decrease erythema and edema induced by UV radiation. It has
also been reported to decrease UV-induced skin tumors in mice.
Recent publications support 300 mg/day of oral EGCG is tolerated.
Licorice Extract
Licorice extract, also known as licochalcone A, exhibits
anti-inflammatory and antierythema properties by indirectly
inhibiting COX and lipoxygenase pathways, reducing UV-induced
erythema, and decreasing the production of proinflammatory
cytokines released by keratinocytes. Topical products containing
licorice extract can be applied daily.
Oatmeal
Colloidal oatmeal is one of the most common ingredients found
in OTC products targeted to help relieve inflammatory skin con-
ditions such as atopic and contact dermatitis. One of the main
components contributing it its anti-inflammatory properties is
the dietary component, beta-glucan. It is found in many OTC
cleansers and moisturizers thanks to its anti-inflammatory and
soothing properties. Beta-glucan has also been studied and found
to have wound-healing properties both topically and orally.
Previous studies note that beta-glucan supports wound repair
by encouraging wound growth factors released by macrophages,
which stimulate fibroblast and collagen activity. hen focusing
on wound-healing properties, a previous study suggested that
topical beta-glucan be applied twice daily or 50 mg/kg/day when
supplemented orally. Topical oatmeal is suggested to be applied
at least twice daily to help relieve inflammation.
13.3 Concluding Thoughts
In this chapter, we reviewed many OTC cosmeceuticals and oral
nutraceuticals that play a role in a comprehensive skin care regi-
men for the aesthetic patient. As the skin is constantly challenged
by many internal and external influences, it is important to discuss
and recommend the vital components of daily proper skin care.
Many of the cosmeceuticals and oral nutraceuticals mentioned in
this chapter play multiple roles in skin care. hether addressing
a specific concern, tailoring for a procedure, or creating a daily
routine, the OTC cosmeceuticals and oral nutraceuticals discussed
in this chapter all play a role in a comprehensive skin care regimen
and can be applied to any aesthetic patient. It ultimately is the
re nd u r eu i i r e Ae e i Surge n
responsibility of the aesthetic surgeon to recommend a regimen
based on clinical judgment and expertise.
Clinical Caveats
• Every aesthetic patient should be educated on and recom-
mended a comprehensive daily skin care regimen.
• Every patient should be educated on the importance of daily
sun safety precautions and be knowledgeable about proper
SPF use.
• It is beneficial to have products available in the office for
purchase or a suggested product list with retailers so that
patients can purchase from verified sources.
• It is helpful to give written instructions for a daily regimen to
ensure proper compliance.
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14 A S ien i A r
Leslie Baumann
Abstract
A scientifically validated approach to diagnose skin phenotype
and customize a targeted skin care regimen to patients is critical
to enhancing skin health. Once an efficacious skin care regimen
has been developed, the physician must communicate the plan
to patients and encourage them to follow it. To match products
properly to patients, and to educate and encourage them to use
the products, it is critical to enlist the help of staff members to
improve efficiency and engagement with patients. A method-
ology to educate staff and patients in a systematic manner is
essential so that patients are given the correct products, told
how and encouraged to use them, and reminded periodically
to stay on the prescribed regimens. This chapter discusses the
science behind a skin typing system known as the Skin Type
Solutions (STS) system, which was developed to streamline the
cosmeceutical recommendation process in a brand-agnostic
manner, enabling physicians to choose what products or brands
they want to retail in their practice and prescribe them using
a scientific method designed to improve outcomes. The STS
system assesses skin based on four primary barriers to skin
health: dehydration, inflammation, dyspigmentation, and skin
aging. Evaluating the presence or absence of these barriers to
skin health in facial skin provides the physician with data to
diagnose the patient as having one of 16 Baumann Skin Types, for
which proper cosmeceutical ingredients can then be prescribed.
The patient’s Baumann Skin Type (BST) is diagnosed using a
customized, expert skin care diagnostic system that diagnoses
the skin type and automatically generates a skin care regimen
that contains ingredients beneficial to that skin type and does
not contain ingredients harmful to that skin type. The STS
system assists physicians in selecting skin care products in an
unbiased, ethical, and methodical way to improve personalized
care for patients. Appropriate use of the system can enhance staff
training and doctor–patient communications, as well as patient
education, compliance, and outcomes. This chapter will discuss
the science of the skin issues that need to be considered when
developing a skin care regimen: sebum production, skin barrier,
presence of inflammation, melanocyte activity, and the presence
of lifestyle habits that lead to skin aging.
Keywords
Skin Type Solutions System, barriers to skin health, Baumann
Skin Type, cosmeceutical, skin aging, skin lightening, skin reju-
venation, sensitive skin, compliance, outcomes, staff training,
antiaging, antioxidants, anti-inflammatory, tyrosinase inhibi-
tors, regimen, skin care
A S ien i A r me eu i
me eu i
14.1 Introduction
To achieve and maintain skin health, consistent daily use of a
skin care regimen ideally suited to an individual’s skin is critical.
Pre- and postprocedure skin care regimens customized specifi-
cally for the patient’s skin type and procedure type will improve
outcomes if the patient is compliant with the directions. It is a
challenge for practitioners to stay up to date on cosmetic science
and to communicate current knowledge to their staff, who are a
vital part of the skin care recommendation process. Establishing
a standard approach or methodology for prescribing skin care
products yields consistency in patient recommendations and
provides a scientific methodology for the staff to follow while
promoting patient education, engagement, and compliance.
Diagnosing a patient’s skin type is the key first step in prescrib-
ing an ideally suited skin care regimen. The Skin Type Solutions
(STS) system, developed by the author to address the essential fea-
tures of the skin, employs a validated questionnaire for patients.
This allows practitioners to diagnose patients as having one of 16
Baumann Skin Types (BSTs).
The STS system evaluates skin according to four spectra or
barriers to skin health:
1. Dehydration (oily O vs. dry D )
2. Inflammation (sensitive S vs. resistant R )
3. Dyspigmentation (pigmented P vs. nonpigmented )
4. Skin aging (wrinkle-prone vs. unwrinkled or tight T )
A validated questionnaire identifies skin phenotype based on these
four parameters, allowing 16 different skin types, each represented
by a four-letter designation as well as color and number designations
to help patients remember their BST (Fig. 14.1; Fig. 14.2). For exam-
ple, an individual with dry skin, redness, even skin tone, and fine
lines would be assigned as a DS (Dry, Sensitive, onpigmented,
rinkle-prone) type, or BST number 4 with a light pink color code.
Multiple forms of labeling are used because studies have demon-
strated that some patients primarily remember the number of their
skin type, while others primarily remember the color, and yet others
the four-letter designation. This skin-typing system facilitates com-
munication between physicians and patients as well as the process
of prescribing the optimal products for a patient’s skin type.
The BST should be diagnosed at least once a year because the skin
type can change based on numerous factors, such as climate, lifestyle
habits, hormone status, pregnancy, medication use, sun exposure,
smoking, and other factors. At each visit the patient’s skin type and
regimen should be evaluated and updated according to the presence
or absence of the four barriers to skin health. This chapter will proceed
with a discussion of diagnosing skin type based on the BST, matching
product ingredients to skin type, and designing a corresponding skin
care regimen. The focus will shift then to the science of skin aging and
pigmentation as well as the cosmeceutical ingredients best suited to
treat these conditions, along with the formulations appropriate for
treating the skin before, during, and after cosmetic procedures.
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 III n urgi me i re men

14.2 Diagnosing Skin Types

The 16 BSTs are based on the presence or absence of these
primary barriers to skin health: dehydration, inflammation,
dyspigmentation, and skin aging. The patient is assigned a
designation for each of the skin status parameters or barriers: O
(oily) or D (dry), S (sensitive) or R (resistant), P (pigmented) or
(nonpigmented), and (wrinkled) or T (tight), with 16 different
combinations possible. There are also four subtypes of sensitive
skin: acne, rosacea, burning and stinging, and susceptibility to
contact and irritant dermatitis.

14.3 Matching Ingredients to

Skin Type
Each of the following factors should be considered when choos-
ing ingredients by facial skin type.

14.3.1 Oily Skin

Individuals with oily skin (O) produce an adequate or elevated
level of skin sebum. Sebum functions as an occlusive that helps
the skin hold on to water, which can compensate for an under-
lying barrier impairment. For this reason, patients with an
adequate or excessive amount of sebum do not have decreased Fig. 14.1 The 16 Baumann skin types. (This image is copyrighted by
amounts of water in the epidermis (i.e., dry skin). An oily Metabeauty Inc. and cannot be used without permission.)
skin type is desirable because of the protective effects that
sebum has on the skin, including hydrating and antioxidant
properties.

Products These Patients Should Use
Salicylic Acid
This lipophilic compound can penetrate into the pores to
facilitate desquamation of the stratum corneum (SC), thus
preventing the clogging of pores and the development of come-
dones (blackheads or whiteheads) and acne. This member in the
salicylate (aspirin) family also confers anti-inflammatory activ-
ity. Cleansers containing salicylic acid are ideal for acne-prone
individuals with oily skin. Such cleansers should be formulated
at a pH of less than 2.97 to be effective.
Foaming Cleansers
Anionic surface-acting agents (surfactants or detergents) pro-
duce foam and display the greatest ability among cleansers to
remove oil, sunscreen, and debris. Only individuals with oily skin
types should use these products, which remove oil from the skin
and can be irritants to dry, sensitive skin types.
Retinoids
Polymers
Skin appearance can be rendered less shiny through the use of
polymers, which surround or sequester oil. These are often called
primers. Polymers should be rinsed off nightly to prevent the
development of comedones.
Products These Patients Should Avoid
Oils
Individuals with oily skin already have increased amounts of
lipids on the skin. They should avoid oils or heavy creams that
contain oils, which feel heavy and greasy on oily skin types. Oily
skin types can omit a moisturizer or choose a light moisturizer
with humectant ingredients instead of occlusive oils.
Comedogenic Ingredients
Oily skin types are more likely to develop comedones. Many
ingredients (Table 14.1) can contribute to comedoformation.
Major culprits include coconut oil, isopropyl myristate, and
isopropyl palmitate.

These vitamin A formulations can help keep pores clear by

regulating keratinization. Oral retinoids can reduce the size of
sebaceous glands, thus diminishing sebum production. Topical
retinoids are unlikely to affect the sebaceous glands directly but
are beneficial in oily skin by preventing comedones.
Silicone-Containing Moisturizers and Sunscreens
Silicones are often used to mask oil on the face but they can hold
sebum and debris in the pore, resulting in comedones. If silicones
are used on the face, they should be washed off at night.

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a b

c d
Fig. 14.2 (a) DRPW: This skin type is characterized by wrinkles, pigmentation and dry skin. (Photo credit El Nariz/Shutterstock.) (b) OSNT: This skin type
often occurs under the age of 30 and is characterized by increased sebum production and inflammation resulting in acne. (Photo credit Vladimir Gjorgiev/
Shutterstock.) (c) OSNW: This skin type has increased production of sebum and often cannot find a sunscreen that does not feel oily. Inflammation in this skin
type results in rosacea and an increased risk of aging. (Photo credit Lipowski Milan/Shutterstock.) (d) OSPW: This skin type is characterized by increased sebum
production. Inflammation and sun exposure has resulted in unwanted pigmentation and an increased risk for aging. (Photo credit Michael Jung/Shutterstock.)

14.3.2 Dry Skin
Individuals with dry (xerotic) skin have an impaired skin barrier,
characterized by the absence of water in the epidermis. Cracks and
fissures appear in the skin when levels of water, the main plasticizer
for the skin, are low. The water content of the SC must surpass 10
for the skin to feel and appear normal. hen a defect in the perme-
ability barrier of the skin permits excessive water to be lost to the
atmosphere, this rise in transepidermal water loss (TEWL) results
in dry skin. Genetic defects, harsh detergents, acetone, alcohol, and
frequent bathing in hot water are among the various factors that
can engender such barrier disturbance. As skin becomes too dry,
desquamating keratinocytes build up on the skin’s surface, making
it rough and unable to reflect light properly. It can become irritated,
inflamed, and itchy. The arms, legs, and torso, which contain rela-
tively few oil glands, are the most vulnerable to this condition.
Products These Patients Should Use
Nonfoaming Cleansers
onfoaming cleansers, which were developed through attempts to
mitigate the irritancy of cleansers by adding secondary components,
are appropriate for patients with dry skin because these compounds
deposit lipids on the skin. Superfatted soaps, transparent soaps,
combination bars (combars), and syndet bars (bars composed of
synthetic surfactants) are the primary nonfoaming cleansers, which
have a neutral pH and include ingredients such as alkyl glyceryl ether
sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium
cocoyl monoglyceride sulfate, and sodium cocoyl isethionate.
Patients are increasingly concerned about the sourcing of products,
so it is important to assure them that organic nonfoaming agents
are also available, including saponins, a large family of plant-derived
structurally related substances, and sucrose laurate.
Hydroxyacid Cleansers
These versatile compounds exhibit humectant activities that help
hydrate the skin and are appropriate for individuals with dry
skin. Humectants are water-soluble materials with high water
absorption capacities. Hydroxyacids help to exfoliate dead skin
cells, which tend to amass on the surface of xerotic skin. Skin
appears more radiant when the skin surface is smooth. It is worth
noting that enzymes that help exfoliate do not work as well when
there is less water on the skin. However, the exfoliating activity
conferred by hydroxyacids allows better penetration into the SC

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Table 14.1 Acne-causing ingredients to avoid for individuals with oily skin
Acetylated lanolin alcohol Colloidal sulfur Isostearyl neopentanoate Pentarythrital tetra isostearate
Algin Corn oil Laneth-10 Propylene glycol (PG) in:
Almond oil Cottonseed oil Lanolin acid • PG caprylate/caprate
Anhydrous lanolin D & C Red # 3 Lanolin alcohol • PG dicaprylate/caprate
Arachidic acid D & C Red # 4 Lanolin oil
Ascorbyl palmitate D & C Red # 17 Lanolin wax • PG dipelargonate
Azulene D & C Red # 19 Laureth-23 • PG monostearate
Beeswax D & C Red # 21 Laureth-4 Polyglyceryl-3-diisostearate
Benzaldehyde D & C Red # 27 Menthyl anthranilate Potassium chloride
Benzoic acid D & C Red # 30 Mink oil PPG (polypropylene glycol) in:
Beta-carotene D & C Red # 36 Myristic acid • PPG 2 myristyl propionate
Beta-hydroxy acid
Bubussa oil
D & C Red # 40
Decyl oleate
Myristyl lactate
Octyl palmitate
• PPG 5 ceteth-10 phosphate
Red algae
Butyl stearate Dioctyl succinate Octyl stearate Sandalwood seed oil
Butylated hydroxyanisole (BHA) Disodium monooleamido Oleth-3 Sesame oil
Cajeput oil Emulsifying wax NF Oleth-10 Shark liver oil
Calendula Ethoxylated lanolin Oleyl alcohol Solulan 1
Camphor Ethylhexyl palmitate Palmitic acid Solulan 16
Capric acid Evening primrose oil Peach kernel oil Sorbitan oleate
Carbomer 940 Glyceryl-3-diisostearate Peanut oil Soybean oil
Carnauba wax Hexadecyl alcohol PEG (polyethylene glycol) in: Steareth-2
Carotene Hydrogenated castor oil • PEG 2 sulfosuccinate Steareth-10
Carrageenan Hydrogenated vegetable oil • PEG 8 stearate Steareth-20
Castor oil Hydroxypropylcellulose
Ceteareth-20 Isocetyl alcohol • PEG 16 lanolin Stearyl heptanoate
Sulfated castor oil
Cetearyl alcohol Isodecyl oleate • PEG 100 distearate Sulfated jojoba oil
Cetyl acetate Isopropyl isostearate • PEG 150 distearate Synthetic dyes (especially, D C Red 3,
Cetyl alcohol
Chaulomoogra oil
Isopropyl lanolate
Isopropyl linoleate
• PEG 200 dilaurate 4, 6, 7, 9, 17, 19, 21, 27, 30, 33, 36, 40),
Cocoa butter Isopropyl myristate • PEG 300 Triethanolamine
Coconut butter Isopropyl palmitate • PEG 400 Vitamin A palmitate
Wheat germ glyceride/oil
Coconut oil Isostearyl isostearate Xylene

by ingredients applied after the cleanser. These compounds are the inclusion of type III synthetic ceramide or pseudoceramide
also suitable for individuals with dry, acne-prone skin because was established nearly 15 years ago as the foundation for such
the low pH contributes to an inhospitable microbiome for innovative approaches to barrier repair. See Table 14.2 for a list
Propionibacterium acnes, rendering it difficult for the bacteria to of fatty acid alcohols suitable for use by patients with dry skin.
thrive.
Products These Patients Should Avoid
Barrier Repair Ingredients
Foaming Cleansers
The topical application of ceramides, cholesterol, and fatty
acids the main skin barrier lipid components has long been As noted previously, only individuals with oily skin types should
targeted as central to enhancing skin barrier function and use these products.
hydration. It is important to apply all three of these in a 1:1:1
ratio because an imbalanced ratio impairs the barrier. In 1993, Alcohols
Man et al demonstrated that barrier recovery was delayed when
These compounds dry skin out and injure the skin barrier (see
ceramide and fatty acid were applied without cholesterol. They
Table 14.3).
also showed that barrier repair was delayed with the application
of two other mixtures of cholesterol plus fatty acid or choles-
terol along with ceramide. Such incomplete mixtures generated
abnormal lamellar bodies, yielding abnormal SC intercellular Table 14.2 Fatty acid alcohols safe in dry skin
membrane bilayers. Conversely, complete blends of ceramide, Cetearyl alcohol Decyl alcohol (1-decanol)
fatty acid, and cholesterol resulted in normal barrier recovery. Stearyl alcohol Lauryl alcohol (dodecanol)
Additional studies have buttressed the importance of including Behenyl alcohol (docosanol) Myristyl alcohol (1-tetradecanol)
Caprylic alcohol (1-octanol) Isostearyl alcohol
all three primary barrier repair ingredients in topical formula- Cetearyl alcohol (very common) Oleyl alcohol (octadecenol)
tions in a minimal ratio of 1:1:1. Investigations in young mice ( Cetyl alcohol (very common)
10 weeks) and humans (20–30 years of age) have revealed that
applying a mixture of cholesterol, ceramides, and essential/non-
essential free fatty acids (FFAs) in an equimolar ratio results in Table 14.3 Alcohols that individuals with dry skin should avoid
normal barrier recovery, and application at a 3:1:1:1 ratio of these Isopropyl alcohol Ethyl alcohol (ethanol)
four ingredients, with cholesterol dominant, accelerates barrier Specially denatured (SD) alcohol Methyl alcohol (methanol)
recovery. Multilamellar emulsion (MLE) technology touting Denatured alcohol Benzyl alcohol

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Hot Water
Individuals with dry skin should avoid prolonged exposure to
hot water, especially if it is hard water (containing iron and
calcium compounds).
14.3.3 Sensitive Skin
A British study in 2001 revealed that 57 of women and 31.4 of
men reported an adverse reaction to a personal skin care prod-
uct at some stage in their lives, with 23 of women and 13.8
of men having had a problem within 1 year of the investigation.
These individuals are described as having sensitive skin. A full
characterization of sensitive skin requires subdividing sensitive
skin into subtypes: acne, rosacea, stinging, and the predilection
toward contact or irritant dermatitis.
Acne-Type Sensitive Skin
A multifactorial process involving the pilosebaceous unit, acne
vulgaris affects between 40 to 50 million people each year in the
United States alone. The majority of these patients, between 70
and 80 , range from 11 to 25 years old. Most patients beyond
this age cohort are adult women who usually display a hormonal
aspect to their acne. A comprehensive discussion of the patho-
physiology of acne is beyond the scope of this chapter, but a brief
review of the salient features of acne pathophysiology as well as
suggestions for treatment and prevention follow.
Pathophysiology
Acnegenesis is characterized by inflammation of the follicular
epithelium, which results in compacted hyperkeratotic material
within the follicle that makes the environment more hospitable
for the P. acnes bacteria, thus engendering pustules and pap-
ules. An overarching etiology for acne is difficult to identify or
isolate because the sources of such lesions vary from person to
person and within individuals. evertheless, the three principal
causative factors sebaceous gland hyperactivity, changes in
follicular keratinization, and the influence of the bacteria P.
acnes have been identified and are known to work interde-
pendently, mediated by significant influences such as heredity
and hormonal activity. P. acnes bacteria divide every 12 hours,
so a topical product geared to eradicate this bacterium should be
used at least twice a day.
Products These Patients Should Use
General guidelines for treating acne include use of the following:
Benzoyl Peroxide
This organic compound in the peroxide family imparts
anti-inflammatory, antibacterial, keratolytic, and wound-healing
activity. It is one of the most common ingredients used topically
to treat acne. It can be used alone or combined with other ingre-
dients. Benzoyl peroxide is safe and effective for treating acne
but is tolerated better by people with oily as opposed to dry skin
because it can irritate the skin of individuals with an impaired
barrier, which permits greater penetration of the product.
Sensitive skin types prone to facial redness often cannot tolerate
A S ien i A r me eu i
benzoyl peroxide without combining it with anti-inflammatory
ingredients.
Retinoids
Several studies have demonstrated the efficacy of retinoids
in treating acne and have resulted in FDA approval of various
tretinoin-, adapalene-, and tazarotene-containing acne medi-
cations. The use of retinoids contributes to the prevention and
elimination of comedones through desquamation, influencing
cell adhesion, and regulating keratinization. The comedolytic
properties of retinoids have been found to be similar to those
linked to benzoyl peroxide and salicylic acid. Retinoids treat
current acne and prevent future acne and are the most important
ingredients to treat acne. The entire skin care regimen should
be designed so that the patient can tolerate using the retinoid.
Applying it over a moisturizer can decrease the redness and
peeling associated with retinoids.
Salicylic Acid
Derived primarily from willow bark, this aromatic acid has
anti-inflammatory and comedolytic properties, which account
for its prominent status in the antiacne arsenal. Salicylic acid
is well established, along with benzoyl peroxide and low-dose
retinoids, for treating mild acne. It is also cited in the FDA mono-
graph for acne for 0.05 to 2 concentrations in over-the-counter
(OTC) products and deemed effective for acne at 3 strength in
prescription medications, as stipulated by the FDA.
Topical Antibiotics
Antibiotic resistance is of great concern in medicine, and P.
acnes resistance rates are estimated to be as high as 60 in some
patient populations. Clindamycin, erythromycin, and methicillin
are the most frequently reported antibiotics to which bacteria
have been found to have developed any resistance. Combining
erythromycin or clindamycin with benzoyl peroxide has been
proven to prevent the emergence of resistant strains of P. acnes;
therefore, the current clinical acne recommendation calls for
including benzoyl peroxide in topical antibiotic antiacne regi-
mens. Antibiotics should never be used alone in the treatment
of acne.
Silver
Silver acts as a bactericidal and anti-inflammatory agent,
without engendering free radicals as benzoyl peroxide does.
Consequently, it is considered a viable option for treating acne.
Silver has not been approved by the FDA to treat acne, but silver
sulfadiazine has been used off-label for this purpose for several
years. Silver sulfadiazine as an acne treatment is limited by the
risk of sulfa allergy and the thick, white, pasty consistency of the
preparation. However, silver-containing cleansers and textiles
can also impart antiacne activity.
Tea Tree Oil
Recent data support the use of the essential oil of Melaleuca
alternifolia (tea tree) to treat acne vulgaris and other conditions
such as seborrheic dermatitis and chronic gingivitis as well as
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 III Nonsurgical Cosmetic Treatments
to promote wound healing. In 2007, a randomized, double-blind
clinical trial in 60 patients with mild to moderate acne showed
the efficacy of 5 tea tree oil gel. Researchers observed that the
botanical gel was 3.55 times more effective than placebo in
lowering total acne lesion counts and 5.75 times more effective
than placebo in decreasing the acne severity index, with the
side effects similarly mild and tolerable in both groups. The
recommended approach to using tea tree oil for acne calls for
three or four topical applications daily. However, many reports
of contact dermatitis to tea tree oil reduce its usefulness as an
acne treatment.
Acne-Prone Types with Dry Skin
Ascertaining the appropriate cleanser for acne-prone skin
depends first on determining where the patient’s skin falls on
the oily–dry spectrum. Individuals who have both dry skin and
acne likely cannot tolerate the drying acne formulations. Two
different cleansers are often needed for such patients. Creamy
cleansers, which are effective for makeup removal, should be
used once daily, ideally at night by individuals who use makeup.
ith a relatively low pH, glycolic acid is the best example of
hydroxyacids effective in a morning cleanser for managing dry,
acne-prone skin. Skin with a lower, more acidic pH is less hospi-
table to P. acnes growth. The use of hydroxyacids can exfoliate
dead skin cells, thus helping to prevent clogged pores and the
development of acne comedones. Glycolic acid offers the added
benefit of acting as a humectant ingredient, providing needed
moisture. Acne-prone patients with dry skin should avoid foam-
ing cleansers and mechanical exfoliators such as scrubs, facial
brushes, and loofahs.
Acne-Prone Types with Oily Skin
Patients with oily skin and acne are easier to treat because these
individuals can better tolerate the drying acne medications. A
salicylic acid cleanser in the morning will help to unclog pores,
and its anti-inflammatory activity helps prevent the develop-
ment of the papules and pustules characteristic of acne. The use
of a foaming cleanser in the evening will remove dirt, makeup,
and other debris that can clog the pores and contribute to or
aggravate acne. For patients with oily skin and acne, the twice-
daily use of salicylic acid would feel too drying when combined
with acne medications such as a retinoid and benzoyl peroxide.
Acne-prone types with oily skin should choose physical sun-
screens rather than chemical sunscreens that often contain
comedogenic oils.
Products and Treatments All Acne Patients
Should Avoid
Comedogenic Ingredients
See Table 14.1 for a list of comedogenic ingredients. Isopropyl
myristate is particularly problematic for acne-prone patients.
This ingredient is found in several hair conditioners and
hair-smoothing products. Face washing for such patients is rec-
ommended to be timed after rinsing out hair conditioner. Hair
products left in overnight can contribute to acne by depositing
on the pillowcase.
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Elective surgery on acne-affected areas
Note that the bacteria P. acnes, which causes acne, is also respon-
sible for wound infections. Therefore, acne must be under control
before any procedures are performed in the affected area(s).
Elective surgical procedures within six months of Accutane
(isotretinoin) use is discouraged or contraindicated because of
an increased risk of scarring.
Rosacea-Type Sensitive Skin
Rosacea is a chronic cutaneous condition in which patients
present with central facial erythema, telangiectasias, papules,
and pustules. Several years ago, a Swedish study indicated a
rosacea prevalence of about 10 in the general population. There
are thought to be approximately 13 million people affected
with rosacea in the United States. Most patients are diagnosed
between the ages of 30 and 50 years, with women affected more
often than men but men experiencing the phymatous changes of
the condition more often. In addition, rosacea is more prevalent
in individuals with fair skin. Risk factors for acquiring rosacea
include sun damage, a propensity to flush, and genetic predis-
position. Rosacea patients tend to experience stinging more
than other skin types. They may not be able to tolerate products
with a low pH, such as ascorbic acid and glycolic acid, and often
experience stinging from chemical sunscreens such as avoben-
zone. Rosacea patients should use special care when starting
retinoids, beginning first with an anti-inflammatory agent to
help minimize retinoid dermatitis. After a month’s time on an
anti-inflammatory agent with good control of redness, a retinoid
can be slowly introduced. Start with a low-strength retinoid
on top of the moisturizer every third night (a pea-size dose) for
2 weeks, then every other night for 2 weeks, and finally every
night. Patients should be advised always to start with a retinol
0.025 or less on top of a moisturizer. The dose and frequency
directly correlate with the incidence of side effects (Table 14.4).
Pathophysiology
There are many hypotheses about rosacea, but there is no
consensus cause that explains all of the types of rosacea that
are seen. Some patients improve with therapies targeted to
kill Demodex mites, while other patients improve on vasocon-
stricting agents and topical metronidazole. One constant across
all rosacea patients is the presence of triggers, which usually
include heat, stress, emotion, hormones, alcohol, heat, and spicy
food. Avoiding these triggers and anything that causes inflam-
mation, such as facial scrubs, loofahs, and microdermabrasion, is
the mainstay of treatment.
Products These Patients Should Use
• Anti-inflammatory ingredients (argan oil, green tea, metroni-
dazole, azelaic acid)
• Vasoconstrictors (oxymetazoline or brimonidine)
• Anti–Demodex mite medications, such as ivermectin cream 1
• An anti-inflammatory moisturizer in the morning
• A physical sunscreen every morning
• A moisturizer in the evening
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Table 14.4 Patient instructions for retinoid use

• Always use retinoids at night, because the sun breaks them down.
• our skin will acclimate to retinoids with time, so use sparingly and be patient.
• Start with the weakest strength (retinol 0.25%) and slowly increase the dose with each new tube.
• Apply retinoid on top of moisturizer until you are tolerating it every night for a month, then apply it before the moisturizer.
• Use only a pea-sized amount every third night for the first 2 weeks.
• If no redness or irritation occurs, increase use to every other night for 2 weeks.
• If no redness or irritation occurs, increase use to every other night.
• Stop using retinoids 1 week prior to waxing.
• Buy retinol products only from a source you trust; there are many counterfeit products online.
• If redness or irritation to retinoids occurs, stop use for 4 days, moisturize twice a day, and restart slowly. Redness and irritation indicate that what
you are using is too much, too strong, or too often.
• Long-term use of retinoids has been shown to improve wrinkles, dark spots, and skin texture and protect skin from further aging. It is worth the
effort to use retinoids.

Products and Treatments These Patients Should Products These Patients Should Use
Avoid
Anti-inflammatories
• Friction, particularly in the form of exfoliating scrubs, brushes,
and microdermabrasion Although stinging is not usually accompanied by redness or skin
changes, anecdotal experience shows that anti-inflammatories
• Menthol, camphor, alcohol
can help reduce stinging (Table 14.5).
• Starting retinoids quickly
• Sunscreens with avobenzone Barrier repair moisturizers
In some cases, repairing the skin barrier will decrease stinging.
Stinging Skin
Stinging skin is common throughout the world. It is common r du e e ien S udA id
in rosacea patients but can also occur in a patient who does
not exhibit redness or any other visible findings. One study has
• Alcohols of any kind, even the fatty acid alcohols (see Table
shown that women are more likely to be sensitive to the subjec- 14.2, Table 14.3)
tive effects elicited by lactic acid than men.
Stinging reportedly occurs most often on the face, especially
• Menthol and other stinging ingredients (Table 14.6)

on the nasolabial folds and cheeks. The hypersensitivity of this • Ascorbic acid, due to its low pH
area is ascribed to a more permeable SC, a high density of sweat • Hydroxyacids
glands and hair follicles, and a convoluted network of sensory • The chemical sunscreen avobenzone
nerves. Much remains to be learned about the stinging response,
particularly on the subject of specificity. For example, an individ-
Caution
ual may be a lactic acid stinger but not react to other ingredients
such as benzoic acid and azelaic acid. In one 2004 study, there Retinoids can exacerbate stinging. If retinoids still emerge as
was no correlation between patients who stung from lactic acid a compelling choice for such patients, they should be started
and those who stung from azelaic acid. The implication is that a slowly (Table 14.4).
specificity in reactivity has not yet been elucidated.

Table 14.5 Anti-inflammatory ingredients for the skin

4-Ethoxybenzaldehyde Grape seed extract
7-(1 H-imidazol-4-ylmethyl)-5,6,7,8-tetrahydroquinoline Green tea:
Allantoin • Epigallocatechin-3-gallate [EGCG]
Aloe
Argan oil
• Epigallocatechin gallatyl glucoside (Unisooth, Givaudan, Vernier,
Switzerland)
Arnica
Bisabolol • Inoveal EGCG
Caffeine Licorice extract
Caffeyl glucoside Macadamia nut oil
Chamomile Niacinamide (nicotinamide)
Colloidal oatmeal Portulaca oleracea extract
Cucumber extract Rosmarinyl glucoside
Feverfew Sa ower oil
Gallyl glucoside (Endothelyol, Givaudan, Vernier, Switzerland) Unimoist U-125 (Givaudan, Vernier, Switzerland)

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 III Nonsurgical Cosmetic Treatments
Table 14.6 Stinging ingredients
Ascorbic acid (vitamin C) Glycolic acid
Avobenzone Isopropyl alcohol
Azelaic acid Lactic acid
Benzoic acid Menthol
Benzophenone Peppermint
Capsaicin Salicylic acid
Denatured alcohol Sorbic acid
Eucalyptus oil Witch hazel
14.3.4 Pigmented Skin
Pigmentation in skin is due to melanin pigment production by
melanocytes. Skin color arises from the incorporation of the
melanin-containing melanosomes, synthesized by melanocytes,
into the keratinocytes in the epidermis and their subsequent deg-
radation. Although skin color is influenced by additional factors,
such as carotenoids and hemoglobin, the amount, quality, and
distribution of melanin in the epidermis collectively represent
the main source of human skin color. Interestingly, the volume
of melanocytes in human skin is equivalent across humanity;
therefore, the factors ascribed to skin color are the activity of the
melanocytes and their interaction with the keratinocytes and
not their number.
Disorders of pigmentation, or dyschromia, can result
when excess melanin is synthesized. UV radiation, estrogen,
melanocyte-stimulating hormones (MSH), stress, inflammation,
injury, infrared (IR) light, and heat are significant factors that can
promote the production of melanin. Melasma, solar lentigo, post-
inflammatory hyperpigmentation, and dark circles under the eyes
are the prevalent forms of dyschromia. There are several common
types of pigmentary disorders.
Melasma
Melasma, also known as chloasma or mask of pregnancy, is a
common condition typically seen in women of childbearing age.
This chronic disorder frustrates patients and physicians because
it recurs frequently, especially due to exposure to the sun or
estrogen. Melasma appears as irregularly shaped, but often dis-
cretely defined, blotches of light- to dark-brown pigmentation.
These patches usually emerge on the upper lip, nose, cheeks, chin,
arms, forehead, and neck. They typically are difficult to treat and
often recur. Patient education is critical in the treatment of this
disorder because it is worsened by heat, stress, UV light, mela-
tonin supplements, and any kind of inflammation. Any topical
treatment of melasma will take 12 to 16 weeks to see results.
Solar Lentigo
Solar lentigos result from acute as well as chronic sun exposure
and appear as macular brown lesions usually 1 cm in diameter.
Areas that receive the greatest amount of sun exposure, such
as the face, shoulders, chest, back, and hands, are most often
affected. These can be treated with destructive methods such as
laser and liquid nitrogen or a series of chemical peels.
in mm ry y er igmen i n
Postinflammatory hyperpigmentation, also referred to as
postinflammatory pigment alteration (PIPA), manifests as a
126
consequence of various skin disorders and procedures. Therapies
for skin disease can sometimes generate or exacerbate dyschro-
mia, such as resurfacing lasers or chemical peels. This side effect
occurs more often in patients with darker skin types. These
lesions are treated in the same manner as melasma.
Cosmeceuticals for Dyspigmentation
A combination of ingredients including tyrosinase inhibitors,
protease-activated receptor 2 (PAR-2) blockers, and exfoliating
agents represents the optimal strategy for treating disorders of
pigmentation. Physicians should also advise patients to practice
sun protection as well as heat and sun avoidance so as to treat
dyschromia successfully. Lasers, light, chemical peels, and
other methods should be used as a last resort or with extreme
caution, because they can cause inflammation and worsen the
pigmentation.
Products These Patients Should Use
Sunscreen
hether or not a patient stays indoors, sunscreen should be a
routine part of the skin regimen. There are several novel SPF for-
mulations that block IR and other forms of light that can aggra-
vate melasma. For patients with oily skin, SPF is recommended
instead of a moisturizer. oncomedogenic sunscreens are best
for acne-prone patients. Oral sun-protective supplements
such as Polypodium leucotomos and pycnogenol also provide
added protection as long as they are used in conjunction with
sunscreen.
Tyrosinase Inhibitors
Tyrosinase inhibitors, which suppress the synthesis of melanin,
include ascorbic acid (vitamin C), hydroquinone, kojic acid,
arbutin, mulberry extract, and licorice extract. Several authors
recommend a tyrosinase inhibitor holiday every 3 to 6 months
to prevent tachyphylaxis, although such a need is anecdotal.
Ascorbic acid can be used during such a break because its structure
differs from those of other tyrosinase inhibitors. Hydroquinone
is the most effective tyrosinase inhibitor, but unfounded public
concerns about its safety have led to the popularity of derivatives
such as kojic acid and arbutin. otably, hydroquinone is consid-
ered efficacious in combination with a retinoid and a steroid in
the ligman formula, because retinoids and steroids such as
fluocinolone block tyrosinase. This triple combination agent
leverages retinoids, which prevent the skin-thinning effects of
steroids, and steroids, which in turn mitigate the inflammation
from retinoids and hydroquinone.
PAR-2 Blockers
Soybean trypsin inhibitor and Bowman-Birk inhibitor, which are
minuscule proteins found in soy, display depigmenting activity
and prevent UV-induced pigmentation in vitro and in vivo. These
soy proteins suppress the cleavage of the seven transmembrane
G-protein–coupled receptor called PAR-2. It is expressed in kera-
tinocytes at intersections with melanocytes and acts like a key
opening a lock, permitting the melanosomes to transfer from the
melanocyte into the keratinocyte. Both soy and niacinamide, a

vitamin B3 derivative, have been demonstrated to inhibit mela-
nosome movement from melanocytes to keratinocytes.
Exfoliants
Removing the top layer of the SC causes the cell cycle to accel-
erate, hastening desquamation of melanosome-laden keratino-
cytes. The melanocytes are unable to manufacture the pigment
rapidly enough to keep the keratinocytes full of melanosomes;
therefore, less pigmentation is seen at the cell surface. Exfoliants
work much better when used along with tyrosinase inhibitors
and PAR-2 blocking agents as well as sunscreen. Exfoliants are
either in chemical form, such as hydroxyacids, or mechanical
form, such as microdermabrasion, scrubs, rotating brushes,
or rough fabrics. Retinoids also act to speed up desquamation.
Such agents can be incorporated into the skin care regimen or
applied in the doctor’s office to treat dyschromia. It is import-
ant to note that overuse or misuse can lead to inflammation,
which would cause the melanocytes to produce more melanin
and worsen the skin condition under treatment. Consequently,
exfoliants should be used with extreme caution, and patients
should be educated about the risks of overexfoliating. The use
of exfoliating cleansers (e.g., hydroxyacid cleansers) is a low-
risk method to include exfoliants in the skin care regimen.
In-office peels should also be used with caution and only by
experienced practitioners, because peels can easily exacerbate
melasma.
Antioxidants
Antioxidants are effective in preventing hyperpigmentation by
suppressing inflammation. Polyphenol antioxidants, in particu-
lar, have been shown to be potent chelators of metal ions, such
as Fe2 , Fe3 , Cu2 , n2 , and Mn2 , and can disrupt the function
of tyrosinase. Antioxidants play dynamic, various roles in the
prevention and treatment of dyschromia, including chelating
copper, neutralizing free radicals, and reducing inflammation.
Tyrosinase needs copper to function properly, and numerous
antioxidants such as flavonoids chelate copper. Free radicals
can incite inflammatory pathways, which elevates melanocyte
activity. Several antioxidants such as argan oil and green tea
exert anti-inflammatory activities independent of their antiox-
idant activity. UV-induced pigmentation is prevented by some
antioxidants that act by altering the p53 pigmentation pathway
through the rate-limiting step of p53 phosphorylation at site
15. Specifically, this phosphorylation step is hindered by the
plant-derived antioxidant phloretin. Ascorbic acid is a unique
antioxidant in that it displays tyrosinase-inhibiting activity
distinct from its antioxidant qualities.
Products and Treatments These Patients Should
Avoid
• Heat
• Sun exposure
• Anything that causes inflammation
• Melatonin supplements
• Estrogen
A S ien i A r me eu i
Regimen Guidelines
Studies of melasma reveal a 1- to 2-grade improvement at 12 to
16 weeks in most cases. Therefore, the treatment regimen should
last 3 to 4 months, and the patient should be advised that mul-
tiple treatment cycles may be necessary depending on melasma
severity, sun avoidance, patient compliance, and the presence
of other factors such as stress and estrogen use. Monthly visits
and the use of photography and Mexameter (Courage hazaka
Electronic GmbH, ln, Germany) or other objective measure-
ments can improve compliance. To prevent discouragement,
which usually emerges around the week 8 visit, patients should
be cautioned that changes in these measurements and in photos
are not typically noticeable until 12 weeks. The treatment cycle
should include the following:
• Daily broad-spectrum SPF
• Twice-daily tyrosinase inhibitor
• ightly retinoid
• PAR-2 blocking agent in a sunscreen, serum, or moisturizer
• Exfoliating cleanser
To improve efficacy and efficiency, the evening product can be
a triple combination of retinoid, tyrosinase inhibitor, and steroid
such as the Kligman formula.
Many physicians choose to do a tyrosinase holiday every 4
months because it is believed, but not proven, that tyrosinase
inhibitors lose efficacy. After 4 months, or once a pigmentation
disorder has cleared, the regimen should segue to a maintenance
regimen. The maintenance regimen should exclude tyrosinase
inhibitors (with the exception of ascorbic acid) but should include
the following:
• Daily broad-spectrum SPF
• Antioxidant such as ascorbic acid
• PAR-2 blocking agent in a sunscreen, serum, or moisturizer
• Exfoliating cleanser
Patients should be counseled to pursue the maintenance regi-
men for at least 1 month or until pigmentation begins to return,
at which point the treatment regimen can be resumed for another
four months. This alternating cycle continues until the dyspig-
mentation clears, with anywhere from one to six treatment cycles
necessary until clearing occurs in almost all cases if the patient is
compliant with the regimen and lifestyle advice.
14.3.5 Aging Skin
The largest market for skin care products is for skin aging, so
that subject will be covered in depth here. Cutaneous aging is
engendered by a wide array of factors both intrinsic and extrinsic.
Influenced by genetics, intrinsic aging emerges from the cellular
processes that occur over time. Diminished function of kerati-
nocytes and fibroblasts, intra- and extracellular accumulation of
by-products, impaired function of sirtuins, mitochondrial damage,
and the shortening of telomeres characterize intrinsic aging.
Conversely, extrinsic aging occurs as a consequence of envi-
ronmental exposures ultimately deleterious to cells, including
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UV light (natural or from tanning beds), IR and other radiation
exposure, air pollution, smoking, alcohol and drug usage, stress,
and poor diet. This type of aging also results from intersecting
processes spurred by free radicals, D A damage, glycation,
inflammation, and other activities of the immune system. Such
harm can be attenuated partially through behavioral change.
For instance, up to 80 of facial aging can be attributed to solar
exposure. Various mechanisms through which sun exposure
triggers aging are well understood. UV light induces covalent
bonds between nucleic acid base pairs and forms thymine dimers,
which can destabilize tumor suppressor gene p53 function, thus
damaging D A and increasing the risk of skin cancers and aging.
UV exposure also creates free radicals, which cause damaging
oxidative stress, thereby galvanizing the arachidonic acid pathway
leading to inflammation.
Cellular Roles in Cutaneous Aging
Keratinocytes
The epidermis is made up of keratinocytes, which are cells found
in layers that resemble the brick-and-mortar structure of a brick
wall. Each epidermal layer is characterized by specific functional
roles and qualities. The skin barrier is represented by the SC, the
top layer of the epidermis, which contains crosslinked proteins
to impart strength, antioxidants to protect the cells from free
radicals, a bilayer lipid membrane layer to prevent water evapo-
ration from the cell surface, immune cells, antimicrobial peptides
(AMPs), and a natural microbiome. Accelerated cutaneous aging
can be stimulated by damage to any layer of the epidermis.
Fibroblasts
Fibroblast cells, which produce collagen, elastin, hyaluronic
acid, heparan sulfate, and other glycosaminoglycans that keep
the skin smooth, strong, and healthy, are the primary active
constituents in the dermis. Collagen imparts strength, elastin
confers elasticity, and the glycosaminoglycans such as hyal-
uronic acid, heparan sulfate, and dermatan sulfate bind water,
deliver volume to the skin, and provide support for important
intercellular communications. As keratinocytes and fibroblasts
age, their responses to cellular signals such as growth factors
may lapse. These foundational skin cells are the primary targets
for protection and rejuvenation in antiaging skin care regimens.
Cellular Damage That Contributes to
Cutaneous Aging
With the accumulation of damage due to intrinsic as well as
extrinsic factors, keratinocytes and fibroblasts falter in syn-
thesizing key cellular components as well as they did when
they were younger. Cellular factors implicated in cellular aging
include impairments to nuclear D A as well as mitochondrial
D A, reduced lysosomal function, and structural weakening of
proteins and cell membranes. The direct effects of UV radiation,
pollution, toxins, free radicals (oxidation), glycation, and inflam-
mation account for such cellular damage.
Patients should use products for the prevention and treatment
of D A damage, as detailed in the following paragraphs.
128
Preventing and Treating DNA Damage
Thymine-thymine dimers, pyrimidine-pyrimidine dimers,
impaired telomeres, or other mutations are manifestations of
D A damage. Use of broad-spectrum sunscreens and sun avoid-
ance are important behavioral steps in preventing D A damage
engendered by exposure to UV radiation. Other cosmeceutical
agents are intended to block the effects of UV radiation or to
foster D A repair. Antioxidants, in addition to sunscreens, are
the chief components in the dermatologic armamentarium
against D A damage. Data revealing the skin-protective effects
of antioxidants have been associated with notable ingredients
such as Polypodium leucotomos (PL), ascorbic acid, and green
tea. A lower volume of data is linked to other antioxidants, but
hypothetically, numerous other antioxidants can confer similar
benefits.
An oral extract derived from ferns, PL has been shown to
exhibit photoprotective activity at an oral dose of 7.5 mg and
has consistently displayed the capacity to render antitumor and
skin-protective effects. Two oral doses of PL were demonstrated
in a 2004 study in humans to have played a role in a significant
decrease in D A damage after UV exposure, while a 2017 study
revealed that PL protected skin D A from UVB. Although PL is
associated with delivering topical benefits, the oral form is most
often used for skin protection.
Ascorbic acid, for which an acidic environment is essential for
optimal absorption, is linked with copious evidence of cutaneous
benefits when given both orally and topically. Topical applica-
tion of ascorbic acid, combined with vitamin E and ferulic acid,
has been shown to decrease the formation of thymine dimers.
Ascorbic acid is also unique in that it stimulates procollagen genes
in fibroblasts to augment collagen synthesis.
iacinamide, also known as nicotinamide, plays a crucial role in
the niacin coenzymes nicotinamide adenine dinucleotide ( AD )
and nicotinamide adenine dinucleotide phosphate ( ADP ) and
their reduced forms ADH and ADPH. These enzymes factor
into D A production and repair and play roles in numerous other
important enzymatic reactions. Topical niacinamide has been
shown to contribute to D A repair by energizing cells so that
the D A repair enzymes can unwind the D A strand, replace
the nucleosides, and rewind the strand. Niacinamide enhances
D A excision repair and correction of UVB-induced cyclobutane
pyrimidine dimers and UVA-induced 8-oxo-7,8-dihydro-2'-deox-
yguanosine. It is used topically because oral forms of niacin are
associated with flushing.
Epigallocatechin-3-O-gallate (EGCG), the main active constitu-
ent in green tea, is known to induce interleukin (IL)-12 to enhance
the synthesis of enzymes that repair UV-induced D A damage.
The established photoprotective effects of topical and oral green
tea include diminishing UV-induced erythema, lowering sunburn
cell formation, and mitigating D A damage.
Preventing and Treating Mitochondrial
DNA Damage
hat is known as the common deletion is mitochondrial
D A damage caused by UV radiation. Impaired mitochondria
synthesize deleterious free radicals known as reactive oxygen
species (ROS). ROS-induced harm to the mitochondria denudes

its capacity to generate ATP energy, which is essential for D A
repair and other cellular processes.
In addition to UV exposure and free radical production, regular
cellular metabolism also exerts damage to mitochondria, ranging
from mitochondrial D A impairment and loss of mitochondrial
enzymes to reduced ATP production. The cellular consequence
is that less energy is available to enact D A repair and other
remedial processes. There are no methods yet known to attenuate
or reverse mitochondrial damage once it has occurred, though
several investigations are under way to achieve this end. The best
option for now is to protect the mitochondria from harm using
sunscreens and antioxidants.
The use of antioxidants can help prevent the damaging effects
of free radicals on susceptible mitochondria. Coenzyme 10
(Co 10), a component of the mitochondrial respiratory chain and
an antioxidant itself, is especially useful in this role and available
in oral and topical formulations. Oral Co 10 should be taken only
in the morning because of its caffeine-like effect. Topical Co 10 is
unappealing to some patients because of its dark yellow color. PL,
the oral form of which is recommended, has been demonstrated
to reduce the number of common deletions found in the mito-
chondria of irradiated keratinocytes and fibroblasts. Curcumin,
another robust antioxidant, is being investigated for the potential
to protect mitochondria. Due to its bold yellow pigment and strong
aroma, curcumin would likely be more welcome by patients in oral
form, though several manufacturers are attempting to develop
cosmetically elegant topical formulations.
Scavenging Free Radicals
Free radical formation is provoked by exposure to UV light,
pollution, and other insults. Unfortunately, even the use of sun-
screen has been implicated in augmenting free radical produc-
tion. ROS traumatize cells in various ways, such as mitochondrial
impairment, D A mutations, glycation, and lysosomal damage,
as well as oxidation of important lipids and other cellular com-
ponents such as proteins. Antioxidants impart multiple benefits,
including scavenging free radicals, diminishing activation of
mitogen-activated protein kinases (MAP ), chelation of copper
required by tyrosinase, and inhibition of inflammatory factors
such as nuclear factor ( F)- B. To prevent the aging of skin,
antioxidants are imperative.
re en ing nd re ing n mm i n
Inflammation emerges from a plethora of etiologic pathways,
with several inflammatory mediators potentially involved,
including histamines, cytokines, eicosanoids (e.g., prostaglan-
dins, thromboxanes, and leukotrienes), complement cascade
components, kinins, fibrinopeptide enzymes, F- B, and free
radicals. Through a variety of mechanisms, cutaneous aging can
result from inflammation. For example, when UV light and free
radicals oxidize cell membrane lipids, an inflammatory chain of
events leads to the release of arachidonic acid. In turn, the ara-
chidonic acid cascade activates cyclooxygenase (COX)-2, which
promotes the production of substances such as prostaglandins
and leukotrienes. These compounds create cutaneous inflamma-
tion and recruit inflammatory immune cells to the area. F- B is
another important regulator of inflammation in the skin.
A S ien i A r me eu i
Myriad anti-inflammatory ingredients have been used suc-
cessfully in topical skin formulations, including aloe, argan oil,
caffeine, chamomile, feverfew, green tea, licorice extract, linoleic
acid (present in high concentrations in argan oil and sa ower
oil), and niacinamide among others. The effect of UV radiation on
COX-2 expression has been shown to be inhibited through the use
of oral PL. Suppression of COX-2 signaling and other inflammatory
mediators has also been displayed via the use of glycolic acid.
Preventing and Treating Glycation
In 1912, Louis-Camille Maillard observed that amino acids can
react with sugar to yield brown or golden-brown substances. The
Maillard reaction, which is especially well known in cooking, is a
chemical chain of events between an amino acid and a sugar that
typically requires heat. Glycation is the result. It was not until
the 1980s that scientists came to understand the significance of
glycation in health.
hen glycation occurs, sugar molecules attach to proteins,
forging crosslinked proteins known as advanced glycation end
products (or AGEs), which incites a series of chemical reactions.
Glycation arises in collagen fibers and culminates in the devel-
opment of crosslinks that bind collagen fibers to each other, thus
rendering the skin stiffer. Glycosylated collagen is thought to be
involved in the appearance of aged skin. Glycation can also impact
elastin insofar as the process can precipitate elastosis, which is
abnormally clumped together elastin and manifests more fre-
quently in aged skin.
Glycation is not a reversible reaction, though many manufac-
turers tout antiaging skin care products as capable of treating
it. Prevention is the only option, currently. Some studies imply
that antioxidants can be used to avert glycation, but the greater
likelihood is that they manage to forestall or divert the process
down a different pathway that still yields glycation. Glycation can
best be impeded or avoided by lowering serum glucose levels. The
recommended approach to achieve this end is dietary interven-
tion and oral metformin.
Reversing the Aging of Skin Cells
Epidermal Keratinocytes
oung basal stem cells produce a profusion of new keratinocytes
that prompts a rapid cell turnover and efficient synthesis of
protective epidermal components. ot surprisingly, old kerat-
inocytes exhibit less energy and diminished responsiveness to
cellular signals and fail to produce these protective constituents.
eratinocyte stem cell function deteriorates over time as defects
accumulate, manifesting in a diminished response to growth
factors, curbed keratinization, and hindered capacity.
Dermal Fibroblasts
oung fibroblasts fabricate important cellular components,
including collagen, elastin, hyaluronic acid, and heparan sul-
fate. Such synthesis dwindles in older fibroblasts. Aged fibro-
blasts, like old keratinocytes, become depleted of energy, with
subsiding responsiveness to growth factors and other cellular
signals.
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 III Nonsurgical Cosmetic Treatments
Using Cosmeceuticals to Rejuvenate Aging Skin
Gene expression, chemokines, cytokines, growth factors, and
receptor activation direct the function of keratinocytes and
fibroblasts. To decelerate or reverse cellular cutaneous aging, old
keratinocytes and fibroblasts must be galvanized to acknowl-
edge such signals or the signals must be heightened.
S imu ing d er in y e nd i r
Energizing gene expression, adding growth factors, prompting
cytokines and chemokines, turning on receptors, and enhancing
cellular responsiveness to signals are the necessary measures to
stimulate aged keratinocytes and fibroblasts.
In uen ing Gene re i n
The use of retinoids can influence collagen genes and foster
activity of procollagen genes, thereby decreasing collagenase
synthesis. Several studies have revealed the efficacy of retinoids
in treating aged skin and preventing skin aging in sun-exposed
as well as non-sun-exposed areas. The prescription retinoids
tretinoin, adapalene, and tazarotene as well as OTC retinol
represent first-line choices for preventing and treating cuta-
neous aging by invigorating old keratinocytes and fibroblasts.
Unfortunately, erythema and flaking are likely consequences, in
the first few weeks of therapy, of exposing retinoic acid receptors
to retinoids. Titrating retinoids slowly is the way to work around
such a result. Physicians should note that retinoid esters such as
retinyl palmitate and retinyl linoleate do not penetrate into the
dermis and are not as effective as retinol, tretinoin, adapalene,
and tazarotene. Compliance with a retinol regimen, as opposed
to prescription retinoids, is more likely because retinol is avail-
able without a prescription and is less expensive.
Alpha hydroxyacids can also spark collagen genes to ramp up
collagen production. Further, ascorbic acid has been shown to
stimulate collagen genes, resulting in fibroblasts increasing Type
1 collagen production.
Growth Factors
Growth factor–containing cosmetic products can be used
toward effecting skin rejuvenation. There are diverse types of
growth factors with the ability to activate old keratinocytes and
fibroblasts to improve function. Growth factors, which are inert
or susceptible to degradation in their native, soluble form, can
directly stimulate genes or serve as a signaling mechanism. To
impart their quintessential activities, growth factors must be
transferred to the appropriate receptor site in order for the cells
to respond to their signals.
Heparan Sulfate
Heparan sulfate is a significant factor in intercellular commu-
nications. It enhances cellular response to growth factors by
promoting the response of old, indolent fibroblasts to cellular
signals, and it binds, stores, and protects growth factors, allow-
ing them to arrive at their targets and present to the appropriate
binding site. A topical analog of heparan sulfate has been shown
to rejuvenate aged skin.
130
Stem Cells
Stem cells packaged in cosmeceutical formulations are essen-
tially useless, as these typically plant-derived substances are
too large to penetrate the SC, have short shelf lives, and do not
act as human stem cells would. Fortunately, novel technologies
have revealed compounds that can coax stem cells to repopu-
late the epidermis and dermis with young cells. Stem cells in
skin include basal stem cells and a collection of 10 different
hair follicle stem cells. The leucine-rich repeat–containing, G
protein–coupled receptor (LGR)6 hair follicle cells are key in
repopulating the epidermis in response to wounds. Aesthetic
physicians have known for several years that inducing skin
wounding with lasers, needles, and acidic peels renders an
improved skin appearance. Researchers have now found that
wounding the skin prompts LGR6 stem cells to repopulate the
epidermis. In response to a wound, neutrophils release the pep-
tide defensin, which drives the LGR6 stem cells to repopulate
the epidermis. Topical defensin, formulated to grant penetration
into hair follicles where the LGR6 stem cells are located, has
been shown to deliver a smoother, more youthful appearance
to the skin.
14.4 Designing a Skin Care Regimen
In addition to knowing which products to include and exclude
in a patient’s skin regimen based on skin type, practitioners
must be aware of the order in which topical products should be
applied to optimize efficacy. This entails understanding of how
cosmeceutical ingredients interact with and alter each other
and how they are influenced by temperature, pH, humidity,
and the microbiome in which they are in contact, as order in
the manufacturing process also impacts product efficacy.
Identifying and obtaining properly manufactured products
are important steps, of course, but there is much more to
designing the patient-tailored skin care regimen than choosing
the products. For instance, a low-pH skin care product (e.g., a
glycolic acid cleanser) selected for a regimen will influence the
efficacy and safety of other products subsequently applied to the
skin. Physicians should consider such chemical reactions when
designing the order of product applications, especially when
including ingredients known to interact with other ingredients,
such as benzoyl peroxide, retinoids, hydroxyacids, hydroqui-
none, vitamin C, and peptides. Fig. 14.3 illustrates the ideal skin
care regimen structure.
14.4.1 Step 1: Cleansers
These products confer a wide range of action, as they can alter
the skin’s pH, loosen attachments between cells, eliminate
lipids and disrupt the bilayer protective membrane, desqua-
mate layers from the SC, and affect the permeability of the
skin for the next topical product that is applied. Therefore,
physicians should recommend cleansers based on the knowl-
edge of which products would best be subsequently applied in
the regimen, ideally according to the patient’s BST, with a goal
of increasing efficacy of the treatment to follow. For example,
cleansers for oily skin should be able to remove excess sebum,
while cleansers intended for dry skin would remove far fewer

Fig. 14.3 Ideal regimen structure.
lipids. ashing skin with a foaming cleanser can disturb the
skin barrier, setting the stage for greater penetration of the
ensuing product application. Among the ingredients that affect
skin penetration are oleic acid, hyaluronic acid, stearic acid, and
other lipids. Every ingredient and characteristic of the cleanser
is important.
14.4.2 Step 2: Eye Products
Topical skin care for the eyes intended to address issues such
as dryness, puffiness, fine lines, and dark circles imparts the
added benefit of protecting the thin delicate area around the
eyes from facial formulations. Eye products, particularly those
containing barrier repair lipids or other protective ingredients,
can also help patients better tolerate potentially irritating
formulations applied subsequently. Pre-emptive use of a pro-
tective eye product before bedtime can prevent an individual
from experiencing irritation from a nighttime treatment
product, as ingredients can smear on pillowcases and transfer
to the upper and lower eyelids. For example, acne patients
frequently develop erythema at the corners of the eyes from
nightly application of benzoyl peroxide or a retinoid. This side
effect can be mitigated by applying an eye cream before using
the acne medication.
A S ien i A r me eu i
14.4.3 Step 3: Treatment Products
Treatment products are defined as targeted to ameliorating skin
conditions such as acne, rosacea, melasma, dryness, skin cancer,
eczema, psoriasis, and photoaging. These may be cosmeceu-
ticals, OTC drugs, or prescription medications. Promoting the
efficacy of treatment products and reducing side effects are the
most important components to consider when designing the
skin care regimen. In order to be effective, treatment products
must be able to reach their target tissue in the proper chemical
form. Each ingredient is characterized by unique constraints.
For example, ascorbic acid, which is a treatment product for skin
pigmentation and cutaneous aging, is optimally absorbed when
formulated at a pH of 2 to 2.5. However, washing skin with a soap
cleanser at a pH of 9 will increase the skin’s pH and decrease
the absorption of ascorbic acid applied subsequently. Instead,
patients using an ascorbic acid treatment product should wash
with a low-pH cleanser such as salicylic or glycolic acid (usually a
pH of 2.5–3.5), which will reduce the pH of the skin and promote
absorption of the ascorbic acid treatment product.
14.4.4 Step 4: Moisturizers
Moisturizers are versatile products that impart skin hydration,
protection, and delivery of key ingredients, as well as the ability
to enhance the efficacy of a previously applied treatment prod-
uct. Typical moisturizer ingredients, all of which can promote
penetration of other skin care ingredients, include oleic acid,
hyaluronic acid, or other fatty acids. Several moisturizers also
deliver an occlusive effect that aids penetration and even pro-
tects the underlying treatment product from getting wiped off
on a pillowcase or into the environment. That is, moisturizers
seal in the treatment product. Heparan sulfate, which is incor-
porated into some moisturizers, may play a role in how well the
skin cells respond to signals elicited by the treatment products.
14.4.5 Step 5: Morning Sunscreen
The importance of a daily sunscreen cannot be overstated. Sun
exposure plays a role in almost every skin condition. A complete
discussion of sunscreens is beyond the scope of this chapter.
There are two main classes of sunscreens: chemical and physical.
Chemical sunscreens absorb UV energy but can produce free
radicals, may cause skin allergies, and are controversial because
they may be absorbed systemically. Some chemical sunscreen
ingredients have been shown to exhibit estrogenic effects.
Physical sunscreens coat the skin and reflect UV rays away from
the skin. They may not block all wavelengths of UV light and can
look white or violet on the skin. The most important consider-
ation when using a sunscreen for patients is which sunscreen
they will accept using every day. The patient should receive
a recommendation for a daily sunscreen that is chosen for his
or her skin type and a higher SPF sunscreen for prolonged sun
exposure. These should be selected by skin type, sport, and other
lifestyle factors. Compliance is key Facial foundation makeup
and powders should not be relied upon for daily sun protection,
as these are used in too small a quantity to actually provide the
SPF that is listed on the label.
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 III Nonsurgical Cosmetic Treatments
14.4.6 Step 6: Evening Retinoids
For patients using retinoids for the first time, physicians should
advise application of the retinoid as the last item over the mois-
turizer. This can reduce the incidence of side effects and increase
compliance. Unlike other ingredients, retinoids penetrate readily
into the deeper layer of the epidermis. These products should
always be limited to nighttime use, as several, particularly reti-
nol and tretinoin, break down easily upon UV exposure. Layering
a retinoid over a moisturizer can help titrate retinoid absorption,
and the moisturizer can be selected to modulate retinoid pene-
tration (Table 14.4).
14.5 Preprocedure Cosmeceuticals
The outcome of any skin procedure, whether a biopsy, micronee-
dling, fillers, toxins, lasers, or surgery, will be enhanced when
the patient engages in proper skin care before and after the pro-
cedure. Educating patients as to proper skin care is a crucial step
toward ensuring compliance and optimizing patient outcomes.
14.5.1 Preprocedure Skin Care and
Supplements
The aim before the procedure is to set the stage for rapid healing
and minimizing infection, scarring, and hyperpigmentation.
Patients should be advised to use products that have been
shown to speed wound healing by increasing keratinization and/
or collagen production for 2 weeks prior to surgery. Retinoids,
such as tretinoin and retinol, are the mainstay ingredients in
this context. Copious experimental data show that pretreatment
with tretinoin speeds wound healing. More than two decades
ago, ligman assessed healing after punch biopsy and observed
that the wounds on arms pretreated with tretinoin cream 0.05
to 0.1 were significantly smaller by 35 to 37 on days 1 and 4,
and 47 to 50 smaller on days 6, 8, and 11 than the wounds on
untreated arms. A pretreatment regimen of tretinoin for 2 to 4
weeks is suggested by the preponderance of studies, because peak
epidermal hypertrophy occurs after 7 days of tretinoin application
and normalizes after 14 days of regular treatment. This approach
provides ample time for the skin to recover from any retinoid der-
matitis prior to surgery. Adapalene treatment should be initiated
5 to 6 weeks before a procedure because it has a longer half-life.
Although wound healing studies have not been conducted in
this area, pretreating skin with topical ascorbic acid and hydroxy-
acids might help hasten wound healing by augmenting collagen
production.
14.5.2 Medications, Foods, and
Supplements to Avoid Prior to
Procedures
To minimize bruising, patients should avoid using or ingesting
aspirin, ibuprofen, naproxen, St. ohn’s wort, vitamin E, omega-3
fatty acid supplements, flaxseed oil, ginseng, salmon, and alco-
hol for 10 days prior to a procedure. Patients should be urged to
avoid smoking for at least 4 weeks prior to a procedure.
132
14.6 Postprocedure Cosmeceuticals
14.6.1 Postsurgery Skin Care and
Supplements
Oral vitamin C and zinc supplements have been demonstrated
to accelerate wound healing in rats when administered imme-
diately after a procedure. Such supplementation in human
patients might speed recovery. To mitigate bruising and
inflammation, oral arnica tablets and tinctures may be taken
prior to and after surgery. There is copious anecdotal support
for the use of arnica, but clinical trial evidence to substantiate
its efficacy to prevent bruising and reduce swelling remains
scant.
Topical products play a significant role in healing after surgery.
A gel pad combining topical arnica and Rhododendron tomentosum
(Ledum palustre) was found to lessen postoperative ecchymosis
and edema after oculofacial surgery. Topical curcumin enhances
wound healing in animals. Another study has shown that an
occlusive ointment containing a trio of antioxidants improved
wound healing.
Defensin, a protein known to be critical in wound repair, is
available in a topical formulation and has been demonstrated to
stimulate LGR5 and LGR6 stem cells. It accelerates wound healing
by expanding LGR6 stem cell migration into wound beds.
ounds should be covered to protect against sun exposure
until re-epithelialization occurs. At that point, patients can use
zinc oxide sunscreens, which have been shown to be safe with
minimal penetration into the skin.
14.6.2 Ingredients to Avoid Postsurgery
Patients should be cautioned not to use topical retinoids after
re-epithelialization is complete. A 1989 study in a porcine
model used 0.05 tretinoin cream daily for 10 days prior to
partial-thickness skin wounding, revealing that such usage prior
to wounding sped re-epithelialization, but use after the proce-
dure delayed wound healing.
Acidic products sting wounded skin. Therefore, benzoic acid,
hydroxyacids, and ascorbic acid should be avoided until the skin
has completely re-epithelialized. Patients should also be advised
to abstain from using products with preservatives or fragrance.
Vitamin E derived from oral supplement capsules has been
shown to slow healing after skin cancer surgery and was accom-
panied by a high rate of contact dermatitis. Chemical sunscreens
have the potential to provoke allergic contact dermatitis, so
patients should be counseled to avoid such products for 4 weeks
after skin surgery. Organic products with essential oils and botan-
ical ingredients may also pose a higher risk for causing contact
dermatitis due to allergen exposure.
14.6.3 Notes on Cosmeceuticals Used
uring S e i r edure
Microneedling
To stimulate collagen production, patients should take ascorbic
acid and retinoids before microneedling. Immediately after the

procedure, nothing should be taken, so as to keep channels open.
Even an SPF product should be withheld for at least 24 hours
after the procedure.
Injectables (Fillers/Toxins/Deoxycholic Acid)
Before injection procedures, patients should be advised to take
arnica oil orally. After the procedure, oral arnica, in gel sheets,
and topical arnica are recommended. Topical bromelain is also
advisable post procedure. Consumption of pineapple, which is
high in bromelain, is also a useful dietary adjunct.
ffi y nd m i n e
o matter how well designed the skin care regimen is, it is
ineffective if the patient does not use the regimen consistently.
Efficacy and compliance go hand in hand, as improper selection
and incorrect layering of skin care products lower efficacy and
raise the risk of adverse effects, leading to poor patient com-
pliance. Studies have revealed that 95 of people underdose,
and one out of every three prescriptions is not even filled. ust
as side effects render patients more likely to underdose or
stop a treatment, properly selected cleansers and moisturizers
that accompany treatment products and alleviate or prevent
side effects increase compliance. Several studies have shown
that compliance is much more likely when physicians provide
patients with written instructions so that they understand the
proper order in which to apply products.
Brand Selection
Manufacturers typically conduct research on individual prod-
ucts, not complete skin care regimens. This leaves practitioners
on their own regarding the construction of a treatment plan.
The author recommends opting for the best technologies from
each brand and combining them using the layering technique to
increase efficacy. It is ideal to choose the best hero products
from the various brands and test the entire regimen on patients
to figure out what combinations yield optimal efficacy and the
least side effects. The author has described over 3,300 distinct
efficacious regimen combinations to treat various skin issues.
Providing a written step-by-step program increases the odds
of patient compliance, because the order of products is very
important to maximize results.
14.7 Concluding Thoughts
All of the best medical knowledge and procedural skill can be
rendered meaningless if patients do not use recommended
products and follow advice. Patient compliance is an integral
part of achieving optimal patient outcomes. Unfortunately,
studies show that compliance is often poor in the treatment of
many dermatologic disorders such as acne and psoriasis. In 2007,
Feldman et al reported that patients are more likely to use their
products in the days leading up to and just after a visit to their
dermatologist. They suggested that more frequent office visits
would improve compliance.
To ensure the best outcome from skin care regimens and surgi-
cal treatments, patient education is also essential. The more that
A S ien i A r me eu i
patients know and understand about the ways in which they can
care for their skin as well as prepare for their procedure and treat
their skin after the procedure, the better the outcomes will be,
including their overall skin health. Practitioners should provide
this type of information in an easy-to-follow printed instruction
sheet because studies show that patients cannot remember most
of the oral instructions offered in the health care setting. Patients
need encouragement. A three-step process of engaging, educating,
and motivating patients can significantly boost compliance. I use
software that automatically generates patient information based
on their BST. This engages them, educates them, and helps moti-
vate them to continue using the correct regimen. Consistent use
of the correct skin care products will improve patient outcomes
and lead to skin health.
Patients should be encouraged to ask questions during their
consultation and procedure and to contact their health care
providers if they have any concerns after they leave. These steps
bolster patient compliance and satisfaction, which will help
the physician maintain a trusting relationship with established
patients and attract new ones through word-of-mouth referrals.
Clinical Caveats
• A patient’s skin type and needs should be assessed prior to
choosing skin care.
• Skin care recommendations should be ingredient-based
according to the patient’s skin type.
• The regimen should be designed so that each product helps
improve the efficacy of the other products.
• Patients should be given printed instructions with clear
regimen steps.
• Pre- and postprocedure regimens can be designed to improve
procedure efficacy.
• The staff should be educated to discuss skin care with every
patient to encourage compliance.
• Outcomes will be improved if patients are properly educated
and are compliant with the skin care regimen.
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15 Botulinum Toxin Injection for Facial Rejuvenation
Sean Michael Devitt and Steven Fagien
Abstract
Nonsurgical procedures are the most common treatment
modality used for facial rejuvenation, with neurotoxin injection
being the most common of these procedure performed. In this
chapter, we discuss the history and development of botulinum
toxin, its role in the nonsurgical management of facial aging,
its advantages and disadvantages, and its clinical applications
for patients undergoing aesthetic surgery. Case examples and
specific injection techniques for each target muscle are provided.
Keywords
neurotoxin, botulinum toxin, Botox, Xeomin, Dysport, euveau,
nonsurgical, facial rejuvenation, safety, rhytids, aging
15.1 Introduction
For a brand name to become a part of the common vernacular,
it often requires being first in a new and unique application,
time-proven benefits, and widespread use that translates to a
strong association with a certain type of product. Use of such
names as Band-Aid ( ohnson and ohnson, ew Brunswick, )
for adhesive bandages in general, Xerox (Xerox Corporation, Palo
Alto, CA) as a verb for the making of a photocopy, and Google
(Alphabet Inc., Mountain View, CA) as a verb for searching the
Internet are examples of this brand recognition. Brand associ-
ation has emerged in the world of aesthetic treatments as well.
Since its FDA approval in 2002 for the temporary treatment of
glabellar rhytids, Botox (onabotulinumtoxinA; Allergan, Irvine,
CA) Cosmetic has transformed aesthetic medicine, and Botox
has become the household name despite the later introduction
of many competitive neurotoxins. aturally, the popularity
and effectiveness of Botox has led to the development and FDA
approval of four additional botulinum toxin type A derivatives
for the temporary treatment of glabellar lines. Dysport (abobot-
ulinumtoxinA; Galaderma Laboratories, Fort orth, TX), which
was approved in 2009, and Xeomin (incobotulinumtoxinA; Merz
Pharmaceuticals, Raleigh, C), which was approved in 2011,
and now euveau (prabotulinumtoxinA-xvfs), with approval in
2019, are widely commercially available. The American Society
for Aesthetic Plastic Surgery (ASAPS) reported that botulinum
toxin type A injections were performed 6.5 times more than
the top five cosmetic surgical procedures combined, and more
than the top four nonsurgical minimally invasive cosmetic pro-
cedures combined. It is crucial for the physician to understand
the similarities and more importantly the differences in these
products to treat patients appropriately. For aesthetic purposes,
botulinum toxin is primarily used in the face and neck, although
unique uses continue to expand for both aesthetic and nonaes-
thetic indications.
u inum in In e i n r i e u en i n
Facial rejuvenation requires an understanding of the natural
aging process and how it is related to a patient’s underlying anatomy.
ithout this knowledge, it is impossible to manipulate a patient’s
tissue to restore a more youthful appearance. hile patients’ over-
all appearance and aesthetics are their focus, a physician must see
deeper and understand how each region of the face ages differently
in order to provide the best guidance and treatment plan. There
are many surgical and nonsurgical methods available to rejuvenate
the face; deciding which method for each specific patient is part
of the art of medicine. Surgical procedures are inherently more
invasive, with longer downtime, but they are often able to make
greater changes and are in general used to restore the effects of soft
tissue laxity and ptosis. Greater does not necessarily mean better,
however, as a patient often seeks subtle changes or just wishes to
slow down the aging process. onsurgical procedures address skin
quality, soft tissue volume, and the hyperdynamic movements of
underlying muscles that lead to both dynamic and static rhytids. A
physician must know the benefits and drawbacks of both surgical
and nonsurgical methods, regardless of the age of the patient, in
order to provide the patient with multiple options for treatment
and to manage patient expectations. Only then can a patient truly
give informed consent and partner with the physician to develop
a rejuvenation plan.
15.2 Nonsurgical Skin Rejuvenation
After seeing a patient in consultation, a physician must decide
whether the patient would benefit more from a surgical or from a
nonsurgical treatment. These are not mutually exclusive, as many
patients benefit from a combination of treatments. Office-based
nonsurgical skin rejuvenation for addressing facial rhytids, and
more broadly facial aging, is performed using one of these three
methods, depending on the nature and location of the concern.
1. Lasers, intense pulsed light (IPL), photo rejuvenation, chemical
peels, and dermabrasion are used for softening static lines and
improving appearance and quality of skin. These resurfacing
techniques have their greatest benefit in leveling the epidermis
and improving collagen in the dermis. Unlike botulinum toxin
treatment, these resurfacing methods require varying lengths of
recovery as the dermis and epidermis heal. Fractional lasers or
subdermal techniques allow for a quicker recovery time.
2. Botulinum toxin is used for the chemodenervation of underlying
muscles to prevent or attenuate dynamic wrinkles in the over-
lying skin. Repetitive motion of the skin during facial expression
leads to dermal atrophy and rhytids. Paralysis of the underly-
ing muscle by botulinum toxin prevents or reduces continued
movement and stress on the skin, improving the appearance
of dynamic lines. In the absence of movement, static lines can
also be improved as dermal repair occurs. Botulinum toxin can
also contribute to facial shaping by decreasing muscle bulk or
altering the dynamic balance between elevator and depressor
muscles.
135
 III Nonsurgical Cosmetic Treatments
3. Tissue fillers are used to replace missing dermal components
or subcutaneous volume. These injectable materials augment
areas of dermal atrophy by supporting or promoting regener-
ation of the dermal matrix or by enhancing volume. There are
many products to choose from, all with varying properties used
to shape and influence the native soft tissue along a spectrum.
They have been traditionally used in the treatment of volume
loss and the correction or improvement of soft tissue contours
and static lines. More recently, however, it has become clear that
with a greater understanding of the unique properties of par-
ticular agents, a variety of soft tissue fillers placed with preci-
sion can influence the excursion of soft tissue with animation
to restore balance of the (dynamic discord) muscles’ dominance
over the failing soft tissue integrity with age. Furthermore, the
effects of soft tissue agents in residence on the retaining liga-
ments and positive distal muscular effects (myomodulation) are
areas of great interest and exploration.
onsurgical and surgical procedures are often used in conjunc-
tion to give the best result. As with most things in medicine, a
patient-specific combination of treatments is better than a one-
size-fits-all approach. onsurgical treatments can complement
and enhance surgical results and are used by many patients to
delay surgical intervention. Patients are hesitant go under the
knife and are more comfortable with office-based procedures.
However, nonsurgical procedures, in general, should not be
considered to be, and rarely are, a satisfactory replacement for
surgical rejuvenation procedures.
hen evaluating a patient for nonsurgical or surgical proce-
dures, the provider must not overlook the quality of skin. Patients
are often surprised at how much a good skin care regimen can
affect their overall appearance. A multimodal plan to improve all
aspects of aging from the outside in leads to facial harmony and a
youthful appearance.
Of the three broad categories of treatment for nonsurgical
facial rejuvenation just discussed, denervation, or more broadly,
neuromodulation with botulinum toxin type A injection still
enjoys the honor of being the most commonly requested proce-
dure among the spectrum of options because of its predictability
and dependability, ease of application, minimal downtime, and
repeatablility. In this chapter we discuss the history and develop-
ment of botulinum toxin, its role in the nonsurgical management
of facial aging, its advantages and disadvantages, and its clinical
applications for patients undergoing aesthetic surgery. It is crucial
that injectors understand the similarities and differences among
Botox, Dysport, Xeomin, and euveau, so we will discuss recon-
stitution, dosing, and storage guidelines, injection techniques,
posttreatment protocols, and potential complications.
A fifth botulinum toxin, Myobloc (rimabotulinumtoxinB;
Solstice eurosciences, San Francisco, CA), is on the market and
is FDA-approved for the treatment of cervical dystonia. Unlike the
three previously mentioned products, which are derived from
botulinum toxin serotype A, Myobloc is derived from botulinum
toxin type B, and its use for aesthetic indications is off label. It is
widely available and is included in our discussion.
Finally, another botulinum toxin type A, DAXI (daxibotulinum-
toxinA; Revance Therapeutics, Inc., ewark, CA), is expected to get
FDA approval in 2020.
136
Due to the lack of or limited experience postmarket with
euveau and DAXI, discussion and comparatives with these two
specific products will be limited.
15.3 History
A toxin produced by the anaerobic bacterium Clostridium botuli-
num was identified in 1897 as the causative agent in descending
muscle paralysis from food poisoning. The toxin was responsible
for devastating the canning industry in the 1930s, until reliable
methods for killing the bacterium’s spores were developed,
and was later purified by the United States Army for biological
warfare research. Some 40 years later, pediatric ophthalmologist
Dr. Alan Scott collaborated with Dr. Edward . Schantz in the
preparation of a batch of crystalline toxin to determine its effec-
tiveness as an injectable agent for producing transient weakness
of extraocular muscles and permanent changes in ocular
alignment in a primate model. In 1980, Scott was the first to use
the toxin in humans to treat strabismus. Since that time, the
clinical use of botulinum toxin has been expanded and applied
to a wide range of conditions for which the principal therapeutic
aim is to reduce undesired or excessive contraction of muscles.
The transition of botulinum toxin’ s use from ophthalmologic to
aesthetic indications is credited to Carruthers and Carruthers in
1992, who serendipitously noted a reduction in glabellar rhytids
when injecting the corrugator supercilii muscles for benign
essential blepharospasm. Table 15.1 provides a brief timeline of
Clostridium botulinum toxin in clinical medicine and highlights
the FDA approval dates for its aesthetic uses to date.
15.4 Nonaesthetic Uses
Once feared as one of the most deadly toxins in the world, botuli-
num toxin is now one of the most widely used medicines, and its
applications are continuously expanding. It has been successfully
used to treat conditions from head (headache, cervical dystonia,
blepharospasm, facial rhytids) to toe (poststroke spasticity) and
everywhere in between. Table 15.2 includes just some of its
clinical uses and is by no means all-encompassing.
15.5 Available Neurotoxins/
Fundamentals
15.5.1 Product Preparation
Botulinum neurotoxin type A (Botox, Dysport, and Xeomin) is
one of seven serologically distinct and species-specific toxins
produced by C. botulinum, a gram-positive, spore-forming, obli-
gate anaerobe that is found naturally in the soil. It is produced by
fermentation of the Hall strain of C. botulinum type A in a culture
medium.
To prepare onabotulinumtoxinA (Botox Cosmetic), the culture
solution is purified by a series of acid precipitations to a crystalline
complex containing the toxin and other proteins. This complex
is then dissolved in sterile sodium chloride solution containing
human albumin and is then sterile-filtered before filling and
 u inum in In e i n r i e u en i n

Table 15.1 Chronology of Clostridium botulinum toxin in clinical medicine

Date en Author
1897 C. botulinum neurotoxin isolated E. Ermengem
1920 Purification attempts H. Sommer
1946 Crystallized type A purified E. J. Schantz
1950 Therapy of hyperfunctional muscles V. Brooks
1973 Pharmacologic weakening of extraocular muscles in monkeys A.B. Scott
1979 Crystalline botulinum toxin A; batch 79–11 E. J. Schantz
1980 Botulinum toxin for treatment of strabismus in humans A. B. Scott
1985 Botulinum A exotoxin used to treat blepharospasm A. B. Scott
1985 Botulinum toxin used to treat spasmodic torticollis J. K. Tsui
1989 FDA approves Botox for treatment of strabismus, benign essential blepharospasm, and hemifacial spasm
1990 Botulinum toxin used to treat dystonias J. Jankovic
1992 Botulinum A exotoxin used to treat glabellar frown lines J. D. Carruthers, A. Carruthers
1993 Botulinum toxin used to treat hyperfunction of facial expression A. Blitzer, M. E Brin
1997 New lot of Botox reformulated and produced from bulk toxin
2000 Myobloc (botulinum toxin type B) approved for treatment of cervical dystonia
2002 FDA approves Botox Cosmetic for treatment of glabellar lines
2004 FDA approves botulinum toxin for treatment of primary axillary hyperhidrosis
2007 Botulinum toxin injections are the most common aesthetic procedure in the United States,
as reported by the American Society for Aesthetic Plastic Surgery (ASAPS)
2009 FDA approves Dysport for treatment of cervical dystonia and glabellar lines
2011 FDA approves Xeomin for treatment of glabellar lines
2013 FDA approves Botox Cosmetic for treatment of crow’s feet
2017 FDA approves Botox Cosmetic for treatment of forehead lines
2019 FDA approves Jeuveau for treatment of glabellar and forehead rhytids

Table 15.2 Partial list of the uses of botulinum toxin in medical therapy
Achalasia Dental procedures Inner ear disorders Spinal cord injury
Anal fissure Esophageal stricture Masseteric muscle hypertrophy Strabismus
Back pain Essential tremor Mohs Micrographic Surgery repair Temporomandibular joint
Benign prostatic hypertrophy Facial nerve disorders Neck pain dysfunction
Blepharospasm Facial spasms Overactive bladder Teeth grinding
Breast reconstruction and Gustatory sweating (Frey’s Parotid fistulas Tourette’s syndrome
augmentation syndrome) Poststroke limb spasticity Vasospastic disorders
Cerebral palsy Headaches Pressure ulcers Vocal cord disorders
Cervical dystonia Hyperhidrosis Reduced appetite Wound healing

vacuum drying. Botox Cosmetic is commercially available as a
sterile, lyophilized powder without preservatives. Each single-use
vial of Botox Cosmetic contains 100 units (10 variation) of botu-
linum type A neurotoxin complex, 0.5 mg of human albumin, and
0.9 mg of sodium chloride. A 50-unit vial is also available.
AbobotulinumtoxinA (Dysport) is prepared by purification
of the bacterial culture supernatant by a series of precipitation,
dialysis, and column chromatography. The neurotoxin complex is
composed of neurotoxin, hemagglutinin proteins, and nontoxin,
nonhemagglutinin proteins. It is commercially available as a ster-
ile, lyophilized powder. Each vial of Dysport contains 300 units
of botulinum toxin type A complex, 125 mcg of human serum
albumin, 2.5 mg of lactose, and trace amounts of cow’s milk pro-
teins. A 500-unit vial is also available for the treatment of cervical
dystonia.
IncobotulinumtoxinA (Xeomin) is also prepared by the puri-
fication of the bacterial culture supernatant. The neurotoxin is
then separated from the accessory proteins (hemagglutinins and
nonhemagglutinins) to yield a purified active neurotoxin. It is a
commercially available as a white to off-white lyophilized powder.
Each 100-unit vial of Xeomin contains 100 units of botulinum
toxin type A, 1 mg of human albumin, and 4.7 mg of sucrose. A
50-unit vial is also available.
RimabotulinimtoxinB (Myobloc), as previously mentioned, is
subtype B. It currently has FDA approval for the treatment of cer-
vical dystonia, but any aesthetic use is considered off-label, so it is
far less used for cosmetic purposes than the preceding three. It is
produced by the fermentation of the Bean strain of C. botulinum
type B, purified by a series of precipitation and chromatography
steps, and packaged as a clear to light yellow injectable solution

137
 III Nonsurgical Cosmetic Treatments
that does not require reconstitution. Each vial of Myobloc contains
5,000 units of botulinum toxin type B in 1 mL of a solution con-
taining 0.05 human serum albumin, 0.01 M sodium succinate,
and 0.1 M sodium chloride at a pH of 5.6. It is also available in
2,500 units (0.5 mL) and 10,000 units (2 mL).
It cannot be stressed enough that the unit dosings among the
four botulinum toxin products are not equivalent.
15.5.2 Mechanism of Action
Both Botox Cosmetic and Dysport are composed of botulinum
toxin type A, each with a unique toxin/protein complex that
results in different dosing between the two products. Once
injected, the botulinum toxin core quickly dissociates from the
complex due to the change in pH. Xeomin is a purified toxin
Type A that is not complexed to any proteins. For all three for-
mulations, the core neurotoxin single-chain protein has a mass
of approximately 150 kDa and is made up of two polypeptide
fragments (a 100-kDa heavy chain, Hc, and a 50-kDa light chain,
Lc) that are linked by a disulfide bond. The neurotoxic effects
occur in four sequential steps:
1. Binding: Hc responsible
2. Internalization: endocytosis into vesicle
3. Translocation: Lc released from vesicle into cytoplasm of presyn-
aptic neuromuscular junction
4. Intracellular proteolysis: Lc cleaves S ARE protein (toxin A
cleaves S AP-25, whereas toxin B cleaves synaptobrevin), pre-
venting vesicles containing acetylcholine (ACh) from fusing with
the presynaptic membrane and thus blocking the release of this
neurotransmitter
Thus the toxin produces chemodenervation by preventing the
release of acetylcholine at the neuromuscular junction of the
peripheral nervous system and at ganglionic nerve terminals of
the autonomic nervous system. This occurs within 6 to 36 hours
of exposure to the muscle, yet the clinical effects of flaccid paral-
ysis are not seen for several days, possibly related to spontaneous
release of ACh at the neuromuscular junction. The maximum
effect of the toxin takes place 7 to 14 days after injection, and the
extent of muscle paralysis and atrophy correlates directly with the
amount of toxin injected.
At therapeutic doses the toxin produces paralysis limited to
the injected muscle; however, the toxin has the potential to cause
paralysis or weakness of adjacent muscles by diffusion or spread.
These terms are oftentimes erroneously confused.
1. results from toxin moving down its concentration gra-
dient and is related to the total dose of toxin and local receptor
concentration.
2. Spread is the physical pushing of toxin from the area of injection
and is related to the solution volume and injection technique.
Therefore, diffusion and/or spread are a function, in part, of
concentration gradient and physical force and may not be attrib-
utable to the specific formulation of toxin. This concept has been
supported by multiple studies showing no difference in diffusion
between the different brands or neurotoxin, while other research
and clinical experience has opposed this concept, suggesting
there may be some subtle differences in what some call field of
effect, whereby there is an apparent and differential effect on
neighboring muscles with seemingly equivalent dosing.
138
Treatment with botulinum toxin has a temporary effect that
last an average of 3 to 4 months. There is ongoing turnover of neu-
romuscular junctions, so muscle function gradually returns. For
unknown reasons, even with high doses of toxin, it is estimated
that paralysis occurs in only 80 of the muscle; although the
functional 20 is not clinically relevant, it may have a protective
effect on the muscle. It is believed that axonal sprouting and reori-
entation of muscle fibers prevent permanent paralysis of muscles
that are treated repeatedly.
15.6 Toxicity
The lethal dose of Botox Cosmetic is measured in units, with
1 unit being the lethal dose of toxin causing death in 50 of a
group of 18- to 20-g female Swiss ebster mice within 3 days of
intraperitoneal injection. The median lethal dose (LD50) has been
estimated to be 2,700 units in a 70-kg human, based on the same
LD50 of approximately 40 units/kg in primates. Species-specific
sensitivity to the toxin precludes a precise calculation of the
human LD50. It is not known what normal dose should be to pre-
vent toxicity; however, single doses exceeding 500 units of Botox
Cosmetic may produce acute symptoms and signs of botulism.
Botulinum toxin is one of the most potent and neurospecific
toxins known. It is also one of the most studied, discussed, and
published substances used in medicine, and it has a long track
record of safety. It is estimated that in a 70-kg adult, the lethal
dose of crystalline botulinum type A would be approximately 0.09
to 0.15 mg by the intravenous or intramuscular route, 0.7 to 0.9 mg
by inhalation, and 70 mg if ingested orally. Considering the type
available in the United States, it would be inaccurate to consider it
as a potential bioterrorism agent (each vial contains only 0.3 of
the estimated lethal inhalation dose for humans and 0.005 of the
estimated lethal oral dose). The toxin does not penetrate intact
skin, and person-to-person transmission does not occur.
The maximum total recommended dose of Botox Cosmetic is
300 to 400 units at any one session and not more than 400 units
over a 3-month period. The maximum dose of Dysport is 1,000
units over a similar period. ( eep in mind that these higher doses
are almost exclusively utilized for noncosmetic purposes.) The
dosage should be adjusted for the following reasons:
1. Anatomic location
2. Muscle mass
3. Age
4. Sex of patient
5. Desired outcome/effect
6. Patient prior experiences/dose of toxin
7. Condition being treated
8. Time interval since last exposure to toxin
15.7 Dilution/Storage
The FDA approval for treatment of with glabellar lines is based
on a dilution of 2.5 mL of 0.9 preserved saline into a 100-unit
vial of Botox Cosmetic and Xeomin or 2.5 mL and 1.5 mL dilutions
into 300-unit vial of Dysport. In practice, there is a large variety
of dilutions that are acceptable and commonly used, as the
injection technique is much more important than the specific

dilution. Most dilution occurs in the range of 1.0 mL to 4 mL.
Large dilutions with lower concentration of toxins require larger
volumes of injection to achieve the desired result. Utilizing a
higher level of dilution can increase the potential for spread (not
diffusion) of the toxin to neighboring muscles. It has also been
suggested that the higher volume of injection may also give a
shorter duration of effect, but this is anecdotal and longevity
may perhaps relate more largely to dosing than to dilution. For
this reason, a low volume and high concentration of botulinum
toxin is preferred for more targeted treatments.
The manufacturer recommendation for diluent for all of the
neurotoxins is nonpreserved 0.9 sodium chloride (based only on
the methods utilized in the registration trials); however, we (and
many) prefer to use benzoic acid–preserved (bacteriostatic) 0.9
saline. In addition to the bacteriostatic properties that help avoid
bacterial contamination, the preserved saline has been shown to
decrease procedural pain during injection in randomized con-
trolled trials. The fragility of the toxin also raises concern during
reconstitution. It is thought that agitation or foaming during
reconstitution can degrade the toxin and decrease the potency
of the injection, but this concept as well has never been proven.
Although studies have shown this is not necessarily true and the
toxin is less fragile than previously anticipated, it is still our prac-
tice to avoid turbulence and foaming by reconstituting the toxin
with a larger-bore (18-gauge) needle.
An additional area of controversy is the length of time neu-
rotoxin can be stored after reconstitution. The manufacturer
recommendations are as follows:
• Botox Cosmetic: Unopened vials require refrigeration at
2 to 8 C (35.6–44.4 F) for up to 36 months; reconstituted vials
should be used within 24 hours
• Dysport: Unopened vials require refrigeration at 2 to 8 C
protected from light for up to 12 months; reconstituted vials
should ideally be used within 4 hours, 24 hours maximum
• Xeomin: Unopened vials can be stored at room temperature or
in a refrigerator or freezer for up to 36 months; reconstituted
vials should be used within 24 hours
• Myobloc: Unopened vials should be stored in refrigerator;
do not freeze or shake; diluted vials should be used within 4
hours, as the formulation does not have a preservative
The length of time a neurotoxin can be stored after reconstitu-
tion has been studied numerous times, with strong evidence to
suggest it can be stored up to 4 to 6 weeks in the refrigerator with-
out any change in potency of the toxin. e make every attempt to
use the toxin within 48 hours after reconstitution but would not
hesitate to use it if stored longer, as long as it is kept refrigerated.
15.8 Aesthetic Indications and
Contraindications
hen discussing the use of botulinum toxin for aesthetic facial
rejuvenation, it is important to decipher between the FDA-
approved indications and the numerous off-label uses of the
toxin. The FDA approved aesthetic uses are as follows:
u inum in In e i n r i e u en i n
• Botox Cosmetic:
1. Temporary treatment of moderate to severe glabellar lines as-
sociated with corrugator and/or procerus muscle activity
2. Moderate to severe canthal lines associated with orbicularis
oculi activity
3. Moderate to severe forehead lines associated with frontalis
muscle activity
• Dysport:
Temporary improvement in appearance of moderate to severe
glabellar lines associated with procerus and corrugator muscle
activity in adult patients 65 years old
• Xeomin:
Temporary improvement in appearance of moderate to severe
glabellar lines with corrugator and/or procerus muscle activity
• euveau:
Temporary improvement in the appearance of moderate to
severe glabellar lines associated with corrugator and/or pro-
cerus muscle activity in adult patients
• Myobloc
The off-label uses of botulinum toxin are far more encompass-
ing and address the muscles in all regions of the face. Although
often discussed in terms of upper, middle, and lower face, it is
always important to treat the face/patient as a whole and tailor
the treatment to a patient’s specific anatomy. Common indications
and their target muscle for treatment with botulinum toxin are as
follows, divided by facial region.
• Upper face: Glabellar lines (procerus, corrugator, orbicularis
oculi), horizontal forehead lines (frontalis), lateral canthal
lines/crow’s feet (orbicularis oculi), brow shape and position
(lateral: orbicularis oculi; medial: procerus, corrugators, orbi-
cularis oculi, depressor supercilii)
• Midface: Infraorbital rhytids (orbicularis oculi), eye aperture
(orbicularis oculi), nasal flare (dilator nasalis), nasal tip ele-
vation (depressor septi nasi), nasal oblique lines/bunny lines
(nasalis, levator labii superioris alaeque nasi, depressor nasi
septi), excessive gingival show/gummy smile (convergence of
levator labii superioris alaeque nasi and zygomaticus minor
with insertion of levator labii superioris)
• Lower face: Downturned commissures (depressor anguli oris),
chin cobblestoning (mentalis), masseter hypertrophy (mas-
seter), perioral rhytids (orbicularis oris), platysmal banding
(platysma)
• Additional uses are following surgical procedures to improve
the result and/or allow healing to occur without tension
caused by movement of neighboring muscles, and in combi-
nation with other facial rejuvenation procedures (fillers/peels/
lasers) and scarring prophylaxis
The contraindications are as follows:
1. Patients with known hypersensitivity to any of the ingredients
in the formulation (botulinum toxin, albumin, sodium chloride)
2. Active infection at the injection site
139
 III Nonsurgical Cosmetic Treatments
3. Patients with a neuromuscular disease (myasthenia gravis,
Eaton-Lambert syndrome, motor neuron disease)
4. Patient with allergy to cow’s milk protein (Dysport)
5. Pregnant or lactating women
6. Patients on other medications that interfere with neuromuscu-
lar transmission (certain antibiotics, including aminoglycosides,
penicillamine, quinine, calcium channel blockers, neuromuscu-
lar blocking agents, anticholinesterases, magnesium sulfate, and
quinidine) that may increase paralytic effect of toxin
7. Patients with unrealistic expectations or poor understanding of
effects of toxin
8. Patients on anticoagulation/antiplatelet therapy or a propen-
sity to bleed from a medical condition (hemophilia; relative
contraindication)
Botulinum toxin treatment in the elderly (over 65 years old) has
been shown to be safe, but these patients are often not ideal candi-
dates for toxin treatment alone. ith age, patients experience an
increase in tissue elasticity as well as a loss of soft tissue and bony
volume. Rhytids are less likely a result of hyperdynamic muscles
and more likely from loss of volume, which botulinum toxin does
not address. Because of the greater frequency of comorbid medi-
cal conditions, if it is decided that an elderly patient is appropriate
for botulinum toxin treatment, we recommend starting with low
initial doses due to changes in muscle mass and function with age.
15.9 The Ideal Patient
1. Has a good understanding of the cause of his or her aesthetic
issue and the potential role of botulinum toxin in improving it
2. Is aware that botulinum toxin’s mechanism of action is to address
hyperkinetic muscles of facial expression, causing them to relax
and therefore releasing the overlying wrinkle rather than filling
it in or decreasing its depth
3. Has relatively isolated defects that are not necessarily the result
of overlapping conditions (dermal or subcutaneous fat atrophy,
excess skin) in addition to the rhytids
4. Understands the chronology of botulinum toxin’s onset of action
and need for continued dosing to maintain effects
5. Understands the value of different surgical and nonsurgical
treatments, how these treatments can be used in combination to
improve their aesthetic and address different issues, and the var-
ious timelines of their effectiveness (botulinum toxin: 3 months,
fillers: 6 months or more, surgery: even longer)
15.10 Pertinent Anatomy
Many facial changes associated with aging are in part related to
facial animation. It is obvious that facial cosmetic procedures
are destined for regression if these known causes are not
addressed. The application of botulinum toxin to modify facial
expression can be used for line reduction, for facial shaping, and
as an adjunct to a variety of plastic surgery procedures. A clear
understanding of the facial musculature anatomic influence on
facial animation and subsequent aging is essential to delivering
the most appropriate application of botulinum toxin. A patient’s
specific anatomy and functional disposition will dictate where
treatment will be most effective.
140
An injector must have a thorough understanding of the facial
muscles, especially those in which botulinum toxin is most
commonly injected. The use of botulinum toxin for rhytids or to
reshape or reposition structures requires an in-depth mastery
of the function and location of the muscles of the face, their
interaction with other muscles (agonist versus antagonist), and
the unique anatomic features of each region of the face. The
muscles must be precisely located by having the patient animate,
and the amount and depth of toxin injection must be tailored to
the patient-specific strength of animation and muscle mass. The
effects of facial aging may likely have more to do with different
animation patterns rather than the actual anatomic component.
The most animated and facially expressive persons seem to exhibit
more facial lines, so these patients should be treated differently
than less expressive individuals (Fig. 15.1).
15.11 Pretreatment Assessment
When a patient presents for consideration of management of
facial aging, it is important to determine treatment options that
specifically address the patient’s desired outcomes and pathol-
ogy. Patients who are candidates for aesthetic improvement with
botulinum toxin range from those who are not quite ready for
surgery because of early age, emotional disposition, multiple
previous surgical procedures, or financial conditions to those
who desire improvement of dynamic and functional facial lines
and furrows, facial asymmetries, and improvement in facial
shape. The patient must be evaluated in three dimensions, noting
the quality of skin, dynamic and static rhytids, and areas of soft
tissue loss or malposition.
A thorough history should take place during the initial consul-
tation, with focus on patient expectations and desired outcomes;
the patient’s current understanding of how botulinum toxin
works; past medical, surgical, and medication history; and any
previous botulinum toxin injections. The patient is asked in front
of a mirror what area or issue is the cause of concern. This allows
the injector and patient to come up with a treatment plan together
while also providing an opportunity for patient education about
what things can and, more important, cannot be treated with bot-
ulinum toxin alone. The patient is asked to frown (glabellar lines),
squint or smile (lateral canthal lines), or look surprised (forehead
lines) to accentuate dynamic facial rhytids. Facial asymmetries
should be pointed out at this time, and photodocumentation is
recommended for future reference. It is also important to identify
any ptosis masked by an overactive frontalis so as to avoid treat-
ment in this area, which will lead to ptosis posttreatment.
As with any medical procedure, patients are required to sign
an informed consent document before treatment. Benefits and
limitations of botulinum toxin treatment are discussed, and alter-
native and supplemental treatments that could benefit the patient
are reviewed. It is important to explain the role of botulinum
toxin, the intended results, the length of time before results are
typically seen, the average length of its effectiveness, and potential
complications. It is emphasized that patients should return to the
clinic within 2 weeks if they have any concerns about asymmetry,
complications, or therapeutic failures. A patient is then given an
opportunity to have any additional questions answered.

Fig. 15.1 Pertinent facial muscular anatomy most commonly injected with botulinum toxin.
15.12 Pretreatment Planning
Prior to injection, all areas of the face that are going to be
treated are cleansed with alcohol to decrease the bacterial load
on the skin and remove makeup. Although we prefer separating
neurotoxin and soft tissue filler treatments (we prefer to treat
with neurotoxin and then have patient follow up 2 weeks later
to address residual soft tissue issues), if both are going to be
injected in the same session, the skin should be cleansed
with chlorhexidine. Every effort should be made to reduce
patient discomfort during injection. The patient is offered
cold compresses, topical anesthesia if requested, for which the
smallest-gauge needle is selected (30-gauge or higher) to lessen
the discomfort. The patient is injected in the upright position,
with the chair placed at a height that is most comfortable for
the injector.
Marking the areas or points to be injected is unnecessary and
inefficient. The patient is an active participant during botulinum
toxin treatment and is asked to exaggerate facial expressions to
guide injection sites. If the patient is going to be injected intra-
operatively, markings can be made in the preoperative holding
area.
u inum in In e i n r i e u en i n
15.13 Injection Technique
The toxin is reconstituted with 2 to 4 mL of 0.9 preserved
saline. The toxin is then drawn into a single-use plastic syringe
with an 18-gauge needle to minimize turbulence, or directly
into an insulin syringe. Preferably, a 32-gauge needle is used for
injection. The skin is then cleansed with alcohol and allowed to
dry completely prior to injection. ith the patient in an upright,
seated position, each muscle of concern is identified and isolated.
The intended muscle is isolated and stabilized or grasped with
the injector’s nondominant hand. Although there are many vari-
ations in injection technique, we have found our technique to be
safe and reliable while providing consistent results, so it will now
be discussed organized by target muscle/indications (Fig. 15.2).
15.14 rge -S e i ing
Recommendations and Pearls
The following section will discuss our dosing recommendations
and technical pearls for injection of Botox Cosmetic or Xeomin
into specific areas. It is recommended that dosing of Dysport be
2.5 to 3 times more units per muscle area.
141
 III Nonsurgical Cosmetic Treatments

Average Treatment
Technique
Muscle Deformity/Aesthetic Concern Patient Concern Depth Dose(Female) Botox
( PHOTOS)
Xeomin:Dypsort
Frontalis Transverse forehead rhytids Surprise lines Subdermal 10–25/30–75

Deep medially, becoming

Corrugator Vertical glabellar rhytids Frown lines 15–25/40–75
superficial at lateral head

Procerus Transverse glabellar rhytids Frown lines Deep 5–10/15–30

Lateral orbital
Lateral orbital rhytids Crow’s feet Superficial (just under dermis) 7.5–15/20–45
orbicularis

Superior orbital
Flat brow, brow ptosis Brow ptosis Superficial (just under dermis) 5–10/15–30
orbicularis

Inferior pre-tarsal Eyelook small/

Decreased eye aperture Very superficial 1–2/4–8
orbicularis squinting

Nasalis Vertical/transverse nasal lines Bunny lines Deep 5/15

Masseter Masseteric hypertrophy Widened jaw Intermediate to deep 25–50/75–150

Vertical peri-oral rhytids: Lip lines/gummy

Orbicularis oris Superficial 5–10/15–30
excessive gingival show smile

Intermediate if treating
Depressor anguli Month always looks midportion of muscledeep
Downturned oral commissures 2.5–7.5/8–20
oris unhappy if treating caudal aspect
over mandible

Mentalis Cobblestoning of chin Bumps on chin Deep 5–10/15–30

Vertical band on 15–25 per band/

Platysma Platysmal bands Intermediate
neck 40–75 per band

Fig. 15.2 Graph of injection target/depth/dosing.

15.14.1 Glabellar Lines 15.14.2 Crow’s Feet

(Corrugator and Procerus) (Lateral Canthal Lines)
Dosing Recommendations Dosing Recommendations
Product labeling recommends 20 units divided into five equal Eight to 16 units on each side of the face, usually three to four
injection points; we recommend starting with 10 to 20 units on injection points per side.
average and going up to 30 or even 40 in those with stronger
muscles (particularly men or otherwise refractory patients).
Technical Pearls
Patients also may require fewer injection points or sometimes
ote regional veins and avoid them; do not inject deep, or it will
as many as seven or eight injection points, and particularly two
cause bruising. Always inject with the needle pointing away
injections to the procerus, depending on individualized activity.
from the eye. Insert needle tangential and superficial to skin
This is all based on a good preinjection assessment.
surface to decrease pain.

Technical Pearls
Identify or occlude supratrochlear vessels when injecting medial/
15.14.3 Lower Eyelid
deep corrugator. Identify the supraorbital notch to avoid the
supraorbital artery. Follow the tail of the muscle and inject more Dosing Recommendations
superficially as you move laterally. Inject deep, directly into the 0.5 unit per eyelid starting dose in two points: the central lower
muscle belly of the procerus. Too superficial of an injection at the eyelid and at the lower eyelid at the lateral canthus; maximum
lateral corrugator may inadvertently target the frontalis muscle, 2.5 units per eyelid.
causing medial brow ptosis.

142

Technical Pearls
Inject just subciliary or at junction of tarsal plate and orbicularis
oculi when appropriate; avoid this injection in patients with dry
eyes, loose lower lids, and scleral show. Stabilize the head with
the nondominant hand to avoid patient movement.
15.14.4 Upper Eyelid
Dosing Recommendations
0.5 units per eyelid starting dose in two points: central upper
eyelid and at upper eyelid at the lateral canthus; maximum 2.0
units per eyelid.
Technical Pearls
Inject very superficial, just above the lashes at the far medial
and far lateral upper eyelid. Avoid this technique in patients
with significant dry eye symptoms. Stabilize the head with the
nondominant hand to avoid patient movement.
15.14.5 Horizontal Forehead Lines
Dosing Recommendations
On-label dosing recommends 20 units in five locations starting
at midforehead and cephalad to this. This paradigm will work for
many but not all, and clinical assessment will dictate optimum
injection points and dosing. General dosing may be very variable,
dosing from 4 to 20 units, but usually between 10 and 20; number
of injection sites varies greatly.
Technical Pearls
Goal is to reduce or remove lines while avoiding a frozen appear-
ance. hen treating frontalis, you often need to treat the glabella
as well to avoid ptosis. Stay 1 to 2 cm above orbital rim. Inject
laterally, sometimes past temporal fusion line, to avoid Spock
eye. Evaluate patient beforehand to make sure the patient is not
using the frontalis to keep the eyebrows elevated.
15.14.6 Lips
Dosing Recommendations
5 units total, 2.5 per side.
Technical Pearls
Inject superficial and symmetrical. Ask patient to pout lips to
target area of most orbicularis recruitment; alter dosing based
on individual experiences. Injection here is often performed in
conjunction with lip fillers or fillers for upper lip fine lines.
15.14.7 Dimpled Chin
Dosing Recommendations
4 to 5 units with two injection sites.
u inum in In e i n r i e u en i n
Technical Pearls
Inject deep at/just above the jawline. A single bullet injection
central to this paired muscle is often both effective and avoids
injection asymmetries.
15.14.8 Depressor Anguli Oris
Dosing Recommendations
2.5 units per side.
Technical Pearls
Two locations can be injected: (1) deep 1 cm lateral to oral com-
missure at jawline or (2) more superficial halfway between the
oral commissure and 1 cm lateral from this at the jawline.
15.14.9 Platysmal Bands
Dosing Recommendations
Variable results and higher risk of adverse events are found in
this area, so there is no recommended dosing. Often at least 2
units are required per injection point, spaced 1 cm along each
band.
Technical Pearls
If you are going to inject in this area, inject superficial (subcuta-
neous) or directly into band in several points along the length of
the band; typically 1 cm spacing.
15.15 Combination/Ancillary
Treatments
As previously stated, most patients seeking facial rejuvena-
tion would benefit from a multimodal approach addressing
all areas that are affected by aging. hile botulinum toxin
injection is an effective treatment for dynamic rhytids caused
by hyperkinetic muscles during facial expression, it is just
one tool in the armamentarium that we have as providers.
The old adage was to treat the upper face with botulinum
toxin, the midface with soft tissue fillers, and the lower face
with a combination of both. After years of experience, it is
becoming clearer that a precise understanding of underlying
pathology will guide which treatments are preferred, and a
more even combination of neurotoxin and filler often gives
the best aesthetic result. hen botulinum toxin is combined
with filler treatment, it tends to prolong the longevity of
the filler by decreasing the metabolism in the surrounding
tissue. Chemical peels, lasers, IPL, and dermabrasion address
more superficial issues such as photodamage, fine rhytids, or
dyschromias. Soft tissue fillers counteract the natural volume
loss and descent that occurs with aging. Excess skin and
dramatic ptosis are best addressed by surgical intervention.
Mastering how and when to combine the different modalities
is the art of facial rejuvenation.
143
 III Nonsurgical Cosmetic Treatments
15.16 Posttreatment Care
Reasons that botulinum toxin treatments have become popular
and widespread include the lack of posttreatment restrictions
and minimal to no social downtime. After injection, any site
that is noted to be bleeding is immediately compressed with
moistened gauze to avoid ecchymosis. The patient is offered cold
compresses to help minimize bruising and swelling. ithin 30
minutes, most patients have no noticeable sequelae of having a
procedure. The patient essentially has no restrictions. Some pre-
viously recommended restrictions (remaining upright, avoiding
lifting, contracting treated muscles to increase toxin takeup,
avoiding air travel, avoiding exercise) have never proven to
increase or decrease the effectiveness of the treatment or change
the rate of adverse events. hen possible, it is preferred that
patients avoid anticoagulants, nonsteroidal anti-inflammatory
drugs ( SAIDs), and other drugs that could increase bruising.
15.17 Complications
hen botulinum toxin is injected appropriately, the rate of compli-
cations is low, but an injector must be aware of the most common
complications and be able to treat or manage them. Complications
can be thought of in three categories: local complications from the
injection, inadvertent muscle paralysis, and therapeutic failures.
15.17.1 Local Complications from
Injection
One could argue that local complications are nothing more than
normal sequelae of having any injection. These include injection
site pain, swelling, edema, erythema, rash, bruising, ecchymosis,
tenderness, headache, and short-term hyperesthesias. Avoidance
of anticoagulants, aspirin, and herbal medications that can thin
the blood for 7 to 10 days prior to injection can help reduce
ecchymosis and bruising. hile injecting, holding immediate
pressure over any site that bleeds will also ameliorate some of
these complications. hen injecting the lateral canthal lines, it
is important to recognize and avoid any superficial vasculature.
Last, providing cold compresses after treatment can decrease
these complications. Local complications are usually self-limited
and resolve within a short period of time.
15.17.2 Inadvertent Muscle Paralysis
The most notable and discussed complications occur when neigh-
boring muscles are inadvertently chemodenervated by diffusion,
spread, or imprecise injection of toxin. Some common examples
of this are lip asymmetries and imbalances of the lower face
(6.9 ), brow ptosis (3.1 ), and blepharoptosis (2.5 ). A thorough
understanding of the agonist and antagonist muscles of the face
can guide treatment in each of these situations. hen asymme-
tries are noted, it is crucial to review preinjection photos to see
whether they existed prior to the intervention. There are three
types of eyelid ptosis :
1. Drug-induced eyelid ptosis results from diffusion or spread of
the toxin to the upper eyelid elevators after injection of the cor-
144
rugator, crow’s feet, or orbicularis oculi. For mild to moderate
degrees of upper eyelid ptosis, the treatment is typically topical
medications/eye drops that stimulate Muller’s muscle (adrener-
gics), such as naphazoline/pheniramine ( aphcon A, Alcon Lab-
oratories, Fort orth, Texas) eye drops three to four times daily
or apraclonidine 0.5 after consulting with the patient’s oph-
thalmologist (drops should not be used in patients with glauco-
ma). These drops provide approximately 1 to 2 mm of elevation
and require continued use for sustained effect. For more severe
lid ptosis, this treatment might be ineffective. Mild to moder-
ate degrees of upper eyelid ptosis usually gradually resolves in
about 2 to 4 weeks. A clue to a prediction of resolution can be
the time of onset postinjection. Late and mild onset, not noted
for at least a week or so, usually portends a quicker recovery,
while severe or complete ptosis occurring in a few (2–3) days
after injection more often suggest that the ptosis might last as
long as the beneficial intended cosmetic effect (months ). The
severe cases typically do not respond well to eye drops.
2. Preexisting eyelid ptosis reflects the unmasking of preexisting
upper lid ptosis that has been compensated for by frontalis
muscle activity; treating the frontalis muscle with neurotoxin
unmasks this. Ideally, this would be recognized as pretreat-
ment by having the patient close and relax the eyes; then
the provider stabilizes the frontalis muscle before having the
patient slowly open the eyes. However, if this complication
does occur, treatment with adrenergic eye drops may be indi-
cated and helpful.
3. True brow ptosis is caused by loss of frontalis muscle activity,
which is attributed to injection of the lower border of the fron-
talis muscle one fingerbreadth below or above the brow. Patients
may present complaining of heavy eyelids despite true eyelid
ptosis, or inability to put on eye shadow. The correct treatment
is avoidance. Once encountered, treating the antagonists brow
depressor orbicularis oculi at the M point can help. Fortunately,
this complication usually gradually resolves in 2 weeks.
15.17.3 Therapeutic Failures
Therapeutic failures can consist of unacceptable or minimal
results after neurotoxin as judged by the patient, the provider, or
both. If presenting within the first 2 to 3 weeks after initial injec-
tion (as stated before, we prefer our first-time injection patients
to return at 2 weeks for evaluation), these failures can be easily
addressed. If asymmetries exist or the patient desires a denser
chemodenervation, reinjection of more neurotoxin may resolve
the issue. The injector must decide whether the asymmetry is
due to the target muscle not being effectively treated or to its
being overinjected. In the former situation, reinjecting of more
neurotoxin is the treatment, while in the latter, injection of the
muscle’s antagonist is indicated.
Rarely, patients return to the office having or claiming to have
had no effect of the treatment. This situation may occur for sev-
eral reasons: for complete nonresponse (extremely rare), either
the neurotoxin was not handled appropriately or the patient has
a previous immunologic reaction to botulinum toxin. It has been
suggested that the immunologic reaction may be attributable to
human serum albumin and results in circulating antibodies. The
development of antibodies seems to correlate with an increasing
number of injections, frequency of treatment, and total cumula-
tive dose; the reported incidence of this problem has gone down
dramatically since the reduction of protein in the formulation in
1997. Both of these can be tested by reinjection with botulinum
 u inum in In e i n r i e u en i n

neurotoxin A into one side of the forehead. If this treatment is

effective, it was likely an issue with toxin storage, reconstitution,
or injection. A theoretical alternative cause is that they patient
had a prior, subclinical exposure to botulinum toxin (botulism).
If the patient once again has no response, the patient can be
treated with an alternative neurotoxin, including botulinum toxin
B (Myobloc).
15.18 Outcomes
Botulinum toxin injection has an excellent safety and tolerability
profile across a spectrum of aesthetic and therapeutic applica-
tions. hen it is injected appropriately for the right indications,
it is nearly 100 effective. Some of the keys to successful out-
comes are as follows:

a b

c d

e
Fig. 15.3 Views of 40-year-old woman pretreatment (left image in each view) and 3 weeks post combined treatment with 3.75 units of Botox
Cosmetic to forehead, glabella, and tail of brow as well as Juv derm Ultra Plus (Allergan, Irvine, CA) to her forehead, nasolabial folds, and commis-
sures (right image in each view). (a) Frontal views. (b) Right oblique views. (c) Left oblique views. (d) Right lateral views. (e) Left lateral views.

145
 III Nonsurgical Cosmetic Treatments
• Comprehensive pretreatment discussion with patient to set
reasonable patient expectations
• Proper storage, reconstitution, and handling of toxin before
and during treatment
• Using a patient’s functional anatomy to guide injections and
dosing
• Thorough understanding of anatomy and avoidance of danger
zones that can lead to ptosis or inadvertent chemodenervation
of adjacent muscles
• Avoidance of masklike countenance from excessive paralysis,
frozen look
• Combining botulinum toxin with other treatments (fillers,
peels, surgery) to address the aging process in three dimensions
a b
c d
Fig. 15.4 Close-up view of glabella and nasal dorsum of the patient
shown in Fig. 15.3. (a) Pre Botox treatment during animation with
evidence of multiple vertical rhytids along the nasal dorsum. (b)
Posttreatment view during animation with decreased vertical rhytids.
(c) Pretreatment view in repose. (d) Posttreatment view in repose.
a b
Fig. 15.6 A 59-year-old woman in repose. (a) Planned injection
points along anterior platysmal bands. (b) At 1 day post treatment of
platysmal bands with neurotoxin.
146
15.19 Patient Results
Fig. 15.3, Fig. 15.4, and Fig. 15.5 show various views of a 40-year-
old woman who received combined treatment with 3.75 units
of Botox Cosmetic to her forehead, glabella, and tail of brow as
well as uv derm Ultra Plus (Allergan, Irvine, CA) filler to her
forehead, nasolabial folds, and commissures.
The 58-year-old woman in Fig. 15.6 and Fig. 15.7 received neu-
rotoxin injections into her platysmal bands. One day posttreat-
ment, the bands are smoothed out even in a grimace. Similarly,
the 59-year-old woman in Fig. 15.8 showed strong and asymmet-
ric platysmal bands; 2 weeks post Botox Cosmetic injection, the
bands are much less evident and more symmetric.
The 47-year-old woman in Fig. 15.9 showed perioral rhytids,
some even in repose. After upper lip injection with 3 units of
a b
c d
Fig. 15.5 Close-up view of forehead and glabella of the patient shown
in Fig. 15.3. (a) Pre Botox treatment during frontalis animation with
multiple deep transverse rhytids. (b) Post Botox treatment during
frontalis animation with resolution of transverse rhytids. (c) Pre Botox
treatment during glabellar animation with vertical rhytids (“11 lines”).
(d) Post Botox treatment during glabellar animation with resolution of
vertical lines.
a b
Fig. 15.7 The woman in Fig. 15.6 with animation. (a) Planned injection
points along length of bands. (b) At 1-day post treatment with
neurotoxin resulting in softening of bands.

Botox Cosmetic, at 2 weeks the static perioral rhytids were gone
and the dynamic ones much less evident.
The 52-year-old woman in Fig. 15.10 and Fig. 15.11 received
treatment of forehead, glabella, and crow’s feet with 50 units of
Botox Cosmetic. At 16 days post treatment, forehead rhytids and
crow’s feet were smoothed out, but there was distinct right brow
ptosis.
a b
c d
Fig. 15.8 A 58-year-old woman who received Botox Cosmetic injec-
tions to platysmal bands. (a) Pretreatment frontal view of platysmal
bands on animation. (b) Frontal view 2 weeks post neurotoxin treat-
ment with near resolution of medial banding. (c) Pretreatment lateral
view on animation. (d) Posttreatment lateral view on animation.
a b
Fig. 15.10 A 52-year-old woman who received treatment of forehead,
glabella, and crow’s feet with 50 units of Botox Cosmetic. Frontal view
in repose. (a) Pre treatment. (b) At 16 days posttreatment, revealing
right brow ptosis.
u inum in In e i n r i e u en i n
The 49-year-old woman in Fig. 15.12 and Fig. 15.13 under-
went treatment of forehead, glabella, and lateral orbit with 37.5
units of Botox Cosmetic. The treatment has nearly resolved the
pronounced rhytids in her forehead and glabella that appear in
animation.
a b
c d
Fig. 15.9 A 47-year-old woman with static and dynamic perioral
rhytids treated with 3 units of Botox Cosmetic to the upper lip. (a)
Pretreatment of upper lip in repose with early static perioral rhytids.
(b) At 2 weeks post treatment in repose, showing resolution of rhytids.
(c) Pretreatment of upper lip with pursing of lips, showing deep peri-
oral rhytids. (d) At 2 weeks post treatment with lip pursing, showing
softening of perioral rhytids.
a b
Fig. 15.11 Close-up view of brows of the patient in Fig. 15.10. (a)
Pretreatment. (b) At 16 days post treatment, with evidence of right
brow ptosis.
147
 III Nonsurgical Cosmetic Treatments

a b

c d

a b

e
Fig. 15.12 Views of 49-year-old woman pretreatment (left image
in each view) and 2 weeks post treatment of forehead, glabella, and
lateral orbit with 37.5 units of Botox Cosmetic (right image in each
view). (a) Frontal views in repose. (b) Right oblique views. (c) Left
oblique views. (d) Right lateral views. (e) Left lateral views. c d
Fig. 15.13 Animation views of the patient in Fig. 15.12. (a)
Pretreatment animation view of forehead with transverse rhytids.
(b) Posttreatment animation view of forehead with near resolution
of rhytids. (c) Pretreatment animation view of glabella with vertical
rhytids. (d) Posttreatment animation view of glabella with near
resolution of vertical rhytids.

148

Clinical Caveats
Suggested Reading
• A thorough conversation with your patient prior to injection
with botulinum toxin, explaining the risks, benefits, and
limitations, is crucial for setting patient expectations.
• The injector as well as the office staff should be trained on
storage and reconstitution of the product.
• The injector must have a comprehensive understanding of
the different available products and recognize that they are
not interchangeable on a unit-for-unit basis.
• Photodocumentation can help guide pre- and postprocedural
discussions.
• A 30-gauge needle or smaller should be used to minimize
patient discomfort.
• Reconstitution with preserved 0.9% saline has been shown to
decrease pain during injection.
• Higher concentration of toxin and lower volume injection is
preferred.
• Avoidance of the “frozen” or masklike facies by overinjection.
• Inject into the mass of the muscle, not the rhytid itself.
• Staying 1 fingerbreadths above the superior orbital rim can
help avoid brow ptosis.
• Treatments should be patient specific based on their functional
anatomy and not “cookie cutter”; the risks and benefits of
injection sites should be weighed for each individual patient.
• Recognize treatment failures or complications early and treat
appropriately.
u inum in In e i n r i e u en i n
1 Carruthers D, Carruthers A. Treatment of glabellar frown lines with C. botuli-
num-A exotoxin. J Dermatol Surg Oncol 1992;18(1):17–21
2 lein A, Carruthers A, Fagien S, Lowe . Comparisons among botulinum toxins:
an evidence-based review. Plast Reconstr Surg 2008;21(6):413e–422e
3 Lorenc P, enkel M, Fagien S, et al. A review of onabotulinumtoxinA (Botox).
Aesthet Surg J 2013; 33(1, Suppl)9S–12S
4 ahai F, Lorenc P, enkel , et al. A review of abobotulinumtoxinA (Dysport).
Aesthet Surg J 2013; 33(1, suppl)13–17
5 Lorenc P, enkel M, Fagien S, et al. IncobotulinumtoxinA (Xeomin): back-
ground, mechanism of action, and manufacturing. Aesthet Surg J 2013; 33(1,
Suppl)18S–22S
6 Lorenc P, enkel M, Fagien S, et al. Consensus panel’s assessment and recom-
mendations on the use of 3 botulinum toxin type A products in facial aesthetics.
Aesthet Surg J 2013; 33(1, Suppl)35S–40S
7 Rzany B, Ascher B, Avelar R, et al. A multicenter, randomized, double-blind,
placebo-controlled single-dose, phase III, non-inferiority study comparing
prabotulinumtoxinA and onabotulinumtoxinA for the treatment of moderate to
severe glabellar lines in adult patients. Aesthet Surg J 2019 Epub ahead of print
https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjz110/5428816 .
Accessed une 7, 2019
8 Sundaram H, Signorini M, Liew S, et al; Global Aesthetics Consensus Group.
Global aesthetics consensus: Botulinum toxin type A evidence based review,
emerging concepts, and consensus recommendations for aesthetic use, including
updates on complications. Plast Reconstr Surg 2016;137(3):518e–529e
149
 III Nonsurgical Cosmetic Treatments
16 Soft-Tissue Fillers
Vic A. Narurkar
Abstract
Soft tissue fillers continue to grow in popularity due to their ease
of use, predictability, and low complication profile. e continue
to a broadening of the products available, giving both patients
and physicians more options to help achieve their goals. Their
use extends beyond simple line filling and now encompasses the
spectrum of volume enhancement and superficial treatment of
the face and neck. As with any treatment, a thorough history
and physical exam, including a detailed analysis, is essential to
determine what is best for each patient.
Keywords
soft tissue filler, uv derm, Restylane, Belotero, Sculptra, Radiesse,
nonsurgical rejuvenation, liquid facelift, hyaluronic acid
16.1 Introduction
The past ten years have seen a revolution in minimally invasive
and noninvasive approaches to facial and nonfacial rejuvena-
tion. At the forefront of this revolution is the development of a
palette of soft tissue fillers, primarily for facial rejuvenation and
more recently for nonfacial areas such as the neck, decollet ,
and buttocks. The trend in soft tissue fillers has shifted from
isolated filling of lines to a more global approach in rebalancing
various anatomic areas, as well as the development of fillers
in various classes and different biologic characteristics. This
allows the physician to tailor treatments in a more precise
and predictable manner. This chapter will review the various
types of materials used for soft tissue augmentation. The word
filler is generally used for these materials, but many are more
appropriately named devices, as their effects are beyond simply
filling in areas of volume deficit. Table 16.1 summarizes the
current U.S. Food and Drug Administration (FDA)-approved soft
tissue fillers.
16.2 Patient Assessment
Appropriate patient assessment is essential to optimize treat-
ment with soft tissue augmentation. Cultural/ethnic factors,
gender, and age-related concerns are all critical in creating a
treatment algorithm. hile there may be established ideals
of facial beauty, the consultation should be individualized to
determine patient goals. This includes a thorough medical
history, patient expectations, and budgetary concerns. In addi-
tion to age-related volume loss, factors such as acne, traumatic
and surgical wounds, facial asymmetries, and conditions such
as lipodystrophy from human immunodeficiency virus (HIV)
infection should be taken into consideration. Finally, realistic
goals that can be achieved with soft tissue augmentation should
150
be discussed in detail, as well as the use of combination ther-
apies, surgical and nonsurgical, that can optimize these goals.
The main goal is to create symmetry and balance between the
upper, mid, and lower face/neck areas, and fillers play a critical
role in accomplishing these goals. Table 16.2 summarizes the
etiologies of facial aging and the corresponding noninvasive
treatment modalities. They include loss of subcutaneous fat
(in which soft tissue fillers can play a major role), changes in
intrinsic muscles of facial expression (leading to exaggeration
of hyperdynamic rhytids), and loss of skin elasticity (leading
to gravitational changes). Underlying bone and cartilaginous
changes can amplify soft tissue changes but are not listed
in the table, because in general they require more invasive
treatments. Photoaging can contribute to significant changes
in the skin, which soft tissue augmentation and injectables in
general cannot treat. Therefore, a thorough treatment algorithm
needs to be established, carefully delineating the role of fillers
in global rejuvenation.
The upper third of the face primarily has age-related changes
with hyperdynamic rhytids from underlying muscle. Temporal
atrophic changes are where soft tissue fillers play a primary role,
while fillers in the upper face are primarily used in combination
with neuromodulators, such as in deep glabellar lines or deep
forehead rhytids. The midface is an area where soft tissue fillers
have truly revolutionized facial aging. A blunting of the ogee curve
of the midface can produce a more sunken in appearance and
obliteration of the so-called apples of the cheeks. eakening of
the orbital septum can produce protrusion of upper and lower lid
compartments, while in others, loss of periorbital subcutaneous
tissue can result in a skeletonized appearance to the orbits and
prominent tear troughs. Rebalancing of these fat loss areas, starting
first with the midface, can collaterally improve the appearance of
lateral tear troughs. The lower third of the face shows age-related
changes in the neck, lower cheeks, chin, and lips. Rotation of the
chin forward can produce a smaller-appearing face. Blunting of
the jawline and development of jowling can further exaggerate
a squarer, lower face in a woman instead of the ideal oval shape.
Dermal fillers placed along the jawline and chin can redefine
these areas and lead to a more balanced lower face, strengthening
these deficient areas.
The optimal approach to treating the face and neck with soft
tissue fillers is to first start at the temples, then the midface, and
finish with the chin and lower face. Fine lines such as the perioral
rhytids can then be treated to complement facial rebalancing. A
careful knowledge of the rheologic characteristics of fillers as well
as their behavior in vivo will determine appropriate selection of
soft tissue augmentation materials. Areas where greater struc-
tural support is needed, such as the jawline) and midface, require
fillers with higher viscosity, while areas where movement is more
dominant, such as the perioral region, require lower-viscosity
fillers. Finally, cultural, ethnic, and gender considerations need to
be taken into consideration.
 S - i ue i er

Table 16.1 FDA-approved fillers

r de n me m ny rim ry Concentration Anesthetic A- r ed indi i n
m eri
Juvéderm Ultra Allergan HA 24 mg/mL None Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra Plus Allergan HA 24 mg/mL None Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra Plus XC Allergan HA 24 mg/mL 0.3% lidocaine Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Juvéderm Ultra XC Allergan HA 24 mg/mL 0.3% lidocaine Correction of moderate to severe facial
wrinkles and folds (such as NLFs) and into the
lips and perioral area for lip augmentation in
patients > 21 years of age
Juvéderm Volbella XC Allergan HA 15 mg/mL 0.3% lidocaine Injection into the lips for lip augmentation and
for correction of perioral rhytids in patients
> 21 years of age
Juvéderm Vollure XC Allergan HA 17.5 mg/mL 0.3% lidocaine Correction of moderate to severe facial
wrinkles and folds (such as NLFs) in patients
> 21 years of age
Juvéderm Voluma XC Allergan HA 20 mg/mL 0.3% lidocaine Deep (subcutaneous and/or supraperiosteal)
injection for cheek augmentation to correct
age-related volume deficit in the midface in
patients > 21 years of age
Restylane Galderma HA 20 mg/mL None Correction of moderate to severe facial
Laboratories, L.P. wrinkles and folds, such as NLFs, and for
submucosal implantation for lip augmentation
in patients > 21 years of age
Restylane Defyne Galderma HA 20 mg/mL 3 mg/mL Correction of moderate to severe, deep facial
Laboratories, L.P. wrinkles and folds (such as NLFs) in patients
> 21 years of age
Revanesse Versa Revanesse HA 22–28 mg/mL 0.3% lidocaine Correction of moderate to severe facial
wrinkles and folds (such as NLFs)
Restylane Lyft with Galderma HA 20 mg/mL 0.3% lidocaine Correction of moderate to severe facial
lidocaine Laboratories, L.P. wrinkles and folds (such as NLFs)
Restylane Refyne Galderma HA 20 mg/mL 3 mg/mL lidocaine Correction of moderate to severe facial
Laboratories, L.P. hydrochloride wrinkles and folds (such as NLFs) in patients
> 21 years of age
Restylane Silk Galderma HA 20 mg/mL 0.3% lidocaine Submucosal implantation for lip augmentation
Laboratories, L.P. and dermal implantation for correction of
perioral rhytids in patients > 21 years of age
Restylane-L Galderma HA 20 mg/mL 0.3% lidocaine Correction of moderate to severe facial
Laboratories, L.P. wrinkles and folds, such as NLFs, and
submucosal implantation for lip augmentation
in patients > 21 years of age
Sculptra Aesthetic Galderma PLLA 367.5 mg in vial None For use in immunocompetent patients as a
Laboratories, L.P. single regimen for correction of shallow to
deep NLF contour deficiencies and other facial
wrinkles in which deep dermal grid pattern
injection technique is appropriate
Belotero Balance Merz HA 22.5 mg/mL None Correction of moderate to severe facial
Pharmaceutical wrinkles and folds (such as NLFs)
Radiesse Merz CaHa - None Correction of moderate to severe facial
Pharmaceutical wrinkles and folds (such as NLFs) and also for
restoration or correction of the signs of facial
fat loss (lipoatrophy) in patients with HIV
Bellafill (ArteFill in UK Suneva Medical, PMMA beads, 20% PMMA 0.3% lidocaine Correction of NLFs and moderate to severe,
and Australia) Inc collagen, microspheres atrophic, distensible facial acne scars on the
lidocaine 3.5% bovine cheek in patients > 21 years of age
collagen
Abbreviations: CaHa, calcium hydroxyapatite; FDA, U.S. Food and Drug Administration; HA, hyaluronic acid; HIV, human immunodeficiency virus; NLF, nasolabial fold;
PLLA, poly-L-lactic acid; PMMA, polymethylmethacrylate.

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 III Nonsurgical Cosmetic Treatments
Table 16.2 Noninvasive approaches to aging face and neck according
to etiology
Etiology rim ry m d i y
Changes in intrinsic muscles Neuromodulators
of facial expression
Loss of subcutaneous fat Dermal filler
Loss of skin elasticity Noninvasive skin-tightening devices
Photoaging Energy-based devices; skin care and peels
16.3 Techniques
Factors to consider when planning for soft tissue augmentation
include the site to be treated (dermis vs. soft tissue), the type of
filler, and the use of delivery systems (needles, cannulas). Areas
that require deep placement of filler include the temple region;
the zygomaticomalar, anteromedial, and subcutaneous areas of
the midface; the chin; and the jawline. Placement in these areas
is done along the periosteum and/or deep subcutaneous plane.
If superficial placement is performed in these areas, especially
with high-viscosity fillers, unsightly nodules can appear. Areas
to be treated in the deep dermis and superficial subcutaneous
areas include the marionette lines and nasolabial folds (NLFs).
Placement of fillers in the superficial dermis is indicated only in
areas of fine lines, such as the perioral rhytids and superficial
lateral cheek rhytids. The type of filler (to be discussed further
in other sections) is also based on the anatomic location. Areas
requiring more structural augmentation necessitate a thicker
filler, while areas of high motility require a thinner filler. The
use of needles versus cannulas is a hotly debated issue. At the
moment, the majority of commercially available fillers come
prepackaged with needles, some which are often not ideal for the
filler. Cannulas can be used as an alternative to needles and may
be beneficial in areas that have a high risk for vascular injury
(Fig. 16.1), such as the anteromedial cheek, orbital rim, and tear
trough. Alternatively, needles may be preferred to treat dermal
Fig. 16.1 Areas at highest risk of intravascular injury after use of soft
tissue fillers.
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volume issues such as perioral rhytids, lip projection, and/or lack
of volume (Fig. 16.2; Fig. 16.3). While no region of the face is
immune to intravascular injury, certain areas the glabella, nose,
and LF carry with them a higher risk for intravascular injury.
Finally, bruising is reduced but not entirely eliminated with the
use of microcannulas. The main disadvantages of microcannulas
are the lack of precision and often the overuse of filler due to
technique.
Another major advance in the use of soft tissue augmentation
has been the addition of anesthetics to the filler material. The
majority of hyaluronic acid (HA)-based fillers and calcium
hydroxyapatite (CaHa) now are manufactured with lidocaine. This
has virtually eliminated the need to perform local anesthesia with
nerve blocks. On rare occasions, some physicians choose to per-
form infraorbital and mental nerve blocks for lip augmentation.
In addition, materials such as poly-L-lactic acid (PLLA) are diluted
with lidocaine as well to increase comfort. ith the advent of a
variety of classes of fillers to address different anatomic areas,
diluting of fillers is less common. Prior to the development of mul-
tiple classes of fillers, the rheologic characteristics of fillers were
modified by blending the filler with saline and/or lidocaine. This is
done routinely with PLLA, as it comes as a solid material that needs
to be reconstituted. It is also done with CaHa to permit better flow
and, lately, also to create a hyperblended form for volumetric defi-
cits. HA-based fillers are often blended in areas requiring softer
fillers such as the tear trough and perioral rhytids. It is a matter
of controversy whether blending fillers creates a more uneven dis-
tribution of the parent filler versus using optimally manufactured
fillers with different rheologic characteristics.
16.4 Rheologic Considerations
Rheological factors affect the performance of soft tissue fillers,
with emphasis on what happens to fillers when they are exposed
to mechanical stress such as shear deformation and compres-
sion/stretching forces. Viscoelasticity has four main parame-
ters: G (overall viscosity or hardness), G (elastic modulus), G
(viscous modulus), and tan (ratio between viscous and elastic
properties). G alone has been emphasized, but all four factors
are important for all biologic fillers. Cohesivity describes how
fillers behave once they are implanted in live tissue. The strength
of internal adhesion forces is a function of concentration of
filler and the cross-linking and nature of filler (smooth versus
granular). Both cohesivity as well as viscoelastic properties are
important in selecting fillers for appropriate anatomic locations.
Areas that require more structural augmentation include the
midface, nose, temples, jawline, and chin. Hence, fillers with a
sufficient elastic modulus (a higher G ) as well as sufficient cohe-
sivity are optimal (Voluma, Restylane Lyft, Radiesse). Lower facial
areas require more tolerance of mobility. These areas require
intermediate characteristics in G and cohesivity ( uv derm Ultra
Plus, Restylane, Restylane Defyne). Finally, fine line fillers require
the lowest G and cohesivity for placement in the subdermis and
intradermal areas (Volbella, Restylane Silk).
The aforementioned factors are in vitro measurements. Recent
studies have compared in vivo behaviors of soft tissue fillers in
an animal model, which provides a platform to make compara-
tive evaluations among fillers. Results indicated that biologic
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a b c
Fig. 16.2 (a) This 51-year-old woman requested lip augmentation. (b) Restylane was injected into the vermilion border (1) and philtral columns (2)
to achieve a narrower appearance. The Restylane was injected from the inside of the lip from the vermilion border to the wet–dry junction (3). With
care, irregularities can be avoided. (c) Patient is shown 3 months after injection with good persistence of the filler. This patient is a good candidate for
treatment with Restylane. She maintained good volume correction for 6 to 7 months, requiring less volume when she returned for a touch-up with
Restylane. The patient was started on acyclovir for herpes prophylaxis.

a b c

d e
Fig. 16.3 (a,d) This 48-year-old woman had periorbital hollowing as well as prominent periorbital fat in the central and medial aspects of her lower
lids. She described this as her “polar bear” appearance and sought a more normal look and contour in her orbital and midface areas. A nonsurgical eye
lift was planned as well as a midface augmentation. (b) The malar bone was augmented with Perlane to increase malar projection and camouflage the
prominent lower lid. Perlane was placed at the depth of the periorbital hollow on the bone and was also placed on the malar bone to augment cheek
projection and minimize negative vectors. A total volume of 1.1 mL was placed per side, mainly in the periorbital hollow (1) but also a smaller amount
was on the malar bone to increase malar projection relative to the eyeball (2). (c,e) The patient is seen 6 months after treatment. She was pleased
with the improvement around her eyes and the increased projection and contouring in the midface.

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 III Nonsurgical Cosmetic Treatments
interaction plays an important role in how filler performs. Filler
lift capacity correlated best with filler composition or type,
with homogeneous fillers having greatest capacity, followed by
nonanimal stabilized HA ( ASHA) and CaHa. Rheology alone was
insufficient to understand filler performance but was most useful
when comparing within fillers of similar composition.
16.5 Types of Soft Tissue Fillers
Table 16.1 summarizes the different types of soft tissue fillers
currently approved for use by the FDA in the United States. Fillers
can be divided into the following classes:
• Biodegradable fillers (nonpermanent)
HA-based fillers
CaHa
PLLA
• onbiodegradable fillers
Polymethylmethacrylate (PMMA) microspheres with
bovine collagen
The most commonly used class of fillers comprises the HA-based
fillers. They have the unique advantage of reversibility with the
use of the enzyme hyaluronidase. They differ in characteristics
based on manufacturing process, which leads to differing rheo-
logic characteristics. The HA-based fillers also offer the widest
range for panfacial augmentation, ranging from structural to fine
line improvement. CaHa- and PLLA-based fillers have a more bio-
stimulatory role, with the former offering a dual effect of filling
and biostimulation and the latter being primarily biostimulatory.
Most dermal fillers have some degree of biostimulatory effects,
but these two classes have the strongest ability. There is some
anecdotal evidence of reversibility of CaHa, but more studies need
to be conducted. PLLA, by contrast, is not reversible. Finally, the
permanent filler containing PMMA with bovine collagen seems
best suited in indications such as acne scarring, where a more
durable product may be advantageous. The main disadvantage
is lack of reversibility if there are any adverse side effects and
permanence in this case.
16.5.1 Hyaluronic Acid–Based Fillers
At present there are four classes of HA fillers approved for use by
the FDA in the United States:
1. ASHA
2. Hylacross-based
3. Cohesive densified matrix-based
4. Vycross-based
All are based on the use of HA, a naturally occurring linear
polysaccharide composed of alternating residues of the mono-
saccharides D-glucuronic acid and -acetyl-D-glucosamine. The
molecular weight of HA depends on the number of pairs of these
two monosaccharides occurring in the HA molecule. HA lacks any
tissue specificity and, in theory, in its pure form, has no immu-
nogenicity. By chemically cross-linking molecules of HA, gener-
ations of more stable macromolecules can be created, resulting
in more prolonged tissue residence time after injection compared
154
with free-standing HA. Degradation occurs by a process known
as isovolemic degradation, which clinically translates into the
implant maintaining a high proportion of its initial space-filling
volume until complete resorption of the material. Moreover, there
is evidence that repetitive injection of HA-based fillers may have a
biostimulatory effect on fibroblasts, potentially leading to greater
duration after subsequent injections.
The ASHA-based fillers include the Restylane family
(Restylane, Restylane Lyft, and Restylane Silk) and the Emervel
family (Restylane Refyne and Defyne). HA can be cross-linked
using 1,4-butanediol diglycidyl ether (BDDE), and the degree
of cross-linking varies based on the filler, producing different
degrees of elasticity and viscosity as measured by G , with the
lower-G products indicated for lips and fine lines, while the
higher-G products are indicated for the midface and nasolabial
folds. As with all fillers, off-label use of ASHA is performed, with
the most popular areas being the tear trough, where a filler with
moderate G is desirable (Restylane), and the jawline, temples, and
chin, where a higher-G product is desirable (Restylane Lyft).
Hylacross is a process in which HA molecules of the same
molecular weight are cross-linked. Hylacross-based fillers include
uv derm Ultra and Ultra Plus and are indicated for lip augmenta-
tion (Ultra) and lines and folds such as the NLFs (Ultra and Ultra
Plus). These are highly cross-linked fillers, and while the G may
be lower than that of ASHA, the cohesivity of these fillers may
overcome the G issue. Off-label uses include the use of uv derm
Ultra Plus in the midface, temples, chin, and jawline, where a
highly cohesive, highly cross-linked HA may be optimal.
Vycross is a process in which HA molecules of higher and lower
molecular weights are cross-linked. Vycross-based fillers include
Voluma, Vollure, and Volbella. Vycross fillers have the unique
ability to have more intercalation in the dermis and subcutaneous
tissue. This can lead to longer duration but also more resilience
to degradation by hyaluronidase. The intercalation coupled with
a higher G in Voluma may produce a unique ability to lift the
midface.
Cohesive fillers include Belotero Balance. This is indicated
for lines and folds such as the nasolabial folds but is often used
off-label for tear troughs and perioral lines for its softer feel. The
duration limits are used in many areas.
Recent studies have shown in vivo effects of fillers in an animal
model. It demonstrated that non-Vycross-based fillers tend to be
more isolated materials in the deep dermis and subcutaneous
tissue, while Vycross-based fillers intercalate more, potentially
leading to greater duration and lifting with higher-G Vycross-
based fillers such as Voluma.
Global facial treatment with HA-based fillers is rapidly gaining
momentum. Our approach is to start at the superior aspect of
the face, generally the temple, which can serve as the anchoring
point above the supraorbital ridge using thicker HA fillers. This
is followed by treatment of the zygomaticomalar area, generally
defined by Hinderer’s lines to delineate the three components of
the midface (Fig. 16.4). Injections here are along the periosteum.
It has been shown that this injection laterally improves the tear
troughs as well as the superior aspect of the NLF. The two other
components of the midface are addressed next: the anteromedial
cheek and the submalar area. In the midface, higher-viscosity
fillers are optimal. The marionette lines are treated next with
moderate-density HA fillers, and finally the jawline or chin if

Fig. 16.4 Hinderer’s lines.
needed to define the lower face further. Fine lines such as perioral
rhytids are generally treated last. This approach can produce
dramatic changes, sometimes referred to as a liquid facelift. In
fact, it is a rebalancing of the facial fat pads, creating the ideal
inverted triangle or heart-shaped face with a well-defined ogee
curve (Fig. 16.3c).
16.5.2 Calcium Hydroxyapatite
CaHa filler (Radiesse, Radiesse Plus) consists of two components:
a gel carrier and the matrix particle. The aqueous gel contains
glycerin, sodium carboxymethylcellulose, and water. The matrix
particle component consists of bioceramic spheres of calcium
hydroxyapatite ranging in diameter from 25 to 125 microns. It is
a radiopaque substance. hen injected, the gel is absorbed and
the residual matrix grows into the scaffolding of the surrounding
tissue, inducing fibroblasts to produce collagen. Hence, it is both a
a b
Fig. 16.5 (a) Pre-treatment and (b) 6-month post-treatment results are shown after injection of 1.3 mL of Radiesse to the left hand in a 60-year-old
woman.
S - i ue i er
filler in a traditional sense and a material that is biostimulatory.
The FDA-approved indications for CaHa are treatment of lines
and folds such as the nasolabial folds and hand augmentation
due to volume loss in the dorsum of hands (Fig. 16.5). Off-label
use is in structural areas such as the midface, temples, chin and
jawline. Recently, the use of hyperblended CaHa is being investi-
gated as a true volumizer in areas requiring significant defects,
such as midface atrophy and temples. The addition of lidocaine in
CaHa (Radiesse Plus) reduces the need for mixing and makes the
material more comfortable as well as produces better flow char-
acteristics. Although there is no established standard of reversal
of CaHA, recent anecdotes using sodium thiosulfate have been
reported. Moreover, anecdotal reports have also suggested using
hyaluronidase if vascular compromise is suspected.
16.5.3 Poly-L-Lactic Acid
PLLA (Sculptra) is polymerized lactic acid in a powdered lyo-
philized form, similar to the material used in Vicryl sutures.
The primary mechanism of PLLA is biostimulatory, with results
becoming apparent over time and usually after serial injections.
The material needs to be reconstituted with sterile water and
lidocaine, with volumes of diluent that vary based on location,
with a general consensus of 8 to 10 mL total. This is a shift from
the original on-label dilution, which may have contributed to the
development of nodules. The FDA-approved indications include
HIV-associated lipoatrophy and lines and folds. The material is
primarily used off-label, most commonly for volume-depleted
areas such as the midface and temples. Recently, off-label uses in
body areas such as buttocks and extremities are being advocated.
Duration of effect can last up to 2 years. Variability in response
can be seen, as this is primarily a biostimulator agent.
16.5.4 Polymethylmethacrylate
PMMA (Bellafill) is the only permanent filler approved by the
FDA. It is approved for the use of nasolabial folds and for acne
scars. It consists of microspheres or beads of PMMA (a non-
resorbable synthetic material), 30 to 42 microns in diameter,
suspended in 3.5 partially denatured bovine collagen. A skin
test is generally recommended. The collagen serves as a vehicle
for the PMMA beads, degrading after several months, and the
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 III Nonsurgical Cosmetic Treatments

microspheres induce a long-term foreign body reaction that
encapsulates them in fibrous connective tissue, producing long-
term augmentation. The main indications for this filler are the
treatment of nasolabial folds and acne scars; this is the only filler
for the latter FDA-approved indication. Off-label use has been
performed in lips (Fig. 16.6) and panfacial regions (Fig. 16.7), but
caution is advised, as there is higher risk of developing nodules,
which can be permanent in these areas.
16.6 Complications
Complications with soft tissue fillers are rare, but a thorough
understanding of the nature of complications and their manage-
ment is essential for optimal patient outcomes. Transient adverse
events for all fillers include bruising, edema, erythema, Tyndall
effect, and asymmetry due to poor technique. Bruising can be
minimized by having the patient avoid blood thinners such as
nonsteroidal anti-inflammatory agents ( SAIAs) and aspirin. The
use of microcannulas can minimize but not eliminate bruising.
Postprocedure bruising can be treated with a variety of lasers
and light sources, usually optimal at 24 to 48 hours postinjec-
tion. Edema is most common in lips, and more with HA fillers,
with their ability to be more hydrophilic. For severe edema, use
of a short course of prednisone may be indicated. Asymmetry
is generally technique-related, but most patients have inherent
asymmetry, which can be exaggerated by improper technique.
The Tyndall effect occurs because of improper plane of placement,
primarily with HA fillers; the superficial placement of fillers that
should be placed more deeply results in a bluish hue. It is also
quite common in the tear trough area and can be delayed due to
filler migration (Fig. 16.8).
Less common side effects of soft tissue fillers include true
allergic reactions, nodules, granulomas, infections, biofilm and
delayed onset nodules (Fig. 16.9). Fillers with longer duration may
have higher incidence of these complications, and certain classes
of fillers, such as the Vycross products (Fig. 16.10), have a higher
reported incidence of delayed-onset nodules, but these can be seen
with all classes of fillers. Lower dilution of PLLA used to result in
more nodules, but with modifications of dilution techniques this is
seen less. ith permanent fillers such as PMMA, nodules and gran-
ulomas have been reported that can only be treated with excision.
Exceedingly rare complications include intravascular injection
of fillers, leading to tissue necrosis and, in rare instances, stroke
and visual compromise. Intravascular injection is of greatest risk
in areas such as the glabella, nose, forehead, temples, and antero-
medial cheek. The use of microcannulas in these areas may reduce
the risk but not entirely eliminate it. Very slow injection, constant
movement, and when possible, reflux prior to injection can also
reduce the incidence.
ith HA fillers, most complications are reversible with the use
of hyaluronidase. Lower-viscosity and lower-cohesivity fillers
require less hyaluronidase. Resilient nodules can then be treated
with intralesional steroids and 5-fluorouracil. Biofilm is a difficult
condition to treat and sometimes requires systemic antibiotics

Fig. 16.6 Lip augmentation with ArteFill (Bellafill), first at the vermilion border (1); at the dry lip, which must be done with care (2); at the wet–dry
junction and the lateral lip, which can be turned out by injecting from the vermilion to the wet–dry mucosal junction (3).

Fig. 16.7 Use of ArteFill in the deep dermis, alone (1) or with Restylane Fine Lines/Touch at the dermal–epidermal junction (2).

156
 S - i ue i er

and, on rare instances, excision. Vascular impairment should be

treated aggressively with repeated, higher doses of hyaluronidase.
Visual compromise is the most serious complication, and it is
unclear whether retrobulbar hyaluronidase provides any benefit.
ith non-HA fillers, resolution of complications generally
requires ultimate resorption of the material. As with HA filler
complications, biofilm and infection can be treated with systemic
antibiotics, intralesional steroids, and 5-fluorouracil. ith PMMA,
this does not occur, and excision of the nodules is often the only
option.

16.7 Concluding Thoughts

The 21st century has seen a renaissance in soft tissue augmen- Fig. 16.8 Tyndall effect due to superficial placement of hyaluronic acid
tation with fillers. Prior to this, options were limited to few (HA) fillers.
space-filling products such as collagen. At present, four subtypes
of fillers exist that are approved by the FDA: HA-based (the most
widely used), CaHa, PLLA, and PMMA, the only permanent filler.
Techniques of soft tissue augmentation have evolved from these
materials simply being used to fill in the lines to panfacial
rebalancing and sculpting. On-label indications for fillers include
the nasolabial folds, perioral lines, lips, and midface. Off-label
use includes the temples, forehead, nose, chin, jawline, necklace
lines, d colletage, and body areas such as buttocks. The availabil-
ity of a variety of classes of soft tissue fillers with varying degrees
of thickness (viscoelastic properties) enables the physician to
tailor treatments based on anatomic location. In the future, we
will continue to see expanded indications for current materials
as well as the development of de novo materials, specifically
Fig. 16.9 Delayed-onset nodules and biofilm after calcium hydroxyap-
fillers that can mimic elastin, as well as those from autologous atite (CaHa) injection midface.
tissue (e.g., the patient’s stem cells) to expand the palette of soft
tissue augmentation options.

Clinical Caveats
• The use of soft tissue fillers continues to grow, as do the
options the physician has. Product choices are determined by
a myriad of factors: recipient bed, degree of motion, thick-
ness of tissues, location of product, risk for adverse events.
• Hyaluronic acid products are used most commonly and enjoy
a variety of options depending on the goals desired. They are
reversible with the use of hyaluronidase.
• Balanced soft tissue filling focusing on both deeper soft tissue
augmentation and superficial line effacement is now the
norm. This is often complementary to the use of skin surface
treatments and neuromodulators.
• Complications can be minimized by thoroughly understand-
ing the product characteristics as well as the implementation
of proper technique. Anatomic danger zones should be
familiar to the injector, and an outlined and detailed plan
for complication treatments should be well known by the Fig. 16.10 Delayed-onset nodules after placement of Vycross-based
injector and the team. fillers infraorbital area.

157
 III Nonsurgical Cosmetic Treatments
Suggested Reading
1 Alam M, Tung R. Injection technique in neurotoxins and fillers: planning and
basic technique. J Am Acad Dermatol 2018;79(3):407–419
2 Alam M, Gladstone H, ramer EM, et al; American Society for Dermato-
logic Surgery. ASDS guidelines of care: injectable fillers. Dermatol Surg
2008;34(Suppl 1):S115–S148
3 Beleznay , Carruthers D, Humphrey S, ones D. Avoiding and treating blindness
from fillers: a review of the world literature. Dermatol Surg 2015;41(10):1097–1117
4 Bhojani-Lynch T. Late onset inflammatory response to hyaluronic acid dermal
fillers. Plast Reconstr Surg Glob Open 2017;5(12):e1532
5 Carruthers , Carruthers A. Three-dimensional forehead reflation. Dermatol Surg
2015;41(Suppl 1):S321–S324
6 Gavard Molliard S, Albert S, Mondon . ey importance of compression proper-
ties in the biophysical characteristics of hyaluronic acid soft-tissue fillers. J Mech
Behav Biomed Mater 2016;61:290–298
7 Gold MH, Sadick S. Optimizing outcomes with polymethylmethacrylate fillers. J
Cosmet Dermatol 2018;17(3):298–304
8 Haneke E. Skin rejuvenation without a scalpel. I. Fillers. J Cosmet Dermatol
2006;5(2):157–167
9 Hermann L, Hoffmann R , ard CE, et al. Biochemistry, physiology and tissue
integration of contemporary biodegradable injectable fillers. Dermatol Surg
2018;44(Suppl 1):SS19–S31
10 Hee C , Shumate GT, arurkar V, Bernardin A, Messina D . Rheological properties
and in vivo performance characteristics of soft tissue fillers. Dermatol Surg
2015;41(Suppl 1):S373–S381
11 Hinderer UT, de Rio Legarreta . Aesthetic surgery of the malar region. In: Reg-
nault P, Daniel R, eds. Aesthetic Plastic Surgery: Principles and Techniques. Boston,
MA: Little, Brown; 1984.
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12 ontis TC, Bunin L, Fitzgerald R. Injectable fillers: panel discussion, controversies
and techniques. Facial Plast Surg Clin North Am 2018;26(2):225–236
13 Lorenc P, Greene T, Gottschalk R . Injectable poly-L-lactic acid: understanding
its use in the current era. J Drugs Dermatol 2016;15(6):759–762
14 Luebberding S, Alexiades-Armenakas M. Facial volume augmentation in 2014:
overview of different filler options. J Drugs Dermatol 2013;12(12):1339–1344
15 arurkar VA, Cohen L, Dayan S, et al. A comprehensive approach
to multimodal facial aesthetic treatment: injection techniques and
treatment characteristics from the HARMO study. Dermatol Surg
2016;42(Suppl 2):S177–S191
16 Patel U, Fitzgerald R. Facial shaping: beyond lines and folds with fillers. J Drugs
Dermatol 2010;9(8, Suppl ODAC Conf Pt 2):s129–s137
17 Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg
2015;41(Suppl 1):S120–S126
18 Ridley MB, Van Hook SM. Aesthetic facial proportions. In: Papel ID, Frodel , Park
SS, Holt GR, Sykes M, Larrabee F, et al, eds. Facial Plastic And Reconstructive
Surgery. 2nd ed. ew ork, : Thieme; 2002:96–110
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fillers and their relevance to aesthetic applications. Plast Reconstr Surg
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17 Non-Light-Based Skin Resurfacing
Christodoulos Kaoutzanis, Blair A. Wormer, and Galen Perdikis
Abstract
Dermabrasion, microdermabrasion, and microneedling are some
of the most frequently used non-light-based skin resurfacing
techniques for the face. Although all three modalities have a
mechanical component that causes some disruption of the skin,
they have distinct technical profiles for targeting skin anatomy
for rejuvenation in different ways. This chapter reviews the three
procedures in detail and specifically discusses their mechanisms
of action, indications and contraindications, relevant prepro-
cedural preparation, required equipment, technical execution,
important postoperative considerations, and safety profiles and
efficacy. It also examines skin changes that occur following these
procedures. Despite their widespread use, current literature is
fairly limited, with a paucity of large randomized, controlled
trials. Future evidence-based medicine will need to include all
skin types and compare different treatment modalities in order
to provide further insight into the short- and long-term effects of
these modalities.
Keywords
aesthetic medicine, dermabrasion, full dermabrasion, micro-
dermabrasion, microneedling, skin cosmetic, skin rejuvenation,
skin resurfacing
17.1 Introduction
Facial aging is an inevitable dynamic process involving changes
to both the skin and underlying tissues through intrinsic and
extrinsic factors. Intrinsic aging consists of the impact of genetic,
chronological, hormonal, and biochemical changes that occur
over time. The effect of these changes is accelerated with the
influence of extrinsic factors, predominantly photodamage via
ultraviolet (UV) light exposure. Photodamage is cumulative from
the first day of exposure until death, with approximately 50 of
the person’s exposure to UV light occurring before the age of 18.
Although multiple factors are responsible for visible skin aging, it
is estimated that sun exposure accounts for up to 90 .
Several factors can affect UV light exposure and thus affect
extrinsic aging, including geography, environment, and
occupation as well as lifestyle, such as the type of clothing the
person wears. UV radiation increases with decreasing latitude
and is compounded 4 for every thousand feet above sea level.
Environmental conditions, such as heat, wind, humidity, pollut-
ants, and reflected sunlight from sand or snow, can also influence
the exposure potential. In addition, the working environment
may play an important role in radiation exposure. For instance,
occupations that require outdoor exposure will increase skin
damage, especially if education on skin protection is lacking and
the appropriate clothing and sunblocks are not used. Smoking
n- ig - ed S in e ur ing
has also been implicated in facial aging, since it causes cutaneous
injury through various mechanisms. It decreases capillary flow to
the skin, depriving it from oxygen and nutrients. It also results in
fewer collagen and elastin fibers in the dermis, which decreases
the elasticity of the skin. Interestingly, previous authors have
found a dose-response relationship between smoking and skin
wrinkling, with smoking being a greater contributor to facial
wrinkling than sun exposure.
17.2 Evolution of Techniques
The importance of resurfacing and restoring the facial skin was
recognized hundreds of years ago. One of the oldest reports
originates from Egypt around 1500 BC and describes removal of
the upper layer of skin to improve surface texture and smooth
out scars using sandpaper-like material. In 1905 Ernst romayer,
a German dermatologist, pioneered facial skin resurfacing with
the use of a motorized dermabrader with rotating burs, which
allowed for removal of skin at various depths. This technique
was encouraging at the time, as it provided healing without a
scar so long as resurfacing was not carried below the papillary
dermis. Greater interest in skin resurfacing began again after
orld ar II in 1947, when Preston Iverson, an American plastic
surgeon, noted promising results in treating tattoo injuries by
sandpaper ablation. A few years later Abner urtin and oel
Robbins developed instruments driven by an electric motor
incorporating the use of wire brushes and diamond-impreg-
nated fraises that allowed the depth of the ablation to be more
controlled.
In the 1980s, the microdermabrasion technique was developed
in Italy as an alternative to more aggressive wounding techniques.
This technique was publicly presented by G. Monteleone at the
Third Meeting of the Southern Italy Plastic Surgery Association in
1998. The first paper in a journal appeared in 1995; in it Tsai et al.
proposed the use of aluminum oxide crystal microdermabrasion
for superficial rhytides. This new technique of microdermabrasion
encompassed some of the concepts of traditional dermabrasion
but utilized a fine beam of aluminum oxide microcrystals to peel
the skin surface precisely and superficially. It was felt to improve
certain types of scars from aged and sun-damaged skin while
avoiding some of the problems seen with traditional dermabra-
sion. Mattioli Engineering brought microdermabrasion to the
United States in 1996. The Food and Drug Administration (FDA)
classified the device as a type I device, which does not require the
manufacturer to establish performance standards through clinical
trials but only to follow appropriate manufacturing practice
guidelines. The device also received an exemption status from
the FDA, which means that it can be sold to and used by anyone
(e.g., spas and beauty salons) without the need for a clearance
letter from the FDA. As a result, it is currently used by physicians,
nurses, and licensed aestheticians.
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 III Nonsurgical Cosmetic Treatments
As the understanding of skin regeneration and scar formation
has become clearer in the past few decades, so has the evolution
of other nonsurgical techniques for skin resurfacing. One such
method gaining in popularity is microneedling, which is based
on the mechanism of noninflammatory wound healing through
percutaneous collagen induction. orman and David Orentreich
first elucidated this property in 1994 in their description of
subcutaneous incisionless (subincision) release of tethered scars
and rhytides. They identified two key features of subincision;
first, the mechanical release of the tethered scar by subcutane-
ous sweeping of the beveled needle, and second, the induction of
neocollagenesis without significant epidermal disruption. These
two events led to significant improvement of scar appearance
and texture. Shortly after, in 1997, Andr Camirand and ocelyne
Doucet, in an attempt to tattoo achromic scars in two facelift
patients, incidentally found that there was loss of the tattoo
pigment at long-term follow-up but a significant improvement
in scar appearance. This built on Orentreich’s subincision find-
ings as a newly reported technique of needle dermabrasion.
Unfortunately, both subincision with a single-bevel needle
and needle tattoo technique lacked larger surface application.
Knowing this, Des Fernandes, a plastic surgeon from South
Africa, developed and showcased the first microneedling
roller (Fig. 17.1) at the International Confederation for Plastic,
Reconstructive, and Aesthetic Surgery conference in 1999. He
published his findings in 2002, marking the genesis of the many
microneedling devices we have today. He built on the theory
of percutaneous collagen induction by using subcutaneous
mechanical disruption to induce neocollagenesis, without abla-
tion of the epidermal layer, and all while being able to treat larger
Fig. 17.1 Initial microneedling device reported by Des Fernandes in 2002. Drum-shaped roller has fine protruding needles used to puncture the skin.
160
surface areas with his microneedling roller. Since then, there
has been a rapid acceptance of this nonsurgical technique, with
literature supporting its efficacy and safety leading to the devel-
opment of different application devices, from the traditional
roller to newer pen-shaped electronic microneedle devices.
More recently, clinicians are using the microneedle device to
facilitate the delivery of topical products such as platelet-rich
plasma, minoxidil, acid peel agents, or even radiofrequency
energy. ith these advancements and growth of its acceptance
in aesthetic treatments, microneedling has poised itself to be
a critical adjunct to the plastic surgeon’s armamentarium for
nonsurgical skin resurfacing.
The key to successful facial resurfacing is safety and precision
that can be achieved only with appropriate patient selection, with
understanding of the skin anatomy and the histologic effects of
the numerous treatment modalities, as well as proper application
of the chosen treatment technique. Incorporating the patient’s
desires and expectations into the treatment plan is a crucial
component of patient compliance and satisfaction. Outstanding
results are obtained not only with experience with the various
techniques but also with critical evaluation of that experience. It
is important for beginners to err on the side of undertreatment
to avoid complications, such as facial scarring, and for them to be
critical of their results on serial patient evaluations.
17.3 Pertinent Anatomy
Regardless of how minimally invasive skin resurfacing may
appear, it is essential to have a thorough understanding of

and systematic approach to the relevant anatomy before any
technique is attempted. For the techniques discussed in this
chapter, the relevant anatomy is confined to skin, including its
components, primarily epidermis, dermis, and subcutaneous
tissue.
Beginning with an analysis of the epidermis, it consists of a
constant turnover of epithelial cells divided into five major strata.
It makes up a tiny fraction of the skin thickness, roughly 0.1 to
0.15 mm in thickness as opposed to the dermis, which measures
0.5 to 3 mm depending on the region of the face and the patient.
The most superficial layer of the epidermis and critical for skin
resurfacing is the stratum corneum (SC). This stratum involves
anucleate cells that are filled with keratin filaments, which have
replaced their original organelle components. There are multiple
layers of these desiccated cells that are continuously sloughed
off through a process of exfoliation. This layer provides a critical
role in epidermal protection and aesthetic appearance of the skin
surface. Microdermabrasion is focused solely on removing this
layer to facilitate minimally invasive skin rejuvenation. The SC is
additionally an important component targeted in the exfoliation
process of many topical therapies and is often a focus of targeted
thickening in skin rejuvenation.
Deep to the SC lies the stratum lucidum, a thin clear layer of
cells in the face but much more robust in the glabrous skin of
the palms and soles of feet with dense keratin for support. The
stratum granulosum is deep to this and functions to prevent
trans-epidermal water loss with lipid rich membrane-coated
granules. This waterproof barrier is a target of humectants in
topical skin treatments. ext deepest is the stratum spinosum,
named for the thick layer of spiny cells rich in cytokeratin. The
final layer is a basement membrane, or stratum basale. This is
the mitotically active layer of cells from which all epidermal cells
originate, slowly migrating toward the surface until they exfoliate.
Deep to the epidermis, the dermis is a much thicker layer of
connective tissue and primarily consists of the papillary and
reticular layers. The papillary dermis lies directly deep to the
stratum basale of the epidermis and is most notable for its
dense capillary plexus. The clinical end point of this anatomical
feature is seen in pinpoint bleeding following puncture of the
dermis with dermabrasion, microneedling, erbium laser, or
other skin resurfacing techniques that reach this depth. This
is a very important endpoint for clinicians to be aware of. This
layer also contains the nerve endings of different sensation and
mechanoreceptors, along with other skin appendages. Deeper to
this is the reticular dermis, composed of dense bundles of colla-
gen, glandular elements, and hair follicles. The reticular dermis
makes up the bulk of the skin thickness and tensile strength. On
clinical exam, it is a white-color layer of parallel lines of collagen.
For the clinician, it is important to know that resurfacing to this
depth will actually decrease bleeding, as it has proceeded deep
to the capillary plexus of the papillary dermis. It is essential to
realize this change quickly during dermabrasion or other ablative
skin resurfacing techniques, as further ablation deep to this may
lead to full thickness dermal violation and dyspigmentation or
scarring. The hypodermis or subcutaneous tissue lies deep to the
dermis and is usually immediately recognizable by the presence
of yellow adipose tissue. Further discussion of this layer is not
relevant for this chapter, as resurfacing techniques will be limited
to the reticular dermis.
n- ig - ed S in e ur ing
17.4 Dermabrasion
17.4.1 Mechanism of Action
Dermabrasion is the controlled mechanical planing of the epider-
mis and a variable portion of the upper dermis using a rotating
abrasive mechanical wheel. Achieving a precise depth of wounding
can smooth and lower rhytides and level irregular scars, producing
a more uniform skin surface. The predictable degree of neocollagen
formation at the upper level of the dermis, along with the re-epi-
thelialization that occurs from the dermal appendages, makes this
technique useful for addressing actinically damaged facial skin.
17.4.2 Patient Selection and
Contraindications
A thorough history and physical should be performed at the
initial consultation to ensure that there are no contraindications
to the procedure, such as clotting disorders, abnormal scarring
tendencies, and wound healing deficiencies. Any pertinent
history should be noted, including the use of anticoagulants and
nonsteroidal anti-inflammatory drugs ( SAIDs), previous history
of poor scarring or keloids, history of koebnerizing disorders,
thyroid disorders, malnutrition, prolonged use of steroids, organ
transplants, immunosuppressive disorders, hepatitis C, human
immunodeficiency virus (HIV), and previous herpetic outbreaks.
If the patient is taking anticoagulants, clinicians should consider
temporary periprocedural discontinuation of such medications
if appropriate after consultation with the prescribing physician.
Dermabrasion is not recommended for individuals with koeb-
nerizing disorders due to their increased risk for skin lesions
after stripping the SC. Isotretinoin, an antiacne drug, has been
implicated in delayed wound healing, hypertrophic scarring, and
keloid formation; therefore, it should be discontinued for at least
a year prior to dermabrasion. Also, patients with bloodborne
pathogens should not undergo dermabrasion, because the blood
can become aerosolized during the procedure, carrying a risk of
infection to the person performing the procedure. Patients with
history of herpetic disease should be definitely managed with
periprocedural prophylactic antiviral medications, such as acy-
clovir, to reduce the risk of inducing a herpetic outbreak. Since
the history of herpetic disease is not always clear, it is common
practice for many practitioners to provide all their patients with
periprocedural prophylactic coverage.
Dermabrasion has numerous applications as a skin resurfacing
technique, but it is typically used for the treatment of perioral
rhytides and fine wrinkles in other areas of the face. Deep rhytides
will also respond to dermabrasion, potentially better than some
laser resurfacing techniques with less hypo- or hyperpigmenta-
tion and less downtime. Of note, the upper and lower eyelid skin
is too thin to tolerate aggressive mechanical abrasion and should
be addressed with other forms of resurfacing. Rhinophyma, which
is characterized by an insidious enlargement of the nose due to
severe hyperplasia of the sebaceous glands, is commonly debulked
with dermabrasion. It is then allowed to heal by secondary inten-
tion, since rapid re-epithelialization occurs. Moreover, dermabra-
sion can be employed to improve the appearance of scars from
acne, trauma, and surgical incisions as well as hypertrophic scars
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 III Nonsurgical Cosmetic Treatments
and keloids. Its use has been encouraged in tattoo removal as a
complement to laser therapy.
Accurate evaluation of the skin condition and, more important,
the depth of the deformation is crucial in determining the suit-
ability of the technique. Typically, dermabrasion is considered
a good therapeutic option if the lesion penetrates but does
not extend deeper than the superficial reticular dermis. The
Fitzpatrick classification system of sun-reactive skin type (Table
17.1) is also a good measure of identifying ideal candidates for
the procedure. Individuals with Fitzpatrick skin type I or II are
ideal patients for a predictable outcome with dermabrasion.
Individuals with Fitzpatrick skin type III or higher have an
increased risk of pigmented abnormalities following the pro-
cedure, such as hypo- or hyperpigmentation. This risk must be
discussed with these patients, and it has to be weighed against
the problems related to the preprocedural aesthetic appearance
of the skin. For this patient population, bleaching creams, such
as hydroquinone, have to be used in the periprocedural period
to diminish melanocytic activity and thus decrease the risk of
pigmentation abnormalities.
17.4.3 Preprocedural Preparation
Once the clinician identifies the appropriate patient, it is imper-
ative to allocate enough time for counseling about the procedure
and its limitations. Perhaps one of the key components of a
successful outcome and a satisfied patient is realistic expecta-
tions. Face diagrams or digital computer programs can be used
to ensure that the patient understands what areas of the face
will be addressed and the degree of improvement. Before-and-
after photos of similar cases can be a useful adjunct to these
conversations.
Skin care before and after the procedure is also very important.
Tretinoin (Retin-A; Ortho- eutrogena, Flemington, ), an agent
that promotes wound healing by increasing collagen formation,
is used to pretreat some patients for several weeks. As previously
mentioned, patients at risk for hyperpigmentation may receive
preprocedural hydroquinone for 4 to 6 weeks, which can be com-
bined with a retinoic acid cream. The patients are also advised
to avoid direct sun exposure for 2 months before and after the
treatment.
Dermabrasion is painful without anesthesia. The best type of
anesthesia is different for every patient, and it has to be individ-
ualized and determined preoperatively. This is a joint decision
between the physician and the patient and is mostly based on
the patient’s pain tolerance and the extent of dermabrasion.
Topical anesthetic creams can be used for superficial derm-
abrasion. erve blocks are useful for regional dermabrasion.
Several options exist for full facial dermabrasion. Intravenous
sedation combined with regional nerve blocks (cutaneous
branches of the trigeminal nerve) is an attractive option for
anxious patients who will not tolerate the procedure while
awake. General anesthesia is another option but is usually
preserved for patients who undergo other surgical procedures
in addition to the dermabrasion. To avoid the last two options,
prior authors have recommended the use of tumescence anes-
thesia, which creates a turgid skin surface that responds well to
mechanical ablation.
162
Table 17.1 Fitzpatrick’s classification of sun-reactive skin type
S in Color e i n ir Summer ure
Type
I White Always burns, never tans
II White Usually burns, tans with difficulty
III White Sometimes mild burn, tanning moderate
IV Moderate brown Rarely burns, tans with ease
V Dark brown* Very rarely burns, tans very easily
VI Black No burn, tans very easily
*For example, East Indian, Asian, Hispanic, or light African descent.
17.4.4 Equipment
Physicians performing dermabrasion should familiarize them-
selves with the required equipment. The technique involves
using a small, handheld, electrically powered motor that rotates
an end piece of choice, the speed of which is controlled with
a knob or a foot pedal rheostat. The motor speed can be up to
85,000 revolutions per minute (rpm). e prefer the use of a
foot pedal, because it allows a wide range of speeds during the
procedure, as opposed to the knob, which limits the control of
speed. The rotational speed and the pressure exerted by the
operator determine the depth of wound penetration and are two
of the main factors that determine the outcome. The faster the
speed and the higher the pressure exerted by the operator, the
deeper the wound penetration. These two variables should not
be increased simultaneously but rather adjusted one at a time, to
avoid the risk of penetrating the skin too deeply.
The end piece comes in different sizes and shapes with variable
coarseness. The operator decides on the most appropriate tip
based on the area requiring dermabrasion and the anticipated
depth of penetration. The two most commonly employed end
pieces are diamond fraises and wire brushes. The diamond fraise
is a diamond-studded tip that is currently offered in various sizes
and shapes, such as cylinder, cone, wheel, and bullet. The diamond
surface is also available in different surfaces, from fine to extra
coarse. Finer surfaces are utilized for superficial scars and small
areas with a more delicate skin, whereas coarser surfaces are
better indicated for deeper scars and larger areas. The diamond
fraise works by causing frictional injury to the skin in a controlled
manner. This end piece is ideal for small areas and delicate skin. It
is also very helpful for skin resting above bony landmarks, such as
the zygomatic arch and nasal bone, because deep abrasion should
be avoided in these regions. If maximal mechanical abrasion is
desired, the speed of the rotatory motor has to be turned up to
60,000 to 85,000 rpm. The wire brush is another commonly used
end piece. Its tip is made up of a cylinder with multiple short
wires (2–3 mm in length) protruding from the central core.
Similar to a diamond fraise, it is available in several sizes, shapes,
and level of coarseness based on the diameter of the wires. Its
mechanism of action involves producing microlacerations to
the skin. The wires are more powerful than the diamond fraises.
Therefore, dermabrasion with a wire brush should not exceed
motor speeds of 25,000 rpm. The operator should also beware
of the orientation of the wire ends. If they are curved, then the
brush rotation should follow the curve of the wire ends. This end

piece is preferred for large surface areas, more problematic scars,
and tattoo removal.
17.4.5 Technique
Prior to the procedure, the area to be dermabraded is marked. If a
large surface area will be treated, it can be divided into sections
or facial subunits to ensure uniformity. It is important that the
patient remove all skin topical ointments, lotions, and makeup
prior to arrival for the procedure. The skin surface is then pre-
pared with an ophthalmologically safe surgical scrub. Protective
personal equipment should be used by the operator and patient
at all times during the procedure. Magnifying loupes can be used
to magnify the surface of the skin and the rhytides.
A variety of dermabrasion techniques have been described.
Operators must be aware of these techniques and apply them
properly based on the patient’s needs. Irrespective of the tech-
nique, appropriate manipulation of the instrument is essential to
ensure maximal control and accuracy. There are two main ways
of holding the dermabrader: it can be held like a pencil or like
the handle of a spatula (Fig. 17.2). Both grips allow the device to
be held securely in order to move in short, controlled sweeps at
different skin angles when necessary. However, the pencil grip
can be less accurate at times, as it can lead to accidental beveling
that can increase the contact of the sharp edge of the instrument
with the skin, leading to undesired deeper wound penetration
(Fig. 17.3).
Fig. 17.2 Different ways to hold the dermabrader securely and
comfortably.
n- ig - ed S in e ur ing
Several working patterns exist for dermabrasion: left to right,
superior to inferior, back and forth, and opposing right angles.
The selection depends on the preference of the operator and
the treatment indication. Continuous movement across the skin
surface with application of gentle pressure is key. The advantage
of continuously moving the end piece across the skin is that the
instrument is in contact with a debris-free surface at all times,
since the skin and debris are elevated and left behind the device
along its path. The pattern of opposing right angles with the use
of the wire brush can be effective when dealing with acne scars
because the microlacerations created by the brush can have a
-plasty effect. It is critical to apply gentle spreading tension to
the skin that will be treated using the nondominant hand, partic-
ularly near mobile structures such as the lip. Also of paramount
importance is that the rotating tip always be at 90 to an edge,
such as the lip, and the contacting surface of the wheel or brush
must be moving off the edge. For example, for the upper lip the
wheel should be at 90 to the lip edge, and the contacting surface
of the spinning wheel should be spinning in an inferior direction
(Video 17.1).
As with any other procedure, dermabrasion should be per-
formed systematically by treating one facial subunit or prede-
termined facial section at a time. Typically, it is advisable to start
with the outermost areas (i.e., lateral cheek) and move inward
(i.e., toward the nose and lips). This technique, with the help of
gravity, ensures that blood flows away from the next facial area to
be treated. The borders of the treated areas should be feathered
to minimize visible areas of transition. Another technical tip to
avoid transition lines is to treat the forehead to the hairline, the
perioral area to the vermilion border, and the chin and cheeks
slightly below the edge of the jaw line. It should be noted again
that mobile structures are at significant risk during dermabrasion,
given the mechanism and speed of the rotary wheel. Special care
and attention must be taken at the hairline and near the eye-
brows, as hair can be caught in the rotary and lead to traumatic
disruption or degloving.
Determining the correct depth of wounding is crucial for a
successful outcome (Table 17.2). When the planing begins, the
outer, tan-colored epithelium is removed, revealing the pinker
dermal–epidermal junction. o bleeding should be seen when
the epidermis is treated because it does not contain vasculature.
As the depth increases, sparse punctate bleeding on a smooth pink
background is noted, indicating entry into the papillary dermis.
More bleeding points are visualized as the depth of the abrasion
increases, and the smooth background has a rougher appearance.
This represents the deep papillary dermis or papillary–reticular
junction, which should be the end point for most patients with
mild to moderate rhytides. A yellow color suggests entry into the
reticular dermis. Entering the deeper reticular dermis, which is
indicated by frayed white strands of collagen, is not advisable
given the high risk for scarring. An absence of pinpoint bleeding
may also be noted, prompting cessation of further dermabrasion.
If the rhytides persist after dermabrasion reaches such a depth, a
secondary procedure should be considered. Of note, an assistant
can dab the bleeding skin with a cotton cloth during the proce-
dure. Any gauze and drapes need to be kept well away from the
dermabrader at all times, because the fibers can get caught in the
rotating tip of the instrument.
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 III Nonsurgical Cosmetic Treatments
Fig. 17.3 The bleeding pattern is a good indicator of depth. The skin should be wiped frequently so that this bleeding pattern can be observed. Care
must be taken to not angulate the fraise or wire brush, because the leading edge can cut into the skin surface and cause undesired pitting, grooving,
and/or scarring. It is critical to maintain the drum parallel to the skin surface.
17.4.6 Postoperative Considerations
Immediately following the procedure, the dermabraded areas
are thoroughly cleansed with saline solution and gauze. Gauze
soaked in saline solution with epinephrine can be temporarily
applied on the open wounds to achieve hemostasis. A moist
environment is needed to promote wound healing during the
re-epithelialization period. This can be achieved in multiple ways,
including petroleum-based or non-petroleum-based creams and
emollients, petroleum-based and non-petroleum-based antibiot-
ics, occlusive dressings, hydrating creams, and biologic dressings.
The type of dressing and the depth of dermabrasion will deter-
mine how long the dressing will stay on. Typically, physicians
avoid the use of bulky dressings that are left in place for several
days and use occlusive ointments. Such dressings can become
sticky and hard to remove, and they trap dry blood and sweat that
not only produces an unbearable odor but also can make these
wounds more prone to infection. The wound is gently cleansed
two or three times a day, and ointment is applied. The patient
should be informed that some erythema, edema, and crusting
are normal postoperative sequelae and should be expected.
Re-epithelialization is completed within 7 to 14 days, and the
erythema can take up to 1 to 6 months to subside. ormally by
the end of the first week, patients can apply makeup. During the
first 2 months, it is advisable for patients to wear nonallergenic
makeup. After re-epithelialization, minimizing sun exposure and
using appropriate sunblocks are of utmost importance for 6 to 12
months to avoid pigmentation-related complications. It has to be
emphasized that sunblock must be worn as the first application
on the skin each morning before makeup is applied and before
leaving the house. In patients with Fitzpatrick skin type III to
VI, Retin-A and hydroquinone should also be considered to help
prevent postinflammatory pigmentation.
17.4.7 Skin Changes and Treatment
ffi y
Evaluating the efficacy of dermabrasion, as with most other
noninvasive facial rejuvenation procedures, is rather challeng-
ing, because the criteria for a good outcome are subjective. It is
164
Table 17.2 Useful signs to determine the depth of wounding during
dermabrasion
S in yer Sign
Epidermis No bleeding
Superficial papillary Sparse punctate bleeding on a smooth pink
dermis background
Deep papillary dermis Abundant punctate bleeding on a rougher
background
Reticular dermis Absence of bleeding on a yellow background
not surprising that the data are limited; however, the available
studies have shown improvement at both the histologic and the
clinical levels following the procedure.
Histologically, mechanical ablation of the dermis disrupts the
collagen infrastructure, which increases fibroblast activity. As a
result, more collagen is produced that remodels the dermis. In
addition, several skin proteins are modified. The amount of col-
lagen formed with dermabrasion seems to be similar to that fol-
lowing Baker’s phenol solution, whereas melanocytic function is
affected to a lesser degree by mechanical ablation than by phenol.
A robust clinical outcome is far more important than histologic
improvement, since it is the only proof of the effect of the treat-
ment for the patient. Regardless of the outcome, patients should
be advised that it is not unusual to notice some change in the color,
tone, and texture of the treated skin. Several studies have demon-
strated the clinical benefit of dermabrasion for the treatment of
photoaged skin and some of its associated conditions, such as
lentigo and actinic keratosis. Other authors have attempted to
compare the two commonly used dermabrasion instruments:
the diamond fraise and wire brush. They have shown a significant
clinical improvement of photoaged skin at 3 and 12 weeks after
the procedure, but no statistically significant difference between
the two methods with regards to clinical efficacy.
17.4.8 Problems and Complications
The results of dermabrasion should be rewarding and predict-
able with the proper patient selection in the hands of a skilled
operator. However, as with any other procedure, problems and
 n- ig - ed S in e ur ing

complications can occur. Some of the main reasons for these issues
include the patient’s preoperative skin condition or pathology, a
noncompliant patient, and a careless or inexperienced operator.
Hyperpigmentation of the skin is more common for patients with
Fitzpatrick skin types III to VI. Although it is usually self-limited,
it can be improved by starting hydroquinone 4 to 6 weeks after
the procedure. Hypopigmentation is less common but can occur if
dermabrasion is very deep. This is due to a decrease in the number
of melanocytes. The formation of milia (small white keratin-filled
cysts) is not unusual. They appear over the surface of the treated
area within 2 to 4 weeks after the procedure. In most patients
they clear spontaneously. Occasionally they persistent and can be
treated with abrasive soaps, extraction, or electrodesiccation.
As mentioned previously, an important principle of the technique
is the application of gentle and even pressure. If the pressure is not
applied evenly, the skin can appear streaky or blotchy. More serious
issues can occur with inadvertent angling of the instrument pene- Fig. 17.4 This 42-year-old woman underwent perioral dermabrasion
for rhytids before prophylactic acyclovir therapy. She gave no history
trating deep to the reticular dermal layer. This can lead to abnormal of “cold sores” at any time during her life. A single lesion of herpes
scarring, including hypertrophic scars and keloids. Scarring can simplex occurred in the central portion of her upper lip 5 days after
also be seen in patients with genetic predisposition, or patients dermabrasion. Her outbreak was treated with acyclovir without
sequelae. It is recommended that all patients, despite a negative
taking certain medications. If penetration to the subcutaneous history, be placed on prophylactic acyclovir therapy for any resurfacing
tissue is noted during the procedure, small sutures can be placed procedure.
to reestablish dermal continuity and allow normal healing. Steroid
injections may be helpful, especially early in the scar formation.
One of the limitations of dermabrasion is the inability to erad-
icate very deep lines fully. Attempting to remove every deep line 17.4.9 Patient Example
can lead to scarring. Surgical judgment is critical in knowing when
The woman shown in Fig. 17.5 presented with severe sun damage
to stop. This is particularly true for postacne scarring. Several
resulting from an active outdoor lifestyle. She requested improve-
treatments might be required to reach maximal improvement.
ment of the deep rhytids in the perioral area as part of her facial
Even then, the scars might not be completely removed, which will
rejuvenation, and perioral dermabrasion was recommended.
make some patients unhappy, especially if they were not informed
Fig. 17.5a shows the patient marked and the dermabrader with a
of this possibility prior to the initial procedure.
barrel-shaped, coarse bur prior to the initiation of the procedure.
Infectious complications are rare but have to be recognized
Fig. 17.5b demonstrates uniform punctate bleeding, which is the
promptly and managed appropriately to avoid scarring. Common
desired end point, and the smaller, less aggressively surfaced bur
causes include Staphylococcus aureus (a bacterium), herpes
used for final smoothing. Fig. 17.5c presents the preoperative
simplex (a virus), and Candida (a fungus). Staphylococcal infec-
(left) and postoperative (right) images of the patient. The perioral
tions present early on, typically 3 to 5 days after the procedure,
rhytids have been smoothed.
with erythema, edema, and lesions with a honey-colored crust.
Sometimes patients will also have constitutional symptoms.
Antibiotics are used for treatment. Herpes simplex virus infection 17.5 Microdermabrasion
usually occurs within the first 5 days following dermabrasion. It
presents with pain out of proportion to the exam findings and the 17.5.1 Mechanism of Action
procedure. It can be treated with an antiviral medication, such as
acyclovir, for a minimum of 7 days. Most of these infections occur Microdermabrasion is a closed-loop process that employs the
in patients who have a history of herpes simplex virus exposure, ablative properties of chemically inert crystals to achieve partial
and they can be prevented by giving these individuals a prophy- skin ablation. During the procedure, a hand-held device, either a
lactic course of acyclovir to start the day of the procedure and controlled-graduated vacuum pump or a compressed air source,
continue for 7 to 10 days after the procedure. Candida infections is used to spray inert crystals continuously onto the skin at sub-
present later, usually 5 to 7 days after the procedure. Patients stantial pressures. The crystals transfer their kinetic energy to the
experience itching and edema, and the wound has exudate and uppermost layer of the epidermis (the SC), leading to detachment
delayed healing. Treatment is with topical or oral antifungals. of sebum concretions, corneocytes, and debris. The concomitant
For example, the 42-year-old woman in Fig. 17.4 underwent use of suction allows aspiration of the crystals and skin debris,
perioral dermabrasion for rhytides before prophylactic acyclovir which are deposited into a disposable waste compartment. The
therapy. She gave no history of cold sores at any time during her depth of ablation depends on several factors including the vacuum
life. A single lesion of herpes simplex occurred in the central por- pressure, the particle flow rate, the particle size, the angle of
tion of her upper lip 5 days after dermabrasion. Her outbreak was impaction, the speed of movement of the probe, and the number
treated with acyclovir without sequelae. It is recommended that of passes. Unlike dermabrasion, in which skin ablation is more
all patients, despite a negative history, be placed on prophylactic operator-dependent, skin penetration during microdermabrasion
acyclovir therapy for any resurfacing procedure. is mostly based on the programmed settings of the device.

165
 III n urgi me i re men

a b

c
Fig. 17.5 Patient example of dermabrasion. (a) Preoperative, showing the dermabrader with a barrel shaped bur prior to the initiation of the
procedure. (b) Uniform punctate bleeding, which is the desired end point. The smaller, less aggressively surfaced bur was used for final smoothing.
(c) Preoperative (left) and postoperative (right) images of the patient. The perioral rhytids have been smoothed.

Another approach to microdermabrasion involves the use of
a vacuum tube with an abrasive diamond tip. Suction is used to
bring the skin up into contact with the abrasive component of
the device. The operator then slides the tip across the skin, which
causes friction and results in subsequent exfoliation.
17.5.2 Patient Selection and
Contraindications
During the initial consultation, a history should be obtained from
the patient, and a focused physical exam should be performed to
ensure that this is a suitable technique for that particular individ-
ual. Microdermabrasion is used to treat multiple skin conditions,
predominantly cosmetic in nature, aiming to improve the tone and
texture of the skin. It can be employed to correct photodamaged
skin, superficial fine rhytides, actinic keratosis, dyspigmentation,
shallow surgical and acne scars, enlarged pores, and striae dis-
tensae. It can also be used as an adjunct to laser tattoo removal or
simply done to enhance the glow and smoothness of the normal
skin. In addition, since microdermabrasion removes the SC, it can
be utilized to improve topical drug delivery. In contrast to derm-
abrasion, microdermabrasion is limited to a more superficial skin
resurfacing, as penetration into the dermis is limited.
Microdermabrasion has a high safety profile with very mini-
mal risk of complications. It is safe in almost all skin types with
extremely low risk of scarring or pigmentation-related changes.
However, practitioners recommending this technique should
be aware of some contraindications. Treatment should not be
offered to individuals with pustular or cystic acne before it is well
controlled. Similarly, viral or bacterial infections should be treated
first with the appropriate oral or systemic agent prior to consid-
ering microdermabrasion. Also, this technique should be avoided
for patients with hypertrophic scarring, history of radiation to the
affected area, facial surgery within the past 2 months, or use of
isotretinoin within a year of treatment.
17.5.3 Preprocedural Preparation
Unlike dermabrasion, microdermabrasion does not cause signifi-
cant pain. Therefore, patients do not need anesthesia and can be
fully awake during the procedure. Depending on the individual’s
pain tolerance, an oral analgesic can be administered 30 to 60
minutes prior to the procedure. This decision has to be made in
advance between the patient and the practitioner performing
the procedure. As previously discussed, active acne or any other
type of skin infection has to be addressed prior to the procedure.

166

17.5.4 Equipment
As previously described, the most commonly used device for
microdermabrasion involves a closed-loop system. The distal end
of a hand-held device contains coarse crystals, and when in contact
with the skin it fires crystals against the skin at a programmable
pressure. Various inert, nonabsorbable solid crystals have been
effective with this technique, such as aluminum oxide, magnesium
oxide, sodium oxide, and sodium bicarbonate. The concurrent use of
a vacuum suction allows collection of the spent crystals and debris
that was produced from the abrasive action of the crystals, which
runs through a separate tubing system into a waste container and
discarded. Of note, the handpiece can be disposable or sterilized. As
mentioned above, a crystal-free device is also available and involves
a handpiece with diamond-studded tip. With the assistance of suc-
tion, the skin is brought up to the tip of the handpiece, which then
exfoliates the skin with its abrasive surface while sliding over it.
17.5.5 Technique
Prior to the initiation of the procedure, all makeup should be
removed from the face with soap and water. The face can be
also wiped with isopropyl alcohol, especially if the patient
has oily skin. During the procedure, patients lie supine on the
examination table. They are instructed to keep their eyes closed
to avoid crystal contact with the conjunctiva. Some practitioners
prefer to use moist gauze pads over the eyes for this purpose. It is
important to warn the patients that some stinging and pulling of
the skin during the procedure is to be expected.
The operator should wear universal precautions and grasp the
handpiece in the dominant hand while holding tension on the area
of the skin to be treated with the other hand to keep it flat. The tip
of the handpiece is placed on the skin, which occludes the opening,
resulting in crystal flow. As with dermabrasion, it is advisable to
approach the face systematically by treating one facial subunit or
predetermined facial section at a time. Typically, three passes are
performed over each area in different directions (vertical, horizontal,
and oblique) to minimize streaking and ensure that the entire surface
is addressed appropriately. Some areas of dry skin are more adherent
to the face and require additional passes. Thinner areas of skin, such
as the eyelids, have to be approached with caution by decreasing
the crystal outflow pressure and vacuum suction in order to avoid
purpura. Erythema indicates the end point of the treatment.
17.5.6 Postoperative Considerations
At the end of the procedure, it is not unusual to notice a chalky
residue on the skin due to crystals and debris from exfoliation.
The treated areas should be wiped with a warm washcloth. A
protective moisturizing cream with sunscreen is then applied
to the skin. The patient is advised to plan on having at least six
treatments, usually on a weekly or bimonthly basis, followed by
additional touch-up treatments as needed.
17.5.7 Skin Changes and Treatment
ffi y
Although microdermabrasion predominantly ablates the SC of
the epidermis, several reports suggest that it has an effect on
n- ig - ed S in e ur ing
the epidermis and dermis with changes at both the histologic
and physiologic levels. Treatment has been shown to promote
thinning of the SC, thickening of the remaining strata of the
epidermis with hyperplasia of the basal cells, and flattening of
the rete ridges. It has also been reported to redistribute the mel-
anosomes and decrease conversion to melanin. All these changes
can positively impact photodamaged skin with aging-related
changes. Additional physiologic changes that may occur after
microdermabrasion include decreased transepidermal water
loss, decreased skin sebum content, and increased epidermal
concentration of ceramide. These changes, along with alteration
of the skin pH, enhance the hydration and texturing of the skin.
Furthermore, microdermabrasion has been described as stimulat-
ing fibroblastic activity and enhance collagen synthesis and depo-
sition with a more regular arrangement of collagen bundles. This
may also be explained by the induction of type I and III procollagen
expression. Elevation of proinflammatory transcription factors (e.g.,
activator protein-1 and nuclear factor-kappa binding) and cytokines
(e.g., interleukin-1-beta) that affect the release of matrix metallopro-
teinases and in turn collagen replacement is also proposed to play a
role in the observed changes during the healing process. However,
not all the available studies have confirmed these findings. Similarly,
some investigators noted an increase in the elastic fibers at the junc-
tion of the papillary and reticular dermis following the procedure,
while others found no change in elastin content. Further histological
improvements that have been documented by other researchers
include increased dermal edema, vascular ectasia, and changes in the
microcirculation. More advanced research is required to verify these
changes and determine the exact dermal remodeling pathways.
17.5.8 Problems and Complications
Complications following microdermabrasion are rare as long as
the patient is appropriately selected and has no contraindications
to the procedure, and provided the operator is thoughtful and
well trained. This is mostly due to the superficial nature of this
ablative technique. Common complaints by patients include tran-
sient mild discomfort, tingling, and erythema shortly after the
procedure. Occasionally, prolonged erythema can be observed,
but it is important to reassure patients that it will resolve with-
out intervention. Patients may develop purpura or petechiae,
especially if they have thin and friable skin or if they are taking
blood-thinning medications, but these issues resolve within days.
A case of severe urticarial reaction has been reported in a patient
with latex allergy. It was unclear whether the rash was related to
hidden latex in the system or was an amplified dermatographism
reaction or a true pressure-induced phenomenon. Regardless,
operators not only must evaluate patients for allergies before
treatment but also should be prepared to deal with unexpected
complications. Minor abrasions may also occur if the operator is
aggressive. Likewise, aggressive ablation can potentially cause
scarring, but this is extremely rare given the limited penetration
of the device. Additionally, ocular complications, such as corneal
irritation due to adherence of crystals to the cornea, is a possible
risk if protective eye equipment is not used by the patient and
the operator. Autoinoculation of certain viral diseases, such as
warts, is another potential hazard. In such cases, a linear pattern
of the disease is noted along the path of the ablative handpiece
that delivered the virus from the affected area.
167
 III Nonsurgical Cosmetic Treatments
17.6 Microneedling
17.6.1 Mechanism of Action
Microneedling works by noninflammatory wound healing through
percutaneous collagen induction. This was initially described as a
subcutaneous incisionless (subincision) release of tethered scars
and rhytides. It was thought to result in the mechanical release of
the tethered scar by subcutaneous sweeping of the beveled needle,
and induction of neocollagenesis without significant epidermal
disruption. Application of this technique to larger surface areas
became possible with the introduction of the microneedling roller.
The initial microneedling roller had needles penetrating at a depth
of 1.5 mm and was reported to stimulate percutaneous collagen
induction by inducing a complex cascade and release of plate-
let-derived growth factor, fibroblast growth factor, and transform-
ing growth factor-beta-3 (TGF- 3). Subsequently, these changes
lead to production of collagen, elastin, and epidermal thickening.
By inducing these controlled skin injuries, there is neocollagenesis
from fibroblast proliferation. Then, a fibronectin network is devel-
oped that provides a scaffold for initial type III collagen deposition
and subsequent replacement with type I collagen in a standard
wound remodeling cascade. Rhytides or areas of depressed scar
benefit most from this healing cascade, as it is believed that the
new collagen formation will fill in and elevate the scar or furrow.
Additionally, the relatively undisturbed epidermis can thicken and
avoid more significant damage that may cause pigment or texture
changes that occur with inflammatory wound healing. Histologic
analyses have since confirmed the altered upregulation of TGF- 3
to promote scarless wound healing, as opposed to TGF- 2-related
healing, which is associated with fibrotic scarring. Increased elas-
tic fiber deposition, preserved stratum corneum, and rete ridges
have also been demonstrated following microneedling, further
supporting its wound healing mechanism of action.
The mechanical penetration with the microneedling device has
also been shown to facilitate enhanced delivery of medications or
radiofrequency. Topical medications, such as minoxidil, trichloroace-
tic acid, and 5-fluorouracil, were found to have improved delivery with
microneedling. In addition, a synergistic effect has been observed
in concomitant therapies. One such example occurs in intradermal
platelet-rich plasma injections performed with microneedling; the
effect is believed to be through the increased concentrations of plate-
let-derived growth factor. ewer devices have combined the benefits
of microneedling with radiofrequency to deliver energy directly
to the papillary and reticular dermis. These combination devices
cite the benefits of therapy of both established modalities working
together to promote neocollagenesis and improved skin resurfacing.
17.6.2 Patient Selection and
Contraindications
Microneedling has a wide variety of applications for skin
resurfacing and treatment (Table 17.3). Initial patient selection
criteria by Fernandes, the Dermaroller inventor, were focused
on selecting patients with early stages of facial aging: those
seeking to restore skin tightness, diminish fine wrinkles, and
seeking to avoid more invasive dermabrasion or laser treatment.
This technique is reasonable for those patients seeking healthier
168
Table 17.3 Microneedling: indications and contraindications
Resurfacing indications:
• Early stages of facial aging or photodamage
• Fine rhytides and furrows
• Restore skin tightness and thickness
• Seeking to avoid dermabrasion or laser treatment
• Seeking rapid recovery with topical anesthesia only
• Seeking to avoid less sun-sensitive skin post-treatment
Other cutaneous indications:
• Scars (atrophic, acne, hypertrophic, burn)
• Alopecia (androgenetic, areata)
• Pigmentary disorders (melasma, vitiligo, periorbital melanosis)
• Primary axillary hyperhidrosis
• Striae rubrae (stretch marks)
• Verruca
• Actinic keratoses
Contraindications:
• Inflammatory acne
• Keloidal predisposition
• Local infection
• Chronic skin conditions (eczema or rosacea)
• Local botulinum toxin use
• Any skin lesion with malignant potential
• Active herpes labialis
• Immunosuppression (chemo or radiation therapy)
skin, using a less expensive technique and with a shorter heal-
ing phase compared with lasers. Microneedling also avoids
sun-sensitive skin following treatment by maintaining the intact
epidermis as opposed to more ablative techniques of resurfacing.
Additionally, patients desiring resurfacing with topical anesthe-
sia only and rapid recovery can also benefit from being selected
for microneedling over more intensive peels or laser therapy.
umerous other indications for microneedling beyond tra-
ditional skin resurfacing have also been studied, such as using
microneedling as a method of drug or energy delivery. These
indications include scars (atrophic, acne, hypertrophic, burn),
alopecia (androgenetic, areata), striae rubrae (stretch marks),
pigmentary disorders (melasma, vitiligo, periorbital melanosis),
verruca, primary axillary hyperhidrosis, and actinic keratosis.
Contraindications for microneedling are few and minimally
reported. Most notable are those at risk of inflammatory or hyper-
trophic scarring, such as patients with a keloid predisposition,
inflammatory acne, or local infection. Care should also be taken to
avoid patients with active herpes labialis or immunosuppression
(chemotherapy or radiation). Practitioners should avoid areas with
chronic skin diseases such as eczema, rosacea, or potential skin
malignancy to avoid disseminating abnormal cells by microneedle
implantation. Counsel and precaution are necessary when patients
have clotting disorders or in patients who are on therapeutic anti-
coagulation, as there can be bleeding. Another avoidable compli-
cation is performing microneedling in the local area of botulinum
toxin injection, as it may lead to diffusion to undesired areas.
17.6.3 Preprocedural Preparation
After screening for appropriate contraindications already listed,
patients should undergo a strategic preoperative planning and

preparation along with informed consent that includes the
benefits, risks, and potential complications of microneedling.
Preoperative pictures are essential in all patients for documen-
tation and meticulous assessment of outcomes following treat-
ments. Practitioners should also consider waiting for any recent
suntan to have faded prior to treatment to avoid post-treatment
dyspigmentation. Also, as with other skin resurfacing techniques,
patients with a history of herpes labialis should be treated with a
1-week prophylactic oral antiviral beginning the day of treatment.
Skin preparation on the day of treatment is essential. Patients
should meticulously clean the area of planned treatment and
ensure that all makeup, lotions, and other topicals are removed
prior to arrival. Depending on the size of the treatment area, topical
anesthesia with lidocaine and prilocaine cream can be applied to
the area and covered with an occlusive dressing for 15 to 45 minutes
before treatment. Other options include compounded 30 lidocaine
cream (nonoccluded) for 20 to 30 minutes. Regardless of the local
topical anesthetic used, once anesthetic effect is reached, it should
be removed with saline-soaked gauze and the skin cleansed with
alcohol before microneedling. In certain sensitive areas such as the
upper lip, local anesthetic injection or nerve block can be beneficial
in certain patients, but this is typically not needed.
17.6.4 Equipment
An understanding of the equipment is important given the wide
variety of microneedling devices and goals of therapy, as it can
also serve as a method of medication or energy delivery.
The original and simplest microneedling device is the drum-
shaped roller pictured in Fig. 17.1. There is a great variability in the
types of rollers, with needles ranging from 0.5 to 3 mm in length
and 0.1 to 0.25 mm in diameter. The microneedles can be made
from any number of nonallergenic materials, including stainless
steel, gold, and titanium. Rollers are typically presterilized with
a b
Fig. 17.6 (a) An example of a microneedling electronic pen device that is commercially available. (b) A patient being treated with a microneedling pen.
n- ig - ed S in e ur ing
gamma irradiation. They are mostly one-time-use devices, as
repetitive use can lead to dull or loose needles. Rollers tend to
offer the best treatment effect over larger flat areas such as the
cheek and forehead. They can become entangled with hair around
the scalp, and their use is difficult for narrow areas as in perioral
resurfacing.
The next most common device is an electronic pen device (Fig.
17.6a), which uses disposable needle cartridges with titratable
needle length and penetration speed. These devices tend to offer
improved control over narrower channels as in the lip, nasal, and
periocular areas of treatment. In addition to the mechanical roller
and pen devices, there are now combination devices that include
microneedling with concomitant fractional radiofrequency deliv-
ered at the needle tip, vacuum-assisted infusion of medications,
or light-emitting diode (LED) therapy. Each has been touted to
provide specific applications and advantages beyond traditional
microneedling alone, but robust evidence is limited at this time.
17.6.5 Technique
Specific technical considerations when performing micronee-
dling must be adhered to in order to provide optimal results.
The needle length and penetration depth should be determined
based on the area of treatment. Thin skin or bony surfaces, as
in the periocular, lip, and nasal areas, require shorter needle
lengths ranging from 0.25 to 0.5 mm. Scars or areas with a
thicker surface, such as cheek, chin, or nonfacial areas, are
much more able to tolerate needle lengths up to 2 mm with
ease. The needle speed can be increased to help minimize pain
during treatment, especially as needle length is increased. After
skin preparation with anesthetic and cleansing as described
previously, the device is often used with a lubricating agent.
Topical hyaluronic acid–based gel is often selected for its active
ingredient and lubricating benefit during treatment. The needle
169
 III Nonsurgical Cosmetic Treatments
length and speed are selected for the area, and the nondominant
hand is used to stretch the face while the dominant hand holds
the device and performs the microneedling (Fig. 17.6b). The
instrument is moved in a direction perpendicular to the direc-
tion of the stretching force of the other hand. The microneedling
device should be passed in multiple directions to avoid creating
track marks or microchannels of larger injury in the same plane.
The clinical end point of treatment is an evenly spread erythema,
mild swelling, and transient punctate/pinpoint bleeding. The
number of passes with the device may be anywhere from 3 to
15 times based on the location, pathology, specific device, and,
more important, when the clinical end points are reached. Once
the end points are reached in one area, saline-soaked gauze
can be placed until other areas are treated. Direct pressure is
usually sufficient for any areas of persistent bleeding. hen the
microneedling is completed, the skin is cleansed with sterile
saline to remove any lubricating agent or debris. At this time, if
an additional topical medication is planned for delivery, it can
be smoothly applied over the areas of microneedling treatment.
The treatment takes no longer than 15 to 20 minutes in total,
depending on the size of area treated, and can be repeated at
monthly intervals until the desired outcome is reached.
17.6.6 Postoperative Considerations
Immediately following the microneedling procedure, the patient
will often have mild swelling, superficial bruising, and punctate
bleeding. After any persistent bleeding has been controlled with
direct pressure and any topicals have been applied, ice-water-
soaked dressings can be used in the immediate setting. There
is often serosanguinous drainage, which may require collection
with dressing changes in the first few hours. At this point a layer
of hyaluronic acid gel can be applied and allowed to dry. After
4 hours, a moisturizing cream or 1 hydrocortisone cream can
be applied to the treatment area up to 4 times a day for the first
3 days, and the patient should avoid any makeup or cosmetic
products during this time.
Although risk of sun exposure is less with epidermal preserva-
tion, protection of the area from sun exposure and an additional
sunblock of SPF 30 or higher over the hydrating cream is recom-
mended in the first 2 weeks after treatment.
Regarding pain control, the patient should expect a mild, sun-
burnlike level of discomfort that should be adequately controlled
with acetaminophen as needed. Depending on the pathology
being treated, repeat microneedling can be performed at monthly
intervals and may require multiple treatments to reach the
desired effect. In resurfacing patients, many will pursue annual or
semiannual treatments to maintain skin quality from photodam-
age and aging changes.
17.6.7 Skin Changes and Treatment
ffi y
Following treatment, skin changes will occur in a
non-inflammatory wound-healing cascade. After the initial
punctate bleeding resolves in the hours after treatment, a mild
swelling, superficial bruising, and erythema will remain. These
will begin to improve along with any skin flaking within 3 days.
170
These skin changes are part of the healing process after injury
from microneedling that leads to platelet and neutrophil release
of platelet-derived growth factor, fibroblast growth factor, and
TGF- 3. This will subsequently lead to the intercellular matrix
production of collagen, elastin, and epidermal thickening. These
clinical and histologic findings will resolve in the first week after
treatment and are followed by fibroblast deposition of collagen
type III, increased gene and protein expression of collagen and
glycosaminoglycans, as well as skin regeneration. Further col-
lagen organization, neovascularization, and remodeling of scar
tissue will lead to clinical improvement seen in 2 to 3 weeks
after treatment with thickened epidermis, improved texture,
and elevation of depressed scar or rhytides. Results can vary,
and multiple treatments may be necessary depending on the
indication of treatment. It is thus important to continue taking
patient photos after each treatment so that both the provider and
the patient can track the progress.
17.6.8 Problems and Complications
Given the relatively noninvasive nature, topical anesthesia, and
preservation of the epidermis, there are few significant complica-
tions that develop following microneedling treatment. Most of the
complications can be avoided if practitioners adhere to the criteria
in the patient selection and preoperative preparation sections,
specifically avoiding patients with active herpes simplex, and
providing prophylaxis in those with a previous history to avoid
reactivation. Infections and hypersensitivity reactions are rare.
They are typically reported secondary to patient use of topical
cosmetic products, makeup, or nonprescribed skin treatments
in the first few days after the procedure. This can lead to immu-
nogenic particles deep within the dermis and, potentially, to the
formation of small granulomas or a skin hypersensitivity reaction.
Some advocate topical antibiotic ointment (e.g., mupirocin) during
the first few days to minimize chances of bacterial infection, but
this is not routinely recommended in the general population.
Dyspigmentation in patients with Fitzpatrick skin type IV to
VI or those with immediate sun exposure is always a concern
in skin resurfacing but has not been as severe in microneedling.
Histologic studies following microneedling have demonstrated an
intact SC and no change in melanocyte number or gene expression
rates, which are typically affected in cases of dyspigmentation.
Protection from UV light is still recommended, but microneedling
appears to tolerate sun exposure better than more invasive resur-
facing techniques that disrupt or ablate the epidermis.
Bleeding and bruising are typically self-limited and rarely a
problem in patients undergoing microneedling. Of note, longer
needle lengths, extending up to 3 mm, may lead to more swelling
and bruising with an extending recovery into the first week after
treatment. More important, the operator should avoid micronee-
dling across the same area beyond the clinical end points,
especially in thinner skin or over a bony prominence. Selection of
appropriate needle length for the specific area of treatment and
avoidance of multiple passes in sensitive areas are essential. There
have been reported cases of tram track–like scarring following
microneedling treatment of acne scars. Practitioners should be
concerned for these complications when treating patients with
significant hypertrophic scarring or predisposition to keloid
formation.

17.7 Concluding Thoughts
Currently various modalities exist for facial rejuvenation and
skin resurfacing. This chapter reviewed dermabrasion, micro-
dermabrasion, and microneedling.
Although dermabrasion can achieve excellent skin resurfacing
outcomes, it requires a certain level of expertise and a consider-
able amount of experience to master the technique. As a result,
its utility in skin resurfacing has been somewhat diminished after
the widespread adoption of lasers, which can deliver a similar
outcome with much less technical involvement by the operator.
Microdermabrasion and microneedling have gained popularity
over the past two decades since they are easy to perform, cheaper,
and less invasive and provide a fast recovery with very low com-
plication profiles, which makes them very attractive for patients
looking for mild to moderate improvement. It is not surprising
that many plastic surgeons and dermatologists dealing with
facial rejuvenation have added these less invasive procedures to
their current practice. Overall, all three techniques are safe and
effective for facial skin resurfacing when performed correctly on
appropriately selected patients.
Comprehensive patient education on the procedure and post-
procedural care, as well as setting realistic expectations, are of
utmost importance for achieving an optimal result and ensuring
patient satisfaction. Given the increasing use of these techniques
in facial rejuvenation, it is vital to continue scrutinizing their
efficacy and safety. In particular, there is a need for randomized
controlled trials that include all skin types and compare different
treatment modalities in order to provide further insight and
evidence-based data on the short- and long-term utility of these
modalities, aiming to optimize patient outcomes.
Clinical Caveats
• Dermabrasion removes the epidermis and penetrates to the
level of the papillary or reticular dermis, whereas microderm-
abrasion removes only the uppermost layer of the epidermis.
Microneedling does not remove any skin layers and works by
penetration of skin with needles.
• Dermabrasion requires a certain level of expertise and expe-
rience to master the technique, whereas microdermabrasion
and microneedling are less invasive and simpler to perform.
• Isotretinoin has been implicated in delayed wound healing
and hypertrophic scarring; therefore, it should be discontin-
ued for at least a year prior to these procedures.
• Patients with history of herpes simplex infection should be
treated with a 1-week prophylactic oral antiviral beginning
the day of treatment to prevent reactivation of the disease
and untoward aesthetic outcomes.
• Although microdermabrasion and microneedling are less
invasive and allow faster recovery than dermabrasion, they
usually require multiple treatments to achieve a less aggres-
sive result. Therefore, realistic goals and expectations should
be set prior to the initiation of treatment to ensure better
patient satisfaction.
• All three techniques are safe and effective for facial skin resur-
facing and can be used either alone or in conjunction with
other procedures for facial rejuvenation.
n- ig - ed S in e ur ing
Suggested Reading
1 Alam M, Omura E, Dover S, Arndt A. Glycolic acid peels compared to micro-
dermabrasion: a right-left controlled trial of efficacy and patient satisfaction.
Dermatol Surg 2002;28(6):475–479
2 Alkhawam L, Alam M. Dermabrasion and microdermabrasion. Facial Plast Surg
2009;25(5):301–310
3 Alster TS, Graham PM. Microneedling: a review and practical guide. Dermatol
Surg 2018;44(3):397–404
4 Aust MC, Reimers , aplan HM, et al. Percutaneous collagen
induction-regeneration in place of cicatrisation J Plast Reconstr Aesthet Surg
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18 Chemical Peels
Richard H. Bensimon and Foad Nahai
Abstract
This chapter addresses the all-important concept of dealing with
the textural and qualitative aspects of skin in order to attain a
more comprehensive result in facial rejuvenation. The main
agents for deeper peeling are discussed: trichloroacetic acid (TCA)
and phenol/croton oil. Preparation, application, and aftercare are
explained in order to obtain consistent clinical results safely.
Keywords
facial resurfacing, comprehensive facial rejuvenation, skin resur-
facing, wrinkle removal, chemical peel, trichloroacetic acid peel,
phenol–croton oil peel, croton oil peel, deep chemical peel
18.1 Introduction
The process of facial aging can be broadly divided into three catego-
ries: structural or gravitational changes, volume depletion, and tex-
tural or qualitative changes of the skin. Surgeons are experienced
in and comfortable dealing with structural changes by means of
a multitude of surgical procedures, which receive the majority of
attention in meetings and professional publications. This is under-
standable, because as surgeons we know how to perform surgery,
and it is within our capacity and experience to read about a new
technique and successfully perform it. Correction of volume loss is
a relatively new field, but many surgeons are increasingly becoming
proficient in the use of alloplastic implants, autologous fat transfers,
and injectable dermal fillers; these nonsurgical treatments are now
an integral part of many plastic surgical practices.
The treatment of well-established rhytids, creases, and textural
changes of the skin is altogether another matter. Surgeons are some-
times intimidated by this aspect of our specialty and tend to sur-
render their patients to aestheticians or use nonablative superficial
techniques that are minimally invasive but may also be minimally
effective. An all too common tactic is simply to ignore the problem.
In doing so, surgeons are missing the opportunity to provide patients
with a more complete rejuvenation and improve fundamental aspects
of aging, such as the quality of the skin. Throughout my plastic surgi-
cal career, the goal of the comprehensive facial rejuvenation is often
mentioned. This has been the title of presentations, panel discus-
sions, even entire meetings. This is a lofty goal to be sure, but unless
pronounced wrinkles and skin quality are addressed, comprehensive
facial rejuvenation remains an empty platitude. Perioral rhytids can
be more troubling to a patient than jowls or loose skin, and the very
best facelift results can be marred by deep creases around the mouth
or forehead. The reality is that there must be a wounding into the
dermis to improve deep wrinkles and etching of the skin, and at
present this requires a more prolonged recovery period than that
experienced after injectables are used. The goal is to find the best,
most cost-effective approach that yields a result significant enough to
warrant the recovery period and inconvenience to the patient.
emi ee
Chemical peels represent an effective method for skin resurfacing
to treat rhytids and other skin problems. Today physicians have a
number of effective chemical peel options from which to choose;
these offer the dermal wounding that is needed, with less morbidity
and fewer adverse effects than with the agents that were available
previously. Physicians can now plan the depth of peel depending on
the patient’s skin type, age, or clinical need. By choosing the appropri-
ate resurfacing agent, solution concentration, and peel application,
the surgeon can have precise control, thereby achieving treatment
goals and avoiding possible problems with hypopigmentation.
18.2 Evolution of Treatment
Chemical peels were introduced to the United States in the early
part of the twentieth century not by doctors but rather by lay
operators. The origin of the formulas used by these flamboyant
individuals is unknown, but what is clear is that they involved the
ingredients phenol and croton oil and that the clinical results were
quite good. The early history of chemical peels has been elegantly
chronicled by Gregory Hetter, and tracing this history is important
to understanding and appreciating where we are today.
These early lay peelers used cumbersome secret formulas that
involved dissolving phenol crystals and drops of the caustic croton oil.
Over the years, as these individuals gained notoriety, the response of
the medical community was to fight them rather than to learn from
them. Eventually plastic surgeons took note, and finally Thomas
Baker published a formula in 1961 that was easily reproduced by
anyone. The ingredients were simple, and it was presumed that
phenol was the peeling agent. In 1962 Dr. Baker altered the volumes
of the formula for convenience, while keeping the 3 drops of croton
oil unchanged. This effectively elevated the croton oil concentration
to 2.1 , and thus he inadvertently altered the history of chemical
peeling. This formula was very successful in improving severe wrin-
kles but also had the significant drawback of causing predictable
and severe hypopigmentation. The peel gave dramatic results, but
patients developed an unnatural porcelain or alabaster look that
required them to wear makeup permanently. For older patients with
pronounced wrinkling and light skin color this was a reasonable
trade-off, but the peel was not done on younger patients or on darker
skin. The peel was considered difficult to perform, and phenol devel-
oped the reputation of having an all-or-none effect that was out of
the surgeon’s control. The presumption was that phenol denatured
the skin and created a barrier that prevented deeper penetration;
a weaker concentration was thought to be dangerous, because it
would peel deeper. It took a great deal of faith and courage to paint
the solution on and hope for the best as the face densely frosted.
Phenol also had the reputation of being cardiotoxic, requiring a
deliberately slow application with strict cardiac monitoring. These
beliefs became dogma, no matter how unsubstantiated, and were
passed on from generation to generation of plastic surgeons. To this
day, these presumptions are still mentioned in professional publica-
tions, and phenol peels have a negative connotation in lay books on
173
 III Nonsurgical Cosmetic Treatments
cosmetic surgery. Although the results were quite remarkable, the
factors just discussed and the long and difficult recovery prevented
this peel from gaining widespread acceptance.
The next development in chemical skin resurfacing was the
popularization of trichloroacetic acid (TCA) peels by dermatologist
ein Obagi. TCA peels had been around for some time, but Obagi and
ohnson’s work in the 1990s brought them to the attention of plastic
surgeons. They popularized the concept of skin pretreatment, as well
as documenting and controlling the depth of TCA penetration. Obagi’s
role was controversial at the outset because of unseemly commer-
cialization with secret formulas and very expensive training pro-
grams, but his book, Obagi Skin Health Restoration and Rejuvenation,
remains an important contribution, especially for plastic surgeons
less familiar with peels and skin anatomy and physiology.
TCA peels were an important addition in that Obagi showed
histologically that different concentrations varied the depth of the
peel and that the application technique was a major determinant
of the depth reached. Lighter to medium peels were possible with
a concentration of up to 25 , and medium to deeper peels occurred
with 35 and 50 concentration for more pronounced rhytids. TCA
therefore largely overtook phenol as the peeling agent of choice,
because of the ability to control the depth of penetration and tailor
the peel to the patient’s skin type. Although higher concentrations
engendered more serious complications, namely scarring, TCA peels
at light- and medium-depth concentrations are viable and popular
options when chemical peels are considered for facial resurfacing.
Another significant advance in peel resurfacing was introduced
by Gregory Hetter in Las Vegas, evada. Interestingly, evada
was a state in which aestheticians could perform weak phenol
peels, and Hetter treated multiple patients who had had such
peels. These patients had not achieved significant improvement
but, more important, had not had any ill effects from the weaker
phenol concentrations, directly contradicting what had been
believed and taught about phenol peels for decades.
ith this in mind, Hetter diluted the Baker formula in half and
successfully performed peels on patients without the hypopigmen-
tation that had attended the older peels. Clearly something different
was at play, and Hetter devised a series of experiments to explain
this phenomenon. Hetter performed peels on a series of patients
with different combinations of ingredients of the Baker formula; he
noted that phenol alone had scant effect and that adding croton oil
to phenol at different concentrations led to deeper peels that were
proportional to the concentration of the croton oil. An analysis of the
classic Baker formula revealed that the concentration of croton oil was
quite high at 2.1 , which was responsible for the results as well as the
familiar drawbacks. Having convincingly shown that croton oil was
the critical peeling agent, Hetter was free to alter the concentration
of the ingredients as desired. He lowered the concentration of phenol
and varied the concentration of croton oil, and in so doing, Hetter
ushered in a new era in chemical peeling. The new formulas had the
advantage of being clinically effective, similar to the classic Baker
peel, without the troublesome complication of hypopigmentation.
Having the freedom to alter the croton oil concentration as needed is
a major advance that allows the peel to be performed superficially or
deep, depending on the circumstance. This versatility makes the peel
applicable to patients of all ages and skin types.
Having the ability to alter the croton oil concentrations has
further ramifications. It is now possible to use croton oil concen-
trations weak enough that the application technique becomes one
174
of the important factors in determining the depth reached. The
entire process is slowed down, so the surgeon can observe the skin
changes and have the opportunity to stop at whatever depth is
deemed appropriate. The all-or-none phenomenon seen with the
Baker peel was simply because the croton oil concentration was
so high that it immediately resulted in dense frosting. This consis-
tently resulted in a peel deep enough to cause hypopigmentation.
Current peeling agents provide physicians with increased
flexibility when treating wrinkles, creases, and skin pigmentation
problems. It is now possible to use chemical peels to achieve
the desired clinical results without reaching a depth that causes
hypopigmentation. Another critical difference is that the surgeon
can choose different concentrations on different areas of the
face, depending on relative skin thickness. Many practitioners of
the traditional peel were reluctant to apply a peel to the eyelids
because of the fear of scarring, but now, with the option of a weak
concentration of peeling solution, the delicate eyelid skin can be
effectively improved with safety and predictability.
18.3 Pharmacology of Chemical
Peeling Agents
18.3.1 Jessner’s Solution
essner’s solution is a standardized mixture of lactic acid, salicylic
acid, and resorcinol (14 each) compounded in 95 ethanol. Alone,
it causes a superficial epidermal peel. It may be an option for
superficial peeling as an adjunctive treatment for acne. It can also
be used as a pretreatment before a TCA peel to enhance penetra-
tion of the TCA solution. It should be noted that salicylate toxicity
(known as salicylism) can cause tinnitus, nausea, and headaches.
18.3.2 Trichloroacetic Acid
TCA, also known as trichloroethanoic acid (CCl3COOH), is an
analog of acetic acid in which the three hydrogen atoms of the
methyl group have been replaced by chlorine atoms. TCA acts
to dissolve keratin and coagulate surface proteins. This produces
a frost as the salts precipitate. It is neutralized by contact with
tissue fluids or topically applied saline solution for surface TCA.
Lower concentrations (10–30 solutions) will produce a super-
ficial epidermal peel. Higher concentrations (35–50 ) penetrate
into the superficial dermis, creating a medium-depth peel.
Concentrations above 50 produce a deep peel, which is usually
avoided, because this can result in scarring.
18.3.3 Phenol
Phenol, also known as carbolic acid or hydroxybenzene (C6H5OH),
is an aromatic hydrocarbon derived from coal tar. The stock phar-
macologic solution of phenol is known as fi This
contains 88 phenol, which is the highest concentration that will
stay in solution at room temperature; 100 phenol is a crystalline
material at room temperature. Similar to TCA, phenol causes
protein coagulation and produces a skin frost almost immediately.
Liquefied phenol USP with croton oil dissolved in it penetrates into
the upper reticular dermis, causing a medium-depth peel. Baker’s
mixture (Table 18.1) is the most commonly used and reproducible

formula; it is approximately a 50 (w/v) solution. These ingre-
dients do not combine easily. The liquid soap (Septisol) acts to
saponify the solution. The solution must be stirred vigorously
before application to ensure even mixture of the components.
Recently Septisol has become problematic because of the preser-
vative Triclosan and has been taken off the market. The very small
volumes used in the peel solutions do not pose a health problem,
but the reality is that Septisol is no longer available.
The necessity to replace Septisol has resulted in an excellent
alternative. The company oung Pharmaceuticals ( ethersfield,
CT) has devised a new surfactant, ovisiol, which results in a
more even solution which remains well mixed throughout the
course of a standard peel.
18.3.4 Croton Oil
Croton oil is an extract of the seed of the plant Croton tiglium.
Croton oil is the source of the organic compound phorbol.
Internally, it is a purgative that causes severe diarrhea. Its action
on the skin is related to free hydroxyl groups. It produces a
caustic, exfoliating effect on the skin, even in low doses. As men-
tioned earlier, Hetter showed that croton oil was the essential
peeling ingredient in Baker’s mixture. Altering the concentration
of croton oil directly alters the depth of the peel. Commonly used
concentrations range from 0.1 to 0.8 croton oil solutions.
Croton oil dissolved in phenol is the basis of the original Baker
peel and subsequent formulations discussed here. egative conno-
tations ascribed to the Baker peel have been a significant imped-
iment to the acceptance of the modern iteration of these peels.
ow, with 17 years of peeling experience and extensive teaching, I
have identified four misconceptions about croton oil peels, which
will be dealt with in detail in later portions of the chapter:
1. Cardiac toxicity
2. Hypopigmentation
3. Difficult recovery
4. Difficult to perform
By understanding and dealing with these issues, the peels can
be more easily assimilated.
18.4 Indications and
Contraindications
As with all aspects of plastic surgery, patient selection for chemi-
cal peels is vital to ensure consistent, reliable outcomes. Chemical
peeling agents are ideal for treating wrinkled skin or skin with
blotchy, irregular pigmentation. There is also some evidence to
show that peeling the skin of patients with dysplastic epithelium
or actinic keratosis may reduce or prevent the development of
Table 18.1 Baker’s phenol mixture
Liquefied phenol USP 88% 3 mL
Distilled or tap water 2 mL
Croton oil 3 drops
Septisol soap 8 drops
emi ee
skin malignancy. The patient must understand that there is a
difference between chemical resurfacing and face lifting. The
chemical peel will improve rhytids and pigmentary changes but
does not treat the gravitational and volumetric effects of aging.
Patient evaluation requires accurate assessment of skin color
and type, skin thickness, and the amount of skin damage (such as
rhytids, actinic damage, and pigmentary changes). Thicker, more
sebaceous skin can tolerate deeper peeling than thin skin can.
However, peeling is not a good treatment for large pores; pore size
is rarely reduced by the peeling process, and in fact, large pores
can become more noticeable and may seem larger after the peel.
Traditionally, the ideal patient has been considered to be one with
thin to moderate skin, a fair complexion, blue eyes, fine to moderate
rhytids, and actinically damaged skin. However, recent experience
and increased knowledge have led to the understanding that chemi-
cal peels can be safely used in a broader spectrum of patients. Still, not
everyone is a suitable candidate. All patients must be fully informed of
the risks of hyperpigmentation and hypopigmentation, as well as the
possibility of a line of demarcation at the margin of the peel. As usual
with all plastic surgery, a thorough history, physical examination, and
pertinent investigations should be performed before the procedure. A
history of renal insufficiency should be investigated, and an electro-
cardiogram (ECG) should be obtained depending on history and age.
18.4.1 i ri i i n S in
Type
The Fitzpatrick classification system can be a useful guide for
evaluating a patient’s skin type and response to sun exposure.
Generally speaking, patients who burn and do not tan (type I) have
a lower incidence of postpeel hyperpigmentation and are more
prone to hypopigmentation. Conversely, patients with higher skin
types (types V and VI) are more likely to develop postpeel hyper-
pigmentation. Fitzpatrick types III and IV tan easily; this implies
that melanocyte proliferation (known as rebound) may occur after
peeling. This tendency must be controlled with a prepeel skin
care regimen. Therefore, the greater the skin pigmentation, the
longer and more intense the skin pretreatment regimen must be
to control this rebound phenomenon (Table 18.2; Fig. 18.1).
18.4.2 G g u i i n
Photoaging
Glogau developed a classification system for photodamage based
on the degree of skin wrinkling. This scale is commonly used to
help determine skin type and thus treatment options (Table 18.3).
Table 18.2 Fitzpatrick classification of skin type
S in y e Color Tanning response
I White Always burns, never tans
II White Usually burns, tans less than average
III White Sometimes burns mildly, tans about average
IV Brown Rarely burns, tans more than average and with ease
V Dark brown Very rarely burns, tans very easily
VI Black Never burns, tans very easily
175
 III n urgi me i re men

Fig. 18.1 Fitzpatrick classification of skin types: (top. left to right) types I, II, III; (bottom, left to right) types IV, V, VI. (Reproduced with permission from
Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)

Patients in Glogau II with moderate aging and pigment spots
can be treated with a medium-depth peel. Medium-depth peels
penetrate the papillary dermis and are effective for fine facial
rhytids and pigmentary problems. Patients with Glogau III and
IV skin have deeper rhytids and therefore require deeper peeling
agents for effective results. Deep resurfacing agents such as
phenol/croton oil may be more appropriate for these patients.
Deep resurfacing is effective for fine and coarse rhytids, hyperpig-
mentation, and epidermal dysplasia.
As discussed earlier, patients with darker skin types are less
suitable for resurfacing. Other relative contraindications include
a history of keloid scarring, cardiac abnormalities, and diabetes
mellitus (unless the disease is well controlled and stable).
Significant medical comorbidities such as hepatorenal disease or

Table 18.3 G g u i i n ging

Group i i n Typical age Description S in r eri i
I Mild 28–35 No wrinkles Early photoaging: mild pigment changes, no keratosis, minimal wrinkles; minimal or
no makeup
II Moderate 35–50 Wrinkles in motion Early to moderate photoaging: early brown spots visible, keratosis palpable but not
visible, parallel smile lines begin to appear; wears some foundation makeup
III Advanced 50–65 Wrinkles at rest Advanced photoaging: obvious discolorations, visible capillaries (telangiectasias),
visible keratosis; always wears heavier foundation makeup
IV Severe 60–75 Only wrinkles Severe photoaging: yellow-gray skin color, prior skin malignancies, wrinkles
throughout, no normal skin; cannot wear makeup because it cakes and cracks

176

immunosuppression are contraindications to chemical peeling,
as are abnormalities of collagen or elastin, such as Ehlers-Danlos
syndrome, scleroderma, or collagen vascular diseases. As with
any plastic surgery, emotional or mental instability is a contra-
indication to chemical peeling. Peeling should be postponed until
at least 1 year and perhaps longer after any treatment with oral
isotretinoin (Roaccutane; Accutane; Hoffmann–La Roche, Basel,
Switzerland) because of the increased risk of unpredictable scar-
ring and keloid scar formation.
18.5 Pertinent Anatomy
Patients who request a chemical peel are commonly middle-aged
and older women with aged or sun-damaged skin. Chronologic
aging results from thinning of the epidermis and dermis along
with loss of elasticity. Actinic changes are the photochemical
effects of solar radiation damage. These changes manifest
histologically as degeneration of the elastic network (elastosis),
disorderly arrangement of the epidermis and collagen fibers,
and flattening of the dermal-epidermal junction with loss of the
rete ridges; thus the resulting dermis is more lax and less elastic.
Melanocytes tend to increase in number but are less evenly
distributed in the basal layer and contain variable amounts of
melanin. Clinically, chronologic aging and photoaging result in
coarse, dry skin that shows wrinkles and tissue sagging.
18.5.1 Depth of Peeling
The comparative depth of penetration of peeling agents can be
seen in Fig. 18.2. In superficial peels, the wounding extends to
the stratum granulosum. Superficial peels therefore affect the
epidermis only. Medium-depth peels extend into the papillary
dermis, and deep peels extend into the mid-reticular dermis.
18.5.2 Histologic Changes with Chemical
Peels
Biopsies taken 2 days after a Baker peel have shown necrosis of
the epidermis. Depending on the depth of the peel, this necrosis
can extend through the papillary dermis. There is a marked
inflammatory response. A medium-depth peel, injuring the
epidermis and papillary dermis, improves actinically damaged
epidermis as well as stimulating neocollagen formation in the
upper dermis. The wounded surface starts to reepithelialize
from the follicular and eccrine duct epithelium. While the epi-
dermis usually regenerates within 7 days, dermal regeneration is
slower. ew collagen formation begins within 2 weeks and may
continue for up to a year. Obagi compared biopsies from 48 hours
post TCA peel with similar biopsies taken 6 weeks after a peel
and found that medium-depth peels show a clearly defined new
layer of fibrillar collagen and delicate elastic fibers in the upper
reticular dermis. Deep peels showed that the neodermis formed
almost the full thickness of the reticular layer. Therefore deeper
peeling modalities produce a greater degree of neocollagen
formation, which is spread deeper into the dermis. The neoder-
mis shows horizontal, thin, compact bundles of collagen and a
dense network of fine elastic fibers. Melanocytes show fine, even
emi ee
Fig. 18.2 Depth of peeling.
distribution of melanin granules. However, melanin synthesis is
impaired, and this can result in a generalized bleaching effect.
18.6 Prepeel Preparation
Regardless of the chemical peel to be used, adequate preparation
of the patient is an important factor contributing to the success
of the treatment. The patient must be motivated and understand
the recovery period required. The reward is a dramatic long-
term improvement in skin texture that is not easily replicated
by any other modality. However, to achieve this, the patient
must be prepared for the postpeel morbidity. The immediate
postpeel phase, although not particularly long, can be trying
for the patient; therefore it must be described realistically and
in considerable detail. Detailed photographs of a representative
patient’s day-by-day recovery are shown to the patient and, if
possible, to the patient’s caregiver. Some patients will not tol-
erate the postpeel morbidity associated with medium to deep
chemical peels. These patients can be treated with superficial
peels, but they must understand that the clinical improvement
will be less dramatic, and regular treatments may be required.
Patients with coarse rhytids requiring deep resurfacing can gain
a dramatic improvement but must be prepared for the signifi-
cant postpeel recovery. It is worthwhile to have a prospective
patient speak or, ideally, meet with patients who have had a
similar peel. Seeing someone in person who has successfully
gone through the process offers invaluable encouragement that
although the recovery is difficult, it will be well worth it. The
peel will be well tolerated and the experience will be a positive
one if the patient is well informed and the physician sets the
proper tone.
Preparation of the skin before the peel is a means of prevent-
ing such complications as pigmentary changes. This is done by
applying aggressive doses of tretinoin and hydroquinone 4 , as
described subsequently. Some companies offer a complete set
of required products and a protocol for their use, such as the
complete Obagi u-Derm system (Skin Specialists PC, Omaha,
177
 III Nonsurgical Cosmetic Treatments
E), which may be of value to practitioners. ith an appropriate
pretreatment regimen, the epidermis is stabilized, the dermis
is stimulated to create more collagen, and the melanocytes are
suppressed. The purpose is to regulate cell function and reduce
the risk of postoperative pigment change. The skin is in essence
revved up for the injury to come.
Preparation begins at least 2 weeks (ideally, 4 to 6 weeks) before
the peel with applications of tretinoin 0.1 (Retin-A or Renova;
Ortho Dermatologics, Bridgewater, ), an acid form of vitamin
A. It acts to decrease the cohesiveness of epidermal cells, which
results in thinning of the stratum corneum. One inch (1 g) should
be applied to the whole face once per day. The application should
include the earlobes, tragus, and hairline, continue to 1 inch below
the mandibular border, and extend up to 1 to 2 mm below the
ciliary edge. The upper lids must be avoided, because application
to this tissue could lead to irritation. The neck can be prepared in
a similar fashion, less frequently, depending on whether irritation
develops.
Hydroquinone 4 or other bleaching creams are used both
preoperatively and postoperatively to reduce the risk of hyper-
pigmentation. Hydroquinone decreases melanin formation by
inhibiting tyrosinase in melanocytes. Therefore it produces a
reversible suppression and regulation of melanocytes. It is used
for 2 weeks preoperatively (again, the ideal is 4 to 6 weeks), then
again after the peel once the skin has resurfaced. Also, to prevent
postinflammatory hyperpigmentation, glycolic acid 8 or phytic
acid 2 is applied once daily to loosen desquamated cells in the
stratum corneum and help accelerate exfoliation.
This process accelerates cellular turnover and results in ery-
thematous, flaky skin; the patient must be prepared to accept this
phase. Retinoid dermatitis is also common preoperatively. This
can be lessened by decreasing the application of tretinoin to every
other day for the first 1 to 2 weeks. The preparation should be
stopped 4 or 5 days before the peel to allow the epidermis to settle.
The patient is instructed not to apply anything on the skin on
the morning of the procedure.
This skin preparation regimen is certainly a nuisance, and there
is controversy as to its absolute necessity. There are practitioners
who successfully perform peels or laser resurfacing without it;
greater experience and specific studies will be required before
consensus is reached. Our experience has been that omitting or
shortening the preparation has led to excessively long erythema.
18.7 Pretreatment Planning
18.7.1 Medications
Antiviral prophylaxis is routinely prescribed to all patients,
regardless of whether they have a history of oral herpes.
Valacyclovir hydrochloride 500 mg, 1 tablet two times a day,
or the equivalent dose of acyclovir or famciclovir, is begun 3
days before the procedure and continued for 7 days after the
peel. Although the postpeel phase is not particularly painful,
narcotic pain medication is prescribed along with ibuprofen 800
mg 3 times daily. Steroids are administered intraoperatively,
but a methylprednisolone dose pack (Medrol Dosepak, Upjohn,
alamazoo, MI) prescribed in the past has been discontinued
due to a possible comedogenic tendency. Sleep medication is
178
prescribed, and a mild sedative may be considered to help the
patient cope with the inconvenience and isolation of the recov-
ery period.
18.7.2 Solution Preparation
TCA
These solutions are generally prepared by a compounding phar-
macist using appropriate weight-to-volume calculations (w/v)
to achieve the correct percentages. As an example, a 35 TCA
solution should be compounded by dissolving 35 g of anhydrous
TCA crystals in a little distilled water; then more water should
be added to bring the final volume to 100 mL. Dissolving 35 g
TCA in 100 mL of distilled water is incorrect, as this will result
in a more dilute solution than expected. The required variety of
concentrations should be compounded by the pharmacist and
not diluted from each other by the surgeon. If stored in acid-re-
sistant plastic bottles, the stock solutions are stable for at least 2
years. Small volumes of each concentration can be poured from
the stock bottles as required.
Using the correct concentration of TCA solution is vitally
important. If the physician does not know a reliable compounding
pharmacist, a national distributor can be used to ensure that the
TCA mixture has been accurately prepared.
Croton Oil
Preparation of the acid peeling solutions is a critical step that
ideally should be performed by the operating surgeon to ensure
accuracy and consistency. The ingredients, including water,
phenol, croton oil, and Septisol (now, ovisol), are the same as
in the classic Baker peel formula. They are inexpensive and can
be obtained from compounding pharmacies or from Delasco
(Council Bluffs, IA), a dermatologic supply company.
Traditional formulations used drops of croton oil, which can
be awkward to deal with and have the potential of dangerous
variability, especially when dealing with small volumes. The
process is simplified significantly by delivering the croton oil in
a standardized stock solution consisting of USP phenol 88 24
mL and croton oil 1 mL. This solution yields a reliably accurate
concentration of 0.04 mL croton oil to 1 mL stock solution. This
increased volume of ingredients enables easy measurement with
standard syringes. As can be seen in Table 18.4, the volumes of
water and Septisol (now, ovisol) remain constant, and by varying
the relative volumes of phenol and stock solution, different con-
centrations of croton oil are possible. As an example, to make a
0.8 croton oil solution, one would mix water 5.5 mL and Septisol
(now, ovisol) 0.5 mL, and add USP phenol 88 2 mL and stock
solution 2 mL. The 2 mL of stock solution contains croton oil 0.08
mL. Because the total volume of the solution is 10 mL, the final
concentration is 0.08 mL of croton oil in 10 mL total volume, or
0.8 . eaker solutions such as 0.1 and 0.05 are very useful; to
make these, one first makes 0.4 and 0.2 that are further diluted,
as noted in the table. The final concentration of phenol in all these
formulas is 35 by volume. If a greater concentration of phenol is
desired, the relative volume of the USP phenol 88 is increased
and the volume of the water is decreased. The stock solution, at
4% croton oil, should always be diluted never applied full strength.

Table 18.4 Hetter peel formulas with a 35% phenol vehicle
Water
Septisol (now Novisol)
USP phenol 88%
Stock solution containing phenol and croton oil (see below)
TOTAL
0.1% = 1 mL of 0.4% + 1.2 mL phenol + 1.8 mL water.
0.05% = 1 mL of 0.2% + 1.2 mL phenol + 1.8 mL water.
Stock solution = 24 mL phenol + 1 mL croton oil (0.04 mL croton oil/1 mL stock solution or 4% croton oil).
18.7.3 Pretreatment Routine
Application of the peel is painful; therefore, intravenous
sedation or general anesthesia is usually necessary. Regardless,
adequate blocking of pain is important to prevent excessive
stimulation and allow the patient a pain-free emergence from
anesthesia and a comfortable initial postpeel course. If the
initial pain cycle is avoided, the entire recovery and general
experience will be better. Some patients report mild tingling
or burning on the first night, but they are usually pain-free the
following morning.
After sedation or general anesthesia, complete local sensory
facial nerve blocks are performed with bupivacaine (Marcaine;
Pfizer, ew ork, ) with epinephrine. These include the
supraorbital, supratrochlear, infratrochlear, zygomaticotem-
poral, zygomaticofacial, infraorbital, dorsonasal, mental, and
cervical nerve branches. Subcutaneous infiltration of dilute plain
bupivacaine throughout the entire operative site is very useful.
Color changes of the skin are important indicators of the depth
reached; therefore epinephrine is not used in the superficial
infiltration to prevent blanching. Intramuscular ketorolac tro-
methamine (Toradol; Hoffmann–La Roche, Basel, Switzerland)
is administered as an adjunct to anesthesia if a concomitant
operative procedure is not being performed. A steroid dose is
administered intraoperatively.
This anesthetic regime was used successfully for 13 years
and can certainly still be used. In recent years, an interesting
alternative has come to light. In an attempt to improve the for-
mulation, I constantly alter the proportions and, for expediency,
try them on my own skin. hile working on a higher-concen-
tration phenol formula for brown spots on the hand, I made the
observation that my skin stung for about 10 to 15 seconds and
then became completely anesthetic, to the point that I could
stick a needle into it without any sensation whatsoever. This
finding was consistent, and therefore I decided to utilize it
during the peels.
My plan was to apply phenol 50 to 60 slowly, for example,
on the lower eyelid. The stinging lasted about 15 seconds and
then subsided, and I would repeat it on the opposite side. Once
both eyelids were comfortable, I could peel as usual without
discomfort. This was an important finding, because now lower
eyelid peeling could be performed as a simple office procedure,
done very expediently, and benefiting a large number of
patients.
emi ee
Croton Oil
0.2% 0.4% 0.8% 1.2%
5.5 mL 5.5 mL 5.5 mL 5.5 mL
0.5 mL 0.5 mL 0.5 mL 0.5 mL
3.5 mL 3.0 mL 2.0 mL 1.0 mL
0.5 mL 1.0 mL 2.0 mL 3.0 mL
10 mL 10 mL 10 mL 10 mL
ith further experience, I advanced to peeling the full face,
under oral sedation, coating sector by sector with the dilute
phenol, then peeling. Although a full-face peel was feasible
in this manner, it was not consistently well tolerated toward
the end of the peel. An important observation was that any
discomfort postpeel was short-lived, and the following day
the skin remained anesthetic and any area that seemed under-
peeled could be easily touched up. This is extremely valuable,
especially when learning where there may be a tendency to
underpeel.
The fear of cardiac toxicity has been historically associated
with phenol peels, but rare reports of death are anecdotal, and
it is impossible to implicate phenol toxicity rather than com-
plications related to anesthesia. The occurrence of arrhythmias
during peeling is well documented, and although rare, these
are not clinically significant. Historically, traditional peels
were performed with anesthesia or sedation but without local
blocks. There is speculation that the catecholamine release from
the intense stimulation caused by the high concentration of
croton oil may have been the cause of the arrhythmias. ith
a lower concentration of phenol (35 versus 49 ), a lower
concentration of croton oil, and thorough local anesthesia of the
face, cardiac complications have not been seen. Thomas Baker,
who popularized the traditional peel, has stated that in his vast
experience he has never encountered cardiac arrhythmias that
required treatment. General recommendations include cardiac
monitoring, adequate hydration, and peeling a full face in no
less than 45 minutes. Following these precautions, we have
encountered no cardiac complications in nearly 15 years of peel
procedures.
This technique of anesthesia had further ramification in
understanding the issue of cardiac toxicity. hen I observed
that full-face peels were not consistently well tolerated with
oral sedation, I switched to intravenous sedation. In my first two
cases, under adequate sedation, I applied the dilute phenol more
quickly and tachyarrhythmias were seen. They were treatable
and transient but nonetheless worrisome. It was clear that the
rapid absorption of the phenol was having a systemic effect. ith
this information, I altered my initial application by proceeding
sector by sector slowly and watching the ECG. If the pulse rose
quickly, I waited until it normalized. ith these modifications,
there have been no further issues. A small dose of intravenous
narcotic is administered at the end of the peel, and usually
patients are comfortable. Any residual burning at discharge or
179
 III Nonsurgical Cosmetic Treatments

the night of the peel is easily dealt with using oral analgesics.
From that point on, there is usually no further discomfort (see the
section on posttreatment care).
Ophthalmic ointment and corneal protectors can be used
during a peel to protect the eyes, but even when they are used,
extreme caution around the eyes is imperative. If excessive oint-
ment is used, any spilled or misplaced chemical may dissolve in
the ointment and prevent immediate flushing out if it becomes
necessary. Alternative measures include avoiding the use of oph-
thalmic ointment altogether or suturing the eyes shut.

18.8 Treatment
18.8.1 Application Routine
ith the patient sedated and the nerves of the face well blocked,
the skin is thoroughly cleaned and degreased with acetone or alco- Fig. 18.3 Eyewash solution. (Reproduced with permission from
hol. This step is vital to allow even penetration of the peeling agent; Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
a splotchy peel can occur as a result of uneven penetration if the
skin still has residual oil. The skin can also be numbed as described
in the preceding section. Thereafter, the application process should
the associated burning sensation. As the skin is treated, it develops
be an orderly and nonintimidating one. The reason for this is that
a whitened color, known as a frost. There is a delay between the
practitioners can choose an adequately weak concentration to slow
application of the solution and formation of the frost. In appropri-
down the process, depending on their preference and experience,
ately pretreated skin, the delay is approximately 60 seconds (45 to
to give ample time to judge the depth achieved. Furthermore, there
120 seconds on average). Therefore, after each pass with the gauze,
are a number of factors at the surgeon’s disposal (as will be dis-
the physician should pause to observe the frosting before further
cussed) that can be used to fine-tune the control of the application.
application to the area. This process requires patience on the part of
In general, the different concentrations of solutions are placed in
the physician but is essential to prevent undesirably deep peeling.
separate, easily identifiable bowls or cups. Materials for application
Each region of the face is treated in turn until the desired depth of
are 2 2 (2 in. 2 in. 5 cm 5 cm) gauze (preferably synthetic fiber,
frosting is achieved, then attention is turned to the next region.
which is less abrasive) and cotton-tipped applicators (Fig. 18.3).
e prefer to peel regions that require deeper penetration first (for
Large round-tipped gyn swabs are also useful.
example, the perioral region and the forehead) and regions to be
Eyewash solution should also be kept in reach, in case an
peeled less deeply (such as the periorbital area) last.
ophthalmic washout is required. For application, the gauze is
Once the desired depth of peel has been achieved, ice-cold
folded twice, dipped into the solution, and carefully wrung out
saline-soaked gauzes are placed on the peeled region. This relieves
to avoid dripping. The solution is stirred before each application
the burning sensation for the patient and helps neutralize any
to ensure even mixing of the ingredients. ith the use of the new
remaining TCA solution on the skin surface to prevent further
surfactant ovisol, this is less important as the solution remains
penetration. The gauzes warm up quickly and should be replaced
stable during a typical peel. An assistant helps dry the applying
or refreshed regularly with ice-cold saline solution. Removing the
hand to prevent inadvertent application where it is not wanted. A
gauzes also allows the physician to assess the resolution of the frost-
practical technique is to have the surgeon clip a surgical towel to
ing. Erythema appears after the frosting resolves, when serum in the
the shoulder, letting it drape to the front much like a chef’s towel.
tissue and vessels neutralizes the TCA and the coagulated proteins
The surgeon can then conveniently dry his or her hands with ease.
resolve. The time taken for the frosting to resolve and erythema to
Consistent vigilance in this respect is imperative, especially in
occur is directly related to the depth of the peel: frosting resolves
segmental peels, where errors will be obvious.
more quickly with superficial peels than with deep peels. According
to Obagi, superficial epidermal peels will resolve in less than 20 min-
18.8.2 TCA Peel utes; the frosting in medium-depth (papillary dermal) peels lasts up
to 40 minutes; and deeper peels into the reticular dermis take longer
Epidermal peels are performed with a 20 TCA solution, whereas
to resolve, with frosting persisting for up to 60 minutes (Table 18.5).
medium-depth peels can be performed with more concentrated
solutions. e generally use a 30 to 35 solution for medi-
um-depth peeling. Deeper peels are produced with 40 to 45 r n uen e e e A ee
solutions. Concentrations higher than 50 are best avoided; at As has been stated, low concentrations of TCA result in a more
such a high concentration, penetration into the dermis occurs superficial peel. Higher concentrations peel more deeply. Peel
rapidly and can be difficult to control. depth is also related to the amount of acid and the preparation of
The wet (not dripping) gauze sponge is used to apply the TCA the skin. Therefore depth can also be increased by applying more
solution in turn to each region to be treated. If the patient is layers of solution or by pretreating the skin with either essner’s
awake, holding a fan close to the peeled area can help decrease solution or mechanical abrasion (for example, with a gauze

180

Table 18.5 Obagi levels of frosting and defrosting times in trichloroacetic acid peels
gi e e ini re e n e
r ing
1 Limited to the epidermal layer; a nonorganized, foggy or cloudy white frost on a pink (erythematous) background
2 Penetration to the papillary dermis; a regular, white-coated frosting with erythema still showing through
3 Penetration into the reticular dermis; a solid, intense white to yellow frosting, with no background erythema
sponge). This becomes particularly important if the patient has
not completed the routine prepeel skin preparation regimen.
Assessing the Depth of a TCA Peel
Obagi has noted that the ability of the body to defend against the
acid depends on the concentration and volume of acid applied, as
well as on the thickness of the skin. Frost (or skin whitening) occurs
as the skin proteins precipitate on application of TCA. The speed
at which the frost develops varies with the concentration of the
TCA used: dilute concentrations take 15 to 60 seconds to produce a
frost, whereas higher concentrations may frost in less than 10 sec-
onds. The precipitated protein disperses with time and therefore
the frost disappears. Frosting of the skin is a helpful clinical sign to
aid the surgeon in deciding when to end the peeling process, as the
amount of frosting is related to the depth of the peel. Obagi grades
frosting as level 1 through 3, as shown in Table 18.5.
In level 1, the peel penetrates the epidermal layer only and
results in a combined pink and white frost that is disorganized or
cloudy. Penetration into the papillary dermis produces a level
2 frost, which is a more uniform white frost, but with erythema
still showing through. Penetration of the peel into the reticular
dermis produces a solid white frost with no visible erythema; this
Fig. 18.4 This patient is shown partway through the peeling process;
she has undergone an upper blepharoplasty followed by a full facial
chemical peel with 30% trichloroacetic acid (TCA). Note the level 2
frosting of the forehead with visible erythema in the base, compared
with the dense, level 3 frosting of the perioral region, where no
erythema can be seen (left). At the end of the peeling process, there is
level 1 irregular frosting of the nasal tip, regular level 2 frosting of the
forehead, cheeks, and mental area, and level 3 frosting of the perioral
regions (right).
emi ee
er ing ime
< 20 min
Up to 40 min
Up to 60 min
is level 3. Deeper dermal penetration of the peel is undesirable;
this produces skin with a grayish appearance and is associated
with long-term scarring (Fig. 18.4).
Obagi also suggested the epidermal sliding sign to show when
a TCA peel has penetrated the papillary dermis. At this level, the
epidermis can slide over the firmer, immobile dermis, since the
rete ridges have been disrupted. Skin firmness (turgor) can also
be palpated. Untreated skin is soft to the touch, whereas a deeper
peel results in firmer dermis caused by an increased amount of
protein precipitation.
Recommendations for TCA Peels
The following are general recommendations for TCA concentra-
tions in specific areas, but it is important to consider individual
variations and to remember that concentration choice is only one
factor influencing the depth of penetration of the peel. Regardless
of concentration, it is imperative to always judge the depth of the
peel as described in the previous section.
The whole face can be peeled with the same concentration
of TCA, with depth varied by increasing the number of layers of
solution applied or by using varied concentrations of solution. In
general, the author prefers to use a single concentration of solu-
tion, usually 30 to 35 TCA, to peel the entire face.
In general, the deepest peel should be performed in the perioral
region. This is followed by the forehead and cheeks, with the
lightest peels performed on the eyelids and earlobes. The perioral
region has deeper rhytids and is peeled until a level 3, dense white
frost is achieved.
Application
The 30 TCA is applied to the perioral region with a cotton-tipped
applicator; this ensures accurate application of the solution into
the perioral rhytids. The forehead and cheeks generally require
a medium-depth peel, depending on the patient. Penetration
into the papillary dermis is ideal; therefore frosting is carried to
level 2. The solution is usually applied with gauze 2 2 squares
to cover a large area evenly (Fig. 18.5).
The solution is applied to the nose with a 2 2 gauze square on
the dorsum and sidewalls, and cotton-tipped applicators are used
to ensure penetration into the alar grooves. Because the eyelids
have thin skin, the solution is carefully applied to this area with a
cotton-tipped applicator. This is usually the last area of the face to
which the solution is applied (Fig. 18.6).
If the neck or d collet region is to be treated, a lower concen-
tration of TCA (such as 20 ) should be used. This is because the
skin in this area has fewer adnexal structures; therefore reepithe-
lialization can be delayed with deeper peels. If the neck is not to be
181
 III n urgi me i re men
Fig. 18.5 Trichloroacetic acid application to the perioral region with a cotton-tipped applicator and to the forehead using a gauze square.
Fig. 18.6 Trichloroacetic acid application to the dorsum of the nose with a gauze square and to the eyelid using a cotton-tipped applicator.
treated, the facial peel should be blended or feathered just below
the mandibular angle by applying solution to this area very lightly.
After the peel is applied to the desired depth, iced saline-soaked
gauze is placed across the patient’s face to cool and relieve the
burning. This is changed regularly to ensure that the gauze stays
cold and that the physician can review the resolution process.
Once the frost starts to resolve, a thin layer of petrolatum-based
occlusive ointment is applied across the peeled surface, and the
patient is transferred to the recovery suite. Complete resolution of
the frosting depends on the depth of the peel. The patient should
be checked in the recovery suite, and the physician should note
how long the resolution process takes. This is a good indication
of the depth of the peel and aids the physician in developing
judgment in the art of peeling (Fig. 18.7; Fig. 18.8).
18.8.3 Croton Oil Peel
ith the damp gauze in hand, the physician makes multiple
passes, observing the color change of the skin to assess the frost
formation. As the application progresses, the depth is gauged by
the degree of frosting, which becomes progressively more dense
and opaque. The speed at which the frost appears depends on
the concentration used and the wetness of the gauze. ith the
182
typical concentrations described and use of a damp (not wet)
gauze, the appearance of the frost is gradual and is seen in about
10 seconds. In contrast to TCA peels, with a croton oil peel there
is no need to wait several minutes to see the final depth. Once the
croton oil solution is applied, there is no neutralizing agent and
the effect is irreversible. The only recourse in this respect is that
if a too-wet application is made, quickly blotting it will diminish
the depth (Fig. 18.9).
r n uen e e e r n
Oil Peel
The versatility and safety of the peel are based on the fact that
there are a number of variables that determine the depth. Hetter’s
invaluable contribution was in demonstrating that the concentra-
tion of the croton oil is a key factor of the depth reached and, com-
pared with older peels, is the demarcation between an excellent
result and hypopigmentation. Regardless of the concentration
used, the number of coats applied has an additive effect; there-
fore a weak concentration applied repeatedly can lead to deep
involvement, even scarring. The safety of a weak concentration is
only relative and should never be taken for granted.
 emi ee

b c

a
Fig. 18.8 Patient in Fig. 18.4
Fig. 18.7 Care after trichloroacetic acid application. (a) Cooling of the face with ice-cold, saline-soaked through 18.7 shown 30 minutes
gauze. (b) Petrolatum-based occlusive ointment applied after the frost begins to resolve. (c) The ointment after the peel, with resolution of
used. the frosting.

Fig. 18.9 Croton oil application. (Reproduced with permission from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)

As previously described, the croton oil concentrations are
relatively weak, so the other main factor of the depth reached
is the application technique, which is directly controlled by the
surgeon. This is the fundamental difference between the modern
croton oil peel and its predecessors. A damp sponge can be rubbed
multiple times, variable pressures can be used, or the gauze can
be wetter and fewer passes made. Theoretically, the same depth
can be reached by using different techniques or even different
concentrations.
The location on the face to which the peel solution is applied
is significant because of the relative thickness and recuperative
potential of the skin. For example, the perioral skin can sustain
a deeper peel than the thinner, more delicate skin of the eyelids.
Assessing the Depth of a Croton Oil Peel
The key to success with these peels, as with any resurfacing
technique, is choosing and safely reaching the appropriate end
point. This depends on the degree of frosting, which is mainly a
visual phenomenon, and therefore subjective and based on expe-
rience. Regardless of these apparent difficulties, photographs and
available videos are very accurate references, and the process is
not as daunting as it may initially appear. Anatomically, a super-
ficial peel wounds all the structures of the epidermis. Such a peel
may have an effect on pigmentary issues and be refreshing, but
it cannot be expected to improve real wrinkles. Usually croton
oil peels are deeper and effect change beyond the epidermis. A
medium-depth peel goes to the papillary dermis. Deep peels go
to the reticular dermis (upper to mid-dermis), and peeling to the
lower reticular dermis can be problematic, leading to hypopig-
mentation and possibly scarring. The recovery, of course, is more
involved with increased depth, but the harsh reality remains
that to provide real change, there must be injury into the dermis.
The visual clues are a thin, transparent frost with a pinkish
background denoting a peel to the papillary dermis. The pink hue
is caused by the subdermal vascular plexus, still intact, showing
through.
A solid, opaque, organized, even frost signifies that the upper to
mid-reticular dermis has been reached (Fig. 18.10).
A thick, gray-white sheet of frost with eventual red-brown over-
tones indicates that the mid-dermis has been reached as deep as

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 III Nonsurgical Cosmetic Treatments

a b
Fig. 18.10 (a) Assessing the depth of a croton oil peel to the papillary dermis and (b) to the upper to mid-reticular dermis.

the peel should go. The red-brown overtones may take 15 minutes
or more to become evident and are a reliable and accurate sign.
Once a dense frost has been achieved, such as in the perioral area,
it is worthwhile to wait to see whether the red-brown appears
before considering further application (Fig. 18.11).
Practitioners familiar with the different degrees of frosting with
deeper TCA peels will have little difficulty transitioning to croton
oil peels. The important concept is that this is a gradual continuum
that is slow enough, with the visual changes easily recognizable and
predictable. An experienced practitioner can control the process,
peeling slowly enough to recognize the various stages, and is able to
stop at the appropriate depth and go no deeper.
Another indicator in evaluating the level of peel is epidermal
sliding, which is seen when the peel reaches the level of the
papillary dermis; the epidermis is separated from the underlying
reticular dermis and slides as a thin, independent sheet. This
Fig. 18.11 Assessing the depth of a croton oil peel. A red-brown color
sliding disappears when the reticular dermis is reached and the indicates that the mid-dermis has been reached. (Reproduced with permis-
epidermis and dermis bond together, forming a single protein sion from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
block. Epidermal sliding is most obvious in thin-skinned areas
such as the eyelids and lateral forehead, as opposed to the perioral
Table 18.6 Defrosting times for croton oil peels
region. Epidermal sliding is a particularly telling indicator in the
very thin eyelid skin, where the margin for error is small. Papillary dermis 5–10 min
Defrosting, or loss of the frost, can also be used to assess or Upper to mid-dermis 15–20 min
confirm the peel depth, although it is already after the fact (Table Mid- to lower dermis 20–30 min
18.6; compare with those for TCA in Table 18.5).

Recommendations for Croton Oil Peels
The following are general recommendations for croton oil
concentrations in specific areas, but it is important to consider
individual variations and to remember that the choice of con-
centration is only one factor. Regardless of the concentration, it
is imperative always to judge the depth of the peel, as described
in the previous section. The perioral area (including the lower
nose) is quite resilient and can be peeled with a strong concen-
tration, such as 0.8 or 1.2 for very pronounced rhytids. This
is extended beyond the chin onto the mental crease. Individual
rhytids are stretched out to allow even penetration. The peel can
be extended into the vermilion to improve lip wrinkles and gain
beneficial lip eversion. The commissures heal well and can be
peeled to a relatively deep level (Table 18.7).
The cheeks and forehead are peeled with 0.4 concentration. The
glabellar area and central forehead are relatively thick and can be
peeled to the mid-dermis (solid white frost). The lateral forehead
and temporal area are more delicate, and peeling to the papillary
dermis is usually more appropriate (a white frost will appear, with
a pinkish background). The peel can be safely extended to the
hairline and brows to avoid lines of demarcation. Deep peeling of
the cheeks is not often needed. Caution should be exercised in the
preauricular area and geniomandibular groove (Fig. 18.12).
The eyelids are peeled with 0.1 , and 0.05 is a consideration for
the upper lids. In the lower lids, the peel is extended close to the
ciliary margin. The peel is applied with a cotton-tipped applicator,
and as in other areas, the relative dampness and number of passes
affect the depth of the peel. The thin eyelid skin responds well and in

184
 emi ee

Fig. 18.12 Recommendations for croton oil peels to the forehead. Fig. 18.13 Recommendations for croton oil peels to the eyelids.
(Reproduced with permission from Bensimon RH. Croton oil peels. (Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.) Aesthet Surg J. 2008; 28:33-45.)

a predictable way to these weak concentrations. Epidermal sliding

and an even white frost are easily recognizable and reliable findings
that denote the proper depth. If there is obvious redundancy of skin
in the upper lid, the peel can be safely extended below the tarsal
fold, possibly with a concentration of 0.05 (Fig. 18.13).
The peel is extended onto the neck using 0.1 (or weaker) with
light, wispy strokes, because this skin is thin and does not heal
as well as the face. The endpoint is a barely visible frost that is
not at all organized. Less is more is a good philosophy in the
neck. The neck skin is too thin to withstand a peel deep enough to
improve wrinkles; doing so will result in hypopigmentation and
quite possibly scarring. The purpose of the neck peel is to prevent Fig. 18.14 Recommendations for croton oil peels to individual lip
the obvious demarcation that is commonly seen with laser resur- rhytids. (Reproduced with permission from Bensimon RH. Croton oil
peels. Aesthet Surg J. 2008; 28:33-45.)
facing and deeper peels.
Precise deeper peeling of individual rhytids without affecting
surrounding areas is a great advantage, especially in the perioral
area and chin. This is done with a wetter cotton-tipped applicator, demarcation between areas peeled with different concentrations,
painting the individual line and then quickly drying it as a dense a weak concentration such as 0.2 or 0.1 is used to blend these
frost appears. This is very useful in troublesome radial lip lines. sections (Fig. 18.14).
More precise application, as in the crow’s-feet, can be done with The best way to learn these peels is to gain experience, but
the splintered wooden end of the applicator. Focal repeeling this must be done safely. Like any difficult procedure worth per-
of persistent rhytids is easy to do with the patient under local forming, whether a deep superficial musculoaponeurotic system
anesthesia. Repeat peeling, either in part or in whole, has an addi- (SMAS) dissection for a facelift or a transverse rectus abdominis
tive effect. If peeling appears to be uneven or if there is a sharp myocutaneous (TRAM) flap in breast reconstruction, diligent

Table 18.7 General peel recommendations*

Location Croton oil concentration
Forehead, temporal area 0.2–0.4%. The glabellar area can be peeled deeper than the lateral forehead and temporal area.
Precise deeper peeling of individual lines is possible with a wetter cotton-tipped applicator and blotting
dry as frost appears.
Perioral area (including lower nose) Precise deeper peeling of individual lip lines is useful.
Cheeks, preauricular area 0.2–0.4%. Deep peeling is rarely needed.
Eyelids 0.1% lower eyelids; 0.1% upper eyelids. Consider 0.05% in upper lids, especially below the tarsal fold.
Neck 0.05% (or weaker). Very light, wispy peeling for blending of color, not for wrinkles.
*Predictable problem areas that require careful attention include the temporal area, immediate preauricular area, geniomandibular area, and the medial upper lid where it
abuts the nasal skin. These are general recommendations. The key to the peel is to always judge the depth by the visual clues described, whatever technique or concentration is
used. There is only relative safety in using a weaker concentration, and similar depths can be reached by the use of different techniques, even different concentrations.

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 III Nonsurgical Cosmetic Treatments
study and attention to detail are required. It is always worthwhile
to watch another surgeon perform a peel, and to this end there
are now live surgery video workshops that are very practical
and useful. Good color photographs in publications and available
videos are valuable to familiarize oneself with the visual aspects
of the frost. One approach is to purposely plan on a lighter peel
using a maximum concentration of 0.4 , with the thought of
performing a repeat peel should it become necessary. Thus, the
surgeon gains experience mixing and handling the solutions and
visualizing the appearance of frost after application. It is never
wrong to underpeel, and once this threshold is crossed, it is not
difficult to progress to full-fledged peels.
18.8.4 Variation of Chemical Peels
Segmental peels are possible with any resurfacing agent but carry
the risk of a mismatch in coloration; therefore good judgment
must be exercised. Skin with widespread solar damage carries a
risk of demarcation, so a full-face peel is preferable. Segmental
perioral peels can be done, peeling to a medium depth at most.
The color takes 8 to 10 weeks to blend adequately, and the patient
can manage color differences in the meantime with makeup.
In selected individuals with isolated upper lip lines, peeling of
the mustache area can produce excellent results (Fig. 18.15).
The skin of the lower eyelid responds very well to chemical peeling.
hen peeled to the appropriate depth, the thin eyelid skin contained
within the borders of the orbital rim is very forgiving. Healing is well
tolerated and easily camouflaged with makeup or glasses, making
this an excellent location for segmental peeling. However, we would
add a note of caution when treating this area: very low concentra-
tions of peeling agents should be used. With croton oil peels we limit
the concentration to 0.1 , and with TCA we limit the concentration
to 20 or a very light pass with 30 (Fig. 18.16).
A major advantage of the lower eyelid peel is that it can easily
be done under local anesthesia or with dilute phenol and in a
gradual fashion. ith regards to anesthetic technique, a welcome
addition has been the introduction of an apparatus that delivers
50 oxygen and 50 nitrous oxide by patient demand through
a mouthpiece the patient holds (Pro- ox, Carestream Medical,
Altamonte Springs, FL). This is weaker than the 70 nitrous oxide
commonly used by dentists and is mainly an anxiolytic rather
than an anesthetic. Using dilute phenol as a first pass, the initial
short-lived stinging is nicely abated by the nitrous oxide, making
this extremely useful in an office setting. If a patient requests a
procedure with a quicker recovery, a lighter peel can be done and
repeated in the future with additive effect. In a real sense, the
lower eyelid can be peeled to the patient’s satisfaction. Treatment
a b
Fig. 18.15 (a) In selected individuals with isolated upper lip lines,
(b) peeling of the mustache area can produce excellent results.
186
of the lower lids is a good option for chemical peeling because of
its safety and predictability; it is a good starting point for patients
(and surgeons) who are reluctant to begin with a full-face peel.
Regardless of the technique chosen, the wise surgeon will avoid
serious problems by accepting that wrinkles cannot be completely
removed with a peel procedure alone.
A novel use of these procedures is to perform a lighter peel in
younger individuals to improve early imperfections while pro-
viding an easier recovery. These peels successfully improve early
wrinkling and solar damage, restoring a brightness or lucency to
the skin that evokes a look of youth. The aim of peels is to keep up
with aging; they can be an excellent adjunct to many facial pro-
cedures, except surgeries in which major skin flaps are elevated
(Fig. 18.17).
18.9 Posttreatment Care
For 15 years after Hetter’s description, I had used bacitracin/
polymyxin B ointment (Polysporin; ohnson ohnson, ew
Brunswick, ) and one tube of lidocaine jelly evenly mixed
together and applied to the peeled skin. This worked well (and
can still be used), but over time some deficiencies became appar-
ent. It required active participation of the patient, who had to
apply ointment frequently on a weeping, swollen, scary-looking
face. Sensitization to the antibiotic was not infrequent, and
breakouts, milia, and troublesome pruritus were seen. These,
and occasional intense erythema, led me to seek an alternative.
Once the peel is completed, the patient is observed until all
frosting subsides. The peeled area is then covered with zinc oxide
pink tape, creating a mask. If the upper lids are peeled, the tape
may interfere with opening the eye well, and with swelling, vision
may be impaired the first night. Utilizing the anesthetic technique
previously described, patients are usually comfortable once the
tape is applied (Fig. 18.18).
The patient returns the next day and the tape mask is removed
(Fig. 18.19). If one remembers to apply petroleum jelly to brow and
hairline, removal is not uncomfortable. This may be hard to believe,
Fig. 18.16 Considerable improvement was achieved after a segmental
peel in this 42-year-old man, whose wrinkled lower eyelid skin was
incongruent with his otherwise youthful looks.
 emi ee

a b c
Fig. 18.17 This 45-year-old woman (a) exhibited generalized elastosis and etching of the chin. (b) Considerable improvement without loss of pigment
is seen at 1 year, and (c) her results remain stable after 6 years. Other than the original Baker peel, no other modality has been able to claim this kind
of longevity of results. (Reproduced with permission from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)

but the entire skin is quite anesthetic, and touch-ups of remaining

lines can be done at this time. The skin is then gently cleansed
with poloxamer 188 (Shur-Clens; ConvaTech, Bridgewater, )
or saline. Poloxamer 188 is an industrial surfactant that is very
healing and stabilizes cell membranes. Plastic surgeons may be
familiar with Shur Clens due to its use for washing out silicone
with ruptured implants.
The next step is mix poloxamer 188 or saline and bismuth subgal-
late powder into a smooth, even paste. Bismuth is a natural element
with well-known healing properties (as in Pepto-Bismol, Procter
Gamble, Cincinnati, OH, and Xeroform, Dynarex, Orangeburg, ).
A little ophthalmic gel adds to the creaminess. Once mixed, the
paste is applied to all peeled areas and allowed to harden, like a clay
mask. A hand-held fan aids in the process (Fig. 18.20).
From this point on, the patient does nothing and is strictly
instructed not to touch the face. The healing skin beneath will Fig. 18.18 Zinc oxide tape is applied to all peeled areas.
gradually shed this mask in roughly 7 to 12 days. The patient is
seen on day 7 and adherence of the mask is assessed. The routine
is to gently apply petroleum jelly or another thick emollient on the
remaining crust, leave it on that day, and allow gentle showering life for the patient. If erythema is problematic, it can be improved
(no direct stream) the next day. The remaining mask will fall off in with judicious short-term use of topical steroids.
the next 2 to 3 days. Our routine is to give the patient Epidermal Management of the postpeel phase begins before the peel
Repair (SkinCeuticals, Dallas, TX) to apply to the newly exposed with adequate information. Patients must fully understand what
skin. It is imperative that neither patient nor surgeon pick at any the experience will be like and how they will look. Showing
of the crust it must be allowed to fall off on its own. Pruritus can photographs of the day-by-day recovery is valuable and ensures
be a problem, for which diazepam has worked well. The healed that the patient will be a willing participant based on accurate
skin typically is less erythematous than when occlusive ointments information. The early recovery can be challenging, but patients
were used (Fig. 18.21; Fig. 18.22). do well if they are well prepared.
The net effect of the tape and bismuth mask has been dramatic.
If adequately educated, patients are very accepting of their bizarre,
green appearance and overall are in better spirits than with 18.10 Problems and Complications
previous techniques. One very tangible improvement is that it has Complications from croton oil peels are the same as with any
significantly cut down on office visits and worried calls (Fig. 18.23). other deep resurfacing technique. The main complications,
As previously mentioned, erythema is less intense, depending scarring and hypopigmentation, are largely preventable by
on the depth of the peel, and can last 8 to 12 weeks. Makeup can controlling the depth of peel. Delayed healing and thickening is
be used after the second week, which is a great help normalizing

187
 III Nonsurgical Cosmetic Treatments

a a

b b
Fig. 18.19 (a) Zinc oxide tape mask after removal. (b) Day 1 after tape Fig. 18.20 (a) Bismuth subgallate paste. (b) Paste applied to peeled
mask removal. areas.

evidence of peeling to the deep reticular dermis. This thickening
or mild scarring can progress to a full scar but can be arrested
and reversed by injecting triamcinolone acetonide 10 mg/mL and
5-fluorouracil (5-FU; off-label use) in a ratio of 3:2 or 1:1. Full-
strength 5-FU is also an option.
Both hyperpigmentation and hypopigmentation can occur as
blotchy areas or homogeneous abnormalities. They are less likely
to occur in lighter-skinned patients. Hypopigmentation can occur
if the peel penetrates deep enough. Alteration in pigmentation is
more common in older patients; it seems to be related to decreased
melanocyte synthetic function. For individuals with pronounced
rhytids, adequate improvement may necessitate peeling to a
depth that will result in hypopigmentation. The improvement is
well worth it, and the porcelain look of the skin that was typical of
formerly used peels is not seen.
Prevention of hyperpigmentation relies on the pretreatment
skin care regimen, which acts to suppress the melanocytes.
Transient hyperpigmentation may be seen during the recovery
period; this responds well to prompt treatment with tretinoin
and hydroquinone 4 over several weeks. Sun protection must be
emphasized to the patient as an important factor in prevention of
hyperpigmentation.
Infection in peeled skin can be bacterial, viral, or fungal.
Bacterial infections tend to develop on postpeel days 2 to 5 and

188
 emi ee

a b c d
Fig. 18.21 Patient, aged 62 years, with bismuth paste. (a) Day 1 post peel. (b–d) Subsequent shedding of mask over next 7 days.

a b
Fig. 18.22 (a) Patient shown in Fig. 18.21 before and (b) 6 months after peel.

are usually caused by common pathogens such as Staphylococcus simplex virus (HSV), the most common viral infection, is often the
aureus, streptococci, or Pseudomonas aeruginosa. Bacterial infec- result of reactivation of a latent infection. It is usually heralded
tions are heralded by pain, fever, and purulence and are treated by dysesthesia or intense pruritus. otably, as the epithelium is
with topical wound care and appropriate antibiotics. Herpes disrupted, the presentation of HSV is atypical, with erythematous

189
 III Nonsurgical Cosmetic Treatments
erosions rather than vesicles being present. Treatment includes
doubling the dose of oral antiviral therapy and adding a topical
antiviral agent, which should be applied with a cotton-tipped
applicator to prevent spreading the infection. A herpes outbreak
can be very impressive but typically does not leave any perma-
nent scars. Fungal infections most commonly occur with Candida
albicans and present as painful ulcerations. Diagnosis is made
with a potassium hydroxide ( OH) smear, and treatment is with
oral antifungal agents such as fluconazole.
A possible objection to the bismuth mask is that it does not
allow direct observation of the skin. A definite advantage is that
the patient is not touching the face and therefore not contami-
nating the skin with the hands. Transference of genital herpes to
the peeled face results in a very virulent infection with possible
scarring. It is the expectation that this would be totally avoided
with the bismuth technique.
Hypertrophic scarring is perhaps the most feared complication
with chemical peeling and one of the most difficult to treat. It
most commonly occurs in areas of thinner skin such as around the
lids or skin overlying bony prominences (for example, the malar
region or chin). As with poor scarring in general, it often occurs in
areas where wound healing is delayed beyond 14 days. Treatment
is generally nonsurgical, involving the application of steroid
creams or topical silicone. If this therapy is ineffective, a course
of triamcinolone steroid injections or 5-FU is recommended.
However, given the difficulty in effectively treating postpeel
scarring, prevention is undoubtedly the best cure through the
judicious use of peeling agents, particularly while the physician is
learning the techniques of chemical peeling.
Ectropion can result from excessive peeling of the lower lids. As
with blepharoplasty, caution should be exercised in patients with
lid laxity. Sequential lighter peeling and temporary suspension
of the lower lid are helpful in preventing this complication. Mild
a b
Fig. 18.23 (a) Husband, day of peel; wife, day 7 post peel. (b) Husband, day 1 of bismuth mask; wife, day 8 post peel. This couple demonstrates a
more light-hearted and accepting attitude toward the healing process.
190
tension in the lower lids is not uncommon and responds promptly
to massage.
Milia are keratin-retaining cysts and can be seen early or late
in the healing process. They occur in up to 20 of patients 6 to 8
weeks after a deep peel. They sometimes respond to an increased
intensity of the skin treatment regimen, specifically increased
tretinoin. Failing that, gentle excision with a fine needle or elec-
trocautery may be required.
Erythema usually resolves in 10 to 12 weeks after the peel
procedure, but prolonged erythema (longer than 12 weeks) can
be troublesome for the patient. Some physicians routinely use a
steroid cream for the postpeel skin care regimen as a preventive
measure. If not used already, steroid should be added into the
regimen if erythema seems excessive and extended. Bleaching
creams such as hydroquinone can also contribute to erythema
and may need to be discontinued, or an alternative pigmentation
prevention treatment can be used, such as azelaic acid 20 cream.
18.11 Outcomes and Results
An invariable observation of the results obtained with croton
oil peels is the overall qualitative improvement of the skin. The
supposition is that there has been a fundamental change in the
skin anatomy that not only dramatically improves wrinkles but
also significantly ameliorates the effects of sun damage. The skin
reflects light differently and brightens the dull, ashen look of
older, actinically damaged skin. This is the critical factor that has
been missing in surgical facial rejuvenation.
A constant observation of the Baker peel is the long-lasting (if
indeed not permanent) results. This has been substantiated by
multiple histologic studies that have shown the deposition of a
significant layer of collagen in the dermis after a peel procedure

that is aligned in an orderly manner and is thought to be the
mechanism for the effacement of wrinkles. This layer remains
constant for years, even decades.
Since 2000, results with croton oil peels show remarkable
improvement in deep wrinkles and actinic damage without
depigmentation. These improvements are completely stable,
and rather than showing diminishing results, the skin appears to
improve with time (Fig. 18.24; Fig. 18.25; Fig. 18.26).
Although not yet confirmed histologically, it is reasonable to
expect that this stability is modulated by a similar deposition of col-
lagen in the dermis, without disrupting the function of the melano-
cytes. The fact that repeated peels produce additive effects suggests
that there is more deposition of collagen each time. The skin looks
younger because, in essence, younger skin is being created.
Histologic studies have also shown eradication of actinic
keratoses in deeply peeled skin. The anecdotal impression of
a b
Fig. 18.24 (a) This 47-year-old woman had brittle, sun-damaged skin
and smoker’s lines. (b) Considerable qualitative improvement is seen
after a croton oil peel, with a stable result 4 years after treatment.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.26 Note the periorbital details in the same patient before
treatment, with posttreatment improvement of texture after 1 year,
and evidence of further improvement after 4 years.
emi ee
experienced practitioners has been that individuals who have
undergone peels do not develop facial basal cell cancer or squa-
mous cell cancer. In a recent study in the dermatology literature,
Hantash et al showed that laser resurfacing, fluorouracil, and 35
TCA peels were equally effective in keeping susceptible individ-
uals free of nonmelanoma cancers for the studied 5-year period.
The deeper croton oil peels are expected to have a similar or better
effect, further expanding the benefits and utility of this approach.
The qualitative degradation of skin with time is obvious, and
many patients consider textural changes to be at least as important
as structural changes. It could be argued that the qualitative and tex-
tural improvements achieved with a peel in the 61-year-old woman
shown in Fig. 18.27 had greater impact than surgery could have.
There are many advanced surgical techniques to deal with grav-
itational and volume changes, but surgery can improve textural
issues only minimally and indirectly and has no effect on the
a b
Fig. 18.25 (a) This 53-year-old woman is shown before a croton oil
peel treatment and (b) 4 years after the peel and a facelift. She also
had an endoscopic brow lift and upper and lower blepharoplasties.
(Reproduced with permission from Bensimon RH. Croton oil peels.
Aesthet Surg J. 2008; 28:33-45.)
Fig. 18.27 ualitative and textural improvements achieved with
a peel in a 61-year-old woman. (Reproduced with permission from
Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
191
 III Nonsurgical Cosmetic Treatments
perioral area, where improvement is often needed most (Fig. 18.28;
Fig. 18.29; Fig. 18.30; Fig. 18.31; Fig. 18.32; Fig. 18.33; Fig. 18.34).
18.12 Concluding Thoughts
Hetter’s work and subsequent experience have greatly clarified
the earlier issues regarding deep chemical peels, which are
generally classified, possibly inaccurately, as phenol peels. A
weaker concentration of phenol does not penetrate more deeply
than a stronger one, refuting long-held beliefs. This allows
greater latitude in the preparation of solutions. Croton oil has
been identified as the critical peeling agent, and a high concen-
tration of phenol is not necessary to obtain a desired peel. This
a b
Fig. 18.28 (a) This 59-year-old woman could certainly have benefited from
a facelift, but her pronounced perioral lines would have been unaltered
and a detriment to the results. (b) The overall qualitative improvement,
especially around the mouth, seen here 1 year after her peel, have had a
greater impact than surgery would have. (Reproduced with permission
from Bensimon RH. Croton oil peels. Aesthet Surg J. 2008; 28:33-45.)
a b
Fig. 18.29 (a) The preoperative view of a 75-year-old woman shows
advanced structural and textural changes of aging. Neither surgery
nor resurfacing alone could provide a complete result. (b) The second
image shows the patient at age 81, 6 years after a facelift and 1 year
after a full-face peel. Croton oil peels provide a powerful and effective
tool to complement surgery and make comprehensive facial rejuvena-
tion a reality. (Reproduced with permission from Bensimon RH. Croton
oil peels. Aesthet Surg J. 2008; 28:33-45.)
192
knowledge also opens the door to investigate other solvents
that may act as carriers of the croton oil and avoid the use of
phenol altogether.
The all-or-none phenomenon attributed to the Baker peel,
which was one of the main sources of intimidation for surgeons,
was simply because the croton oil concentration was so high that
the operator had little control over the application process. By
lowering the concentration of croton oil, application technique
and concentration choice now become the main factors that deter-
mine the depth of the peel. In this manner, the main complication
of the traditional peel can be avoided while still providing the
desired clinical result. The principal objections to deep phenol
peels were misconceptions based on the experience of older peels
that are now obsolete: hypopigmentation is largely avoidable by
controlling the depth and by exercising rudimentary precautions,
and cardiac toxicity is better understood and easily avoided.
Obagi’s work with TCA in the 1990s was also an important
addition to the field. Concentrations from 20 to 50 were found
to be effective at producing superficial to medium and deeper
peels, while largely avoiding the complications of scarring and
hypopigmentation. ith multiple concentrations of croton oil and
TCA available as peeling agents, surgeons have significant control
and specificity. This fact makes chemical peeling available to any
age group and skin type. The possibility of doing weaker peels on
younger patients with the thought of keeping up with aging is an
exciting prospect that has the potential of greatly expanding the
patient base. eaker concentrations of peeling agent can likewise
be used to great advantage on delicate eyelid skin. Precise deeper
peeling can be done on problem rhytids without adversely affect-
ing other sectors of the face. The potential use of these peels in the
prevention of basal cell and squamous cell carcinomas is a new
frontier ripe for investigation.
The main drawback of modern chemical peels is the difficult
recovery; the zinc oxide tape/bismuth mask technique is a signifi-
cant advancement that has simplified postpeel care and improved
the experience for patients.
a b
Fig. 18.30 (a) This 67-year-old woman had undergone two previous
facelifts and overresection of the lower eyelids with rounding of the
outer canthi. (b) A corrective facelift and internal suspension of the
orbicularis oculi muscles certainly improved the situation, but the
subsequent peel was critical in completing the look of youth.
 emi ee

a b

i j

c d k l

e f m n
Fig. 18.31 (a,c,e,g,i,k,m) 61-year-old woman, active smoker, with widespread wrinkling, sun damage, and pigmentary changes. (b,d,f,h,j,l,n)
Dramatic improvement 6 months post croton oil peel alone.

193
 III Nonsurgical Cosmetic Treatments

a b
Fig. 18.32 (a) This patient had splotchy pigmentation from actinic exposure and upper lip rhytids. (b) Note the improvement after a 35% TCA peel
and upper lip dermabrasion.

a b

c d
Fig. 18.33 (a,c) This patient sought treatment for her fine facial wrinkles, particularly in the periorbital region. (b,d) She is shown 5 months after a
35% TCA peel.

a b
Fig. 18.34 (a) This patient was displeased with her periorbital rhytids and lower lid pigmentation. (b) A 35% TCA peel was performed with good results.

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 emi ee

Clinical Caveats
• Modern croton oil peels are a cost-effective means to
achieve long-lasting results in facial resurfacing without
hypopigmentation.
• Skin pretreatment and patient education are important
aspects of the process to decrease postpeel erythema and
assist the patient in dealing with the postpeel recovery
period.
• The recognition of croton oil as the critical peeling agent
allows the formulation of solutions with different croton oil
concentrations.
• Choice of concentration and control of the application tech-
nique allow the surgeon to choose the depth of peel desired.
• The depth of peel is determined by the appearance and
quality of frosting. This is a predictable and easily recognized
phenomenon.
• The preceding points afford the surgeon great control and
specificity. This enables treatment of a large range of ages
and skin types.
• The novice can approach the learning curve by peeling more
lightly with the option of repeeling. This is a safe way to gain
experience.
• Repeated peels provide additive effect. This is especially
valuable in the effective treatment of lower eyelid skin.
• Modern chemical peels are an important option for resur-
facing. Surgery can deal with the gravitational and volume
changes associated with aging, while chemical peels are an
excellent adjunct to treat the textural and pigmentary skin
changes that result from age and solar damage. Through a
combined approach, the goal of facial rejuvenation can be
attained.
3 Baker T . Chemical face peeling and rhytidectomy for facial rejuvenation. Plast
Reconstr Surg 1962;29:199–207
4 Bensimon RH. Croton oil peels. Aesthet Surg J 2008;28(1):33–45
5 Demas P , Bridenstine B. Diagnosis and treatment of postoperative complica-
tions after skin resurfacing. J Oral Maxillofac Surg 1999;57(7):837–841
6 Demas P , Bridenstine B, Braun T . Pharmacology of agents used in the
management of patients having skin resurfacing. J Oral Maxillofac Surg
1997;55(11):1255–1258
7 De Rossi-Fattaccioli D. Histologic comparison between deep chemical peels
(modified Litton’s formulae) and extreme pulsed laser CO2 resurfacing [in Span-
ish . Dermatol Peru 2005;15:181–184
8 Dinner MI, Artz S. The art of the trichloroacetic acid chemical peel. Clin Plast
Surg 1998;25(1):53–62
9 Edison RB. Lighter phenol peel allows faster recovery and less discomfort. Aesthet
Surg J 1996;16(4):239–240
10 Hantash BM, Stewart DB, Cooper A, Rehmus E, och R , Swetter SM.
Facial resurfacing for nonmelanoma skin cancer prophylaxis. Arch Dermatol
2006;142(8):976–982
11 Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the
formula. Plast Reconstr Surg 2000;105(1):227–239, discussion 249–251
12 Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers
and their croton oil formulas. Plast Reconstr Surg 2000;105(1):240–248, discus-
sion 249–251
13 Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic
surgeons’ role. Plast Reconstr Surg 2000;105(2):752–763
14 Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel
results with different concentrations of phenol and croton oil. Plast Reconstr Surg
2000;105(3):1061–1083, discussion 1084–1087
15 ohnson B, Ichinose H, Obagi E, Laub DR. Obagi’s modified trichloroacetic acid
(TCA)-controlled variable-depth peel: a study of clinical signs correlating with
histological findings. Ann Plast Surg 1996;36(3):225–237
16 ligman AM, Baker T , Gordon HL. Long-term histologic follow-up of phenol face
peels. Plast Reconstr Surg 1985;75(5):652–659
17 Landau M. Cardiac complications in deep chemical peels. Dermatol Surg
2007;33(2):190–193
18 Obagi E. Obagi Skin Health Restoration and Rejuvenation. ew ork, :
Springer-Verlag; 2000
19 Rubin MG. f fi . Philadelphia,
PA: Lippincott illiams illiams; 1995
20 Stagnone , Stagnone G . A second look at chemabrasion. J Dermatol Surg Oncol
1982;8(8):701–705
21 Stegman S . A comparative histologic study of the effects of three peeling

Suggested Reading agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg
1982;6(3):123–135
1 Baker T . Is the phenol-croton oil peel safe Plast Reconstr Surg 22 Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. ew ork,
2003;112(1):353–354 : Thieme Medical Publishers, 2018
2 Baker T , Stuzin M, Baker TM. Facial Skin Resurfacing. St Louis, MO: uality 23 Truppman ES, Ellenby D. Major electrocardiographic changes during chemical
Medical Publishing; 1998 face peeling. Plast Reconstr Surg 1979;63(1):44–48

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 III Nonsurgical Cosmetic Treatments
19 Lasers and Light-Based Devices in Plastic Surgery
Noelani E. González and David J. Goldberg
Abstract
Cosmetic surgeons and specialists have a range of options when
it comes to patient care, including surgical and nonsurgical
procedures. The popularity of less invasive cosmetic procedures
continues to grow among patients. Plastic and cosmetic surgeons
who do not offer these procedures might find themselves at a dis-
advantage. Aside from the latest surge in patient demand, these
less invasive options can also be performed as a complement to
surgical procedures. Careful patient selection and knowledge
of the different laser devices is vital in order to obtain worthy
outcomes. This chapter will review laser and light-based devices
that are currently available for the treatment of vascular lesions,
pigment abnormalities, skin tightening, and skin resurfacing. It
will also detail other less common uses for these devices, possi-
ble side effects, and postprocedure care.
Keywords
laser devices, radiofrequency, skin tightening, skin resurfacing,
rejuvenation, intense pulsed light, vascular lasers
19.1 Introduction
Lights and laser devices have experienced a boom in popularity
among patients seeking noninvasive, nonsurgical cosmetic pro-
cedures during recent years. As a consequence, cosmetic surgeons
and physicians are continuously expanding their practices to
include such procedures and devices. A 2017 American Society
of Dermatologic Surgery (ASDS) consumer survey on noninvasive
cosmetic dermatologic procedures found that the four most popu-
lar procedures patients are considering are body sculpting; treat-
ments to tighten skin or smooth wrinkles using ultrasound, laser,
light or radiofrequency devices; microdermabrasion; and laser
hair removal. Aside from the demand patients are exhibiting for
noninvasive procedures, these procedures can also be performed
as adjuncts of more invasive surgical procedures. For example,
radiofrequency and other tightening devices are being used more
frequently after blepharoplasty, liposuction, and tummy tucks,
among other body contouring surgeries. There are many devices
available that can complement the plastic surgery practice, among
which are resurfacing lasers, vascular lasers, and skin-tightening
devices. The nature of the device to be purchased depends on the
scope of practice of the particular surgeon and how that device
might complement his or her own practice.
19.2 Laser Resurfacing
There are many devices used for skin resurfacing. These can be
classified largely into ablative and nonablative devices. Ablative
devices remove the entire topmost layer of the skin, the epider-
mis, and produce damage to the dermis. onablative lasers, on
196
the other hand, deliver energy to the dermis and cause damage
at this level without removing the epidermis. Furthermore,
these devices can be classified into fractional and nonfractional
or f fi laser devices. Fractional devices create microscopic
treatment zones (MT ) of injury in a columnar array, whereas
full-field devices do not discriminate and treat the entire
selected area. Tighter skin and an improvement in rhytids are
achieved by damage to collagen bundles and stimulation of
dermal fibroblasts. In order to produce this damage, energy
needs to be delivered to the skin’s dermis at a minimum of 65 C,
which is the temperature required to damage collagen. Ablative
lasers require a great amount of recovery time, in comparison to
nonablative or fractional lasers, which do not require as much
downtime but do require more treatment sessions to achieve the
desired results.
19.2.1 Full-Field and Fractional
Resurfacing Devices
Ablative Full-Field Lasers
The first laser invention used in treatment was the carbon
dioxide (CO2) laser by Bell Laboratories, which is used for skin
pigmentation, texture, warts, scars, and rhytids and remained
the only energy-based device until the mid-1990s. Subsequently
a surge in innovation took place and continues to this day in the
revolutionary field of laser technology. Ablative lasers, such as the
CO2 laser, heat tissue to temperatures higher than 100 C, causing
vaporization of the epidermis and coagulation of the underlying
tissue and dermis. This creates damage to collagen, which stim-
ulates dermal fibroblasts and collagen production. This damage
in the skin and re-epithelialization in turn result in improvement
in skin texture, laxity, and dyspigmentation. Currently, there are
three ablative full-field laser platforms available: the CO2 laser,
the erbium:yttrium aluminum garnet (Er: AG) full-field laser,
and the yttrium scandium gallium garnet ( SGG) full-field laser.
Table 19.1 breaks down the different types of resurfacing
devices and their wavelengths, as well as the type of resurfacing
that can be achieved with each.
The CO2 laser has a wavelength of 10,600 nm, and its active
chromophore is water. After being developed in 1964, its first
uses were cutting and vaporizing. It has since become the gold
standard for the treatment of medium to fine lines and rhytids,
as well as tightening of lax tissue. Healing time for this laser is
approximately 10 to 14 days, and patients could experience
prolonged erythema that could last for a few months. Prolonged
downtime, and cases of delayed hypopigmentation, among
other complications, have caused these lasers not to be used as
frequently. Although nonfractional ablative CO2 lasers produce
excellent improvement in skin texture, laxity, pigmentary issues,
and rhytids, their 2-week recovery period is not popular. During
this recovery time patients can experience edema, burning, and
 er nd ig - ed e i e in i Surgery

Table 19.1 Resurfacing devices

me e eng nm A i e n i e u - ie d r i n
CO2 10,600 Yes No Yes Yes
Erbium 2,940 Yes No Yes Yes
YSGG 2,790 Yes No Yes Yes
Thulium 1,927 No Yes No Yes
Er:Glass 1,540 No Yes No Yes
Nd:YAG 1,440 No Yes No Yes
Nd:YAG 1,319 No Yes Yes Yes
Nd:YAG 1,064 No Yes Yes No
Abbreviations: AG, yttrium aluminum garnet; SGG, yttrium scandium gallium garnet.

crusting and can experience an average of 4 months of treatment dermabrasion, since appendages may have been damaged in the
site erythema. These platforms also carry a risk of permanent past and skin may not heal properly. Consumers and physicians
hypopigmentation, herpes simplex virus outbreak, scarring, milia eventually opted for procedures with less downtime and risks,
formation, and acne flares. thus the arrival of nonablative and fractional devices.
The Er: AG laser has a wavelength of 2,940 nm and ablates
tissue comparably to the CO2 laser. Overall it was created to pro-
Nonablative Nonfractional Lasers
duce similar results to the CO2 laser but provides more precise
Ablative lasers, as mentioned previously, can produce remark-
ablation, causing less thermal damage. This platform was designed
able results and have been the gold standard for rejuvenation;
to be able to modify the ablation depth as a change in energy is
however, their prolonged recovery time and potential side
made. hereas CO2 lasers can ablate at a set depth of 75 m and
effects have made these lasers less appealing. The development
cause thermal damage that can extend to the 100 m range, the
of nonablative nonfractional lasers provides an alternative to
Er: AG laser leaves about 5 to 10 m of residual thermal damage.
these other devices.
Consequently, this laser gives the provider the option of delivering
onablative nonfractional lasers provide heat that denatures
more or less energy to cause varying amounts of tissue removal
proteins in collagen without any vaporization or any removal of
or ablation without the residual thermal damage that would be
skin tissue. These devices, which are in the mid-infrared range,
incurred were one using the CO2 laser. Recovery time is 7 days and
cause heating and thermal injury of the mid to upper dermal
can be followed by 3 to 6 weeks of erythema. The Er: AG laser
matrix. The skin’s healing response, in turn, causes neocolla-
can produce results similar to the CO2 laser but with less tissue
genesis, skin tightening, and improvement in mild wrinkles. In
destruction and thus less downtime, shortening the patient’s
comparison to ablative lasers, these nonablative counterparts
recovery period. Although the CO2 laser has been found to have
have drastically reduced downtimes, which can even be limited
better results in various studies, the Er: AG laser is an excellent
to a single posttreatment afternoon. In turn, their results are
option for dyspigmentation, rhytids, and skin textural changes
not as drastic, although still present. These lasers can be used to
and presents less downtime and complications than the CO2 laser
treat fine lines and wrinkles; however, results can take time to be
(Fig. 19.1; Fig. 19.2).
appreciated, and in some cases multiple treatment sessions are
The SGG laser, with a wavelength of 2,790 nm, does not have
warranted.
the same affinity for water as the CO2 and Er: AG lasers have, but
Among these devices are the 1,450-nm diode (SmoothBeam;
downtime is only a few days. Because it does not have as much
Syneron Candela, ayland, MA), 1,320-nm d: AG (CT3Plus,
affinity for water, deeper resurfacing cannot be done with this
CoolTouch, Rosedale, CA; Harmony XL, Alma Lasers, Buffalo Grove,
laser.
IL), and 1,319-nm pulsed energy (ThermaScan, Sciton, Palo Alto,
Ablative, full-field lasers are overall great workhorses for skin
CA). These devices have cooling systems that are used to minimize
tightening, wrinkles, and skin texture. Patient selection and
side effects such as pigmentation changes and epidermal damage.
an appropriate treatment approach are paramount. Skin type,
Various clinical studies have demonstrated mild improvement,
ethnicity, discussion of downtime, skin pathology, and even
and results are not always reproducible. In a comparative study
patient finances should be taken into consideration. As mentioned
of the 1,450-nm diode and the 1,320-nm d: AG lasers done to
previously, the greatest issue with these lasers is the pronounced
treat atrophic facial scars, the 1,450-nm diode was shown to be
downtime and recovery, as well as unwanted pigmentary problems
more efficient.
such as hypo- and hyperpigmentation, and even scarring. These
An added benefit of nonablative lasers is the decreased risk of
can be seen in any patient if treatment is not done correctly, but
hypopigmentation in darker skin types (Fitzpatrick skin types
most complications arise in patients with Fitzpatrick skin types
V and VI); therefore, these laser modalities can be used in this
IV to VI. Therefore, we do not recommend treating patients with
patient population, but should always be approached with
these skin types. Other contraindications include active infection,
caution. Furthermore, these modalities produce only dermal
as well as relative contraindications such as keloid history, skin
changes; therefore, the patient who comes in with photodamage
grafts, history of cold sores, or previous laser resurfacing or deep

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 III Nonsurgical Cosmetic Treatments

Fig. 19.2 Results on the patient shown in Fig. 19.1, 6 months after
Fig. 19.1 Photodamage and rhytides before erbium laser resurfacing. erbium laser resurfacing.

that includes epidermal and dermal changes will need a multi- laser ( AFL) has since become the go-to laser for acne scarring,
modal approach. In conclusion, these modalities provide modest skin rejuvenation, and skin tightening.
although inconsistent results at time with significant less The population of color continues to increase, and it is esti-
downtime. mated that by 2060, nearly 60 of the United States population
will have skin of color. ith this continuous growth, the myriad of
laser options for this subset of patients also continues to advance.
Nonablative Fractional Laser
AFLs are safe for use in patients with skin types V through VI;
In 2004 fractional thermolysis was introduced and provided yet
however, it is recommended that experienced hands treat this
another treatment approach that was effective and that resulted
subset of patients.
in significant less downtime than ablative modalities. Fractional
The first fractional laser that was developed was the Fraxel laser
thermolysis involves the generation of targeted heated columns
(Solta Medical, Bothell, A), a nonablative fractional device that
or microscopic thermal zones (MT s), which can be controlled
used an erbium-doped fiber laser with a wavelength of 1,550 nm.
in their ablative depth and their columnar width. These MT s
The MT s created by this laser were between 125 and 250 per
are one-tenth the width of a hair follicle. These heated columns
square centimeter. Multiple passes were performed, with a final
produce thermal damage to levels of the epidermis and dermis,
density of 1,000 to 3,000 zones per square centimeter, a small frac-
without producing any damage to overlying skin or stratum
tion of the skin. Multiple sessions were performed (usually three
corneum; thus they are nonablative. ater is this laser’s targeted
to five) spaced 2 to 4 weeks apart. Other manufacturers developed
chromophore. Because only a portion of the skin is resurfaced,
nonablative fractional lasers with different wavelengths (1,319,
leaving some skin intact, downtime is minimal, spanning to an
1,440, and 1,540 nm), energies, and spot sizes, including a 1,927-
average of about 3 days. To achieve desired outcomes, multiple
nm thulium laser that was introduced to treat actinic keratosis.
treatment sessions may be necessary. The nonablative fractional

198

AFLs have been shown to be effective in treating photoaging.
Manstein et al first demonstrated an improvement in periorbital
wrinkles after performing four treatments in a 3-month span.
Acne scarring has also been treated with this modality, which has
become the treatment of choice. Both eiss et al and Alster et al
demonstrated the effectiveness of this laser, with eiss showing
a median of 50 to 75 improvement in acne scars and Alster
demonstrating between 51 and 75 improvement in mild to mod-
erate acne scarring, using the 1,550-nm fractional laser system.
Erbium-doped 1,550-nm nonablative lasers (Fraxel re:store Dual
1550-nm; Solta Medical, Bothell, A) have been successful in
the treatment of acne scars in Fitzpatrick skin types I through VI,
but with a significant incidence of self-limited postinflammatory
hyperpigmentation among those with Fitzpatrick skin types
IV to VI. Preoperative treatment with hydroquinone does not
diminish this risk. In addition to atrophic acne scarring, other
types of scars, such as hypertrophic and hypopigmented scars,
can also be treated successfully with this modality. There have
been mixed reports and studies in terms of these lasers’ effective-
ness to treat melasma; however, many providers continue to use
these modalities. The same holds true for the treatment of striae.
onablative facial remodeling ( AFR) has been FDA-approved for
the treatment of stretch marks; however, studies are lacking to
determine its true effectiveness.
To summarize, these lasers are mostly used to treat acne
scarring, fine lines, wrinkles, photodamage, and melasma among
other things. Postprocedure patients typically experience mild
bronzing of the skin and mild erythema. Downtime is minimal,
and results take a range of multiple treatments to achieve. hat
distinguishes these types of lasers from others is the fact that they
can be safely used in patients with darker skin tones and also in
other parts of the body aside from the face. These types of devices
would be a great companion to plastic surgical procedures to
correct or minimize postoperative scars.
As in the rest of the aforementioned modalities, patient selec-
tion is the key to success. Expectations should be discussed, as
well as treatment time and desired goals of treatment. To achieve
a desired outcome, multiple treatment sessions spaced about 4
weeks apart are needed, and dramatic results will not be a true
outcome after their first treatment.
Ablative Fractional Lasers
Ablative fractional laser use began in 2007. Its development
increased efficacy over nonablative fractional lasers. Three wave-
lengths are currently used for fractional ablative resurfacing:
CO2, 10,600 nm; erbium, 2,940 nm; and SGG, 2,790 nm. They
differ in their amount of water absorption and in the resultant
amount of thermal damage created. These lasers create MT as
does AFL, sparing tissue that surrounds these columns; tissue
within these columns is ablated or destroyed to the choice of
depth of the provider. They essentially cause dermal miniholes
or ablation holes. Postprocedure edema and/or erythema may
last for up to 3 days.
These devices are used to treat fine and deeper lines and wrin-
kles, acne scars, dyschromias, and photodamage. These devices
can create more skin tightening than AFLs. Downtime can vary
depending on ablation depth, density of treatment, and spot size
but, in general, is much less than for full-field ablation.
er nd ig - ed e i e in i Surgery
19.2.2 Postprocedure Care
For any of the aforementioned devices, a test spot should always
be performed in high-risk patients prior to actual treatment.
For full-field ablation, Aquaphor (Beiersdorf, ilton, CT) or
petrolatum jelly ointment should be applied to skin until
re-epithelialization is complete, followed by a lighter nonocclu-
sive dressing. Silicone gels are another option; these gels form
a sheet that protects the underlying skin and decreases the
duration of erythema and healing time. Once epithelialization
is complete, a skin care regimen of the provider’s choice should
be instituted. Some providers opt for a lighter, noncomedogenic,
cream-based regimen for fractional and nonablative procedures.
As with any other procedure, sun avoidance and the use of
sunscreen are paramount and should be an integral part of the
patient’s skin care regimen. Other postprocedure care, such as
antibiotics for acneiform eruptions and pre- and/or post anti-
virals, will not be discussed in this chapter; however, these are
conditions that a laser surgeon must know how to treat.
19.3 Vascular Lasers and
Light-Based Treatments
19.3.1 Vascular Laser Devices
Initially, lasers such as copper vapor (578 nm), krypton (568 nm),
and argon dye (577 nm) were used to target vascular lesions,
but they were eventually abandoned because of unwanted side
effects such as scarring. Technology later developed to include
selective photothermolysis, which allowed for targeting of spe-
cific chromophores and minimizing damage to the surrounding
tissue. hen targeting vascular lesions, the specific chromo-
phore targeted is oxyhemoglobin. Oxyhemoglobin has absorp-
tion peaks at the 410- to 429-nm, 541-nm and 577-nm ranges, as
well as between the 700-nm and 1,100-nm ranges, although less
significantly. These lower absorption peaks also compete with
melanin absorption, and can result in preventable side effects.
Care must also be taken when selecting treatment parameters,
as they can also cause purpura and ecchymoses when aggressive
settings are used.
Pulsed Dye Laser
The pulsed dye laser (PDL) is known as the gold standard for the
treatment of vascular lesions. The traditional 585-nm PDL was
popular until the newer 595-nm PDL was introduced. PDLs are
very effective in treating portwine stain (P S), rosacea, telan-
giectasias, and postprocedure bruising, among other things.
Because of the short pulse durations and high fluences needed to
treat vessel structures, vessels rupture and subsequently hemor-
rhage into surrounding tissue, causing ecchymoses that can be
commonly observed. This resulting purpura or ecchymoses can
last between 1 and 2 weeks and decrease patient satisfaction.
Some patients can even suffer from postinflammatory hyperpig-
mentation due to the purpura caused. Other side effects, such as
scarring and pigmentary disturbances, are not commonly seen.
To prevent the unwanted associated purpura, providers can
lengthen the treatment’s pulse duration, use multiple passes,
199
 III Nonsurgical Cosmetic Treatments
or can use lower fluences and incorporate pulse stacking to
achieve the intended outcome without producing any purpura.
Additionally, there are newer devices which emit multiple
subpulses as a way of preventing unwanted side effects. The
newest addition to this group of lasers is a solid state 589-nm
wavelength laser (ADVATx; AdvaLight, San Marcos, CA), which
delivers individual pulses of energy at a repetition rate of 12 kHz,
with shortening of individual pulse duration and pulse spacing,
thus minimizing trauma to surrounding tissue. This laser has
FDA clearance for the treatment of hemangiomas, rosacea,
venous lakes, P S, and poikiloderma of Civatte.
Potassium Titanyl Phosphate
In contrast to the PDL, the potassium titanyl phosphate ( TP) laser
emits light at a wavelength of 532 nm. The TP laser is a great
alternative for the treatment of vascular lesions and is mostly used
for superficial and finer vascular lesions such as finer blood ves-
sels, telangiectasia, leg veins, and cherry angiomas. These lesions
would typically be harder to treat with PDLs. Because the TP
laser emits longer pulse durations, up to 100 ms, causing targets
Fig. 19.3 Telangiectases before potassium titanyl phosphate (KTP)
laser treatment.
200
to be heated slowly, the risk of purpura is greatly decreased,
which positions this laser at an advantage. However, because the
wavelength of this laser is close to the melanin absorption peak,
there is a greater risk of hypo- or hyperpigmentation. The TP
laser should be used in lighter skin types, I to III, as unwanted side
effects are more commonly seen with darker skin types. Transient
erythema, edema, and crusting can be observed. There have also
been reports of atrophic scarring, particularly when treating small
perinasal telangiectasias using high fluences (Fig. 19.3; Fig. 19.4).
19.3.2 Near-Infrared Devices
Red and near-infrared lasers provide an option for patients of
skin of color and for larger vessels or deeper targets. Because of
their wavelengths, set around 700 to 1,200 nm, which are near
the absorption of oxyhemoglobin and far enough from melanin’s
absorption peak, these lasers allow deeper penetration and use
in darker skin types. Among these devices are the 755-nm alex-
andrite laser, the 800- to 980-nm diode lasers, and the 1,064-nm
neodymium-doped yttrium aluminum garnet ( d: AG) laser.
e will concentrate on the d: AG laser, since it is the device
Fig. 19.4 Results on the patient shown in Fig. 19.3, 3 months after
potassium titanyl phosphate (KTP) laser treatment.
 er nd ig - ed e i e in i Surgery

with the most applications, so it would be the vascular device
that would make most sense in a plastic surgery office setting.
The 1064- d: AG laser has relatively low hemoglobin absorp-
tion, good water absorption, and almost no melanin absorption.
Because of its low hemoglobin absorption, higher fluences are
needed to destroy the selected target. These high energy levels
increase the risk of blistering and scarring, so treatments should
be exercised with care. Since these lasers have very low melanin
absorption, they are safe to use in all skin types. d: AG lasers
have been used to treat deeper and larger targets such as blue
varicose veins, resistant P S, hemangiomas, and venous mal-
formations. They are the gold standard for laser hair removal in
persons with skin of color.
The latest d: AG systems use a microsecond ( s) pulse
duration technology. These have shown results in treating
facial erythema, telangiectasias, postsurgical Mohs scars, and
even acne. These newer models, in the 300- to 650- s range,
minimize the risk of damaging surrounding tissue and scarring
and are less painful than their conventional millisecond d: AG
counterparts.
19.3.3 Pulsed-Light Devices
The intense pulsed light (IPL) system was designed in the 1990s.
It emits broadband light from 500 to 1,200 nm at varying ener-
gies and pulse duration. This system differs from other devices
previously mentioned in that in contrast to lasers, which have
a specific wavelength (emit monochromatic light), IPL devices
deliver multiple wavelengths of light simultaneously and target
different structures or chromophores. These devices have partic-
ular filters that restrict the emitted wavelengths. For example,
a 560-nm filter would allow passage of all wavelengths below
the 560-nm range. Additionally, there is a peak of energy at the
lowest cutoff, which in the previous example would be around
the 560-nm range. Care must be taken to choose the appro-
priate filter, since shorter wavelengths could cause potential
pigmentary problems in darker-skinned individuals due to the
absorption of melanin at these wavelengths. Most platforms
include a myriad of filter options, so that the provider can choose
shorter wavelengths for lighter-skinned patients or to treat
deeper targets such as deeper vessels and longer wavelengths
for more superficial targets, with longer pulse durations used for
darker-skinned individuals. Overly aggressive settings can cause
blistering and postinflammatory pigmentary alterations.
The most common indications for these devices are pigmentary
and vascular lesions. IPL devices allow for the treatment of a
wide range of skin conditions, including photoaging, wrinkles,
ephelides, solar lentigines, telangiectasias, hemangiomas, venous
malformations, P Ss, and poikiloderma of Civatte.
Pigmentary lesions are mostly treated with the 500- to 560-nm
range of wavelengths due to the increase in melanin absorption
at these wavelengths. This is typically termed a photofacial.
These wavelengths are most commonly used on patients with
Fitzpatrick skin types I to III; however, these may be used with
darker skin types at lower fluences. Lesions will turn darker right
after treatment and should flake off eventually. Vascular lesions
in turn require filters in the 585- to 595-nm range, which is the
vascular absorption peak. Lesions will turn darker as well before
improvement is noted. Multiple handpieces can be used to achieve
the desired outcome, and multiple treatment sessions should be
expected (Fig. 19.5; Fig. 19.6).
These devices have incorporated contact cooling, which aids in
the prevention of epidermal injury. There are many IPL devices
available from different manufacturers, with differing filters and
cooling systems. Specifications from one system should not be
assumed in another or compared, since different manufacturers
have differing setting specifications and parameters.
Selecting a Vascular Treatment
Both the PDL and TP lasers are great workhorses for the treat-
ment of vascular lesions, including malformations, angiomas,
and venous anomalies or varicosities. However, a PDL or TP
laser would not necessarily be the go-to laser or a cost-effective
option in a plastic surgery setting. The 1,064-nm d: AG laser
or an IPL system would be a more appropriate option, given its
wider range of treatment options, including vascular lesions,
pigmentary lesions, and finally hair removal (which is not dis-
cussed here, although further reading is provided at the end of
the chapter).
The various vascular devices available are detailed in Table 19.2.
Table 19.2 Devices used to treat vascular lesions
e i e e eng nm S in y e Tan
Pulsed dye 585–595 I–III No
Diode 589 I–III? No
KTP 532 I–III No
Nd:YAG 1,064 1–VI Yes
IPL/BBL 585+ 1–III No
Abbreviations: BBL, broadband light; KTP, potassium titanyl phosphate; IPL,
intense pulsed light.
19.3.4 Postprocedure Care
In order to minimize any side effects such as blistering, scarring,
or pigmentary disturbances, epidermal cooling should be applied
immediately postprocedure after any vascular lesion is treated.
This should be strictly enforced in darker skin types. Moreover,
we recommend the use of light-emitting diode (LED) lights post-
procedure in darker-skinned patients, to minimize inflammation
and prevent any unwanted hyperpigmentation or scarring.
19.4 Noninvasive Skin Tightening
Increasing demand for noninvasive procedures has led to the
development of many devices that can be used to treat skin
laxity. oninvasive skin tightening of the face, neck, and abdo-
men is commonly sought after; furthermore, skin tightening of
the arms, knees, d colletage, and chin has started to increase in
popularity as well. Although more invasive surgical options such
as facelifts and rhytidectomy still remain the optimum treatment
for skin laxity, these newer devices provide the patient with less
invasive options and less to even no downtime. As mentioned

201
 III Nonsurgical Cosmetic Treatments
Fig. 19.5 Photodamage before intense pulsed light (IPL) treatment.
before in this chapter, ablative resurfacing is considered the gold
standard for laser skin tightening and rejuvenation; however,
with the invention of newer skin-tightening devices, the surgeon
has a wide range of tools to choose from to reduce skin laxity.
This tightening effect can be achieved with various modalities;
the most commonly used devices are radiofrequency devices
and ultrasound devices. Most recently, needle-based devices and
picosecond lasers are starting to be used for this purpose. Patient
selection is crucial in obtaining optimum results.
All skin-tightening devices function by delivering heat in
the form of energy to the underlying skin and structures. This
heat in turn damages these structures, causing contraction of
collagen, neocollagenesis, and eventual tightening through the
wound-healing process. These devices are mainly indicated for
mild to moderate skin laxity.
19.4.1 Microfocused Ultrasound
Microfocused ultrasound (MFUS), with or without visualization,
targets deep to superficial subcutaneous and dermal tissues. This
technology works by heating tissue secondary to the absorption
202
Fig. 19.6 Improvement of photodamage in the patient shown in Fig.
19.5, 6 months after four intense pulsed light (IPL) treatments.
of acoustic energy. Cellular friction caused by acoustic energy
causes precise heating. This then leads to tissue contraction,
destruction, and collagen synthesis and remodeling, avoiding
gross necrosis or affecting surrounding tissues. Research done on
human cadavers showed that this technology was able to target
the superficial musculoaponeurotic system (SMAS) without
causing injury to nontargeted adjacent structures.
Ultherapy (Ulthera, Inc., Merz Device Innovation Center, Mesa,
A ) is the first and only major MFUS system available that has
FDA clearance for the indications of lifting skin on the brows,
submental, and neck tissue and improving the rhytids of the chest
and d colletage area. It received its first FDA approval in 2009 for
the indication of brow lift. This device uses different transducers
at varying frequencies. The transducers operate at 4 or 7 MHz and
at fixed depths of 1.5 mm, targeting the superficial dermis; 3.0
mm, targeting the deep dermis; or 4.5 mm, targeting the SMAS.
The higher the frequency, the more superficial the tissue that is
targeted, such as the neck and periorbital areas, and it can be
used for tightening of skin crepiness. In contrast, lower frequen-
cies target deeper tissue and thicker skin, such as the cheeks,
and provide more of a lift of structures. Treatments usually last

between 30 and 90 minutes depending on the treatment areas,
and there is no patient downtime. Topical anesthetic is typically
applied prior to treatment to enhance patient comfort. Alam et
al carried one of the first clinical trials and showed significant
improvement in brow elevation in more than 83 of patients. The
average increase in brow elevation was between 1.7 and 1.9 mm;
these results were still present at 10-month follow up. Suh et al
treated 22 Asian patients with a single treatment with an average
of 200 lines. These patients reported a 77 and 73 subjective
improvement in their nasolabial folds and jaw line, respectively.
Histologic analysis showed increased dermal collagen and thick-
ness and straightening of elastic fibers in the dermis. Similarly,
noticeable improvement was noted when treating the d colletage
area, and over 60 patient satisfaction was observed. The thighs,
knees, and arms have also been studied. Patients’ knees and arms
demonstrated better results than their thighs did. Additionally, a
study on the buttocks done on 19 patients showed 89.5 subject
global assessment improvement at 180 days.
19.4.2 Radiofrequency Devices
Unlike ultrasound devices, radiofrequency (RF) devices function
by heating a broad, nonspecific area to target temperatures of
40 to 45 C. Energy is transmitted via radio waves. Initially, due to
the heat, collagen fibers thicken and denature, and an immediate
tightening effect can be seen; however, this is only temporary.
Once the healing process begins and new collagen is produced,
true tightening is observed. These devices have been shown
to produce neocollagenesis and neoelastogenensis. There are
currently many radiofrequency devices on the market; these can
be divided into bipolar, monopolar, and unipolar devices. Bipolar
devices have both electrodes at the patient’s treatment site.
Monopolar and unipolar devices have one treatment probe on
the treatment site, with the returning probe placed at a distant
location. Only a few will be discussed in this section.
Monopolar RF
Monopolar RF utilizes a grounding pad to pass electrodes or an
electric current back and forth between it and target tissues,
which heats the dermis, subdermis, and even subcutaneous fat
below it. Monopolar RF can reach the highest treatment depth in
comparison with other RF systems, and depth increases with the
diameter of the treatment electrode.
The first system of its kind was Thermage ThermaCool TC (Solta
Medical, Bothell, A), which uses a stamping grid treatment
with epidermal cooling. It has FDA indications for the nonin-
vasive treatment of periorbital wrinkles and rhytids including
the upper and lower eyelids, noninvasive treatment of wrinkles
and rhytids, and temporary improvement in the appearance of
cellulite. It is the first and only system to receive FDA clearance
for noninvasive, energy-based eyelid treatments. Fitzpatrick et
al treated 86 patients in their periorbital areas with high-energy
fluences, resulting in 92.8 of treated areas being improved or
remaining the same at 6 months. The average brow lift was 1.30
to 1.49 mm, and 50 of patients were satisfied with the results. It
was noted, however, that treatment at higher fluences resulted in
scarring and other adverse effects. A subsequent study treating
patients with lower fluences and multiple treatments resolved
er nd ig - ed e i e in i Surgery
this difficulty. eck and cheek laxity was also studied, resulting in
objective improvement in 93 of patients.
ThermiSmooth 250 (ThermiGen, South Lake, TX) is another
monopolar RF indicated for the temporary reduction in the
appearance of cellulite and used as well for tightening of the face
and neck, among other bodily locations. Providers place a probe in
constant contact with the patient’s skin and in constant motion,
and the system provides real-time temperature feedback. Similar
to ThermiSmooth, Pellev MRF system (Cynosure, estford, MA)
requires a handpiece in constant motion over the skin, and it has
demonstrated an improvement in skin laxity of the face and neck,
among many other bodily areas.
Unipolar RF
Unipolar RF differs from monopolar RF in that it uses high-fre-
quency electromagnetic radiation instead of electrical currents
to produce heat. This heat can penetrate up to 20 mm in depth.
The RF device Accent Prime (Alma Lasers, Buffalo Grove, IL) is
indicated for the noninvasive treatment of wrinkles and rhytids
and demonstrates a reduction in cellulite and thigh circumfer-
ence of 2.45 cm (Fig. 19.7; Fig. 19.8).
Bipolar RF
Bipolar RF is typically used in combination with other devices or
can be included in different platforms. It has been suggested that
energy penetration is half the distance between the two probes,
to a maximum depth of 4 mm. In addition, these can be combined
with IPL devices, diodes, or even mechanical massage suction
devices such as the Velashape (Syneron Candela, ayland, MA),
which has proven to improve the appearance of cellulite and to
result in reduction in circumference of the postpartum abdomen
and arms.
Multipolar RF
These devices use three electrodes or more to produce skin tight-
ening. The Apollo (Pollogen Ltd, Tel Aviv, Israel) is FDA-approved
for the noninvasive treatment of mild to moderate facial
wrinkles and rhytids and has been used for cellulite reduction
and to decrease body circumference areas. This RF system
requires constant contact with the treatment area and constant
motion. Another one of these devices is the 3DEEPtechnology by
EndyMed, or the EndyMed Pro (EndyMed Medical Ltd, Caesarea,
Israel), which is indicated for the noninvasive treatment of mild
to moderate facial wrinkles and rhytids. It has shown efficacy
in treating facial laxity as well as clinical benefit treating the
abdomen and thighs, cellulite, and body circumference.
Other RF technologies that have been shown to produce skin
tightening and correction of laxity are fractionated bipolar RF
devices and microneedling fractional bipolar RF. The latter devices
have needles that penetrate into the skin and deliver their energy
at the penetrating level, thus being more selective in their thermal
damage, avoiding any adjacent epidermal injury, and potentially
producing a greater tightening effect.
In general, results observed from RF devices can be unpredict-
able and rely heavily on patient selection. Patient expectations and
potential results should be discussed extensively. Most require
local anesthetic. These devices have an advantage over others in
203
 III Nonsurgical Cosmetic Treatments
Fig. 19.7 Cellulite before treatment with monopolar radiofrequency.
that they have minimal side effects, have little to no downtime,
and are safe to use on all skin types. ounger patients with mild
to moderate laxity are more likely to receive better results than
are older patients with extreme skin laxity. Both ultrasound and
RF devices are good potential adjuncts to any surgical skin laxity
procedures, where the patient might desire some additional skin
tightening, or they can be an option for those patients looking for
less invasive options.
Picosecond Lasers
Among the latest devices currently being studied for skin reju-
venation and tightening are picosecond lasers. Various studies
have been carried out using an alexandrite picosecond laser with
a diffractive array, which has shown improvement in patients’
wrinkles, skin texture, and photoaging. However it is not clear
whether these results are maintained over time, as long-term
studies have not been done. In one of these studies, results were
not maintained at 3-month follow-up.
19.5 Concluding Thoughts
The number of patients seeking noninvasive and nonsurgical
options, including laser and laser-like devices, continues to grow.
Currently, the cosmetic surgeon has many treatment options to
choose from, many of which are nonsurgical, while others can
be used to complement surgical treatments. Every plastic and
cosmetic surgeon should have at least a basic knowledge of these
devices. Depending on the patient’s condition and needs, com-
bination treatments frequently yield increasingly better results
than monotherapy. As technology progresses, these devices will
become more advanced, perhaps competing one day with many
surgical procedures and even providing similar results. Light
204
Fig. 19.8 Only right thigh treated with monopolar radiofrequency.
Note improvement.
energy–based devices are ever changing, just as the field of plas-
tic surgery is. The plastic surgeon will continuously be tasked
with being a part of this change and innovation.
Clinical Caveats
• Combination laser treatments yield the best results.
• Laser resurfacing can be classified into ablative or nonablative.
• Skin resurfacing can be performed as either fractional or full-
field resurfacing; fractional resurfacing poses less downtime
for the patient.
• Nonablative lasers have a decreased risk of pigmentary
changes in patients of darker skin types.
• Skin tightening can be achieved with radiofrequency and/or
ultrasound devices.
• Pulsed-light devices can be used to treat vascular lesions and
pigmentary irregularities, and even for hair removal.
• With any type of laser device, patient selection is crucial, and
adequate postprocedure care is vital.
Suggested Reading
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able-pulse high-fluence pulsed-dye laser: comparison of efficacy with
fluences immediately above and below the purpura threshold. Dermatol Surg
2003;29(7):681–684, discussion 685
2 Alam M, hite LE, Martin , itherspoon , oo S, est DP. Ultrasound tighten-
ing of facial and neck skin: a rater-blinded prospective cohort study. J Am Acad
Dermatol 2010;62(2):262–269 10.1016/j.jaad.2009.06.039
3 Alexiades-Armenakas MR, Dover S, Arndt A. The spectrum of laser skin resur-
facing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol
2008;58(5):719–737, quiz 738–740
4 Alexis AF. Lasers and light-based therapies in ethnic skin: treatment options
and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol
2013;169(Suppl 3):91–97 10.1111/bjd.12526

5 Beasley L, eiss RA. Radiofrequency in cosmetic dermatology. Dermatol Clin
2014;32(1):79–90 10.1016/j.det.2013.09.010
6 Carruthers , Fabi S, eiss R. Monopolar radiofrequency for skin tightening:
our experience and a review of the literature. Dermatol Surg 2014;40(Suppl
12):S168–S173 10.1097/DSS.0000000000000232
7 Ciocon DH, Doshi D, Goldberg D . on-ablative lasers. Curr Probl Dermatol
2011;42:48–55 10.1159/000328249
8 Clementoni MT, Gilardino P, Muti GF, et al. Intense pulsed light treatment of
1,000 consecutive patients with facial vascular marks. Aesthetic Plast Surg
2006;30(2):226–232 10.1007/s00266-005-0086-0
9 DeHoratius DM, Dover S. onablative tissue remodeling and photorejuvenation.
Clin Dermatol 2007;25(5):474–479 10.1016/j.clindermatol.2007.05.006
10 Dunbar S , Goldberg D . Radiofrequency in cosmetic dermatology: an update. J
Drugs Dermatol 2015;14(11):1229–1238
11 Elsaie ML, Choudhary S, Leiva A, ouri . onablative radiofrequency for
skin rejuvenation. Dermatol Surg 2010;36(5):577–589 10.1111/j.1524-
4725.2010.01510.x
12 Fabi SG, Massaki A, Eimpunth S, Pogoda , Goldman MP. Evaluation of mi-
crofocused ultrasound with visualization for lifting, tightening, and wrinkle
reduction of the décolletage. J Am Acad Dermatol 2013;69(6):965–971 10.1016/j.
jaad.2013.06.045
13 Fitzpatrick R, Geronemus R, Goldberg D, aminer M, ilmer S, Ruiz-Esparza .
Multicenter study of noninvasive radiofrequency for periorbital tissue tighten-
ing. Lasers Surg Med 2003;33(4):232–242 10.1002/lsm.10225
14 Garden M, Tan OT, erschmann R, et al. Effect of dye laser pulse duration on
selective cutaneous vascular injury. J Invest Dermatol 1986;87(5):653–657
15 Geronemus RG. Fractional photothermolysis: current and future applications.
Lasers Surg Med 2006;38(3):169–176
16 Goldberg D , Fazeli A, Berlin AL. Clinical, laboratory, and MRI analysis of
cellulite treatment with a unipolar radiofrequency device. Dermatol Surg
2008;34(2):204–209, 10.1111/j.1524-4725.2007.34038.x
17 Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional
laser photothermolysis: experience with 961 treatments. Dermatol Surg
2008;34(3):301–305, discussion 305–307
18 ey D . A preliminary study of a transdermal radiofrequency device for body
slimming. J Drugs Dermatol 2015;14(11):1272–1278
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19 Manstein D, Herron GS, Sink R , Tanner H, Anderson RR. Fractional photother-
molysis: a new concept for cutaneous remodeling using microscopic patterns of
thermal injury. Lasers Surg Med 2004;34(5):426–438
20 Manuskiatti , Fitzpatrick RE, Goldman MP. Long-term effectiveness and side
effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am Acad
Dermatol 1999;40(3):401–411
21 Ortiz AE, Goldman MP, Fitzpatrick RE. Ablative CO2 lasers for skin tightening: tra-
ditional versus fractional. Dermatol Surg 2014;40(Suppl 12):S147–S151 10.1097/
DSS.0000000000000230
22 Preissig , Hamilton , Markus R. Current laser resurfacing technologies: a review
that delves beneath the surface. Semin Plast Surg 2012;26(3):109–116 10.1055/s-
0032-1329413
23 Ratner D, Tse , Marchell , Goldman MP, Fitzpatrick RE, Fader D . Cutaneous
laser resurfacing. J Am Acad Dermatol 1999;41(3 Pt 1):365–389, quiz 390–392
24 Ross EV, Mc inlay R, Anderson RR. hy does carbon dioxide resurfacing work
A review. Arch Dermatol 1999;135(4):444–454
25 Schmults CD, Phelps R, Goldberg D . onablative facial remodeling: erythema
reduction and histologic evidence of new collagen formation using a 300-mi-
crosecond 1064-nm d: AG laser. Arch Dermatol 2004;140(11):1373–1376
10.1001/archderm.140.11.1373
26 Tanaka , Tsunemi , awashima M, Tatewaki , ishida H. Treatment of skin
laxity using multisource, phase-controlled radiofrequency in Asians: visualized
3-dimensional skin tightening results and increase in elastin density shown
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dsu.0000000000000047
27 Taub AF. Fractionated delivery systems for difficult to treat clinical applica-
tions: acne scarring, melasma, atrophic scarring, striae distensae, and deep
rhytides. J Drugs Dermatol 2007;6(11):1120–1128 http://www.ncbi.nlm.nih.gov/
pubmed/18038500. Accessed December 16, 2017
28 Ulrich H, B umler , Hohenleutner U, Landthaler M. eodymium- AG laser for
hemangiomas and vascular malformations long term results. J Dtsch Dermatol
Ges 2005;3(6):436–440 10.1111/j.1610-0387.2005.05723.x
29 at H, u DC, Rao , Goldman MP. Application of intense pulsed light in
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205
 III Nonsurgical Cosmetic Treatments
20 Sclerotherapy and Laser Vein Treatment
Gilly Munavalli, Mitchel P. Goldman, and Robert A. Weiss
Abstract
Venous disease encompasses a wide spectrum of clinical manifes-
tations, including medical and cosmetic concerns. A knowledge
of the lower-leg venous anatomy is helpful for translating clinical
symptoms and signs into localized and diagnosable venous
disease. The zones of influence of the great saphenous and short
saphenous veins can determine whether new-onset or persistent
telangiectasia (spider veins) are associated with saphenous
reflux. Cosmetically sensitive telangiectasias/venulectasias and
reticular veins can be treated with either sclerotherapy or laser.
There are several sclerosing agents to choose from, depending
on the vessel size and location. Laser, specifically the 1,064-nm
wavelength, can be useful for treating telangectasia in situations
where needle injection is not desirable. Sclerotherapy can also
be used for treating other cosmetically undesirable veins in areas
such as the chest and dorsal hands.
Keywords
sclerotherapy, varicose, veins, spider veins, saphenous reflux,
laser, 1064 nm
20.1 Introduction
Venous disease encompasses a wide spectrum of clinical man-
ifestations, including asymptomatic unwanted small red, blue
reticular, and larger varicosities; intermittently bulging branches
of the great saphenous vein (GSV) that course down the medial
thigh and calf as well as extend across the thigh, knee, and calf
with terminal blue veins both large and small on the ankle and
feet; dull, achy pain in the posterior calf after prolonged standing
and, in the most advanced cases, golden-brown pigmentation of
the skin of the lower legs; ulcerations secondary to minor trauma
that are very slow to heal; and veins that are inflamed with the
potential progression of blood clots into the deep venous system.
The science of treatment of venous disease, phlebology, has roots
dating to 400 BC: the ancient Greeks recognized venous disease
as an undesirable and unsightly condition. Procedures involving
the use of instrumentation to traumatize veins were described
by Hippocrates in the fourth century BC, and procedures such
as cauterizing veins with a hot iron or surgically removing them
in pieces or in long segments (vein stripping) were routinely
practiced in the years that followed.
Today venous disease still presents a formidable challenge to
diagnose and treat. It affects 40 to 55 of the population, with
common symptoms of leg pain, swelling, and skin changes. Upward
of 80 of people aged 80 will have signs and/or symptoms of
venous disease. Venous insufficiency, which is caused by valvular
incompetence and a reversal of blood flow in the deep or superfi-
cial venous system, is the most common form of venous disease.
Deep venous insufficiency occurs when valves are damaged by
206
thrombosis and is beyond the scope of this chapter. Superficial
venous insufficiency occurs when high-pressure leakage develops
between the deep and superficial systems or within the superficial
system itself. This elevated venous pressure results in sequential
failure of the more distal venous valves in superficial veins. Venous
insufficiency allows venous blood to escape from its normal
flow to the heart and flow in a retrograde direction down into an
already congested leg, thus increasing lower-leg venous pressure.
Over time, this elevated pressure and valvular-incompetent super-
ficial veins acquire the typical dilated and tortuous appearance
of varicosities. Furthermore, insufficiency can lead to chronic
morbidity of the skin as a result of compromised deoxygenated
skin, with subsequent fibrosis manifesting as stasis dermatitis,
lipodermatosclerosis, atrophie blanche, or edematous skin changes
eventuating in cutaneous nonhealing ulceration.
Farther downstream, changes involving the smaller branching
vessels, such as unsightly or symptomatic venulectasis and/or
telangiectasias, are a major consequence of superficial venous
valvular insufficiency. These entities occur in 29 to 41 of women
and 6 to 15 of men in the United States. Although up to 53 of
patients with leg telangiectasias have associated symptoms, the
most common reason patients seek consultation is cosmetic.
In the upper extremity, the forearm and dorsal hand veins rep-
resent the equivalent of varicose veins of the lower extremities.
Sunlight, gravity, and other environmental exposures subject the
hands to unique combinations of physiologic and environmental
stress. ith the passage of time, the hands lose volume as a result
of muscle atrophy, bone demineralization, and loss of adipose
tissue. Elasticity is lost, and skin texture dramatically changes.
This process is accelerated by solar-induced damage, which
results in wrinkled, dyschromic skin and prominent and tortuous
varicosities of the superficial veins of the hand and forearms, such
as the cephalic vein and the basilic vein.
20.2 Pretreatment Assessment
20.2.1 Lower Extremity
Careful patient assessment is essential for patients seeking
amelioration of the symptoms of venous disease. Evaluation and
treatment in the lower extremity should be directed in a system-
atic fashion toward the size and type of vessel, starting with the
proximal, larger vessels and working down to the distal, smaller
vessels (Fig. 20.1). Vessel types classified in the superficial venous
system (from largest size to smallest) include the following:
• The GSV and small saphenous vein (SSV) with their respective
direct tributaries
• onsaphenous vein varicosities (often visibly bulging veins)
• Reticular or feeder veins (often bluish colored)
• Spider veins or telangiectasia (located just below the
epidermis)

Fig. 20.1 An algorithm for evaluation of lower-extremity venous disease.
The majority of symptomatic lower-extremity venous insuf-
ficiency is attributable to the superficial venous system and
specifically includes reflux of the GSV. Reflux of the SSV accounts
for approximately 5 of superficial venous disease, whereas the
remaining division of the superficial system is called the lateral
subdermic venous system. Younger patients, in their twenties
and thirties, usually present with telangiectatic webs on the
lateral thigh originating from reticular vein reverse flow or reflux
in the lateral venous system. hen there is a family history of
large varicose veins, reflux originating from the GSV or SSV
must be suspected. A duplex ultrasound study in patients who
presented for cosmetic treatment of leg veins has been shown
to demonstrate a relatively high incidence of early associated axial
or truncal reflux in the GSV.
During an initial consultation, reflux in the GSV is first sus-
pected based on active symptoms elicited during a thorough
history and physical examination. Often these patients have a
strong family history of venous disease, especially the presence
of varicose veins in immediate family members. Symptoms of
venous disease are most often localized to the medial surface
of the leg and exacerbated by prolonged standing, or during the
premenstrual period in women, and are typically relieved by cold,
ambulation, or rest with leg elevation or by wearing graduated
compression stockings. Characteristics of venous pain can include
a dull ache; burning, heavy legs; throbbing; leg cramping; or
pruritus that worsens at the end of the day. Generally speaking,
abnormalities on physical examination of the lower extremities
such as pain, bulging veins, or skin findings such as discoloration
or ulceration located on the medial thigh and ankle correspond
with the GSV distribution, whereas those located on the posterior
calf and lateral ankle correspond to the SSV distribution.
S er er y nd er Vein re men
Unlike the symptomatology associated with reflux in the larger
vessels, telangiectatic lesions more often present as a cosmetic
concern. The term telangiectasia was first used in the early 1800s
to describe a superficial vessel of the skin visible to the human
eye. These typically measure 0.1 to 1 mm in diameter and can be
either a distended arteriole or a venule. A host of conditions can
precipitate telangiectasia formation (see Table 20.1). Varicose
veins most likely lead to the formation of telangiectasias through
either associated venous hypertension with resulting angiogen-
esis or vascular dilation. These varicose veins may or may not be
clinically evident at the time of telangiectasia presentation but
should trigger the systematic proximal-to-distal vein evaluation
Table 20.1 Select conditions precipitating telangiectasia formation
Hormonal factors:
• Pregnancy
• Estrogen therapy
• Topical corticosteroid preparations
Physical factors:
• Age
• Trauma (contusion, surgical incision, lacerations)
• Infection
• Radiation dermatitis
• Erythema ab igne (chronic thermal injury)
• Actinic neovascularization
Component of a primary cutaneous disease:
• Varicose veins
• Necrobiosis lipoidica diabeticorum
• Capillaritis (progressive pigmentary purpura)
207
 III Nonsurgical Cosmetic Treatments
of the affected extremity in efforts to unmask subclinical venous
disease.
Normal Venous Anatomy of the Lower
Extremity
nowledge of superficial venous anatomy and the location of
important perforating vessels is fundamental to recognition of
normal patterns of varicose veins (Fig. 20.2).
The GSV is of primary concern when treating venous problems
in the lower extremity. The saphenous vein originates on the
dorsum of the foot in the dorsal venous arch, passes anterior to the
medial malleolus, progresses through the medial calf across the
posteromedial aspect of the popliteal space, ascends in the medial
thigh, and terminates in the femoral vein at the saphenofemoral
junction. It dominates the anteromedial superficial drainage
system. As the saphenous vein reaches its termination, it receives
Fig. 20.2 Illustration of the superficial venous anatomy of the anterior
lower extremity that is important for evaluation of varicose veins.
208
important tributaries medially and laterally. Duplex ultrasound
examination may identify reflux in one or more of these vessels.
The anatomy of the GSV is relatively constant. It is understood
that this vein lies on the deep fascia of the leg and thigh, but it is
less well recognized that it lies below or deep to the superficial
fascia. Current descriptions of the anatomy of the lower-extremity
vasculature do not always make this distinction, yet this fact is
crucial to understanding the development of varicosities.
In varicose venous anatomy, the important tributaries to the
GSV extending upward from below are the posterior arch vein
(vein of Michelangelo), which receives the three Cockett perfo-
rating veins (posterior tibial perforators); the anterior tributary
vein to the saphenous system, which lies below the patella and
collects blood from the anterior and lateral surface of the leg; and
the posterior tributary vein, which also empties into the GSV in
the upper anteromedial calf. Other tributaries that may terminate
high in the saphenous system near the groin are the posterior
medial thigh vein and the anterior lateral thigh vein. Either or
both of these veins may become the site of varicose clusters.
Less common in primary varicosities, and more important in
recurrent varicose veins after treatment, are other tributaries
to the GSV as it terminates in the fossa ovalis. These include the
superior external pudendal vein, the superior epigastric vein, and
the superficial circumflex iliac vein.
Leg varicose veins could be the result of retrograde flow from
pelvic vein varicosities from the connection of pelvic veins, the
external pudendal vein, and the saphenofemoral junction. The
findings of varicose veins of the medial groin, medial buttocks,
and pubic area in patients with chronic pelvic pain should lead
one to suspect pelvic congestion syndrome.
The 34-year-old woman in Fig. 20.3 presented with recurrent
varicose veins of the left groin and thigh 2 years after she under-
went endovenous laser ablation for left GSV reflux. She reported
having felt heaviness and intermittent pain of the left pelvic area
and groin for the past several years; her symptoms worsened with
prolonged standing and during menstruation. Physical examina-
tion revealed reticular veins and bulging varicose veins of the left
medial groin in addition to a varicose vein of the left thigh.
Duplex ultrasound showed several dilated veins in the left
groin that continued proximally to the pelvic area. Her magnetic
resonance imaging (MRI)/magnetic resonance venography (MRV)
Fig. 20.3 A patient with medial thigh and groin varicose veins 2 years
after endovenous laser ablation of the great saphenous vein. Magnetic
resonance imaging (MRI)/magnetic resonance venography (MRV) revealed
an enlarged left gonadal and pelvic vein associated with pelvic conges-
tion syndrome. (Reproduced with permission from Alam M, Silapunt S,
eds. Treatment of Leg Veins, 2nd ed. Elsevier; 2010.)
 S er er y nd er Vein re men

showed an enlarged left gonadal and pelvic vein. She was diag- Telangiectatic Leg Veins
nosed with pelvic congestion syndrome and was treated, with no
Telangiectatic leg veins may be described as venous spiders,
subsequent recurrence of varicose veins.
spider veins, sunburst veins, starburst veins, venous plexuses,
Posteriorly, the most important of the axial veins is the SSV. This
dilated venules, venous blemishes, venulectasias, superficial or
vein originates on the lateral aspect of the foot in the dorsal venous
minor varicosities, essential cutaneous telangiectasias, vanity
arch and ascends virtually in the midline of the calf, between the
veins, and cosmetic veins (Fig. 20.6). All of these terms describe
bellies of the gastrocnemius muscle. Unlike the GSV, the SSV may
the type of telangiectatic networks that may cause physical
penetrate the deep fascia at any point from the middle third of
symptoms of pain and discomfort. More than 50 of patients
the calf upward. This fact explains its segmental rather than total
presenting for treatment of these spider veins express aching
nature of reflux.
associated with them. These symptomatic veins are best catego-
Important tributaries to the saphenous vein are variable in
rized as arborizing networks (according to the Redisch and Pelzer
location or existence but may include the posterolateral trib-
classification). They are actually combinations or networks of
utary vein. Superiorly, this tributary may be associated with a
telangiectasias (0.1–1 mm) and venulectases (1–2 mm). Painful
lateral thigh vein called the fi
telangiectasias on the leg are usually grouped; they are rarely
Another important and frequently encountered vein is the vein
present as isolated telangiectatic vessels or spider angiomas with
of Giacomini, which connects the lesser and greater saphenous
a central arteriole. More important, symptomatic telangiectasias
veins. It may originate from the SSV or from its thigh extension
and ends in the GSV or its posterior accessory.
The value of knowing the gross anatomy of the superficial veins
of the lower extremity is that any one of the systems may be the
site of the growth of clusters of varicosities (Fig. 20.4).

Signi n er r ing ein

The perforating veins connect the superficial venous system to
the deep venous system and penetrate the fascia. Any one of
these veins, alone or in combination, may be the source of hydro-
dynamic forces of venous hypertension that produce superficial
varicosities. It is the abnormally high pulses of hydrodynamic
pressure transmitted through incompetent valves that affect rel-
atively unsupported superficial veins. Such pulses of increased
fluid force originate to some extent from increased abdominal
pressure and to a greater extent from increased compartmental
pressure during muscular contraction.
The best-recognized connections between the superficial venous
system and the deep venous system are the saphenofemoral and
saphenopopliteal junctions. Incompetence of the check valves at
their termination has been suggested as the cause of distal vari-
cosities from gravitational reflux. This reverse flow is said to dilate
veins in a progressive fashion, from proximal to distal.
Because it is frequently the site of the first varicose veins or
the first reticular veins that become varicose, Boyd’s perforating
vein in the anteromedial calf has come to receive great attention
by physicians who treat venous problems. Experience with the
duplex scanner reveals that venous incompetence at this level
may be isolated and may be the first reflux to appear. Such incom-
petence may be asymptomatic; however, when the incompetence
is symptomatic, it produces aching pain, fatigue, and even a throb-
bing discomfort as mentioned previously. These symptoms can be
relieved by firm local pressure. Progressing proximally from Boyd’s
communicating vein are the perforating veins in the distal third of
the thigh. These veins are named for English surgeon Harold Dodd
and may be found in any location along the saphenous pathway in
the distal third of the thigh. The third important series of commu-
nicating veins, the Hunterian (midthigh) perforators, are named
for Scottish surgeon and anatomist ohn Hunter (Fig. 20.5).
Recognizing the normal anatomy and the most common perfo-
rating vein sources of varicosities makes identification of patterns Fig.20.4 Illustration of the superficial venous anatomy of the posterior
of varicosities relatively easy. lower extremity.

209
 III Nonsurgical Cosmetic Treatments
Fig. 20.5 Illustration of the superficial venous anatomy of the medial
lower extremity.
and venulectases commonly are associated with slightly larger
blue veins, which have been called feeder veins, reticular veins,
or minor varicose veins. These small subdermal blue veins may
be tributaries of the saphenous system. Reticular veins are most
commonly part of a superficial venous system that is separate
from either of the saphenous systems, originally described as the
lateral subdermic venous system by Albanese et al.
To diagnose and treat painful telangiectasias in a logical way,
a precise classification is helpful and is given in Table 20.2. This
includes telangiectasias (type I), venulectases (type II), associated
blue reticular veins (type III), and reflux from primary varicose
veins (types IV and V).
A disturbance of normal venous physiology with back pressure
and reverse flow or reflux through incompetent valves results
in transmission of pressure through reticular veins into venules,
causing their expansion into telangiectasias and venulectases.
210
Fig. 20.6 Illustration of telangiectatic leg veins of the lower extremity.
Telangiectasias located on the anterior aspect of the thigh could
occur as a consequence of reflux in the following vessels: anterolat-
eral tributary of the GSV, inguinal fold reticular veins, incompetent
saphenofemoral junction, superficial axial branches of the GSV, or
anterior branches of the lateral subdermic venous system. Although
painful telangiectasias and venulectases may appear anywhere on
the leg, they are most likely to occur near the knee.
Regions in which painful groups of telangiectasias and venulec-
tases are most likely to occur are shown by the shaded areas in Fig.
20.7. Patients most often complain of focal burning, throbbing,
and aching in these areas.
20.2.2 Upper Extremity
The veins of the upper extremities, primarily the cephalic and
basilic veins, are analogous to the great and small saphenous veins
 S er er y nd er Vein re men

Table 20.2 Revised vessel classification (eliminating the mixed telangiectasia/varicose category)
Type I Telangiectasia, spider veins
0.1–1 mm diameter
Usually red (rarely, may be cyanotic)
n Type IA
Telangiectatic matting
< 0.2 mm diameter network, bright red
Type II Venulectasis (usually protrudes above skin surface; distinguished from telangiectasia by deeper color and larger diameter)
1–2 mm diameter
Violaceous, cyanotic
Type III Reticular veins (“minor” varicose veins, “feeder” veins)
2–4 mm diameter
Cyanotic to blue
Type IV Nonsaphenous varicose veins (primary varicosity of saphenous tributary usually related to incompetent perforator)
3–8 mm diameter

Blue to green
Type V Saphenous varicose veins (varicosities associated with reflux at saphenofemoral or saphenopopliteal junction or major perforators of
saphenous system causing enlargement of great or small saphenous vein)
Usually > 8 mm diameter
Blue to bluish-green
Because most patients have a combination of multiple varicose vein types, a description of type I in association with type II or type III varicosities is simpler. Classifying varicose
veins in this way facilitates a more straightforward treatment plan.
Note: Data from Goldman MP. Sclerotherapy treatment for varicose and telangiectatic leg veins. In: Coleman WP, Hanke CW, Alt TH, et al, eds. Cosmetic Surgery of
the Skin. Philadelphia: BC Dekker; 1991: 197-211; and Duffy DM. Small vessel sclerotherapy: an overview. Adv Dermatol. 1988; 3:221-242.

of the superficial venous system in the lower extremities (Fig. 20.8).

Because of the proximity of these veins to the radial and ulnar veins,
they are commonly used as bypass routes for procedures such as
arteriovenous shunts in patients with renal disease. Sclerotherapy
of upper-extremity veins is not commonly performed for several
reasons. Because these veins are not subject to the same hydrostatic
pressures as the lower-extremity veins, valves in cephalic and basilic
veins do not commonly exhibit reflux and associated symptomatol-
ogy. These veins usually do not appear overly distended or tortuous,
and varicosities/telangiectasias do not generally develop in the
upper extremities. A noted exception occurs with upper-extremity
exercisers, such as weight lifters, who perform frequent Valsalva
maneuvers during exercise. Prolonged increase in intrathoracic
pressure will increase flow through upper-extremity veins and can
result in clinically noticeable vein distention. This is a normal phys-
iologic response and not considered pathologic. In our experience,
branches of the cephalic vein in the forearm and dorsal hand are the
Fig. 20.7 The shaded regions are most likely to be effected by groups of
most common areas treated with sclerotherapy. Detailed upper-ex-
telangiectasias and venulectases causing burning, throbbing, and aching.
tremity venous anatomy is beyond the scope of this chapter.

20.3 Treatment Options
Ideally, treatment for unwanted leg veins would be performed
in one session, cause no pain, and be 100 effective in clearing
vessels, with no associated side effects. Unfortunately, the
variations in vessel size, flow, depth, and type preclude the pos-
sibility of a single effective treatment modality. However, there
are a number of effective treatments that can produce excellent
results, including conventional and duplex-guided sclerotherapy
for the treatment of larger vessels and telangiectasias and laser
treatment of reticular and spider veins.
20.3.1 Conventional (Visual) and
Duplex-Guided Sclerotherapy
Conventional sclerotherapy is indicated for the elimination
of unwanted reticular veins and telangiectasias (Table 20.3).

211
 III Nonsurgical Cosmetic Treatments
Fig. 20.8 The venous system of the upper extremity is illustrated here.
hen leg veins are managed in a systematic approach, feeder
vessels or larger varicose veins are first eliminated surgically
or with radiofrequency or laser ablation, and sclerotherapy
proceeds from largest to smallest vessels, with 80 to 90 of ves-
sels responding to one or two treatments. As with endovenous
ablation, sclerotherapy is performed in patients of all age groups,
ranging from patients in their late twenties to early seventies.
If treatment is initiated early in the course of the disease and
with proper proximal-to-distal treatment techniques, patients
can expect to achieve excellent results. Although hypertonic
saline solution is the sclerosant most widely available and
used in the United States, it is approved by the Food and Drug
Administration (FDA) only as an abortifacient and is the most
painful of sclerosing solutions, with the highest risk for causing
cutaneous necrosis if extravasated into soft tissue. Two FDA-
approved sclerosing solutions, polidocanol (Asclera; Merz, Mesa,
A ) and sodium tetradecyl sulfate (STS; Sotradecol; Mylan,
Institutional LLC, Cannonsburg, PA) are less painful to inject and
less ulcerogenic if extravasated. Vessel size and, to some extent,
location are two of the most important factors to consider when
choosing a sclerosant.
In expert hands, nearly any vessel can be treated with traditional
sclerotherapy techniques. It is more difficult to treat larger vessels,
vessels with a high-grade source of reflux, vessels with a complex
pattern of reflux, and vessels that lie deeper beneath the surface
of the skin. Failures can be caused by incorrect assumptions about
the patterns of flow, incomplete understanding of the anatomy, or
incorrect placement of the delivery catheter or needle.
212
Direct duplex ultrasound visualization offers an alternative to
blind sclerotherapy that has one very important advantage
after a treatment under direct visualization, there can be no doubt
that sclerosant has been delivered where it was intended and that
all areas of reflux have been exposed to the sclerosing solution.
An important secondary benefit is that observable spasm is a
predictor of vessel closure.
Common indications for injection with duplex ultrasound
visualization include the following:
• Great saphenous vein without junctional incompetence
• Small saphenous vein without junctional incompetence
• Truncal or tributary vessels with large failed perforating veins
• Varicosities with saphenofemoral incompetence
• Varicosities with saphenopopliteal incompetence
• Resistance to other techniques of sclerotherapy
• ontruncal varicosities larger than 5 mm in diameter
• Venous component of arteriovenous malformations
• Varicosities eroding into soft tissues
• Vulvar or scrotal varices
• Varicosities with large open connections to the deep venous
system
Although sclerotherapy is generally safe and effective, situa-
tions do arise in which it is contraindicated. Any patient with a
medical history significant for deep venous thrombosis should be
 S er er y nd er Vein re men

Table 20.3 Indications for sclerosant usage

S ui n e e i e r de n me e ni m Ad n ge i d n ge
concentrations)
Reticular veins
Polidocanol Asclera Detergent Always painless Urticaria (immediate) at injection site
(0.5–1%)* (emulsifier) Cutaneous necrosis low Skin necrosis from painless
Effective at low concentrations arteriolar injection
Expensive
Sodium tetradecyl Sotradecol Detergent Painless intravascular Skin necrosis with extravasation of
sulfate (0.2–5%) (emulsifier) Painful extravascular concentrations 1.0%
Strong for varicose veins Expensive
Effective at low concentrations Dissolves rubber; must use latex-
free syringes to avoid allergic
response
Hypertonic saline None Hyperosmolar Low risk of allergic reaction Painful stinging and cramping
solution (20–23.4%) Readily available Highly ulcerogenic—high risk for
Rapid action skin necrosis if extravasation occurs
Saline and dextrose Sclerodex Hyperosmolar High viscosity; remains in treated Too weak for larger varicosities
(25% dextrose and veins Slight stinging
10% sodium chloride Low risk of allergic reaction One concentration only
phenethyl alcohol)* Low risk of necrosis
Telangiectasias

Polidocanol Asclera Detergent (emulsifier) Always painless Urticaria (immediate) at injection site
(0.25–0.6%)* Cutaneous necrosis low Skin necrosis from painless
Effective at low concentrations arteriolar injection
Sodium tetradecyl Sotradecol, Fibrovein, Detergent (emulsifier) Painless intravascular Skin necrosis with extravasation of
sulfate (0.1–0.5%) Thrombovar Painful extravascular concentrations > 0.25%
Strong for varicose veins Expensive
Effective at low concentrations Hyperpigmentation postsclerosis
Dissolves rubber; must use latex-
free syringes to avoid allergic
response
Hypertonic saline None Hyperosmolar Low risk of allergic reaction Painful stinging and cramping
solution (11.7–23.4%) Readily available Highly ulcerogenic—high risk for
Rapid action skin necrosis if extravasation occurs
Saline and dextrose Sclerodex Hyperosmolar High viscosity; remains in treated Too weak for larger varicosities
(25% dextrose and veins Slight stinging
10% sodium chloride Low risk of allergic reaction One concentration only
phenethyl alcohol) Low risk of necrosis Not FDA-approved
Glycerin (72% solution None Osmotic Relatively painless Can cause hematuria at high
mixed 2:1 with 1% Lower potential to cause volumes (>10 mL per treatment
lidocaine with or hyperpigmentation session)
without epinephrine Cutaneous necrosis low High viscosity
1:100,000) Lower potential to cause telangiectatic Cannot be used with lidocaine- or
matting epinephrine-sensitive patients
Off-label use in United States
*Now FDA-approved.
Note: Modified from Weiss RA, Dover JS. Leg vein management: sclerotherapy, ambulatory phlebectomy, and laser surgery. In Kaminer MS, Dover JS, Arndt KA, eds.
Atlas of Cosmetic Surgery. Philadelphia: WB Saunders; 2002: 309-328.

thoroughly evaluated with duplex examination of the deep and
superficial venous systems before treatment. If sclerotherapy is
to be performed, these patients must be anticoagulated. Patients
with a history of arterial insufficiency or hypercoagulable states
should not be considered candidates for treatment. Additionally,
sclerotherapy should not be performed on patients who are preg-
nant, bedridden, or severely diabetic.
20.3.2 Laser Treatment of Reticular
Vessels and Telangiectasias
Although sclerotherapy remains the mainstay of treatment
of varicose and reticular veins, lasers may play a role in the
treatment of lower-extremity telangiectasias, especially those
that remain after effective treatment of feeding reticular veins.
Upper-extremity or dorsal hand varicose veins are best treated
with sclerotherapy. Lasers typically have no role in the treatment
of upper-extremity varicosities.
In general, treatment with lasers and light sources is more
expensive, is more painful, require more treatment sessions, and
has less predictable results, and the risk of side effects is at least
as high as with sclerotherapy. Candidates suitable for laser or light
source treatment are those who are needle phobic, have failed
sclerotherapy, or have developed untoward side effects from
sclerotherapy. Others suited for laser treatment are fair-skinned
individuals who have either vessels smaller than the caliber of

213
 III Nonsurgical Cosmetic Treatments
a 30-gauge needle or foot and ankle vessels that are notoriously
difficult to treat with sclerotherapy.
Lasers are typically reserved for the smallest telangiectasias
of the leg, but newer long-wavelength lasers can be useful for
reticular veins up to 2 mm in diameter, especially in the lateral
orbital region of the face.
Despite the fact that sclerotherapy has a long list of potential
side effects, including pain, swelling, urticaria, systemic allergic
reaction, hyperpigmentation, telangiectatic matting, skin necro-
sis, and phlebitis, it remains the treatment of choice for most leg
veins less than 4 mm in diameter.
20.4 Overview of Sclerotherapy
Treatment Regimen
The usual number of treatments is two to five per region, with
a typical interval between treatments of 4 to 8 weeks. After a
series of successful treatments, a rest period of 6 months is
preferred to observe for second-generation vessels and to allow
venous pressure to normalize. Reevaluation is done at 6 months
if new or recurrent vessels appear (Fig. 20.9).
20.4.1 Patient Education
Before treatment is initiated, the patient is asked to view a sclero-
therapy consultation video that explains the pathophysiology of
Fig. 20.9 An algorithm for treatment of lower-extremity venous disease. STS: sodium tetradecyl sulfate.
214
spider veins, treatment options, preoperative and postoperative
care, and the need for compression therapy, among other issues.
After the test treatment and before the next treatment session,
the patient is instructed to eat beforehand to avoid a vasovagal
response. Female patients are told not to shave their legs or use
moisturizers on the night before and the day of treatment, to
wear shorts during treatment sessions, and to bring properly
fitted medical graduated compression stockings to the visit.
e highly recommend stocking these compression stockings in
the clinic so that accurate leg measurements and fittings occur,
since an improperly fitted stocking can produce a tourniquet
effect.
Graduated compression therapy is very important to improve
and maximize the results following sclerotherapy. External
compression collapses and decreases blood flow in the treated
veins, allowing maximal sclerosant effects on the vessel walls
and minimizing intravascular thrombosis. To achieve adequate
compression, different posttreatment regimens are utilized. In
one of the authors’ posttreatment protocols, it is recommended
that patients use class II (30–40 mm Hg) compression stockings
24 hours a day for the first 7 days and then class I (20–30 mm Hg)
stockings for at least 2 weeks while standing.
It is not uncommon for patients to present for a treatment
session and request that lasers be used in place of sclerotherapy.
Patients must be counseled that lasers are a second-line treat-
ment for spider and varicose veins. They are not as effective as
conventional sclerotherapy. Treatment with currently available

Fig. 20.10 Patient undergoing sclerosing agent injections for treat-
ment of lateral thigh spider veins (arrow).
lasers requires longer sessions, is generally more painful, and
poses more risk of causing harm.
20.4.2 Technique
Glycerin Sclerotherapy
Glycerin is usually supplied in 100 or 72 solutions. Because
glycerin injected at 100 is painful and too viscous to inject
through a 30-gauge needle, it is usually diluted 2:1 volume/
volume with 1 lidocaine with 1:100,000 epinephrine. It acts as
an osmotic corrosive agent, causing damage to the vessel wall
directly, and works very well on vessels 0.5 mm or smaller. To
minimize the risk of hematuria, the use of less than 10 mL of
glycerin per treatment session is recommended.
Lateral Thigh Telangiectasias
The 35-year-old woman shown in Fig. 20.10 presented with
concerns about a spider vein on her right thigh (arrow). The veins
had appeared after the birth of her first child 4 years earlier and
persisted without worsening.
A clustering of 0.5- to 0.8-mm bluish-colored telangiectasias
was evident on the right anterior thigh. These vessels were
associated with a 2-mm reticular vein, which was injected. These
associated telangiectasias were not located in the typical distribu-
tion for the GSV.
The patient underwent a test treatment with two different
sclerosants, 72 glycerin solution (compounded by the University
Compounding Pharmacy, San Diego, CA) and 0.1 STS (Mylan
Pharmaceuticals, USA), and wore compression stockings, 20 to 30
mm Hg, during waking hours for the next 2 weeks to ensure the
best results.
The patient returned for a full sclerotherapy session 4 to 5
weeks after the test treatment. The previously treated areas
were evaluated and showed good resolution of vessels, without
evidence of hyperpigmentation.
The patient was placed in the supine position on a surgical
table with a sclerotherapy tray (Fig. 20.11; Table 20.4) nearby.
After wiping with isopropyl alcohol, a disposable 30-gauge needle
S er er y nd er Vein re men
Table 20.4 Standard sclerotherapy tray contents
• Cotton balls, dry and soaked with 70% isopropyl alcohol
• Protective nonsterile gloves
• 30-gauge and 32-guage, 0.5-inch disposable plastic-hub needles
• Clearly labeled sclerosing solutions in 0.5-mL aliquots in 3-mL
disposable latex-free syringes
• Disposable latex-free syringes
Fig. 20.11 The components of a standard tray used for sclerotherapy,
listed in Table 20.4.
connected to a 3-mL syringe filled with 1 mL of the 72 glycerin
solution was used to cannulate the vein. The needle was bent
at a 30 angle to facilitate cannulation. The solution was slowly
injected into several places in the vein.
On withdrawal of the needle, immediate but transient blanch-
ing of the telangiectasias was noted (Fig. 20.12). After treatment,
mild erythema and urtication were noted along the course of the
treated vessels.
Foamed Sodium Tetradecyl Sulfate or
Polidocanol Sclerotherapy
Foamed sclerosant is an alternative to traditional liquid sclero-
sant; it offers several advantages:
• Better displacement of the venous blood to allow intimate and
prolonged contact with the vessel wall
• Ability to maintain its concentration better than liquid sclero-
sant, which is diluted by venous blood
• Ability to travel farther along the vessel than liquid sclerosant
• Doubling of potency of the sclerosing solution with dilution
4-fold
Currently, foam sclerotherapy is an off-label use. Foamed STS is
generally prepared using the Tessari technique, in which 0.5 mL
of the sclerosant in a latex-free syringe is mixed with 2 mL of air
in an empty syringe connected to the other using a Baxa RapidFill
connector (Baxter; Deerfield, IL) .
215
 III Nonsurgical Cosmetic Treatments
Fig. 20.12 Telangiectasias (arrow) will blanch immediately after
injection and withdrawal of the needle.
Fig. 20.13 Patient with varicose veins located on the posterior leg in
the popliteal fossa.
216
ie u ging e i u r Vein
Foamed sclerosant was used to treat the patient shown in Fig.
20.13, who complained of bulging varicose veins, approximately
2.5 mm, located on the posterior leg, in the popliteal fossa.
The patient was placed in the supine position on a surgical table
with a sclerotherapy tray nearby. A disposable 30-gauge needle
connected to a 3-mL latex-free syringe was used to canalize the
vessels. After flashback was visualized, the sclerosant solution,
0.5 mL of 0.2 foamed STS (prepared using the Tessari technique),
was slowly injected into the reticular veins. On withdrawal of
the needle, the areas treated were gently massaged in a proximal
direction (Fig. 20.14).
Dorsal Hand Veins
A foamed sclerosant is also used for hand sclerotherapy in
patients who have cosmetic problems with enlarged dorsal hand
veins.
Careful consideration during the medical examination includes
any history of hand trauma, weakness, carpal tunnel syndrome,
need for frequent intravenous medications, and foreseeable need
to canalize hand veins. Consent must include the fact that the
treated vein will no longer be usable in the future for intravenous
access. During the physical examination, the brachial and ante-
cubital veins need to be identified, which can be accessible in the
event of a future need for intravenous access.
The patient is placed in the supine position, and the arm and
forearm on the side to be treated should be placed along the
bedside. A disposable 30-gauge needle connected to a 3-mL
latex-free syringe is used to canalize the vessels. The sclerosant
solution, 0.25 to 0.5 foamed STS, is commonly used for hand
sclerotherapy. Alternatively, 0.5 to 1.0 polidocanol (Asclera) can
also be used, foamed. Vein distention and mild blanching occurs
while the foam is being injected (Fig. 20.15).
The 49-year-old woman shown in Fig. 20.16 presented with
cosmetic concerns about her hands. She thought they looked old
and worn down. She inquired about any treatments that could
revitalize the appearance of her hands. She was distressed about
the dorsal hand veins, which were especially prominent and
had become more noticeable over the past 5 years. On physical
examination, a bluish superficial varicose vein of approximately 5
a b c
Fig. 20.14 (a) Patient in Fig. 20.13 being shown having her varicose
veins injected with 1% foamed sodium tetradecyl sulfate solution
starting proximal and moving distal every 4 to 5 cm. (b) The area is
massaged after each injection. (c) The patient after treatment.
 S er er y nd er Vein re men

Fig. 20.15 Patient being injected to treat veins on the dorsum of the hand with 1% foamed sodium tetradecyl sulfate solution.

mm was noted on the dorsal aspect of the left hand. One year later,
marked reduction of dorsal hand veins was seen on the left hand
compared with the untreated right hand (Fig. 20.17).
The patient should elevate the treated hand immediately after
injection to minimize dilution of the foam sclerosant with venous
blood and to maximize the contact of the sclerosant with the vein
walls. Compression wrapping or a gauntlet is placed on the treated
hand while the entire upper extremity is still elevated. The patient
is instructed to monitor carefully for any changes in sensation, tem-
perature, color, and decreased motion in the fingers on the treated
hand. If these symptoms occur, the patient should loosen the
compression bandage; otherwise, it should be kept on overnight.

Foamed Sodium Tetradecyl Sulfate

Sclerotherapy Fig. 20.16 Patient presenting with concerns of prominent veins on the
dorsum of her hand, which have become more noticeable over the past
5 years.
ue u er e e u Syndr me
Blue rubber bleb nevus syndrome (BRB S) is a rare vascular
anomaly syndrome consisting of multifocal venous malforma-
tions (VM). The malformations are most prominent in the skin,
soft tissues, and gastrointestinal (GI) tract but may occur in
any tissue. The cutaneous lesions of BRB S are generally small,
measuring less than 1 to 2 cm, and blue to purple. They are often
very tender to the touch or external trauma and can occasionally
engorge with blood. Patients may have from several to hundreds
of cutaneous lesions. GI lesions of this syndrome are more clin-
ically relevant than the skin and soft tissue lesions. Therefore,
workup should include imaging of the GI tract. Most cases are
sporadic in nature and not hereditary.
The 58-year-old man shown in Fig. 20.18 was seen for evalu-
ation and treatment of longstanding, intermittently tender blue
nodules on the volar aspect of his left arm. He had been diagnosed
with BRB S 20 years prior and had a negative GI exam at that
time. He had since been followed with regular colonoscopy and
imaging, with no visceral involvement. Multiple spongy 6- to
12-mm, bluish-purple papules and nodules were noted on the Fig. 20.17 One year post sclerotherapy, marked reduction of dorsal
hand veins is seen on the left hand of the patient in Fig. 20.16
flexor aspect of the left arm (Fig. 20.18a).
compared with the untreated right hand.
The patient underwent a duplex ultrasound examination of
these lesions on his left wrist, which revealed superficial, thin-
walled nodules as vascular lesions with no communication to
deeper structures. Indeed, the vascular lesions of BRB S are con- A solution of 0.5 foamed STS was slowly injected with a
sistent with congenital VMs rather than proliferative tumors (Fig. 30-gauge 0.5-inch needle after withdrawing slightly to visualize
20.18b). The patient was willing to undergo foam sclerotherapy blood flashback in the needle hub. A total of 2.0 mL of foamed STS,
injections to debulk and treat these lesions. prepared using the Tessari technique, was injected during the first

217
 III n urgi me i re men

visit. Immediate blanching and slight spasm of the lesions were
noted after treatment. The patient had no complaints of pain at
the conclusion of the treatment (Fig. 20.19a).
At the follow-up visit 4 weeks later, the patient noted a decrease
in the lesion size and was treated again, resulting in the improve-
ment shown (Fig. 20.19b).
In the immediate postoperative period, the patient’s arm was
elevated. A compression dressing was placed on the area and
secured with Coban wrap (3M, St. Paul, M ). The patient was told
to remove this dressing the following day. o further care was
needed.
Long-Pulse Laser Therapy
Long-pulse neodymium:yttrium aluminum garnet ( d: AG)
1,064-nm lasers have been developed in an effort to target deep,
relatively large-caliber cutaneous vessels. The primary benefit of
this wavelength is its capacity for relatively deep penetration to
approximately 0.75 mm in human skin, allowing targeting of ves-
sels in the mid-dermis. The wavelength is well absorbed by water
and hemoglobin but not by melanin, thus allowing treatment
even in deeply pigmented individuals. However, high energies
must be used for adequate penetration in these individuals. Only
with sufficient fluence and facilitation of heat dissipation can the
posterior wall of a larger-diameter (1- to 2-mm) vessel filled with
deoxygenated hemoglobin be reached and heated.
The newer pulsed 1,064-nm lasers have pulse durations
between 1 and 200 msec and are capable of more than 350 /cm2
at small spot sizes. In general, treatment with long-pulse 1,064-
nm laser light is relatively painful and requires cooling and topical
anesthesia. Large-caliber vessels, greater than 0.5 mm in diameter,
respond best. Vessels up to 3 mm can be treated with long-pulse
d: AG lasers. Some of the effects of hydrostatic pressure may
be addressed by treating these larger vessels, although the pain
experienced by patients significantly increases beyond a 2-mm
vessel. Recent data suggest that with use of smaller spots and even
higher fluences, even small vessels respond (Fig. 20.20).
It is likely that the 1,064-nm laser achieves its vasodestructive
effects by penetrating deeply enough to cause complete, circum-
ferential thermal damage to the vessel wall. For patient comfort
and epidermal sparing, some type of cooling must be employed,

a b
Fig. 20.18 (a) Patient presents with long-standing blue-colored nodules on the flexor aspect of the left arm. (b) Duplex ultrasound showing a venous
malformation with incompetent, refluxing perforator communicating between the radial vein and the more superficial cephalic vein.

a b
Fig. 20.19 (a) The nodules of the patient in Fig. 20.18 were injected with foamed sodium tetradecyl sulfate (STS). (b) Postprocedure photos show
improvement after STS injections 4 weeks later.

218

whether in the form of contact cooling, cryogen cooling, or ice-
cold gel.
Anterior Thigh Telangiectasias
This 41-year-old woman in Fig. 20.21 presented with a 5-year
history of anterior right thigh telangiectatic vessels. She had long
wished to be rid of the unsightly, asymptomatic veins but had
an overriding fear of needles, which prevented her from seeking
treatment.
She agreed to undergo a series of test pulses with the long-
pulsed d: AG 1,064-nm laser Vbeam Prima (Candela Corp,
Fig. 20.20 The long-pulse 1,064-nm lasers penetrate more deeply and
cause circumferential thermal damage to the vessel wall.
Fig. 20.21 Patient presenting with telangiectatic vessels on the
anterior right thigh.
S er er y nd er Vein re men
ayland, MA; Fig. 20.22) to a small segment of the veins. She
underwent a duplex examination of the right GSV and right
saphenofemoral junction, which revealed no abnormalities.
Duplex examination did reveal enlarged anterosuperior branches
of the lateral subdermic venous system. The patient was unwilling
to undergo duplex-guided sclerotherapy for the reflux and instead
opted for 1,064-nm laser treatment of her spider veins. She was
informed that the results of this treatment would likely not be
permanent.
A grouping of telangiectasias on the patient’s thigh were
selected and treated at a constant fluence of 120 /cm2 with a spot
size of 2.5 mm and varying pulse durations from 10 to 40 msec.
Ice-cold gel was applied to the skin before laser treatment. A pulse
duration of 30 msec produced the best immediate contraction, as
illustrated by hand-held digital microscopy (Fig. 20.23).
Postoperatively the patient requires minimal care. He or she
should be made aware of the potential for posttreatment hyper-
pigmentation, which results from the hemosiderin degradation
Fig. 20.22 Candela Vbeam Prima dual wavelength 595 nm pulsed
dye and long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG)
1,064-nm laser.
219
 III Nonsurgical Cosmetic Treatments

20.5 Concluding Thoughts

Sclerotherapy is a safe, effective treatment for leg and hand
varicosities. The surgeon must recognize various patterns of var-
icose veins, thoroughly understand the pertinent anatomy, and
be familiar with sclerosants, injection techniques, and the use of
compression therapy; these are the keys to successful treatment.
Underlying superficial or deep venous insufficiency requires
management before one attempts to treat clinically apparent
reticular or spider veins, to avoid failure of the sclerotherapy and
potential complications.

a Avoid halogen surgical lighting—indirect lighting is best.
b Stop if the patient complains of discomfort at the first
Fig. 20.23 (a) Pretreatment hand-held digital microscopic view of
telangiectasias. (b) Response of telangiectasias treated at a constant
fluence and spot size with varying pulse durations from 10 to 40 msec.
The 30-msec pulse duration produced the best immediate contraction.
products of blood trapped in the vessel during and after treat-
ment. The larger the treated vessel, the more likely the chance that
hyperpigmentation will occur. Most hyperpigmentation resolves
spontaneously within 3 to 6 months.
Clinical Caveats
• Sclerotherapy:
Be aware of your body position; avoid neck and back strain.
Use magnification (1.5–33).
For smaller matting, use double-polarized light.
Apply alcohol to decrease white scale reflection.
Stretch the skin taut for easier cannulation.
Bend the needle 30°.
Obtain 30-gauge disposable needles with a plastic hub;
the needle should be changed frequently if it dulls.
Do not attempt to withdraw blood into the hub with
vessels less than 0.55 mm in diameter; intravascular place-
ment cannot be confirmed except by the smooth flow of
solution.
Before solution is injected, producing a tiny air bubble
(approximately the volume in the hub) may be helpful to
clear the existing blood.
Inject very slowly, with little pressure, 0.1 to 0.3 mL at each
site.
Advise the patient to wear graduated compression hose,
30 to 40 mm Hg, 24 hrs a day for 7 days, then 20 to 30 mm
Hg while standing for the 2 weeks after treatment.
• Foam sclerotherapy:
Be aware of the anatomy and orientation of each individual
patient.
Use latex-free syringes when using STS.
Produce a small bolus of air or foam preceding injection of
the sclerosant when possible.
Visualize the initial injection of foam or sclerosant.
Stop if distention or bulging around the vein occurs.
moment of injection.
Note immediate vessel contraction as a treatment
endpoint.
• Duplex-guided sclerotherapy:
Try to identify reticular veins, which may be difficult to
appreciate clinically but feed smaller vessels; if they are
identified, treat those first.
Draw venous blood (low pressure and darker) freely back
into the syringe before injection.
Visualize the initial injection of several drops of foam or
sclerosant.

220

Stop if distention around the vein is seen on ultrasound.
Stop if the patient complains of discomfort at the first
moment of injection.
The proper endpoint is total contraction.
Foam resting in the vein is often seen on duplex imaging.
• Long-pulse laser therapy:
Use 1,064-nm laser for treatment of leg telangiectasias.
Always check that safety glasses are in use by all.
Target only superficial reticular and telangiectatic vessels.
Use long-pulse laser therapy for vessels larger than 0.5 mm.
If the vessel is 0.5 mm or larger, start with a modest flu-
ence of 60 to 80 J/cm2 at a pulse duration of 30 msec (given
a 2.5-cm spot size) and gradually increase the fluence.
If the vessel is 0.5 mm or smaller, start with a pulse dura-
tion of 15 to 16 msec.
Have ice-cold gel on hand to decrease the sensation of
pain and avoid epidermal injury.
Strongly avoid double-pulsing or pulse-stacking the laser
at these settings; vessels can be re-treated after several
minutes if the settings need to be modified.
After successful treatment, note the vessel contraction,
perivessel erythema, and edema.
Suggested Reading
1 Albanese AR, Albanese AM, Albanese EF. Lateral subdermic varicose vein system
of the legs. Its surgical treatment by the chiseling tube method. Vasc Surg
1969;3(2):81–89
2 Bergan , eiss RA, Goldman MP. Extensive tissue necrosis follow-
ing high-concentration sclerotherapy for varicose veins. Dermatol Surg
2000;26(6):535–541, discussion 541–542
3 Bowes LE, Goldman MP. Sclerotherapy of reticular and telangiectatic veins of the
face, hands, and chest. Dermatol Surg 2002;28(1):46–51
S er er y nd er Vein re men
4 right AD, inmonth B, et al. Discussion on primary treatment of varicose
veins. Proc R Soc Med 1948;41(9):631–639
5 Cabrera , Cabrera r, Garcia-Olmedo MA, Redondo P. Treatment of ve-
nous malformations with sclerosant in microfoam form. Arch Dermatol
2003;139(11):1409–1416
6 Callam M . Epidemiology of varicose veins. Br J Surg 1994;81(2):167–173
7 Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in abnormal varicose
hand veins. Plast Reconstr Surg 1999;104(5):1474–1479, discussion 1480–1481
8 Engel A, ohnson ML, Haynes SG. Health effects of sunlight exposure in the
United States. Results from the first ational Health and utrition Examination
Survey, 1971-1974. Arch Dermatol 1988;124(1):72–79
9 Glassberg E, Lask GP, Tan EM, Uitto . The flashlamp-pumped 577-nm pulsed
tunable dye laser: clinical efficacy and in vitro studies. J Dermatol Surg Oncol
1988;14(11):1200–1208
10 Goldman MP, Guex , eiss RA. Sclerotherapy: Treatment of Varicose and Telangi-
ectatic Leg Veins. 6th ed. London, U : Elsevier; 2016
11 Goldman MP, Fitzpatrick RE, Ross EV, ilmer SL, eiss RA: Lasers and Energy De-
vices for the Skin. 2nd ed. Boca Raton, FL: CRC Press, Taylor Francis Group; 2013
12 Goldman MP, Fronek A. Anatomy and pathophysiology of varicose veins. J Der-
matol Surg Oncol 1989;15(2):138–145
13 Ibegbuna V, Delis , icolaides A . Effect of lightweight compression stockings
on venous haemodynamics. Int Angiol 1997;16(3):185–188
14 Merlen E. Red telangiectasias, blue telangiectasias. Soc Franc Phlebol
1970;22:167–174
15 Raju S, Fredericks R. Venous obstruction: an analysis of one hundred thirty-seven
cases with hemodynamic, venographic, and clinical correlations. J Vasc Surg
1991;14(3):305–313
16 Redisch , Pelzer RH. Localized vascular dilatations of the human skin, capillary
microscopy and related studies. Am Heart J 1949;37(1):106–113
17 Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing
foam in the treatment of varicose veins. Dermatol Surg 2001;27(1):58–60
18 Thibault P, Bray A, lodarczyk , Lewis . Cosmetic leg veins: evaluation using
duplex venous imaging. J Dermatol Surg Oncol 1990;16(7):612–618
19 eiss RA, Dover S. Leg vein management: sclerotherapy, ambulatory phlebec-
tomy, and laser surgery. Semin Cutan Med Surg 2002;21(1):76–103
20 eiss RA, Feied CF, eiss MA. Vein Diagnosis and Treatment: A Comprehensive
Approach. ew ork, : McGraw-Hill; 2001
21 eiss RA, Sadick S, Goldman MP, eiss MA. Post-sclerotherapy compression:
controlled comparative study of duration of compression and its effects on
clinical outcome. Dermatol Surg 1999;25(2):105–108
221
 III Nonsurgical Cosmetic Treatments

21 Nonsurgical Treatment of the Face and Neck

Michael P. Ogilvie and Julius W. Few Jr.

stackable therapies or using multiple nonsurgical therapies in a

Abstract
Facial plastic surgery has undergone tremendous change as the
paradigm for facial rejuvenation has shifted away from invasive,
surgical techniques. Facial rejuvenation has been revolutionized
by the rapid innovation of noninvasive or minimally invasive
procedures, which has been fueled by patients’ desires for
near-surgical results without significant risk and minimal recov-
ery time.
Facial aging is defined by decreased skin quality, predictable
volume loss, and skin ptosis. In addition to the signs of facial
aging, one issue that concerns many facial rejuvenation patients
is excess fat. This chapter discusses several noninvasive or min-
imally invasive techniques, used either alone or in combination,
aimed at alleviating the telltale signs of aging and reducing excess
fat, helping provide near-surgical facial rejuvenation results. In
particular, we discuss deoxycholic acid ( ybella, Allergen, Irvine,
CA) injections as well as cryolipolysis (CoolSculpting, eltiq
Aesthetics, Pleasanton, CA) directed at volume reduction. The
use of energy-based modalities such as microfocused ultrasound
(Ultherapy, Ulthera, Mesa, A ) or radiofrequency devices (Pellev ,
Cynosure, estford, MA; Venus Freeze/Legacy, Venus Concept,
eston, FL; and ThermiRF, ThermiGen, South Lake, TX) as well
as the latest technology in thread lifting (Silhouette InstaLift,
Sinclair Pharma, Irvine, CA) to improve skin ptosis are discussed.
Last, we discuss laser therapy (Halo Hybrid Fractional Laser,
Sciton, Palo Alto, CA) for facial skin resurfacing and describe our
techniques to combine these modalities to achieve near-surgical
results.
single setting, near-surgical results may often be obtained.
onsurgical or minimally invasive procedures typically follow
the same core principles of surgical facial rejuvenation, namely
to replenish lost volume, remove excess, and lift and/or tighten
where indicated, which are often directed at the key elements of
aging. Facial aging is the result of several physiologic processes,
including decreased skin quality from photodamage, fat atrophy
and subsequent loss of facial volume, and loss of elasticity result-
ing in ptotic skin.
In this chapter, we discuss specific nonsurgical modalities
focused on fat reduction, namely lipolytic therapy with deoxycho-
lic acid injections, submental cryolipolysis, as well as nonsurgical
devices or techniques to improve ptotic skin, namely energy-based
therapies such as microfocused ultrasound and radiofrequency
(RF) as well as the minimally invasive technique of thread lifting.
e briefly discuss the lasers we use in our practice to improve
skin quality; however, nonsurgical therapies for volume replace-
ment (e.g., dermal fillers) and for skin quality improvement (e.g.,
lasers and other devices in plastic surgery) are covered in more
detail in other chapters.
21.2 Volume Reduction
onsurgical removal of unwanted fat, namely submental fat, is
a common theme among cosmetic facial rejuvenation patients.
Previously, submental liposuction was the only tool available in the

Table 21.1 American Society for Aesthetic and Plastic Surgery top ten
Keywords procedures for 2015
facial rejuvenation, nonsurgical techniques, fat reduction, n Nonsurgical procedure um er Percent increase
microfocused ultrasound, radiofrequency, thread lifting, laser procedures
resurfacing, stackable therapies 1 Botulinum toxin injection 4,267,038 18.9
2 Hyaluronic acid filler 2,148,326 26.6
injection
21.1 Introduction 3 Hair removal (laser or 1,136,834 37.2
pulsed light)
Surgical rejuvenation of the face has been the gold standard of
therapy for many years, but with noninvasive and minimally 4 Chemical peel 603,305 24.6
invasive cosmetic medicine applications undergoing rapid 5 Microdermabrasion 557,690 33.7
innovation and development, current procedures have already 6 Photorejuvenation 483.792 30.3
revolutionized the treatment paradigm for facial rejuvenation (intense pulsed light)
and may be some of the most significant changes in the recent 7 Nonsurgical skin 471,759 58.2
history of facial plastic surgery. tightening
As patients have become younger, busier, and less tolerant of 8 Full-field ablative laser 326,120 −20.2
surgical complications or longer recovery times, nonsurgical or skin resurfacing
minimally invasive procedures have been on the rise. Data from 9 Sclerotherapy 322,170 2.0
the American Society for Aesthetic and Plastic Surgery (ASAPS)
10 Nonsurgical fat reduction 160,763 18.7
collected yearly since 1997 have shown the rapid rise of non-
surgical options (Table 21.1). These therapies may be used as an Data from American Society for Aesthetic Plastic Surgery. 2015 Cosmetic Surgery
National Data Bank Statistics. http://www.surgery.org/sites/default/files/ASAPS-
adjunct to surgery, or, as introduced in 2012 with the concept of Stats2015.pdf. Accessed October 9, 2019.

222
 n urgi re men e e nd e

aesthetic surgeon’s armamentarium. However, two nonsurgical fat in adults. Careful consideration must be given for the use of
modalities have recently been made available to offer alternatives ybella in patients with excessive skin laxity or prominent pla-
to traditional surgical therapy: deoxycholic acid and cryolipolysis. tysmal bands, for whom reduction of submental fat may result in
an aesthetically undesirable outcome. ybella is contraindicated
in the presence of infection at the injection sites.
21.2.1 Deoxycholic Acid
Deoxycholic acid ( ybella, Allergan, Irvine, CA; Fig. 21.1), cur- Technique
rently defines a new category of injectable agents known as lipo-
Administration of ybella is considered fairly straightforward.
lytic therapy. It is a cytolytic drug indicated for the improvement
Over a period of 15 to 20 min, the patient’s submental area is
in the appearance of moderate to severe fullness associated with
typically injected with 4 to 6 mL (two or three vials) of agent.
submental fat in adults. In 2015, deoxycholic acid subcutaneous
ybella is injected using a 30-gauge needle into subcutaneous
injections received approval from the FDA for submental lipoly-
fat tissue. A single treatment consists of a maximum of 50 injec-
sis as a nonsurgical alternative to liposuction.
tions, 0.2 mL each (up to a total of 10 mL, or five vials), spaced 1
ybella is currently formulated as a nonhuman, nonanimal
cm apart. Up to six treatments may be administered at monthly
version of deoxycholic acid (as sodium deoxycholate, 10 mg/
intervals. Prior to each treatment, it is important to palpate the
mL), a naturally occurring bile acid that, in the intestinal tract,
submental area to ensure sufficient fat and to identify subcuta-
solubilizes dietary fat in humans and other animals, enabling it
neous fat between the dermis and platysma. To avoid injury to
to be absorbed. In tissue, however, deoxycholate induces pores in
the marginal mandibular nerve, do not inject above the inferior
cellular membranes, producing leakage of cytoplasmic contents,
border of the mandible or within a region defined by a 1.5 cm line
membrane destabilization, and subsequent lysis. Thus, ybella is
below the inferior border (from the angle of the mandible to the
a cytolytic agent that destroys cell membranes. Once injected into
menton). Superficial injections into the dermis may result in skin
subcutaneous fat, it causes lysis of adipocytes, killing them so they
ulceration. Postprocedure care includes wearing a chin strap for
can no longer store or accumulate fat. These lytic effects occur
a few days after the procedure to minimize edema.
within minutes of injection and account for the brisk, localized
inflammatory response. Replacement of grossly injured adipose
tissue with fibrosis may account for subsequent fat reduction and
skin retraction observed after treatment.
Several large, multicenter, randomized, double-blinded Phase
III trials have confirmed, with statistical significance, the efficacy
of ybella subcutaneous injections to reduce submental fat and
improve submental profile and skin laxity with a 79 patient sat-
isfaction rate (Fig. 21.2). These results illustrate that deoxycholic
acid is a promising, less invasive alternative to liposuction for the
reduction of submental fat.

Patient Selection
ybella is indicated for improvement in the appearance of mod-
erate to severe convexity or fullness associated with submental

Fig. 21.2 Composite responder rates of Kybella compared to

placebo. Abbreviations: CR, clinician reported; PR, patient reported;
SMFRS, submental fat rating scale. (Reproduced with permission
Fig. 21.1 Deoxycholic acid (Kybella, Allergan, Irvine, CA). (Courtesy from Allergan. Clinical Results. 2018. http://hcp.mykybella.com/
Allergan, Inc.) clinical-results.)

223
 III Nonsurgical Cosmetic Treatments
Results
Significant improvement in submental fat reduction is typically
seen after one to two treatments, but up to six treatments may
be required for optimal results. Severe adverse events are rare,
and patient satisfaction has been reported as high as 79 . Hence,
ybella is considered a safe and effective, minimally invasive
alternative to liposuction in the submental area (Fig. 21.3;
Fig. 21.4).
Complications
Although deoxycholic acid appears to be safe and efficacious,
side effects have been noted. ybella’s ability to destroy cell
membranes its cytotoxic property is not specific to adipose
tissue; therefore, there exists the theoretical risk of unwanted
tissue destruction (e.g., skin and muscle). Additionally, within
the clinical trials, 4 of patients suffered temporary marginal
mandibular nerve injury, 2 suffered temporary dysphagia, and,
most commonly, 72 of patients suffered from various degrees
of edema, bruising, pain, numbness, or redness. These findings
led to defining certain anatomic landmarks to avoid, as described
previously in the technique, as well as to avoiding the use of
deoxycholic acid in patients with active dysphagia or a history of
a b
Fig. 21.3 Submental fat (a) before and (b) after treatment with
Kybella injections. (Reproduced with permission from Few JW. The Art
of Combining Surgical and Nonsurgical Techniques in Aesthetic Medicine.
New ork, N : Thieme; 2018.)
a b
Fig. 21.4 Submental region (a) before and (b) after treatment with
Kybella injections. (Reproduced with permission from Few JW. The Art
of Combining Surgical and Nonsurgical Techniques in Aesthetic Medicine.
New ork, N : Thieme, 2018.)
224
dysphagia. Typical adverse events related to deoxycholate have
involved local, transient injection site reactions of mild to mod-
erate intensity. The most common adverse events include pain,
erythema, edema, ecchymosis, and numbness. The amount of
postinjection inflammation and edema seems to be proportional
to the amount of submental fat that is present. Patients with
severe submental fat require a greater amount of deoxycholate
and tend to experience more inflammation and edema after the
treatment.
21.2.2 Cryolipolysis
Cryolipolysis has become a mainstay modality in noninvasive
fat reduction, particularly as it pertains to body contouring. For
the purposes of this chapter, cryolipolysis has gained approval
for submental fat reduction, and with some degree of skin laxity
improvement, it has shown itself to be a viable option for many
patients with submental fat excess.
Cryolipolysis consists of the use of controlled cooling to reduce
fat deposits. Fat cells are uniquely sensitive to cold and crystallize
at a higher temperature than water in surrounding tissues does.
Consequently, cooling to a point above the freezing point of water
induces apoptosis in fat cells and an inflammatory response in the
treated tissue, without damage to overlying skin and surrounding
muscles, nerves, and blood vessels. This process protects the skin
from freezing while the adipose cells are exposed to therapeutic
levels of cooling. Over the course of 2 to 4 months, the damaged
fat cells are metabolized, resulting in gradual, permanent fat
reduction in the treated region.
Several studies on the effects of cryolipolysis on peripheral
nerves and lipid levels in various areas of the body have validated
it as a safe and effective procedure for reducing subcutaneous
fat. CoolSculpting ( eltiq Aesthetics, Pleasanton, CA; Fig. 21.5) is
the only cryolipolysis machine in the United States approved by
the Food and Drug Administration (FDA). In 2010, CoolSculpting
was approved for use on the abdomen. Since then, the FDA has
approved its use on the flanks (2012), thighs (2014), and submen-
tal area (2015).
Patient Selection
Proper patient selection is essential to achieving an optimal
result. Cryolipolysis has been proven effective and safe, but it is
not the fat-reduction strategy of choice for everyone.
All patients should be counseled on a treatment-to-transforma-
tion basis. The patient should be aware of the optimal number of
cycles required for desired fat reduction, which in the submental
region may be one to three depending on the degree of fat excess,
particularly if significant lateral excess is present.
Two crucial factors to assess during the patient examination
are local skin laxity and thickness of adipose tissue. Gender and
ethnic background do not affect outcomes. Treatment should
be avoided in patients with cold agglutinin disease, cryoglobu-
linemia, or paroxysmal cold hemoglobinuria; while the effects
of CoolSculpting in patients with these disorders has not been
studied or reported, it is reasonable to assume an exacerbation of
these conditions with induced cooling. Additionally, when using
the CoolMini applicator to treat the submental region, an enlarged
thyroid should be avoided as well.
 n urgi re men e e nd e

Technique
Cryolipolysis in various areas of the body requires the use of
applicators, of which the CoolSculpting system offers nine (Table
21.2). In the submental region, the CoolMini is the applicator
of choice. The use of the CoolMini applicator can be slightly
different from that of the rest. Patient assessment and marking
should be performed in the standing position. The operator
begins by outlining the area of interest with a pen, encircling
the borders of excess adiposity and drawing a mid-sagittal line
or X through its apex to assist with CoolSculpting applicator
placement. The patient is then positioned in a reclining chair. The
eltiq Pretreatment Skin ipe is used to clean the skin with firm
pressure to remove skin oils. A transparent tape dressing such as
Tegaderm (3M, St. Paul, M ) is used as the liner and placed over
the metal cupped plate (Fig. 21.6). The vacuum is turned on to a
preset 50 mm Hg of negative pressure. The film dressing is then
drawn into the applicator. The vacuum must be maintained for
skin protection from the plates. Once the tape remains adherent
to the plate, the gel trap is placed in the middle of the cupped
device. The entire eltiq Cool Gel Mini syringe is applied on the
skin, extending 1 cm beyond the treatment area. For the sub-
mental area, place the patient’s head between a head-stabilizing
pillow. The applicator is placed over the marked area, and a strap
is then used to hold the applicator in place. The patient should
be comfortable without pressure on the thyroid cartilage. The
umbilical is placed in the securement arm using a C clamp. It is
helpful to remove any slack in the umbilical to prevent it from
pulling the applicator out of position.

Fig. 21.5 CoolSculpting ( eltiq Aesthetics, Pleasanton, CA) cryolipoly-

sis control unit. (Courtesy eltiq Aesthetics, Inc.)

Table 21.2 CoolSculpting applicators

me Im ge Description re men Are
V uum i r
CoolAdvantage Sculpting applicator; interchangeable Outer thighs and abdomen; off-label
flanges use for posterior thighs
CoolAdvantage Petite Upper arms
CoolAdvantage Plus Larger treatment areas

CoolCore Sculpting applicator; same foot print as Abdomen

CoolCurve+ but a different flange that is
more ideal for bulges with more gentle
curves
CoolCurve+ Sculpting applicator; ideal for curves Flanks
CoolFit Sculpting applicator; ideal for longer, Abdomen; off-label use for arms;
vertical areas of fat occasionally inner thighs.
CoolMax Debulking applicator for larger surface Abdomen and flanks.
areas
CoolMini Sculpting applicator; ideal for smaller, Abdomen; off-label use for arms;
pliable tissue occasionally inner thighs.
Nonvacuum applicators

CoolSmooth Pro® Sculpting applicator; ideal for larger Outer thighs and abdomen; off-label
surface areas with less tissue pliability use for posterior thighs
and pinchability; requires 75 minutes of
treatment
Source: eltiq Aesthetics, Inc. CoolSculpting Applicators. http://coolsculptinghcp.com/fat-freezing-science/applicators/. Accessed October 9, 2019.

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 III Nonsurgical Cosmetic Treatments
Fig. 21.6 CoolMini uses tape adhesive in place of the protective gel
pad. This tape adhesive must be secured around the end. Suction
is applied, and then a gel trap is placed in the middle of the cupped
applicator. (Courtesy of eltiq Aesthetics, Inc.)
Postprocedural Care
Once the treatment concludes, the applicator is removed, and
a 3-minute firm massage of the treated tissue ensues; in the
submental area, hand massage is preferred. This posttreatment
massage results in an increase in fat reduction. This additional
fat reduction may be attributable to ischemic perfusion injury
from rewarming the cooled adipose tissue with massage.
Multiple treatments (2 to 3) may lead to further contour
improvement, though the efficacy of cryolipolysis may be
attenuated with successive treatments. Additional cryolipolysis
a b
d e
Fig. 21.7 Woman aged 44 (a,b,c) before and (d,e,f) 3 months after a single CoolSculpting application to the submentum.
226
is recommended for most areas 8 weeks after initial treatment
to allow resolution of inflammation. On average, excess adipose
tissue may be reduced by 20 to 25 per treatment cycle.
Results
The efficacy of this technology has been demonstrated not only
by patient satisfaction and independent rater scales but also
objectively, using a variety of techniques including standardized
clinical photography, ultrasound evaluation of fat layer reduction,
fat caliper measurements, and circumferential measurements, as
well as via three-dimensional vector imaging. Overall, patients
can expect a gradual fat layer reduction over the course of 2 to 4
months after treatment, and, as previously mentioned, results can
be enhanced with immediate posttreatment massage. Without
significant weight change, long-term fat reduction in the treated
area remains for up to 5 years after cryolipolysis (Fig. 21.7).
21.3 Ptotic Skin
As we age, the facial anatomy undergoes largely predictable
changes. The skin tends to become thinner with loss of elasticity,
leading to rhytides, which are often compounded by photoaging.
Ptosis of various facial components adds to the aged appearance
of the face and neck. The face has several distinct fat compart-
ments, which in youth are nondiscernible. However, with aging,
these compartments become more evident due to fat descent,
selective atrophy, and attenuation of the intervening retaining
ligaments. The facial skeleton tends to change dramatically with
c
f
 n urgi re men e e nd e

significant resorption around the orbit, maxilla, and pre-jowl Technique

area of the mandible. These changes tend to interplay, causing
As Ultherapy treatment can cause discomfort, patients require
the face to exhibit an upright triangle appearance emphasized
some form of pain management with some combination of oral
by midface volume loss and deepening of the nasolabial folds and
medications. At the Few Institute, we prefer a combination of
marionette lines, along with significant jowl formation, instead
800 mg oral ibuprofen with a low-dose benzodiazepine. e have
of the inverted triangle of youth.
a low threshold to use small-dose, depot injections of lidocaine
At present, the superficial musculoaponeurotic system (SMAS)
with epinephrine, subcutaneously placed, using no more than
rhytidectomy is the gold-standard treatment for moderate to
0.2 mL per site of injection. For a lower-face treatment, we use an
severe ptosis of the skin and soft tissue in the midface and neck.
average of 6 mL of 1 lidocaine with epinephrine. It is important
However, there has been a recent trend by patients, particularly
to avoid intradermal injection of local anesthesia so as to avoid
younger patients, to opt against surgery because of its potential
potential hot spots on the skin surface.
complications and prolonged recovery. This is nowhere more
Once patient comfort is achieved, we use the scanning ultra-
evident than in the data for surgical versus nonsurgical facial
sound to interpret the thickness of the skin being treated. Ultherapy
rejuvenation released by ASAPS: between 1997 and 2016, surgical
treatment of the face may be performed alone or in continuity with
facial rejuvenation saw a percent increase of 19.5 , while nonsur-
a neck. Typically, treatments are performed at a minimum of two
gical facial rejuvenation procedures saw a 6,956.6 increase. This
depths, with 1 pass of a 4.5-mm transducer (DS 4-4.5) and then
in turn has led to the search for and development of less invasive
re-treating the area with a more superficial 3.0-mm transducer
methods to improve facial aging, particularly skin ptosis.
(DS 7-3.0). The first two depths may be followed with an advanced
treatment protocol using the 1.5-mm transducer (DS 10-1.5) for
21.3.1 Energy-Based Devices dermal tightening. This multiple-depth treatment protocol is
based on previous studies where dual-depth treatments improved
Microfocused Ultrasound subjective outcomes on the upper face and midface.
Similar to Ultherapy treatments of the face, neck treatments
Ultrasound use as a therapeutic modality has evolved from its
are performed at a minimum of two depths with one pass of
early neurologic applications in the 1950s. The application for
facial rejuvenation utilizes thermal injury delivered through
intense focused ultrasound. This is accomplished by a pulse
duration of 50 to 200 ms, a frequency of 4 to 7 MHz, and an energy
quantity of 0.5 to 10 . This technology was commercialized as
the Ultherapy System (Ulthera Inc., Mesa, A ; Fig. 21.8) in 2004,
and several clinical studies refined the device and supported its
ability to create thermal coagulation points (TCPs) at specific
tissue depths. Intense focused ultrasound energy is delivered
through the skin’s surface, with selective creation of thermal
injury zones in the SMAS, heating the fascia in a pinpoint way,
resulting in contraction of the fascia. Additionally, this thermal
insult leads down the path of collagen damage, collagen shrink-
age, and finally neocollagenesis as part of the healing response.
This results in lifting and tightening of the skin on the neck,
under the chin, along the jawline, and on the brow.
In 2009, a study resulted in FDA approval for a brow lift indi-
cation. In 2012, neck improvement was demonstrated, giving the
device an FDA-approved neck lift indication as well.

Patient Selection
An ideal patient is usually younger with a robust wound healing
response, mild lipoptosis, and good skin elasticity. Additionally,
for previous surgical patients, microfocused ultrasound may be
able to tighten recurrent neck skin laxity further without requir-
ing additional operative procedures. For those patients unhappy
with persistent or recurrent skin laxity, this modality provides
a noninvasive alternative that is well tolerated. However, it is
not ideal for the older patient with extensive photoaging, severe
skin laxity, marked platysmal banding, or a very heavy neck (i.e.,
patients with body mass index 30 kg/m2). e have found that
patients with Fitzpatrick skin types IV to VI do particularly well Fig 21.8 Ultherapy system (Ulthera, Mesa, A ). (Reproduced with per-
with this technology, and these findings may be linked to inher- mission from Few JW. The Art of Combining Surgical and Nonsurgical
ent photodamage protection found with increased melanin. Techniques in Aesthetic Medicine. New ork, N : Thieme; 2018.)

227
 III Nonsurgical Cosmetic Treatments
the 4.5-mm transducer and then re-treating the area with the
3.0-mm transducer. The first two depths may be followed with
an advanced treatment protocol using the 1.5-mm transducer for
dermal tightening.
Postprocedural Care
Following treatment, some patients may experience dermal
swelling that may last for a day or two. A light moisturizer and
sunscreen are applied after the treatment. o specific aftercare
is required, and patients may resume their normal skin regimen
immediately after treatment. Immediately after the treatment,
the skin feels tighter to patients. This initial response may shift
to visible changes in 3 to 6 months.
e u
As already stated, patients do report an immediate feeling of
skin tightening; however, visual changes may take up to 2 to
6 months. Typical results will last 1.5 to 2 years and may be
repeated as necessary (Fig. 21.9; Fig. 21.10).
m i i n
Usually 2 to 3 hours of erythema is expected after the procedure,
but occasionally this may last 1 week or longer. This resolves
spontaneously without intervention. Bruising is an infrequent
but self-resolving complication. Sensory innervation to the
treated areas is reportedly affected in up to 18 of patients.
Temporary numbness usually resolves without intervention in
2 to 3 weeks. Facial motor nerve injury has also been reported.
Full function of a near-total frontal branch paresis returned by 6
months with observation alone.
Radiofrequency
In the early 2000s, manufacturers responded to patients’ desire
to receive skin tightening without surgical intervention or abla-
tive treatment. Delivery of transcutaneous RF energy provided
a b
Fig. 21.9 Woman aged 40 (a) before and (b) 3 months after Ultherapy
treatment of the lower face and neck.
228
an option that fitted these constraints. The goal of this tech-
nology is to deliver energy beneath the skin surface to induce
neocollagenesis. RF devices apply alternating electrical current
to tissue within the electrical path between oppositely charged
electrodes. This alternating current forces oscillations in polar
molecules (such as water) in the target tissue, ultimately gen-
erating heat. It is this heat that causes collagen breakdown and,
ultimately, neocollagenesis with subsequent collagen contrac-
tion. Because RF current is not scattered in tissue or absorbed by
melanin, it is safe to use in patients of all Fitzpatrick skin types.
Currently, there are four types of RF devices available: monop-
olar, bipolar, multipolar, and fractional. Each device requires a
specific electrode configuration and generates a different pulse
duration and frequency. The nonablative RF devices used in med-
icine typically have an alternating current frequency between
0.3 and 10 MHz (for comparison, AM radio is around 1 MHz, and
FM radio is around 100 MHz). Varying the oscillations of energy
delivered changes the target tissue depth, with lower frequencies
having longer wavelengths and thus greater depth of penetration.
Technologies typically approach delivery through two methods.
The first is the outside-in approach through transcutaneous
energy application; such devices include Pellev (Cynosure,
estford, MA; Fig. 21.11) and Venus Freeze/Venus Legacy (Venus
Concept, eston, FL) (Fig. 21.12; Fig. 21.13). The second is the
inside-out approach, where energy is delivered subcutaneously
with a fiber, needle, or probe; such devices include ThermiRF
(ThermiGen, South Lake, TX; Fig. 21.14). The two approaches are
distinguished in Fig. 21.15.
Patient Selection
Because RF energy is directed toward the dermis, it is blind to
a patient’s Fitzpatrick skin color typing and can be used on all
skin color types without the need for pre- or posttreatment
skin-bleaching creams.
RF devices are best used in patients with minimal to moderate
skin laxity and lipodystrophy. As with any nonsurgical modality,
the patient’s need to understand that improvement in skin laxity
a b
Fig. 21.10 Woman aged 48 (a) before and (b) 5 months after
Ultherapy treatment of the lower face and neck.
 n urgi re men e e nd e

Fig. 21.11 Pellev radiofrequency device (Cynosure, Westford, MA).

(Courtesy Cynosure, Inc.)

Fig. 21.12 Venus Freeze (Venus Concept, Weston, FL) radiofrequency

device. Licensed by Health Canada. (Courtesy Venus Concept.)

Fig. 21.13 Venus Legacy (Venus Concept) radiofrequency device.

Licensed by the U.S. Food and Drug Administration. (Courtesy Venus Fig. 21.14 ThermiRF device (ThermiGen, South Lake, T ). (Courtesy
Concept.) ThermiGen, LLC, an Almirall Company.)

229
 III Nonsurgical Cosmetic Treatments

Monopolar Micro-invasive
RF device RF thermal probe

Epidermal cooling Local anesthetic

required required

Insulated needles
Area of RF current
and variable heating
Area of RF current
and increased
temperature

a b
A Outside-in approach B Inside-out approach
Fig. 21.15 (a) “Outside-in” approach to radiofrequency energy delivery, where current is delivered transcutaneously through the epidermis and
dermis, causing thermal contraction. (b) “Inside-out” approach to radiofrequency energy delivery, where current is delivered via probes subdermally
to create tissue coagulation and collagen deposition/remodeling during healing.

and lipodystrophy, especially in the neck, may lead to other cos-
metic deformities, such as exposure of platysmal bands or uneven
correction of adiposity, which may require additional treatments
for correction. Patients with severe skin laxity and lipodystrophy
are best treated with surgical options. That being said, a series of
treatments is often needed, typically comprising between three
and five. hile there is no predictable correlation, the more
treatments provided, the better the clinical results. Although this
has not been scientifically corroborated, we have observed that
patients who are relatively younger obtain a more consistent skin
tightening with current RF treatment technology, which may be
related to an improved physiologic response to dermal heating.
Contraindications for use of RF include pregnancy, any
implanted electronic device, hip replacement, hip or femur sur-
gery, or any other metallic device that could be disrupted by RF
energy, and any active dermatologic or collagen vascular disorder,
active or recent malignancy, any history of disease that may be
exacerbated by heat, current use of isotretinoin, and history of
blood coagulation disorders.
e ni ue u ide-In A r coagulation and so induce collagen deposition/remodeling
Treatment end points are typically based on a manufacturer’s
recommendations, which are based partially on posttreatment
skin temperature change, by external or internal temperature
monitor in response to each treatment. Lower energy settings
may require only topical anesthesia; due to discomfort, regional
nerve blocks are often needed to obtain good clinical results and
provide optimal patient comfort when higher settings are used.
Transcutaneous RF is used to heat the epidermis and dermis
and cause thermal contraction. After the treatment area is
cleaned, a baseline temperature is taken. A thin layer of glycerin
gel is applied, and the RF application is initiated. The length and
temperature used are based on the area being treated. The end
temperature should be between 39 and 45 C, and for optimal
results, a series of three to six treatments are necessary. hen
treating the face, due to the reflection of energy, device settings
may need to be reduced over bony regions such as the forehead
and malar/zygomatic arch. hen treating the perioral region, it is
prudent to insert a protective barrier between the mucosa of the
lips and underlying teeth.
e ni ue In ide- u A r
In this setting, energy is applied under the skin to create tissue
during healing. Using a microinvasive RF thermal probe, the
insulated needle is passed back and forth under the skin, with

230
 n urgi re men e e nd e

concomitant monitoring of the tissue temperatures produced in
proximity to the needle combined with skin surface temperature
optical monitoring. This feedback monitoring ensures that the
target temperature believed to be adequate for achieving a result
is obtained and maintained for an adequate interval, and it safe-
guards against overexposure or temperature excess, which could
create complications, including burns.
Due to patient discomfort, local anesthesia is required. Initially,
0.5 to 1 xylocaine with epinephrine is warmed. Typically, 10-mL
syringes are placed in a warmed water bath 15 minutes prior to
injection, as room temperature anesthetic cools the subcutane-
ous tissues, making treatment longer and more difficult. After
waiting 15 minutes, a 16-gauge needle is used for the access sites
and the probe is inserted. The treatment area is broken down
into segments and approached from two directions. The area is
homogenously treated to an internal temperature of 55 to 60 C
and a temperature of 45 to 47 C at the surface.
Postprocedural Care
For the outside-in approach, typical facial recovery includes
mild to moderate swelling for 1 to 3 days and transient skin
redness for less than 24 hours, depending on device settings and
energy delivered. In general, such a recovery is needed to provide
improvement in skin contour. For the inside-out approach,
patients do experience swelling for 7 days; therefore, they are
typically supported with an elastic chin strap during that time.
e u
The major limitation of the RF modality is that currently there
are not enough published data regarding the optimal tempera-
ture and duration of treatment at that temperature to obtain
ideal results. That said, lasting results have been seen with the
improvement of skin laxity and rhytides (Fig. 21.16; Fig. 21.17).
m i i n
Possible complications related to RF therapy include erythema,
persistent pain, edema, ecchymosis, and burns. As with all of the
other nonsurgical devices, a third of patients have a noticeable
positive response, a third illustrate minimal change, and a final
third have no response to treatment. Localized fat necrosis may
occur in some patients. This typically is self-limiting. Temporary
neuropraxia of the marginal mandibular nerve can be seen
and is most commonly transient. There are some shortcomings
to current RF devices. Often these devices decrease soft tissue
excess to a greater extent than overlying skin laxity, which may
lead to unwanted contour deformities or exposure of underlying
platysmal bands along with persistent skin excess.

Fig. 21.16 (a) Before and (b) 6 months after eight perioral bipolar radiofrequency treatments. (Reproduced with permission from Few JW. The Art of
Combining Surgical and Nonsurgical Techniques in Aesthetic Medicine. New ork, N : Thieme; 2018.)

Fig. 21.17 (a) Before and (b) 1 week after ThermiTight application. (Courtesy ThermiGen LLC, an Almirall Company.)

231
 III Nonsurgical Cosmetic Treatments
21.3.2 Thread Lifting
hile surgery is still the gold standard for rejuvenation of ptotic
skin of the face, due to the invasive nature of surgery, there is
an ongoing search for nonsurgical or less invasive techniques
to treat ptotic skin. In 2004, the FDA approved thread lifting for
this very purpose. onabsorbable barbed suture was introduced
under the skin, hoisting the dermis to create a lifted appearance.
This was short-lived, though, as thread lifting lost FDA approval
in 2007 due to serious complications associated with its use.
In 2015, the FDA approved Silhouette InstaLift (Sinclair Pharma,
Irvine, CA) for facial rejuvenation of patients with ptotic skin of
the mid and lower face. Each thread is a biodegradable suture
that measures 26.8 to 30 cm long and is equipped with a 12-cm
23-gauge needle on each end. There is a 2-cm gap in the middle of
the suture with two sets of bidirectional cones (either four, six, or
eight cones per side) and knots on either end, allowing for equal
tension and weight distribution across the face (Fig. 21.18). The
cone and knot system is a significant component to the suture’s
configuration, providing a 360 surface for effective anchoring
points by fastening the suture to the subdermal fascia. The fila-
ment and cones are composed of polyglycolide/L-lactide (PLGA), a
biodegradable and biocompatible polymer.
Patient Selection
There are no direct contraindications to thread lifting, and it
can be utilized in a large array of patients. The ideal candidate is
someone with good skin quality with mild to moderate laxity of
the midface, lower face, and neck. Patients with advanced signs
of aging or very thin skin should be avoided.
Technique
ith the patient sitting in repose, the desired vector of move-
ment is identified and marked (Fig. 21.19). The face is then
cleansed sterilely and injected with 0.5 mL of 1 lidocaine with
epinephrine (1:200,000) at each entry and exit site. For the
mid- and lower face, eight-cone sutures are used, separating
the entry and exit points by 6 cm. For the neck, 12-cone sutures
are used, separating the entry and exit points by 9 cm. Initial
access into the face is made with an 18-gauge pilot needle. The
double-armed suture is then introduced into a subdermal plane
and passed in opposing directions parallel to the desired vector
of movement. Using gentle massage, the tissue is advanced
over the suture’s cones, taking care to avoid bunching of the
skin. The needles, which pass through to exit points, are cut
Fig. 21.18 Suture design of the Silhouette InstaLift. (Adapted with
permission from Sinclair Pharmaceuticals. Instruction Packet—InstaLift.
http://www.instalift.com. 2015. Accessed Sept 5, 2016.)
232
once the desired effect is achieved. Two to four sutures are
used per side as necessary to achieve the desired amount
of lift.
Postprocedural Care
Most patients experience periprocedural edema, which resolves
within 24 to 48 hours. Other common side effects include pin-
point bleeding and minor ecchymosis. Makeup is avoided for 24
hours to allow the access sites to heal, and patients are asked to
treat the face gently and avoid excessive facial motions/expres-
sions for 4 to 5 days, as these may unhinge the sutures.
e u
Recent analysis of the procedure has illustrated high rates of
safety, efficacy, and satisfaction. The majority of patients found
the procedure to be tolerable (96 ) with manageable discomfort
(89 ) and few minor side effects (i.e., ecchymosis and edema;
89 ). Most saw an immediate improvement in age-related
changes (68 ) and were overall quite satisfied with their experi-
ence (79 ). Of patients, 83 felt that the treatment was effective
in improving their age-related changes. The longevity of results
is still being discovered; results have been maintained up to 36
months. The newest version of thread lifting has been illustrated
to be both safe and effective and a viable option for nonsurgical
lifting of ptotic skin (Fig. 21.20; Fig. 21.21; Fig. 21.22).
m i i n
Most patient experience some degree of edema as well as possi-
ble pinpoint bleeding and minor ecchymosis. There have been no
reported instances of nerve damage or facial palsy nor of sutures
requiring extirpation or breaking after placement. Cone palpa-
bility has been reported early in the recovery process, but there
have been no reports after the first week. Dimpling or excessive
skin bunching may be seen with placement but is self-limiting
as the skin relaxes. As with all nonsurgical techniques, there
is some rate of nonefficacy. As reported, only 16.5 of treated
patients illustrated no improvement, with the majority of
patients experiencing mild to moderate improvement.
21.4 Laser Skin Resurfacing
The primary goal of skin rejuvenation is to combat aging and
photodamage to skin, which manifest as facial lines, irregular
pigmentation, telangiectasias, and textural changes. Five major
classes of lasers are in common use: ablative and nonablative
lasers in both fractional and unfractional forms as well as radiof-
requency technologies.
The introduction of ablative laser skin resurfacing techniques
with high-energy, pulsed CO2 and erbium-doped yttrium alu-
minum garnet (Er: AG) devices was met with great enthusiasm
because of their excellent clinical outcomes in the treatment of
scars and photodamaged facial skin, but the prolonged recovery
and risk of potential side effects made them less attractive treat-
ment alternatives. The subsequent development of nonablative
laser devices improved recovery and tolerability, although limited
clinical efficacy was associated with these less invasive treatments.

Fig. 21.19 Representative patient markings for Silhouette InstaLift suture placement (red dots: entry points; blue dots: exit points).
The concept of fractional photothermolysis, coined by Manstein
and colleagues, has revolutionized the field of laser skin resurfac-
ing by providing the ability to obtain significant clinical results
with minimal posttreatment recovery. Advantages of factional
over fully ablative lasers include faster reepithelialization after
treatment, shorter posttreatment skin care, less frequent acnei-
form eruptions, and quicker resolution of postoperative erythema.
hile laser resurfacing began with CO2 lasers in the 1960s,
the Er: AG laser was approved for skin resurfacing by the FDA in
1996. Its 2,940-nm wavelength is absorbed 12 to 18 times more
efficiently than is the CO2 laser emission, enabling more superficial
absorption with less penetration. This allows even less collateral
damage. At typical Er: AG treatment parameters, dermal heating
is limited, with subsequent reduced effect on tissue tightening,
but postoperative healing times are shortened compared with CO2
lasers.
Patient Selection
Patients should be educated about the course and importance of
their postoperative care and potential complications. Indications
for laser skin resurfacing include improvement in sun-damaged
skin, facial rhytids, dyschromias, and scar revision. Patients with
darker skin types (Fitzpatrick III–VI) have a higher likelihood
of developing postinflammatory hyperpigmentation (PIH). PIH
is much less frequent with fractional laser skin resurfacing
than with other ablative procedures. These patients should be
informed about PIH, with treatment initiated when indicated.
Any factors that may affect the pilosebaceous glands, such as
previous facial irradiation or use of oral retinoids within the past
n urgi re men e e nd e
year, can increase the risk for poor healing after treatment. Other
contraindications include active skin infections, vitiligo, and a
history of keloids or hypertrophic scars. Antiviral medications
should be started 1 day prior to the procedure and continued for
a week.
Technique
At the Few Institute, for patients requiring skin rejuvenation, the
Halo hybrid fractional laser (Sciton, Palo Alto, CA) has become
a workhorse (Fig. 21.23). It is a single laser platform based
on evidence that a combined ablative/nonablative approach
produces results that we see with the use of the Palomar Icon
2940 (Cynosure, estford, MA) combined with a pre treatment
of 1,540 nm but with similar or decreased postprocedural issues
(i.e., pain, erythema, and petechiae).
The Halo laser is a dual-wavelength platform, incorporating
both 1,470 nm for coagulation and 2,940 nm for ablation. The
1,470 nm can be adjusted for a depth of 200 to 700 microns to
optimally target epidermal and dermal pigmented lesions, dermal
elastosis, fine lines, texture, and pore size, whereas the 2,940 nm
can be adjusted for a depth of 0 to 100 microns to remove stratum
corneum and epidermis. This allows for an optimal effect on both
the superficial and deep layers of the skin, providing ablative
results with nonablative downtime.
Postprocedural Care
Patients may require cooling after the procedure. Based upon
the depth of treatment, patients will experience varying degrees
233
 III Nonsurgical Cosmetic Treatments

a b c

d e f

g h i

j k l
Fig. 21.20 Woman aged 46 (a,b,c) before, (d,e,f) 6 months after, (g,h,i) 18 months after, and (j,k,l) 24 months after Silhouette InstaLift suture
placement.

234
 n urgi re men e e nd e

a b c

d e f

g h i
Fig. 21.21 Woman aged 54 (a,b,c) before, (d,e,f) 1 month after, and (g,h,i) 6 months after Silhouette InstaLift suture placement.

of edema, erythema, and dyschromia. Typically, a moisturizer is

applied that day. Patients may start to wash their faces gently
three times daily, starting the morning after with reapplication
of the moisturizer. After healing is complete, typically after 5 to 7
days, mineral makeup may be reinitiated if so desired.

e u
Laser resurfacing performs excellently in promoting facial skin
rejuvenation, particularly when it comes to reducing and/or
alleviating fine rhytides, dyschromia, and texture irregularities.
ith the advent of the hybrid fractional laser, significant results a b
may be seen in a few weeks as opposed to months with a tradi- Fig. 21.22 Woman aged 51 (a) before and (b) 1 month after Silhouette
tional ablative laser (Fig. 21.24; Fig. 21.25). InstaLift suture placement.

m i i n
Mild complications include prolonged erythema, acne, milia, and
contact dermatitis. Moderate complications include infection,
pigmentary alteration, and eruptive keratoacanthomas. Severe
complications include hypertrophic scarring and ectropion
formation. Prolonged erythema is defined as posttreatment
erythema that persists longer than 4 days with nonablative
resurfacing and beyond 1 month with ablative treatment. It
has been reported in 1 of nonablative and 12.5 of ablative

235
 III n urgi me i re men

Fig. 21.23 (a,b) Halo Hybrid Fractional Laser (Sciton, Palo Alto, CA). (Courtesy Sciton, Inc.)

a b c d e

f g h i j
Fig. 21.24 Woman aged 61 (a,b,c,d,e) before and (f,g,h,i,j) 6 months after a single pass with the Halo Hybrid Fractional Laser.

laser-treated patients, although erythema typically resolves in
these latter cases within 3 months. Fractional laser resurfacing
treatments that use multiple laser passes or inadvertent stacking
increase the risk of prolonged erythema.
The rate of herpes simplex virus (HSV) infection, the most
common type of infection after fractional laser skin resurfacing,
has been reported in 0.3 to 2 of cases. To minimize the risk of
HSV reactivation, antiviral prophylaxis should be administered
when a prior history of facial HSV is documented or if full-face
ablative laser procedures are performed. Oral antiviral agents
should be initiated 1 day before treatment and continued for 5 to 7
days. Bacterial infections are rarely observed after fractional skin
resurfacing. Given potential progression to scarring, broad-spec-
trum empiric antibiotics should be initiated and further adjusted
based on culture results.

236

Fig. 21.25 (a) Before and (b) 1 month after single pass with Halo Hybrid Fractional Laser. (Courtesy Sciton, Inc.)
PIH is much less frequent with fractional laser skin resurfacing
than with other ablative procedures, but it is observed in 1 to 32
of patients, depending on the system used, parameters applied,
and skin phototypes treated. Patients with darker skin phototypes
(Fitzpatrick III–VI) have a higher likelihood of developing PIH,
although hyperpigmentation often resolves without treatment
and is typically never permanent. Application of topical steroids
and bleaching and peeling agents can hasten its resolution.
Hypopigmentation is extremely rare with a delayed onset (6 to 12
months postoperatively).
Hypertrophic scarring is a rare complication of ablative skin
resurfacing and is usually due to use of excessively high energy
densities, postoperative skin infection, and improper technique.
The neck is especially susceptible to the development of scarring
because of the small number of pilosebaceous units, and thin
skin renders it more susceptible to thermal injury. Patients with
a history of radiation, surgical procedures involving the neck or
eyelids, postoperative wound infection, contact dermatitis, or
keloid scarring have the highest risk of scarring. Early treatment of
hypertrophic scarring involves the use of topical corticosteroids,
silicone gel, and intralesional corticosteroid injections.
21.5 Stackable Therapies
Facial aging is a multifaceted process, and no one modality can
address all components. It has been our experience that nonsur-
gical techniques are a viable alternative to surgery; however,
n urgi re men e e nd e
they frequently need to be used in combination to achieve the
greatest results, depending on the severity of the patient’s case.
In our patient population, we are strong proponents of comb-
ing multiple modalities to achieve surgical results. Our typical
sequence starts with lifting of ptotic tissue before adding volume,
which allows for more effective, anatomic placement of filler and
avoids premature breakdown of filler or toxin by heat. Secondly,
we fill the volume deficit before skin resurfacing, which allows
more effective resurfacing with lasers. Last, we lift ptotic tissue
before or during resurfacing of the skin. It is routine in the senior
author’s practice to combine Silhouette InstaLift with Ultherapy
with neuromodulators and dermal fillers in the same setting. As
discussed earlier, lasers, particularly the Halo Hybrid Fractional
Laser, have become an integral addition for global improvement
in skin rejuvenation.
Many of the therapies discussed may be blended with surgery
as an adjunct to improve outcomes and have longer-lasting results
(Fig. 21.26, Fig. 21.27, Fig. 21.28).
21.6 Concluding Thoughts
The treatment paradigm for facial rejuvenation has shifted
significantly due to the development of several noninvasive
or minimally invasive cosmetic medicine applications. hile
surgical procedures are still the gold standard, at this time
more than ever there are nonsurgical modalities, from hybrid
fractional lasers to injectable lipolytic therapy, that combat the
237
 III Nonsurgical Cosmetic Treatments

a b c a b c

d e f
d e f
Fig. 21.27 Woman aged 56 (a,b,c) before and (d,e,f) 3 months after
Fig. 21.26 Woman aged 48 (a,b,c) before and (d,e,f) 3 months after Ultherapy, Silhouette InstaLift suture placement, and Halo Hybrid
Silhouette InstaLift suture and dermal filler placement. Fractional Laser to the periorbital area.

a b
Fig. 21.28 Woman aged 56 (a) before and (b) 5 years after multiple stackable therapies, including neuromodulators, dermal fillers, ablative laser,
Silhouette InstaLift suture placement, and Ultherapy.

238

telltale signs of aging. hat we have learned from our experi-
ence with stackable therapies is that these modalities may be
safely and effectively combined in certain algorithms to produce
near-surgical results without nearly the risk of complication
or extensive recovery times. It is our feeling that nonsurgical
modalities are the present, and will only continue to grow and
be the future, of facial rejuvenation.
Clinical Caveats
• Deoxycholic acid:
Indicated for moderate to severe submental fat; however,
caution use in patients with excessive skin laxity or promi-
nent platysmal bands.
May inject a total of 6 mL at a time using a 30-gauge
needle, 0.2 mL per injection, spaced 1 cm apart.
Do not inject above the mandibular border, or within the
region 1.5 cm below the border, to protect the marginal
mandibular nerve.
• Cryolipolysis:
For submental fat, 1 to 3 cycles may be required depend-
ing on degree of fat excess, particularly if lateral excess is
present.
Modality should not be performed in those with cold
agglutinin disease, cryoglobulinemia, or paroxysmal cold
hemoglobinuria.
A 3-minute tissue massage post-procedure is instrumental
in improving fat reduction.
• Microfocused ultrasound:
Not ideal for older patients with extensive photoaging,
severe skin laxity, marked platysmal banding, or very
heavy necks.
Treatment may cause discomfort, and do recommend
pain management with a combination of oral medications
with low-threshold-to-use subcutaneous injections of
local anesthesia.
Visible changes may take 3 to 6 months to be evident.
• Radiofrequency:
Multiple devices available that follow the “outside-in” or
“inside-out” technique.
Safe to use in all skin types. as energy is directed at the
dermis.
Edema and redness may be present from 1 day up to 1
week depending on the modality and settings used.
• Thread lifting:
No specific patient contraindications; however, caution
use in those with very thin skin or with severe signs of
aging.
Patients may return to normal activity after procedure;
however, recommend avoidance of gregarious facial
expressions for up to 1 week so as to avoid unhinging
sutures.
Results may last 18 to 36 months depending on technique
and number of sutures placed.
• Laser resurfacing:
Single-platform laser combining both ablative and nonab-
lative modalities.
n urgi re men e e nd e
Excellent for promoting facial skin rejuvenation, partic-
ularly when it comes to reducing and/or alleviating fine
rhytides, dyschromia, and texture irregularities.
Continued caution in dark skin phototypes given the
higher risk of PIH.
• Stackable therapies:
Multiple modalities may be used in a single setting to
address aging components.
Typical sequence involves lifting ptotic tissue first, fol-
lowed by volume replenishment and last, facial resurfacing
to finish.
While each modality may be used in combination, they
may also be used as an adjunct to surgery to improve
outcomes with longer lasting results.
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 Part IV
Hair Transplantation

IV

22 Applied Anatomy in Hair Transplantation
Alfonso Barrera
Abstract
e review the importance of hair as well as its embryology and
histology, the phases of its growth cycle, and important details
about the importance of preserving complete anatomic intact-
ness and handling of follicular unit grafts to have optimal growth
at the time of hair transplantation.
Keywords
hair follicular units, anagen, catagen, telogen
22.1 Introduction
Historically, hair has been a source of pride to humans and serves
as a distinguishing feature that adorns as well as protects. It is
also one of our most variable characteristics. ide differences
in color, density, texture, length, and style characterize differ-
ent races and ethnic groups. Hairstyling and adornment have
evolved throughout the ages. Today men as well as women
place a premium on hair fashion and products to enhance their
appearance. Considering its significance, it is easy to understand
why hair loss often causes severe emotional distress and why
people seek hair restoration.
For a surgeon performing hair transplantation, it is important
to have a basic understanding of anatomy and aesthetics to obtain
optimal results. The character and texture of hair vary depending
on its stage of development and location. Lanugo hair is the soft,
fine, and usually clear, nonpigmented hair that covers the fetus
and generally sheds around the eighth gestational month. Vellus
hair is the fine, clear, almost invisible hair seen on the forehead.
Terminal hair, which is coarse, long, and of variable pigment,
characterizes the adult years. Subtypes of terminal hair are found
on the scalp, eyebrows, upper lip, chin, axillae, chest, and pubis.
Vellus hair may become terminal hair and vice versa; for example,
facial vellus hair in adolescents may develop into a beard, and ter-
minal hair on the scalp may turn into vellus hair in male pattern
baldness and androgenic alopecia in women.
In an embryo, the hair follicles originate from both ectoderm and
mesoderm in the third gestational month and continue to develop
over the next 3 months. Hair follicles develop from microscopic
indentations of ectoderm, the outermost of the three embryonic
tissue layers. These indentations meet and combine with small
elevations of mesoderm, the middle layer of embryonic tissue. The
cells that form the hair dermal papillae, the fibrous sheath of the
follicle, the blood vessels, and the arrector pili muscles originate
from the mesoderm.
The cells that form the hair matrix and the melanocytes are
of ectodermal origin. The melanocytes produce the pigment
granules in the central, hollow core of the hair shaft that give hair
its natural color. The cells from the matrix divide and are pushed
upward; they are continuously replaced by new cells forming
A ied An my in ir r n n i n
beneath them. Later, two buds are formed from special cells to
create the sebaceous glands and the arrector pili muscles.
As the matrix cells continue to be pushed up and outward and
become dehydrated by an extrusion process, they form a tubular
hair shaft of dead protein called keratin. This hollow tube is then
filled with pigment granules (melanin) that give hair its natural
color. As we age, the melanocytes cease functioning, resulting in
gray or white hair (Fig. 22.1).
22.2 Histology
To accomplish natural, aesthetic results in hair transplantation,
one must pay attention to many seemingly small details, starting
with the important histologic features of hair follicles (Fig. 22.2).
Transverse sections demonstrate that hair follicles grow in fol-
licular units. In his landmark 1984 article Transverse Microscopic
Anatomy of the Human Scalp, Headington described the follicular
unit as including one to four terminal hairs, one vellus hair (rarely
two), nine sebaceous glands, insertions of arrector pili muscles, a
perifollicular vascular plexus, a perifollicular neural network, and
perifolliculum (a circumferential band of fine adventitial collagen
that defines the unit). This suggests that a unit constitutes, at least
to some degree, a physiologic entity (Fig. 22.3).
22.3 Design of the Hairline
The design of the hairline or the area to be transplanted is crucial,
the idea being to mimic nature as much as possible. The position
of the front hairline is critical for a natural result; conservatism
is in order. The goal is to achieve a mature hairline. The size and
shape of the head vary from person to person, as does the posi-
tion of a mature hairline. Generally, the midline of the new hair-
line is approximately 8 cm from a horizontal line immediately
above the eyebrows. In some patients a slightly longer or shorter
distance is appropriate, depending on the specific facial features,
shape, and size of the head as well as the interrelationship and
proportions of the face and skull (Fig. 22.4).
22.4 Growth Cycle
There are three life cycle phases of hair growth (Fig. 22.5). The
living cells at the base of the hair follicle first show active, mitotic
growth, eventually forming a compact column that extends toward
the surface of the skin. A zone of keratinization then forms directly
above the actively dividing cells. The living cells become dehydrated,
eventually die, and are ultimately converted into a mass of keratin.
The keratin filaments are finally cemented together by a matrix rich
in cystine. The average rate of growth of scalp hair is approximately
0.35 mm/day or 1 cm/month. The dermal papilla, which is situated
just under the actively dividing cells of the follicle, plays an import-
ant role in the regulatory control of the hair’s growth cycle.
243
 IV Hair Transplantation

Fig. 22.1 Illustration of a hair follicle anatomy, showing the hair shaft, hair bulb, erector pili muscle, sebaceous gland, sweat glands, and a section of
the root sheath.

Fig. 22.2 Epidermis, dermis, dermal appendages, subcutaneous fatty
tissue, and hair follicles in vertical histologic sections of skin.
The first phase, anagen, is the active growing phase in which the
follicular cells are actively multiplying and keratinizing. In a non-
balding scalp, approximately 90 of the hairs are in this phase, which
lasts about 3 years. During the second phase, catagen, the base of the
hair becomes keratinized, forming a club, and separates itself from
the dermal papilla. It then moves toward the surface and is even-
tually connected to the dermal papilla only by a connective tissue
strand. This phase lasts 2 to 3 weeks. The third phase, telogen, is also
known as the resting phase. During this phase the attachment at
the base of the follicle becomes weaker until the hair finally sheds.
During this period the follicle is inactive and hair growth ceases. This
phase lasts 3 to 4 months and commonly occurs after hair trans-
plantation. For this reason, significant growth of the hair grafts is
not seen until this phase is over. In addition, some of the native hair
often goes into the catagen phase and then into the telogen phase
from the insult of the surgery; this is called .
Approximately 10 of hair follicles in a nonbalding scalp are in
the telogen phase. hen the rate of hair loss exceeds the rate of
growth, thinning and eventually baldness develop.

244
 A ied An my in ir r n n i n

a b

c d
Fig. 22.3 Histology of hair follicles as seen on horizontal sections. (a) Multiple follicular units of various sizes. (b) Close-up view. (c) Two-hair follicular
unit. (d) One-hair follicular unit.

the most common type, male pattern baldness primarily affects

Fig 22.4 Design of a mature hairline.
22.5 Applied Anatomy
Male pattern baldness is a gradual conversion of hairs from the
terminal (healthy, thick) to the vellus (clear, microscopic) state. In
the top of the head while the hair on the temporal and occipital
areas is preserved. Hair loss in women, female androgenic alope-
cia, occurs less frequently and is more diffuse. In women, the front
hairline is usually preserved. Both of these are naturally occurring
and have primarily a genetic origin. This is a hereditary condition
that appears to be controlled by a single dominant, sex-linked
autosomal gene. The expression of this gene is dependent on the
level of circulating androgens. Testosterone, secreted by the testes,
is the principal androgen circulating in plasma in men, whereas
in women the adrenal steroids dehydroepiandrosterone sulfate,
androstenediol sulfate, and 4-androstenedione are the most
abundant proandrogens 19-carbon steroids that are converted at
the target tissue into active androgen. The enzymatic reduction
of testosterone and the aforementioned androgens in females by
5-alpha-reductase into dihydrotestosterone is necessary for the
induction of androgenic hair loss both in men and women.
The initial signs of thinning clearly correlate with puberty in
males, when the levels of androgens (testosterone) start to rise,
gradually converting terminal hair into vellus hair. Initially, this
results in a receding hairline. Depending on the genetic features

245
 IV Hair Transplantation

Fig. 22.5 Hair growth cycle.

inherited, hairline recession may progress until only a temporal
and occipital fringe remains.
Although genetic predisposition is the cause for most forms of
hair loss, other sources of hair loss include the following (in order
of frequency in my practice):
• Hair loss associated with aesthetic facial rejuvenation surgery,
coronal, and endoscopic forehead lifts, such as loss of sideburns,
temporal hairline, and distortion of the retroauricular hairline
• Scalp and facial hair loss associated with burns or other trau-
matic injuries
• Congenital abnormalities of the face or scalp, such as vascular
malformations and melanotic nevi, that require surgical
excision
• Postoncologic resections resulting from the excision of tumors
of the skin or scalp
unit micrografts to the bare hair shaft may decrease the percent-
age of graft take. hether it is the perifollicular vascular plexus,
the sebaceous glands, or other appendages that are necessary
for survival is unknown. Seager reported 113 hair survival and
growth with follicular unit grafts. Presumably, this result means
that hairs that were in the telogen phase were not initially counted
but ultimately grew hair. These hairs in the telogen phase are also
included when slightly chubby micrografts and minigrafts are
transplanted. This most not be misconstrued as requiring grafts
be too chubby, either. Additionally, when transplanting eyebrows
or eyelashes, we need very skinny grafts; we most gently trim
single-hair follicular units close to the hair shaft, as these areas
require ultrafine grafts (Fig. 22.6; Fig. 22.7).

Surgeons must be equipped to restore sideburns, the temporal

hairline, the retroauricular hairline, eyebrows, eyelashes, mus-
tache, beard, and areas of the scalp. Many remedies have been
described over centuries to enhance and/or regrow hair none of
which has been truly effective. However, as we have learned more
about the anatomy and physiology of the hair, it has become clear
that optimal graft survival and ultimate hair growth depend on
transplanting more than just the bare hair shafts.
Slightly chubby grafts and intact follicular unit grafts thrive Fig. 22.6 Illustration of ideal hair grafts (one- or two-hair follicular and
maximum three- to four-hair units).
better, as demonstrated by Seager in 1997. Dissecting follicular

246

Fig. 22.7 Photo of Ideal hair grafts (one-, two-, and three hair follicular
unit grafts).
22.6 Anatomic Concepts to Keep in
Mind
hen harvesting the donor ellipse, which generally is taken hor-
izontally from the occipital and sometimes extending to the tem-
poral areas, the surgeon must keep the incision superficial to the
fascia to preserve the occipital nerves and vessels. Dissection should
separate the plane between the subcutaneous tissue and fascia.
The elasticity of the scalp in the donor area is usually greatest in
the midline, and the scalp becomes less elastic laterally toward the
ears (especially above the mastoid area) and then often increases
toward the temporal areas.
The density of hair is usually greatest at the midline and dimin-
ishes as one proceeds laterally.
Minigrafts and micrografts should be inserted in the recipient
site following the same angulation and orientation of the residual
hair to mimic the natural direction of hair growth.
The epidermis of the graft should remain superficial to the epider-
mis of the scalp to avoid ingrown hairs and epidermal inclusion cysts.
Minimal incisions at the recipient site will avoid detectable
scarring.
Grafts larger than one follicular unit will produce an unnatural
appearance due to compression.
A ied An my in ir r n n i n
22.7 Concluding Thoughts
In recent years some physicians have been developing a pref-
erence for doing what is called follicular unit extraction (FUE),
which means extracting follicular units with a 0.8- to 1.0-mm
diameter punch directly from the donor area. Their reasons
include avoiding a horizontal scar on the donor area, quicker
recovery, and less postoperative pain and discomfort.
I am very familiar with the FUE technique. The main disad-
vantages to this, in my opinion, are that it is more predictable to
harvest intact follicular units by conventional strip harvesting and
then, under magnification, visualizing and dissecting the follicular
units, allowing for better quality of grafts as well as their growth.
Most physicians agree that the growth is stronger and more
predictable using strip harvesting. The scar is often minimally
detectable. However, in selected cases, I can see the benefit of FUE,
as in patients who wear very short hair (shaved or almost shaved),
such as men in the military; this way completely avoids the risk of
having a linear scar on the donor area.
Clinical Caveats
• It is imperative to do a very accurate dissection of the hair
follicles.
• Keep the grafts wet on chilled saline solution.
Suggested Reading
1 Harris . Conventional FUE. In: Unger , Shapiro R, Unger R, Unger M, eds. Hair
Transplantation, 5th ed. London, U : Informa Healthcare; 2011:291–295
2 Headington T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456 PubMed
3 Orentreich D, Orentreich . Androgenic alopecia and its treatment. In: Unger P.
Hair Transplantation, 3rd ed. ew ork, : Marcel Dekker; 1995:4
4 Rassman R, Bernstein RM, McClellan R, ones R, orton E, Uyttendaele H.
Follicular unit extraction: minimally invasive surgery for hair transplantation.
Dermatol Surg 2002;28(8):720–728 PubMed
5 Rose PT. The development, anatomy, and physiology of the hair follicle. Hair
Transplant Forum Int 1999;9:197
6 Seager D . Micrograft size and subsequent survival. Dermatol Surg
1997;23(9):757–761, discussion 762 PubMed
7 Vallis CP. Hair replacement surgery. In: McCarthy G. Plastic Surgery. Philadel-
phia, PA: B Saunders; 1989:1519
247
 IV Hair Transplantation

23 Clinical Decision Making in Hair Transplantation

Alfonso Barrera

Abstract
For hair transplantation, as with any surgical procedure, we must
evaluate each patient individually. There are various factors we
must consider, particularly the degree of hair loss as it relates to
the amount of donor hair available. To date we are not able to clone
hair follicles, so we can only work with the patient’s own existing
donor hair. All we do is redistribute the patients’ own existing,
durable hair roots from the donor area to the recipient area.
e review the most frequent classification for male pattern
baldness and female pattern alopecia. e show various exam-
ples of the most frequent cases we treat: correction of alopecias
secondary to previous surgery, cases of scarring alopecia, and
alopecia secondary to burn accidents (including scalp, mustache,
beard, eyebrows, and eyelashes).
Fig. 23.1 Typical case of male pattern baldness.
Keywords
male pattern baldness, female pattern alopecia, scarring alope-
cia, mega session

23.1 Introduction
To date, we have no method for creating new hair where none
exists. All current techniques for hair restoration involve redis-
tributing the patient’s existing hair. Therefore, candidates for
hair transplantation are limited to those who have a favorable
donor site surface area and hair density relative to the size of the
area to be transplanted. Several centers worldwide are working
on tissue engineering in an attempt to clone hair follicles or cul-
ture and multiply hair follicles in the laboratory setting. hen
this is successful, we will be able to treat patients with limited
donor hair and will need only harvest a sample of hair follicles. Fig. 23.2 Typical case of female androgenic alopecia.
Unfortunately, male pattern baldness is a progressive condition.
However, the rate of hair loss may slow down after an individual
is about 40 years of age, although it never stops completely. Thus, Table 23.1 Norwood classification for male pattern baldness
the preoperative plan must ensure a natural-looking long-term Type I There is minimal or no anterior hairline recession at the
result. frontotemporal areas.
Type II Triangular, symmetrical frontotemporal recessions extend
posteriorly no more than 2 cm anterior to a coronal plane
23.2 Hair Loss Patterns drawn between the external auditory canals.
Type III The frontotemporal recessions extend posteriorly beyond
The most frequent types of hair loss include male pattern 2 cm anterior to a coronal line drawn between the external
baldness, postsurgical alopecia, posttraumatic alopecia, and auditory canals.
congenital hair loss. Type IIIvertex Hair loss is primarily in the vertex area but may be
Male pattern baldness is by far the most frequent type of hair accompanied by a frontotemporal recession that does not
exceed that described for type III.
loss, followed by androgenic (pattern) alopecia in women (Fig.
23.1; Fig. 23.2). Type IV Telangiectatic matting
Type V < 0.2 mm diameter network, bright red

23.2.1 Male Pattern Baldness Type VI Venulectasis (usually protrudes above skin surface; distinguished
from telangiectasia by deeper color and larger diameter)
The most commonly used classification system for male pattern Type VII 1–2 mm diameter
baldness is the one described by orwood (Table 23.1; Fig. 23.3).

248

Fig. 23.3 Example of scarring alopecia of the sideburn and temporal
hairline after a facelift procedure.
orwood also described a less common variant (type a) that
applies to about 3 of cases of male pattern baldness; in this variant
the baldness starts at the anterior hairline without a peninsula of
hair and advances in a posterior direction (Fig. 23.4). The type a
anterior variance patterns are classified as described in Table 23.2.
Fig. 23.4 Norwood classification, the most common classification used
for male pattern baldness. (Reproduced with permission from Norwood
OT, Shiell R. Hair transplant surgery. Charles C. Thomas; 1984.)
Table 23.2 Norwood type a anterior variance patterns
Type IIa The entire anterior hairline is high on the forehead. The
midfrontal peninsula is represented only by a few sparse
hairs. The area of denudation extends no farther than 2 cm
from the midfrontal line.
Type IIIa The area of denudation essentially reaches the midcoronal line.
Type IVa The area of alopecia extends posterior to the midcoronal line.
Type Va This is the most advanced degree of alopecia and
extends farther posteriorly. If it progresses, it may be
indistinguishable from types V and VI.
ini e i i n ing in ir r n n i n
23.2.2 Female Androgenic Alopecia
The most common classification system used for female andro-
genic alopecia is the Ludwig classification (Fig. 23.5). It is based
on three grades: I: mild, II: intermediate, and III: severe.
Thinning is usually more generalized than in male pattern
baldness, in most cases sparing the front hairline, with significant
thinning of the vertex, temple, and parietal areas. The occiput
tends to be the only area of reasonably good hair quality and den-
sity. omen who develop androgenic alopecia do not necessarily
have an abnormal increase in circulating androgens or hormonal
imbalances; many, in fact, have normal adult female androgen
levels. It may be that the androgen receptors in the hair follicles
are hypersensitive to or have a greater binding affinity to dihydro-
testosterone, which may or may not be genetic in origin.
23.2.3 Other Causes of Hair Loss
After facial rejuvenation or craniofacial procedures, loss of side-
burns and of frontal, temporal, and/or retroauricular hair is not
uncommon. Posttraumatic alopecia includes hair loss from inju-
ries such as burns, traumatic injuries of the scalp and eyebrows,
and scalp avulsion (Fig. 23.6).
Examples of congenital hair loss include the absence of mustache
hair in cases of bilateral cleft lip (not obvious until after puberty),
triangular temporal alopecia, and nevus sebaceous of adassohn.
Fig. 23.5 Norwood classification anterior variance. A small percentage
of the cases of male pattern baldness affect primarily the front part of
the scalp, not affecting the crown. (Reproduced with permission from
Norwood OT, Shiell R. Hair transplant surgery. Charles C. Thomas; 1984.)
Fig. 23.6 The Ludwig classification, the most common classification system
used for female androgenic alopecia. (Reproduced with permission from
Ludwig E. Classification of the types of androgenetic alopecia (common
baldness) occurring in the female sex. Br J Dermatol. 1977; 97:247-254.)
249
 IV Hair Transplantation
Preoperative Assessment
Careful patient selection and good communication are essential.
Patients must have realistic expectations about the result that can
be achieved. They must understand that the procedure involves
redistributing their existing hair. To obtain the best result possible
often takes two sessions and in some cases three. In some cases, a
reasonable improvement can be obtained in just one megasession.
I have found that patients under 30 years of age are the most
demanding. They must understand that because they are young,
it is impossible to determine in advance the end point of their hair
loss. A conservative approach is recommended in these cases.
hen patients receive proper instruction and have realistic
expectations, I have found that 97 are satisfied after a single
hair transplantation session. Moreover, the 3 of patients who
had been dissatisfied with their hair density after surgery subse-
quently underwent second sessions to improve the density and
were ultimately pleased with the results.
Indications and Contraindications
Based on the principles we have learned for the treatment of male
pattern baldness, and with slight modifications, we are able to help
most cases of hair loss by transferring primarily micrografts (one-
and two-hair follicular unit grafts) and minigrafts (three- and four-
hair follicular unit grafts). In select cases, flaps or tissue expansion
may be used. The following patient examples represent the range
of clinical challenges encountered in a hair restoration practice.
The 32-year-old man shown in Fig. 23.7 had orwood type IV
male pattern baldness but good donor hair, which was coarse. He
underwent 1,500 follicular unit grafts in a single session, primar-
ily to the frontal scalp and a few to the crown. Further grafting to
Fig. 23.7 This 32-year-old man with male pattern baldness type IV had
good donor hair; his hair was coarse, which could help to obtain nice
coverage in one session (left). He underwent 1,500 follicular unit grafts in a
single session, primarily to the frontal scalp and a few to the crown (right).
250
the crown should be deferred until the patient is older, when his
hair loss pattern can be more accurately assessed and the amount
of donor hair available determined. The patient must understand
that because of his young age, further sessions will be needed in
the future as hair loss progresses.
The 53-year-old man shown in Fig. 23.8 was an ideal candidate,
because his pattern ( orwood type VI) was well established and was
not expected to change dramatically. In such cases a maximal density
procedure (2,000–2,500 follicular unit micrografts and minigrafts)
can be planned. His donor hair had good density and thickness, and
the entire area of baldness was grafted. A hairline pattern consistent
with the patient’s mature age is the preferred approach to produce the
most natural result. Thus, a slight frontotemporal recession was left.
The 56-year-old man in Fig. 23.9 had a more mature pattern of
baldness than the previous patient. Although his hair loss would
continue to progress, his future hair loss pattern could be better
determined, making a more aggressive approach acceptable. He
had a reasonably good, dense donor area and a well-established
pattern of baldness. He underwent 2,040 follicular unit grafts in
one session (megasession).
The 43-year-old man in Fig. 23.10 had male pattern baldness
type IIIvertex without frontotemporal recession. The density and
thickness of his donor hair were excellent. The front part of his
scalp was covered with healthy, full hair. His pattern of baldness
was well established and limited to the crown. I recommended
two sessions of micrografts and minigrafts a year apart to achieve
an optimal result. The crown typically takes at least two sessions
to obtain reasonable coverage. Although the whirl can be recon-
structed by placing the grafts in a circular orientation, it probably
does not warrant the additional time and effort.
The 42-year-old man in Fig. 23.11 presented with male
pattern baldness type VII, the most severe form of male pattern
baldness. There was insufficient donor hair to transplant the
entire area. Flaps, tissue expansion, and scalp reduction were
treatment options because of the sparse donor hair and exten-
sive area of baldness. I advised a session of 1,300 follicular unit
micrografts and minigrafts but only to the median forelock area,
Fig. 23.8 This 53-year-old man with male pattern baldness type VI was
an ideal candidate, because his pattern of hair loss was well established
and probably would not change dramatically (top). He received a
maximal density procedure (2,000–2,500 follicular unit micrografts
and minigrafts) over the entire area of baldness (bottom), leaving a
slight frontotemporal recession consistent with his mature age.
 ini e i i n ing in ir r n n i n

the rhomboid-shaped area on the front part of the scalp, where

strategic transplantation would help frame his face even though
his crown would remain bare. One year postoperatively, the hair
on the top of his head blended naturally with the temporal fringes.
The 37-year-old man in Fig. 23.12 had male pattern baldness
type IV. His coarse, wavy donor hair would provide good coverage.
Because his hair loss was not very severe, approximately 700 to
800 follicular unit micrografts and minigrafts would be sufficient
to strengthen both the front scalp and crown. He must expect
further temporary thinning.
The 43-year-old woman in Fig. 23.13 had Ludwig grade II to III
female androgenic alopecia. Such patients tend to exhibit uniform
thinning over the entire scalp with preservation of the front hairline.

Fig. 23.10 This 43-year-old man had well-established male pattern

baldness type IIIvertex without frontotemporal recession, excellent
density and thickness of donor hair, and healthy, full hair on the front
part of his scalp. The author recommended two sessions of micrografts
and minigrafts a year apart to achieve an optimal result.

Fig. 23.9 This 56-year-old man with male pattern baldness type VI had
a more mature pattern of baldness than the patient in Fig. 23.8 did.
His expected hair loss pattern could be better determined, making a
more aggressive approach acceptable. He underwent 2,040 follicular
unit grafts in one session (megasession).
Fig. 23.11 This 42-year-old man presented with male pattern baldness
type VII, the most severe form of male pattern baldness, and insufficient
donor hair to transplant the entire area (left). A session of 1,300 follicular
unit micrografts and minigrafts to only the median forelock area (top
center) would help frame his face. One year postoperatively (right), the
hair on the top of his head blended naturally with the temporal fringes.

251
 IV Hair Transplantation

Fig. 23.12 This 37-year-old man has male pattern baldness type IV. will
provide good coverage. Because his hair loss is not very severe, approxi-
mately 700 to 800 follicular unit micrografts and minigrafts of his coarse,
wavy donor hair should be sufficient to strengthen both the front scalp and
crown. The hair must be continuously parted as the grafts are inserted;
however, it is not necessary to shave the residual hair in the recipient areas.
He must be forewarned that there will be further temporary thinning.
Candidates for the procedure must have an area with good hair
quality and density, which tends to be in the occipital region. I
recommended that this patient undergo a megasession of 1,000 fol-
licular unit micrografts and minigrafts. The patient was forewarned
that she could expect further temporary hair thinning for the first
3 to 4 months in the area grafted (telogen e uvium). I recommend
that female patients use 2 minoxidil twice a day postoperatively to
help preserve and thicken the existing hair as well as the grafted hair.
The 50-year-old woman in Fig. 23.14 was concerned about her
hair thinning on the front of her scalp. Because she had good density
on her remaining scalp, I recommended a session of 400 micrografts
and minigrafts. This treatment added hair precisely where needed
and was easily performed with the patient under local anesthesia
with mild intravenous sedation. I would not advise scalp flaps, strip
grafts, or tissue expansion in such a case. These treatments would
have been excessive, causing a scar at the front hairline, and she
would have had to endure an unpleasant expansion phase. Her post-
operative results are very natural, without any detectable scarring.
Fig. 23.13 This 43-year-old woman had Ludwig grade II to III female
androgenic alopecia, exhibiting uniform thinning over the entire scalp
with preservation of the front hairline as well as good hair quality and
density in the occipital region, supporting a megasession of 1,000
follicular unit micrografts and minigrafts. The patient was forewarned
to expect further temporary hair thinning for the first 3 to 4 months in
the area grafted (telogen e uvium) and advised to use 2% minoxidil
twice a day postoperatively to help preserve and thicken the existing
hair as well as the grafted hair.
hair shafts, texture and color, and curliness. Furthermore, the
contrast of colors between the scalp and the hair has a significant
influence on the optical illusion of fullness. Most experts today
agree that the average healthy, nonbalding patient has one fol-
licular unit/mm2, and each unit contains an average of two hairs
(that is, a density of 2 hairs/mm2), giving a density of about 200
hairs/cm2 (range 130 to 280 hairs/cm2). Since an average scalp
has an area of approximately 500 cm2 (50,000 mm2), there are
approximately 100,000 hairs on the average head (Fig. 23.15).
However, most experts also agree that only 100 hairs/cm2 (range

23.3 Preoperative Planning

23.3.1 Aesthetic Considerations
The appearance of fullness has to do with hair mass, which is
related to the number of hairs, the thickness of the individual

a b
Fig. 23.14 (a) This 50-year-old woman was concerned about her hair
thin-ning on the front of her scalp. She had good density on her remaining
scalp. (b) A session of 400 micrografts and minigrafts, under local anesthe-
sia with mild intravenous sedation, added hair precisely where needed. Her
postoperative results are very natural, without any detectable scarring.
Fig. 23.15 An average scalp has an area of approximately 500 cm2
(50,000 mm2). The normal nonbalding scalp has one follicular unit/
mm2, and each unit contains an average of two hairs (that is, a density
of 2 hairs/mm2), for approximately 100,000 hairs on the average head,
varying from patient to patient.

252
 ini e i i n ing in ir r n n i n

65–140 hairs/cm2) are needed to give an appearance of normal

density.
Realistically, this number of micrografts and minigrafts can
be transplanted in two sessions. To obtain a surgical result that
mimics nature, a large number of randomly transplanted small
grafts (follicular unit–sized grafts) is essential, providing a result
unmatched by any other method of hair restoration. Patients
should be advised that two, and occasionally three, sessions may
be necessary to obtain the desired density. Often, however, signif-
icant improvement is seen after just one session, and results will
persist for years without a repeat procedure.
If the ratio of donor site area to recipient site area is favorable,
I transplant the entire area of baldness. If the ratio of donor site
area to recipient area is not favorable, I may transplant only the Fig. 23.16 A long, narrow, horizontal donor ellipse is preferable to a
front hairline or a median forelock. If it is clear that there is insuf- short, wide ellipse. Hair density and the elasticity of the donor occipital
ficient donor hair, it is better not to proceed with transplantation. site are usually greater near the midline, while the hair becomes
sparser and the scalp less elastic more laterally, particularly over the
It is a judgment call. mastoid area. The scalp above the ears is usually quite inelastic. These
When feasible, I prefer to transplant the entire bald area, with factors must be taken into consideration so that the ellipse can be
a focus on providing the greatest density possible at the front closed with minimal tension.
hairline. Patients can style their hair so that it layers farther back
to give the visual appearance of density in the back.

23.3.2 Donor Site Harvesting

The many variables encountered during donor site harvesting
test the surgeon’s clinical judgment. The size of the donor ellipse
will vary, depending on the number of grafts planned or the size
of the area to be grafted, as well as the hair density of the donor
site and the pliability and elasticity of the donor scalp. Only the
amount of scalp needed should be harvested, yet the surgeon
must ensure that enough donor scalp is obtained for the number
of grafts planned and that the donor defect can be closed under
minimal tension.
The laxity of the scalp varies from person to person. The sur-
geon must be alert to the presence of scar tissue from previous
procedures, since this will result in reduced elasticity and pliabil-
ity of the donor scalp. Most patients’ scalps permit ellipses 1 to 1.5
cm wide (occasionally up to 2 cm) to be harvested with minimal
tension on closure. The surgeon must feel the donor scalp to assess
its laxity, elasticity, and pliability.
A long, narrow, horizontal donor ellipse is preferable to a short,
wide ellipse. Hair density and the elasticity of the donor occipi-
tal site are usually greater near the midline. The hair becomes
sparser and the scalp less elastic more laterally, particularly
over the mastoid area. The scalp above the ears is usually quite
inelastic. These factors must be taken into consideration so that
Fig. 23.17 Assuming a density of 150 hairs/cm2, an ellipse 10 by 1 cm
the ellipse can be designed to allow closure with minimal tension will yield approximately 1,500 hairs. With one to four hairs per follicular
(Fig. 23.16). unit, an ellipse of this size will yield approximately 500 to 600 grafts.
ormally, as previously stated, the hair density in the donor
area is approximately 200 hairs/cm2 (range 130 to 280 hairs/cm2).
The diameter of the individual hair shafts varies from 0.06 to If hair density is approximately 150 hairs/cm2, a horizontal,
0.14 mm. occipital donor ellipse of 20 by 1 cm with 3,375 hairs will be
Assuming a density of 150 hairs/cm2, an ellipse 10 by 1 cm will needed to produce 1,000 to 1,200 micrografts and minigrafts with
yield approximately 1,500 hairs. aturally occurring follicular one to four hairs per unit (Fig. 23.18).
units have one to four hairs per unit. These units must be kept A maximal density procedure (2,000 to 2,500 grafts) in patients
intact as much as possible. The exact number of grafts can be with type VI or VII male pattern baldness makes harvesting
determined only after dissecting the donor ellipse into grafts, but enough donor tissue a greater challenge. In these cases, we har-
an ellipse of this size will yield approximately 500 to 600 grafts vest a horizontal ellipse approximately 30 to 32 cm long and 1 to
(Fig. 23.17). 1.5 cm wide at the midline (scalp elasticity permitting), gradually

253
 IV Hair Transplantation

Fig. 23.19 A maximal density procedure (2,000 to 2,500 grafts)

Fig. 23.18 If hair density is approximately 150 hairs/cm2, a horizontal,
occipital donor ellipse of 20 by 1 cm, with 3,375 hairs, will be needed
to produce 1,000 to 1,200 micrografts and minigrafts (one to four
hairs per unit).
requires harvest of a horizontal ellipse approximately 30 to 32 cm
long and 1 to 1.5 cm wide at the midline (scalp elasticity permitting),
gradually tapering the width laterally to 1 to 0.5 cm at the ends. In most
patients this yields approximately 2,000 to 2,500 follicular unit micro-
grafts and minigrafts and allows closure with minimal if any tension.

tapering the width laterally to 1 to 0.5 cm at the ends. In most and closure under minimal or no tension are key to the success
patients this yields approximately 2,000 to 2,500 follicular unit of this approach.
micrografts and minigrafts containing between 5,000 and 6,000 hen feasible, it is best to make the micrografts and minigrafts
hairs and allows closure with minimal if any tension (Fig. 23.19). from hair-bearing areas surrounding the wound (local hair), espe-
cially for the eyebrows (the contralateral eyebrow or residual hair
from the same eyebrow), because they normally exhibit a very
23.3.3 m u ging S S r different growth pattern from that seen in scalp hair.
Patients are often seen with scars on the scalp or the front
hairline as a result of accidents, surgical interventions, or poor
healing after an aesthetic surgical procedure. Micrografts and
minigrafts can frequently benefit such patients.
Even when incisions are made parallel to the hair shafts on the
scalp or on the hair-bearing skin (eyebrows, beard, or mustache)
and closed without significant tension, a fine hairline scar is often
inevitable. These scars are sometimes detectable because of the
absence of hair at the scar line. Micrografting and minigrafting
offer an excellent solution for these deformities (Fig. 23.20;
Fig. 23.21). The technique is basically the same as that for male
pattern baldness or female androgenic alopecia, except that the
direction of the graft insertion may be more critical for controlling
the direction of hair growth.
hen working on the temporal hairline, eyebrows, or mus-
tache, for example, the direction of the natural hair growth at the
respective sites must be followed. Micrografts or minigrafts can
be added at the newly closed wound suture line in hair-bearing
Fig. 23.20 This 15-year-old girl had an otoplastic procedure
incisions. These small grafts thrive even if the blood supply is performed. A tight dressing placed around the head and knotted at the
precarious and will help minimize hair loss at the incision site. front hairline level resulted in a pressure sore and loss of hair in an area
The use of atraumatically dissected micrografts and minigrafts about the size of a half dollar.

254

Fig. 23.21 Correction for the patient shown in Fig. 23.20. The area of
alopecia was excised, but an area of hair loss remained. Scar revision
by a plastic surgeon left a widened scar. The patient was referred to
the author for further revision and/or micrografting. The scar was
reexcised, and about 25 micrografts and minigrafts were placed at the
suture closure line and 25 around the closure.
23.3.4 Correction of Sideburns after
Facelift Procedures
Surgeons who perform facelift procedures acknowledge that
upward displacement of the sideburn, temporal hairline, and
retroauricular hairline is not uncommon, especially in patients
undergoing secondary facelifts. The sideburn is an important
aesthetic unit of the face.
Sideburn loss is a telltale deformity unique to facelift proce-
dures. Patients attempt to style their hair to camouflage the area,
but this may be futile if they live active outdoor lives. Such upward
displacement can often be prevented if prehairline incisions are
used. If sideburn loss does occur, it can be corrected with various
scalp flaps, but I prefer the use of micrografts and minigrafts for
several reasons:
1. A natural result can be achieved in just one session.
2. The direction of the hair can be controlled by angling the surgi-
cal blade.
3. The desired hairline design can be followed with precision.
4. A transition zone can be readily created that avoids a scar in
front, a common sequela of flap techniques.
An example of the results can be seen in Fig. 23.22.
a b c
Fig. 23.22 (a) This 52-year-old woman came for a consultation 3 years
after a facelift. (b) In a single session, 850 follicular unit micrografts
and minigrafts per side were transplanted to restore the lost sideburns,
temporal hairline, and some at the front hairline. (c) Postoperatively,
blending of the grafts with the natural direction of hair growth is
evident.
ini e i i n ing in ir r n n i n
23.3.5 Restoration of the Eyebrows,
Mustache, and Beard
Fujita first described the use of single hair grafts to reconstruct
the eyebrows in 1953. This was the first mention of the use of
micrografts since Tamura reported transplanting single hair
grafts from the pubic area in 1943. It would be another four
decades before there was further experimentation with small
grafts. More recently, Gandelman published his superb results
using micrografts and minigrafts to restore the eyebrows.
Fortunately, micrografts and minigrafts grow anywhere on the
face and thus are useful for restoring the eyebrows, mustache, and
beard. However, because the consistency of facial skin is softer and
more elastic than that of the scalp, the surgeon will encounter more
problems with grafts popping out when transplanting facial areas.
On the face I personally prefer to make most of the recipient
sites first, allow a few moments for coagulation, and then insert
the grafts (Fig. 23.23; Fig. 23.24). For the eyebrows I prefer a to use
a 21-gauge needle to make the recipient sites; on the moustache
and beard, the 22.5 SharPoint (Surgical Specialties Corp., Reading,
PA) blades.
23.3.6 Treatment of Burn Alopecia
Various methods have been used for the treatment of burn
alopecia, including punch grafts, local scalp flaps, free scalp
flaps, and tissue expansion. The fibrotic scar tissue that normally
forms after burn injuries has a precarious blood supply and is
not an optimal site for any type of graft. Single- and double-hair
grafts (micrografts) and grafts with three to four hairs (small
minigrafts) have fewer metabolic requirements because of their
small size, which probably permits them to survive in this hos-
tile environment.
Having seen these small grafts survive in patients with male
pattern baldness who had scarred scalps from previous surgical
procedures, I decided to try them in patients with burn alopecia
(Fig. 23.25). The success of this approach has been reported in the
literature.
I think that it is important to allow sufficient time for the scalp
to heal, soften, and fully recover from the insult of surgery or
a b
c d
Fig. 23.23 (a) This 20-year-old man presented with scarring alopecia
of his beard and moustache. (b) First all the recipient site incisions
were made before insertion of the grafts. (c) Immediately after
insertion of the grafts. (d) One year postoperative.
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 IV Hair Transplantation
a ing hair density. Furthermore, the sessions would have to be performed
b 23.25 using a 350-mL crescent-shaped expander inflated to 210 mL.
c
Fig. 23.24 (a) This 19-year-old woman presented with scarring alope-
cia of right eyebrow and upper lid eyelashes. (b) Follicular unit grafts in
place, and a strip (composite graft) for eyelash reconstruction). (c) One
year postoperative.
trauma before proceeding with hair transplantation, especially in
the case of burn alopecia, where tissue expansion may be neces-
sary first (Fig. 23.26; Fig. 23.27; Fig. 23.28).
23.3.7 Eyelash Reconstruction and
Augmentation
The eyelash of the upper eyelid is an important structure both
functionally and aesthetically. The upper eyelashes resemble
256
Fig. 23.25 This 18-year-old woman developed chemical burn alopecia
after applying highlights to her hair. She had very high density in the
surrounding areas and requested quick results, because she was leaving
for college in a few months. Follicular unit micrografts and minigrafts
would have provided a nice result but would have taken at least two
sessions and perhaps three to blend reasonably well with the surround-
at least 6 to 8 months apart and would thus take 18 to 24 months to
complete. Scalp reduction was not an option, because her scalp was a bit
tight. Even though serial excisions might have improved the tightness,
they would have been repetitive and would have resulted in a hairless
scar line at best. Therefore the author recommended tissue expansion
with micrografts inserted between the sutures during closure.
Fig. 23.26 Tissue expansion was performed on the patient in Fig.
The expander was removed after 3 months.
Fig. 23.27 With the patient in Fig. 23.25 and Fig. 23.26 under con-
scious sedation and local anesthesia, the areas of alopecia were excised
by tailoring the expanded scalp (left). The wound was closed with a
simple running 3–0 Prolene suture (center). Approximately 50 grafts
were placed between sutures to camouflage the closure further. Three
months postoperative, she shows excellent hair density (right).
a b c
Fig. 23.28 This 43-year-old man sustained third-degree burns to his
upper body, chest, neck, face, and scalp. He underwent multiple surgical
procedures, including rib-graft ear reconstruction. He was referred to the
author for restoration of frontotemporal, left frontotemporal-parietal,
sideburn, and eyebrow hair. (a) He requested postponing eyelash
reconstruction. (b) He received a single session of 1,525 follicular unit
micrografts and minigrafts to both temples and the frontal hairline and
125 grafts to each eyebrow. (c) He returned 8 months postoperatively for
a second session to increase his hair density further.
 ini e i i n ing in ir r n n i n

an awning, preventing the entrance of small foreign bodies

that may cause microtrauma to the conjunctiva and cornea.
Eyelashes contribute to the aesthetic appearance of the eyes
and face. Lack of eyelashes can result in a strange, owl-eyed
appearance that is both embarrassing and damaging to the
self-esteem (Fig. 23.25). Eyelash reconstruction is suggested for
the following conditions:

• Congenital absence of eyelashes

• Eyelash loss from traumatic injury, burns, or dermatologic
disease
• Eyelash loss caused by oncologic surgery or radiotherapy
• Iatrogenic loss resulting from the use of silver nitrate to pre-
vent trachoma

Some anatomic features are especially noteworthy for

successful eyelash reconstruction. The central portion of the
orbicularis oculi muscle covering the eyelid is referred to as the
palpebral portion. This is further divided into the preseptal and
pretarsal muscles based on their relationship to the underlying Fig. 23.30 Sagittal section through the upper eyelid showing the
orbital septum and the tarsal plate, respectively (Fig. 23.29). superficial and middle structures of the upper eyelid, including the
levator aponeurosis, preseptal and pretarsal portions of the orbicularis
The pretarsal muscle is firmly attached to the underlying tarsal
oculi muscle, and eyelid skin. The drawing also demonstrates the
plate. However, the upper part of the upper pretarsal muscle is relationship of the pretarsal portion of the orbicularis oculi muscle,
attached to the levator aponeurosis and thus is separated from eyelash hair follicle, and eyelid skin.
the tarsus at that point. There are approximately 100 to 150
lashes on the upper eyelid. The eyelashes emerge in two to three
irregular rows from the eyelid margin anterior to the gray line
(mucocutaneous junction). Sweat glands (of Moll) and sebaceous
glands (of eis) enter the follicular structure of the cilia. The skin
of the eyelids is the thinnest of the entire body. There is a thin
fascial layer between the skin and the orbicularis oculi muscle.
a b c
There is virtually no subcutaneous fat in this area, and the skin is
tightly applied over the pretarsal muscle and loosely adherent to
the preseptal muscle (Fig. 23.30).
The patient in Fig. 23.31 requested restoration of the eye-
lashes over a small segment of the lower eyelid. I recommended
a strip graft and decided to choose eyebrow hair for the donor
d e
Fig. 23.31 (a) This 23-year-old man requested restoration of a small
segment of eyelashes in his left lower eyelid. A strip graft and a total
of five follicular unit micrografts to both the upper and lower eyelids
were recommended. (b) He had dense eyebrows, and since the area
of demand was small, a small donor strip was harvested from the
contralateral eyebrow in a spot that had good density with desirable hair
direction. (c) The strip was turned and positioned in the most desirable
orientation to mimic the missing eyelashes as best as possible. (d) He is
shown immediately after surgery with the scleral shield still in place and
(e) 1 year postoperatively.

strip, because its features are similar to those of eyelashes.

Although it is a challenge to encourage transplanted eyebrow
hair to grow in the same direction as natural eyelashes, a strip
graft, rather than follicular unit grafts, provides additional
control.

Fig. 23.29 Anatomic features especially noteworthy for successful

eyelash reconstruction. The central (palpebral) portion of the orbicu- 23.4 Choosing the Best Option
laris oculi muscle covering the eyelid divided into the preseptal and
pretarsal muscles based on their relationship to the underlying orbital Recommended procedures for hair restoration in the various con-
septum and the tarsal plate, respectively. ditions discussed in this chapter are summarized in Table 23.3.

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 IV Hair Transplantation

Table 23.3 Choosing hair restoration procedures

Condition Scalp
i u r uni mi r gr i u r uni minigr Strip ye r Tissue
ne r ir ree r ur ir gr donor expansion
Male pattern baldness ü ü
Female pattern baldness ü ü
Lost sideburn and retroauricular area hair ü
Scalp burn alopecia and scalp-scarring alopecia ü ü ü
Eyebrow restoration* ü ü
Eyelash restoration ü ü ü
Mustache and beard restoration ü ü
Pubic hair restoration ü ü
Body and lower leg ü ü
*In selected cases.

Clinical Caveats
• The follicular units should be maintained as intact as is
feasible.
• For patients with dark hair, 3.5 loupe magnification and
background lighting are sufficient to dissect most grafts as
follicular units.
• For patients with light hair or gray hair, surgical microscopes
and background lighting may be needed for more accurate
dissection.
• Always consider which donor area is most desirable. In most
cases, it is the occipital area; for eyelashes and eyebrows I
usually use scalp hair, but pubic hair may be considered for
eyebrow reconstruction.
Suggested Reading
1 Barrera A. Discussion of Seyhan A, oleri L, Barut u A. Immediate hair transplan-
tation into a newly closed wound to conceal the final scar on the hair-bearing
skin. Plast Reconstr Surg 2000;105:1871
2 Barrera A. Hair transplantation. In Lin S , Mustoe TA, eds. Lin and Mustoe’s Aes-
thetic Head and Neck Surgery. McGraw-Hill Plastic Surgery Atlas. ew ork,
McGraw-Hill Professional; 2013:196–201
3 Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting.
St. Louis, MO: uality Medical Publishing; 2002
4 Barrera A. Micrograft and minigraft megasession hair transplantation results
after a single session. Plast Reconstr Surg 1997;100(6):1524–1530
5 Barrera A. Micrograft and minigraft megasession hair transplantation: review of
100 consecutive cases. Aesthet Surg J 1997;17(3):165–169
6 Barrera A. Reconstructive hair transplantation of the face and scalp. Hair resto-
ration: state of the art. Semin Plast Surg 2005;19:159–166
7 Barrera A. Refinements in hair transplantation: micro- and minigraft megases-
sion. Perspect Plast Surg 1998;11(1):53–70
8 Barrera A. Surgical correction of alopecia in the male patient. eLearning course. St
Louis, MO: uality Medical Publishing, 2010
9 Barrera A. Surgical correction of alopecia secondary to face lift procedures.
eLearning course. St Louis, MO: uality Medical Publishing, 2010
10 Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
11 Barrera A. The use of micrografts and minigrafts for the treatment of burn alope-
cia. Plast Reconstr Surg 1999;103(2):581–584
12 Barrera A, Phillips LG, Barrera FF. Hair grafts in lower leg reconstruction. Plast
Reconstr Surg 2007;120(2):22e–25e
13 Buhrer DP, Huang TT, Yee H , Blackwell S . Treatment of burn alopecia with
tissue expanders in children. Plast Reconstr Surg 1988;81(4):512–515
14 Cronin TD. Use of hair-bearing punch grafts for partial traumatic losses of the
scalp. Plast Reconstr Surg 1968;42(5):446–449
15 Fujita K. Reconstruction of eyebrows. Leprosy 1953;22:364
16 Gandelman M. Eyebrow transplantation. Hair Transplant Forum Int 1994;4:17–18
17 Gandelman M. Eyelash reconstruction. Hair Transplant Forum Int 1996;6:18
18 Giraldo F, Gonz lez C, Garnica I, Ferrón M, Rus A. Sideburn reconstruc-
tion with an expanded supraauricular trapezoidal flap. Plast Reconstr Surg
1997;100(1):257–261
19 Harii K, Omori K, Omori S. Hair transplantation with free scalp flaps. Plast Recon-
str Surg 1974;53(4):410–413
20 Hata Y, Matsuka K. Eyelash reconstruction by means of strip skin grafting with
vibrissae. Br J Plast Surg 1992;45(2):163–164
21 Headington T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456
22 Hern ndez- endejas G, Guerrerosantos . Eyelash reconstruction and aes-
thetic augmentation with strip composite sideburn graft. Plast Reconstr Surg
1998;101(7):1978–1980
23 Hudson DA, Grobbelaar AO. The use of tissue expansion in children with burns of
the head and neck. Burns 1995;21(3):209–211
: 24 Kasai K, Ogawa Y, Takeuchi E. A case of sideburn reconstruction using a temporo-
parieto-occipital island flap. Plast Reconstr Surg 1991;87(1):146–149
25 Leighton WD, ohnson ML, Friedland A. Use of the temporary soft-tissue ex-
pander in posttraumatic alopecia. Plast Reconstr Surg 1986;77(5):737–743
26 Lucas M . Partial retransplantation. A new approach in hair transplantation. J
Dermatol Surg Oncol 1994;20(8):511–514
27 Norwood OT. Classification of male pattern baldness. In orwood OT, Shiell R,
eds. Hair Transplantation Surgery, 2nd ed. Springfield, IL: Charles C Thomas,
1984
28 Seyhan A, Yoleri L, Barut u A. Immediate hair transplantation into a newly closed
wound to conceal the final scar on the hair-bearing skin. Plast Reconstr Surg
2000;105(5):1866–1870, discussion 1871
29 Tamura H. Pubic hair transplantation. Jpn J Dermatol 1943;53:76
30 Uebel CO. Micrografts and minigrafts: a new approach to baldness surgery. Ann
Plast Surg 1991;27:476–487
31 Vogel E. Correction of the cornrow hair transplant and other common problems
in surgical hair restoration. Plast Reconstr Surg 2000;105(4):1528–1536, discus-
sion 1537–1541

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 ir r n n i n i u r ni i r gr
24 Hair Transplantation: Follicular Unit Micrografting and
Minigrafting–Current Techniques and Future Directions
Alfonso Barrera
Abstract
In this chapter we review a brief history of hair transplantation
and then a step-by-step description of my preferred technique
for hair transplantation, embodying what I have learned over
the last 25 years doing this procedure. I show you how to con-
sistently obtain natural and aesthetically pleasing results with
minimal scarring. It is a labor-intensive procedure and requires
a skillful team. My preferred technique is the stick and place,
in which the surgeon makes the small incision at the graft recip-
ient site and the assistant inserts the graft immediately. So far,
I have personally transplanted every single graft myself on all
my patients. I will describe the details of equipment, instrumen-
tation needed, and preferred surgical blades and microscopes.
The most frequent cases of hair loss in my practice include male
pattern baldness, female pattern alopecia, scarring alopecia
secondary to previous surgeries (postrhytidectomy sideburn and
temporal hairline alopecia). The future of hair transplantation is
focused on bioengineering and cloning hair follicles.
Keywords
follicular unit grafts, follicular unit transplantation (FUT), fol-
licular unit extraction (FUE), female pattern alopecia, scarring
alopecia
24.1 Brief Historic Review of Hair
Transplantation
ith the advances in hair transplantation technique available
today, we can truly provide natural and aesthetically pleasing
results, using one- and two-hair follicular unit grafts (micro-
grafts) and three- and four-hair follicular unit grafts (minigrafts).
I have incorporated hair transplantation into my practice for 25
years, and it constitutes 60 of my practice. Initially I was treating
primarily male pattern baldness (MPB), but soon thereafter, I
started finding other applications, particularly enhancing aes-
thetics in reconstructive cases of the face and scalp: scar alopecia
after facial rejuvenation surgery (the loss of the temporal hairline
and sideburn); alopecia due to trauma, burns, radiation therapy,
or congenital defects (e.g., bilateral cleft lip on male patients). This
procedure in some cases helps correct untoward effects of surgery
and may help conceal some of the ramifications of congenital
deformities.
A complete historic review of hair restoration procedures
is beyond the scope of this chapter. Suffice it to say that .
Orentreich from ew ork popularized hair transplantation
by introducing the use of punch grafts (hair plugs) in 1959. In
addition, he described the concept of donor dominance over 40
ing nd inigr ing urren e ni ue nd u ure ire i n
years ago, which is key to successful hair transplantation: that
essentially each individual hair follicle contains its own unique
genetic makeup and that, when transplanted to another site,
these unique genetic properties are preserved regardless of the
transplantation site. The hair will grow at the recipient area with
the characteristics and longevity of the donor site. Fortunately,
most individuals with MPB tend to lose their hair only on the
top and crown, sparing the temporal and occipital areas. When
utilizing these areas as donor sites, we can expect the growth to
be as permanent at the recipient site.
The old punch graft, or hair plug, technique resulted in an
unnatural look, giving the appearance of clumpy grafts (often 4
mm) containing high-density hair follicles separated by empty
spaces. A movement toward smaller grafts allowed hair trans-
plantation to move toward a more natural look.
The use of single-hair grafts is not a new concept; it was
described as early as 1943 by Tamura, who transplanted in the
pubic area, and then Fujita, who described reconstructing the
eyebrows in 1953.
Our goal is to use our artistic, technical skills and expertise in
a way that provides a final outcome that has natural feathering of
boundaries without clumping of the follicles with an appropriate
density for the anatomic region.
Great advances toward a natural result in hair transplantation
techniques have occurred in the past 4 decades. Ideally, success in
hair transplantation required very small follicular unit hair grafts
in large numbers. This was first described by ordstrom in 1981,
who used a large number of single-hair grafts to the front hairline
of the scalp to camouflage the clumpy appearance of existing
punch grafts. It was a tedious, time-consuming effort, and at the
time it seemed unrealistic to think about transplanting the whole
top of the head in this fashion.
Subsequently, Carlos O. Uebel in Brazil in 1991 was the first to
report in the literature the use of follicular unit micrografts and
minigrafts to cover the entire area of baldness, doing well over a
thousand grafts in a single session. Based on his work, I started
doing hair transplantation.
The use of micro- and minigrafts produced a more natural
appearance, eliminating the clumpy and cobblestoned appear-
ance seen with punch grafts, row or strip grafts, flaps, or scarring
associated with these techniques. The use of follicular unit micro-
grafts (one- and two-hair grafts) and follicular unit minigrafts
(three- and four-hair grafts) has become my preferred method of
hair transplantation because of the predictability of the results
without visible scarring on the recipient scalp and minimal scar-
ring on the donor site.
hen considering donor hair harvesting techniques, I prefer
the strip method, in which a horizontal 1-cm-wide strip is har-
vested from the occipital area, extending often into the temporal
areas (10 to 25 cm in length, or longer depending on the number
259
 IV Hair Transplantation
of grafts intended), allowing a tension-free closure, resulting in
minimal scarring. This method allows the preservation of at least
95 of the hair follicles harvested. Using 3.5 loupe or 10 micro-
scope magnification including background lighting translumina-
tion, intact follicular unit grafts can be incised parallel to the hair
shafts on both edges. The donor site is camouflaged immediately
by combing the hair down (hair is trimmed only on the donor
strip itself).
Recently another technique for donor hair harvesting has been
described: follicular unit extraction (FUE). This technique consists
of shaving a wide area of donor hair and using 0.8- to 1-mm
diameter sharp punch knives, either manually or with rotation
power or robotics, extracting the grafts individually. This can
be technically demanding, requiring great skill to avoid wastage
of hair follicles, of which in some cases up to 30 to 40 may be
wasted. The challenge lies in precisely incising the grafts parallel
to the hair shafts along their entire length. Additionally, the donor
site cannot be immediately camouflaged, as a large area of hair is
shaved.
Other surgical techniques described in the past to treat areas of
baldness include the following:
• Scalp reduction
• Scalp flaps
• Tissue expansion
These techniques are seldom used except in select cases where
tissue expansion and serial excisions may be beneficial.
Currently, we can only redistribute the patient’s own existing
hair roots (follicles), so a prerequisite to be a candidate for this
procedure is having a sufficient supply of donor hair. For success,
it is imperative to maintain a good supply and demand ratio.
hen the ratio is unfavorable, we have to select what area of the
scalp is most important to transplant and leave some baldness in
a b
Fig. 24.1 The importance of the direction of hair growth, showing a case of scarring alopecia of the sideburn area, (a) before and (b) after
transplantation.
260
a less important area. Alternatively, the patient could be deemed
not a candidate for hair transplantation. In our opinion, the front
hairline is more important than the crown area. It is important to
understand that as we age, the area of demand enlarges and the
area of supply shrinks.
24.2 Essentials for a Natural Result
in Hair Transplantation
Surgery
1. Small grafts: Graft individual follicular units: one- and two-hair
follicular unit grafts at the front hairline, two-, three- or four-
hair follicular unit grafts posterior to that.
2. Level of the hairline: There are no standardized measurements
for the ideal hairline in patients. These vary from person to per-
son, and we must aim for the most aesthetically pleasant level
and plan for the long term (6–9 cm from the eyebrows).
3. Design: There should be a slight irregularity to the hair pattern
to mimic nature.
4. Density: Sufficient density is needed to blend naturally with the
neighboring areas, generally a minimum of 70 to 100 hairs per
square centimeter.
5. Direction of hair growth: The direction of the hair and its growth
should be consistent with residual native hair, particularly at the
boundaries of the affected areas. Anteriorly at the front hairline,
the follicles are oriented at a 30 angle and a slight left or right
direction. This can vary and may be straight on the sideburns.
At the temporal areas the most optimal direction often is in a
downward position, but it can be in a diagonal, posterior direc-
tion or occasionally a straight, posterior direction (Fig. 24.1).
6. Absence of detectable scarring: Of course today’s techniques
enable us to perform hair transplantation without visible scar-
ring. This is accomplished by using ultrafine scalpels, such as the
 ir r n n i n i u r ni i r gr ing nd inigr ing urren e ni ue nd u ure ire i n

15 or 22.5 SharPoint blades (Surgical Specialties Corp., Read- • 120 mL of normal saline with 20 mL of 2 plain Xylocaine
ing, PA) for transplantation of the hair follicular units, and doing
• 1 mL of epinephrine 1:1000
a slight trichophytic closure of the donor site and closing with-
out tension. • 40 mL of triamcinolone ( enalog)

24.3 Technique for the Treatment of
Male Pattern Baldness
and Female Pattern Alopecia
24.3.1 Anesthesia and Preparation
The patient is placed in the supine position, under intravenous
(IV) sedation with midazolam (Versed) and fentanyl (Sublimaze)
as well as occipital and supraorbital nerve blocks with 0.5 bupi-
vacaine (Marcaine) with epinephrine 1:200,000 (Fig. 24.2a, b).
Once the area is locally well anesthetized, we use tumescence
infiltration along the donor ellipse, allowing for hemostasis
and ease of graft dissection (Fig. 24.2c). Our wetting solution
consists of the following:
The same solution is used to infiltrate both the donor and the
recipient area. By adding enalog, we have found significantly less
postoperative pain and edema. e generally use a total of about
150 mL of tumescence solution throughout the procedure at both
the donor and recipient sites.
24.3.2 Donor Ellipse Harvest
A horizontal ellipse of scalp is harvested from the occipital
area, often extending to the temporal areas, frequently from
above the ear on one side to above the ear on the other side.
The ellipse will vary in dimensions depending on the number of
grafts planned and the density of the donor site. hen we plan
on 2,000 or more grafts, the ellipse will measure 20 to 25 cm 1
cm. It is imperative to avoid tension at the closure, allowing for

a b c

d e f

g h
Fig. 24.2 Anesthesia preparation and donor strip harvest. (a) Supraorbital and supratrochlear nerve blocks with 0.5% bupivacaine (Marcaine) with
epinephrine 1:200,000. (b) Reinforcing the block just in front of the proposed hairline. (c) Infiltration of the donor ellipse, starting at the caudal
margin. (d) Making incision using a no. 10 scalpel blade, incising parallel to the hair shafts. (e,f) One side of donor site closed with 3–0 Prolene simple
running suture. (g) The head is turned to the right to enable harvest of the other half of the donor strip. (h) Donor site closed on the left side (3–0
Prolene simple running suture).

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 IV Hair Transplantation

optimal healing and preservation of donor site hair. e begin by
harvesting the right half of the donor ellipse under 3.5 loupe
magnification. Incisions are made precisely parallel to the hair
shafts (Fig. 24.2d, e).
The plane of dissection is just deep to the hair follicles and
superficial enough to avoid injury to significant vessels and sen-
sory nerves. This results in the preservation of a small amount
of subcutaneous fatty tissues over the galea or fascia. The site is
closed without the need to undermine using a continuous running
suture of 3–0 Prolene. The contralateral side is then harvested
and closed while assistants dissect grafts from the right side (Fig.
24.2f; Fig. 24.2g; Fig. 24.2h).
24.3.3 Graft Dissection
The assistants work under microscope at 10 magnification
(Fig. 24.3a). Using background lighting and a transparent sterile
silicone block is important for increased visualization of the
follicular units (Fig. 24.3b). Using a no. 10 blade and jeweler’s
forceps, the assistants process the donor ellipse into 1.5- to
2-mm-thick slices and subsequently dissect it into follicular unit
grafts as the surgeon continues the donor site harvesting and
closure (Fig. 24.3c). The harvested scalp and all slices and grafts
are kept chilled in normal saline until transplanted (Fig. 24.3d).
The thin slices are next dissected into one- and two-hair fol-
licular unit micrografts and three- and four-hair follicular unit

a b c

d e

f g
Fig. 24.3 Dissection of follicular unit grafts from the donor strip. (a) Use of 10 magnification with microscope. (b) Use of background lighting and
a transparent sterile silicone block is important for increased visualization of the follicular units. (c) Notice a needle securing the tail of the strip,
allowing for traction and countertraction, facilitating the dissection. (d) The harvested scalp and all grafts are kept chilled in normal saline until
transplanted. (e) Dissection of the thin slices into one- and two-hair follicular unit micrografts and three- and four-hair follicular unit minigrafts with
background lighting and use of no. 10 scalpel blades and magnification. (f) Close-up view of one-, two-, and three-hair follicular unit grafts. (g) Lining
up the grafts in groups of 10 by 10 (groups of 100).

262
 ir r n n i n i u r ni i r gr ing nd inigr ing urren e ni ue nd u ure ire i n

minigrafts, again using background lighting, no. 10 scalpel blades,

and magnification (Fig. 24.3e). This is the most tedious part of the
procedure but one of the most important steps. The grafts must
be handled gently and atraumatically. The darker and thicker the
individual hair shafts, the easier it is to dissect the grafts. The ideal
grafts have intact hair shafts all the way from the subcutaneous
fatty tissue to the scalp surface and contain from one to four hairs
each, as they come in nature (Fig. 24.3f). Several hundred grafts
will have been dissected at this point. They are lined up in rows on
a wet green or blue surgical towel and are ready for insertion (Fig.
24.3g). The process of graft dissection and insertion continues
until all the grafts are transplanted. It is imperative to keep the
grafts wet, as desiccation damages the hair bulbs.
Fig. 24.4 Stick-and-place technique. The surgeon makes the small
incision, and the assistant slides the graft into position with the use of
24.3.4 Graft Insertion jeweler’s forceps. (Reproduced with permission from Barrera A, Uebel
CO. Hair Transplantation: The Art of Follicular Unit Micrografting and
Our team uses a stick-and-place technique. Infiltration of tumes- Minigrafting. 2nd ed. St Louis MO: uality Medical Publishing; 2014.)
cent solution into the recipient area is important for several
reasons, the most important of which are to promote hemostasis
and to produce temporary edema of the scalp, which facilitates
I select where each graft goes and its orientation, making the
graft insertion. The surgeon makes the small incision, and then
incision with the blade in the desired direction of growth. This is
the assistant slides the graft into position with the use of jewel-
followed by insertion of the graft by one of the assistants. This is
er’s forceps (Fig. 24.4; Fig. 24.5).
repeated until the procedure is complete. This is a time-consuming
Due to the nature of these procedures, it is very important to
process and often takes our team 4 to 6 hours depending on the
have a good surgical team, enabling cases to go smoothly and
number of grafts being performed. Most of our sessions range
obtain optimal results. e have two registered nurses (R s) and
from 1,500 to 2,800 grafts per session (Fig. 24.6).
one surgical assistant on the team, with me personally inserting
every single graft on all my patients.
One R , under my supervision, administers the IV sedation 24.3.5 Postoperative Care
(midazolam and fentanyl as stated previously) and circulates
while I harvest the donor strip with one assistant. hile the For dressing we use Adaptic ( ohnson ohnson, ew Brunswick,
assistants are preparing the grafts, I see office patients for about ) impregnated with bacitracin/polymyxin B ointment (Polysporin,
an hour and then return to begin transplanting the first 500 grafts. ohnson ohnson, ew Brunswick, ), erlex bandages (Cardinal

a b c

d e
Fig. 24.5 Graft insertion. (a) Using the 22.5° SharPoint blade ready to create a recipient site. (b) Now creating the recipient site, angling the blade in
the desired direction for the hair growth. (c) Graft being inserted by the assistant with jeweler’s forceps. (d) The tip of the SharPoint blade holds the
graft in place as the jeweler’s forceps come out. (e) SharPoint blade.

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 IV Hair Transplantation

a b

c d
Fig. 24.6 (a) The author personally inserts every single graft. (b) End of surgery, view from the head of the table. (c) End of surgery front view. (d)
End of surgery, left side view.

Health, Dublin, OH) and a 3-inch Ace bandage (3M, St. Paul, M )
for the first 48 hours (Fig. 24.7), then allow the patient to shampoo
gently daily. The sutures are removed on the 10th day.
The after care is simple and safe, reinforcing to the patient the
need to be gentle with the scalp for the first 2 weeks. A large portion
of the transplanted hair will go into telogen (rest phase) and will
shed in the first 2 to 3 weeks. It is very important that the patient
understands the natural evolution of the grafts. At 12 to 14 weeks
the follicles shift into anagen (growth phase) and the hair begins
to grow, most noticeable by the third or fourth month. During the
ensuing 6 to 10 months the hair will gain length and thickness,
with the final result evident at 1 year following the procedure. If the
patient desires greater hair density, additional sessions can be done.
24.3.6 Examples
Example 1
The 60-year-old man with MPB, orwood type VI, shown in Fig.
24.8a received a single session of 1,500 follicular unit grafts to
the front scalp area. Minimal grafting was done to the crown
because he had limited donor hair. Simply restoring the front
hairline produced a significant degree of aesthetic improvement
and rejuvenation, as seen 1 year later in Fig. 24.8b.
Example 2
The 61-year-old man with MPB type V in progress to type VI
shown in Fig. 24.9 received a single session of 2,600 follicular
unit grafts.
Example 3
The 52-year-old man with MPB type II shown in Fig. 24.10
desired to have his front hairline brought forward 1.5 cm and as
dense as possible. It took four sessions of follicular unit grafting
to get the degree of density shown, comprising approximately
2,800 grafts total, all in the front.
Example 4
The 29-year-old man with MPB type II shown in Fig. 24.11
desired his front hairline to be moved anteriorly 2.5–3 cm. He
received approximately 1,000 follicular unit grafts.
Example 5
The 59-year-old woman with female androgenic alopecia (FAA)
Ludwig type II shown in Fig. 24.12 received a single session of
1,800 follicular unit grafts.

264
 ir r n n i n i u r ni i r gr ing nd inigr ing urren e ni ue nd u ure ire i n

a b

c d
Fig. 24.7 Postoperative dressings. (a) Several layers of Adaptic impregnated with Polysporin ointment, anterior view. (b) Adaptic impregnated with
Polysporin, lateral view. (c) On top of the Adaptic are two Kerlex bandages and a 3-inch Ace bandage; anterior view. (d) Kerlex and Ace bandages,
lateral view.

24.4 Correction of Scar Alopecia
Secondary to Facelift
Procedure
Facelift incisions may result in a variable degree of cephalic and
posterior advancement of the temporal hairline and sideburn,
creating an unsightly stigma of a poorly performed facelift.
Other areas that may be distorted following rhytidectomy pro-
cedures may include alopecia of the retroauricular hairline and
elongation of the forehead following brow lift procedures.
These deformities can predictably and consistently be cor-
rected by using follicular unit hair transplantation techniques. e
first reported our technique for the correction of this condition
in 1998. It is essential to place very small single- and double-hair
grafts in a natural direction, downward or posterior, to match the
patient’s hairline.
For the treatment of sideburn alopecia we prefer to use the
occipital area for the donor site. Most patients have sufficient
donor hair to restore the sideburns and the temporal and retroau-
ricular hairline, as it is not a large area, but confirmation should be
done to ensure the supply-to-demand ratio is favorable.
Expectations must be realistic, and the patient should be aware
that a second session may be required to obtain sufficient hair
density.
For these deformities we may utilize between 300 and 1,500
grafts per session, depending on the degree of alopecia and the
size of the area to be covered. e address this area just as in cases
of MPB and FAA (Fig. 24.13).
24.5 Complications
hile hair transplantation is a very safe procedure, minor com-
plications can sometimes occur.

265
 IV Hair Transplantation

a b
Fig. 24.8 Man aged 60 with Norwood type VI male pattern baldness, (a) before and (b) a year after a single session of 1,500 follicular unit grafts
to the front scalp area. By simply restoring the front hairline a significant degree of aesthetic improvement and rejuvenation was accomplished.
(Procedure by Alfonso Barrera, M.D.).

a b c d

e f g h

i j k l
Fig. 24.9 A 61-year-old man with male pattern baldness type V in progress to a VI (a,c,e,g,i,k) before and (b,d,f,h,j,l) a year after a single session of
2,600 follicular unit grafts. If the patient desires further hair density, a second session can be done any time after a year postoperatively.

266
 ir r n n i n i u r ni i r gr
a b
c d
e f
Fig. 24.10 (a,c,e) A 52-year-old man with type II male pattern baldness
desired the front hairline brought forward 1.5 cm and as dense
as possible. (b,d,f) It took four sessions of follicular unit grafting,
including approximately 2,800 grafts total, all in the front, to get this
degree of density.
24.5.1 Ingrown Hairs and Cysts
The most frequent complication after hair transplantation is
ingrown hairs and cysts. This may occur when the grafts are
placed too deep, which allows the recipient scalp to heal on top
of the graft, creating a cyst. hen doing large procedures such as
2,000 grafts, one may encounter a few cysts in the postoperative
period. If mild they are self-resolving, eventually erupting and
draining spontaneously. Occasionally treatment may require
digital compression or an 18-gauge needle to facilitate drainage.
a b
Fig. 24.12 This 59-year-old woman presented with female androgenic alopecia Ludwig type II. (a) Before and (b) a year after a single session of 1,800
follicular unit grafts.
ing nd inigr ing urren e ni ue nd u ure ire i n
a b
c d
e
Fig. 24.11 This 29-year-old man with male pattern baldness type II
desired his front hairline to be moved anteriorly 2.5–3 cm. (a) Before.
(b) Immediately post approximately 1,000 follicular unit grafts. (c)
Ten days postoperative; usually most or all of the scabs have come off
by then. (d) Six months postoperative, showing nice improvement,
but the final result takes a year. (e) One year postoperative. Optionally
more grafts can be added after this.
24.5.2 Widening of the Donor Site Scar
Widening of the donor site scar is due to tension at the closure
and incisions that were not parallel to the hair shafts (resulting on
excision of hair roots at the closure). This can usually be avoided
by accurate dissection and closure with minimal tension.
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 IV Hair Transplantation

a b c

d e
Fig. 24.13 This 59-year-old woman had scarring alopecia secondary to a facelift procedure. (a,d) Preoperative. (b) Preoperative marking, right side.
(c,e) Six months post single session of 1,200 follicular unit hair grafts between both sides.

24.5.3 Keloids Clinical Caveats

eloids are extremely rare; harvesting too caudally (near the
lower boundary of the occipital hairline) is more prone to this
complication.
24.6 Future Directions
The idea of replication of a single hair into thousands of hairs
suitable for transplantation remains an exciting frontier for hair
transplantation. Many bioengineering centers worldwide con-
tinue trying to clone hair follicles. There are many patients with
limited or almost no available donor hair who would immensely
appreciate this technique when it becomes possible.
• Make sure to spend the necessary time to explain to the
patient what is possible and what is not. Make sure realistic
expectations are established.
• More than a single session may be required for optimal
correction.
• It is important for both the surgeon and patient to under-
stand the supply and demand ratio. It is ideal to have a high
hair density donor area and a limited area of hair loss.
• If there is limited or not enough hair density, it is better not to
do the hair transplantation.
• The future of hair transplantation lies with cloning and bioen-
gineering of grafts.

24.7 Concluding Thoughts Suggested Reading

The use of follicular unit grafts, both micrografts and minigrafts,
for hair transplantation is a safe and predictable procedure to
help correct male pattern baldness, female pattern alopecia,
and hair loss secondary to facial rejuvenation surgery as well as
many other types of scarring alopecias. These procedures result
in high patient satisfaction.
1 Barrera A. Micrograft and minigraft megasession hair transplantation: review of
100 consecutive cases. Aesthet Surg J 1997;17(3):165–169
2 Barrera A. Micrograft and minigraft megasession hair transplantation results
after a single session. Plast Reconstr Surg 1997;100(6):1524–1530
3 Barrera A. Refinements in hair transplantation: micro- and minigraft megases-
sion. Perspect Plast Surg 1998;11(1):53–70
4 Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting, 1st ed.
St. Louis, MO: uality Medical Publishing; 2002

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 ir r n n i n i u r ni i r gr ing nd inigr ing urren e ni ue nd u ure ire i n

5 Barrera A, Uebel CO. Hair Transplantation: The Art of Follicular Unit Micrografting
and Minigrafting, 2nd ed. St. Louis MO: uality Medical Publishing; 2014
6 Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
7 Barrera A. Correcting retroauricular hairline deformity after face lift. Aesthet Surg
J 2004;24(2):176–178
8 Harris A. Follicular unit extraction (FUE). In: Unger , Shapiro R, Unger
M, Unger R, eds. Hair Transplantation, 5th ed. London, U : Informa Health-
care;2010:23–34
9 Headington T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456
10 ordstr m REA. Micrografts for improvement of the frontal hairline after hair
transplantation. Aesthet Plast Surg 1981;5:97–101
11 Orentreich . Autografts in alopecias and other selected dermatological condi-
tions. Ann N Y Acad Sci 1959;83:463–479
12 Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann
Plast Surg 1991;27(5):476–487

269
 IV Hair Transplantation
25 e er i n e nemen nd re men
after Hair Transplantation
Jack Fisher
Abstract
This chapter analyzes the many factors that can lead to an
unsuccessful hair transplant. Once the source of the problem
has been identified, the next step is planning and executing a
solution. These two basic steps proper analysis of the etiology
of the problem and creating a solution are both critical in order
to resolve the unsatisfactory hair transplant.
Sources of failure are described, including improper patient
selection, inappropriate hairline design, and failure to evaluate the
patient’s family history. Some patients were poor candidates for a
hair transplant and should not have had the procedure originally.
Poor surgical technique and surgical complications are further
possible causes.
Another critical factor in reducing potential complications
in the long term is designing a hairline that is both age- and
gender-appropriate. Extremely low hairlines in men frequently
lead to problems as they age. Also, a curved or rounded hairline
usually creates a feminizing appearance. Another obvious prob-
lem is an extremely straight hairline without irregularity or
feathering, creating an artificial appearance. Methods to correct
these untoward outcomes surgically are discussed in detail.
In the final analysis, an ideal hair transplant should not be iden-
tifiable but should enhance the facial aesthetics of the patient,
whether male or female.
Keywords
patient selection, hairline, family histories, age-appropriate, fol-
licular units, hair angulation, graft excision, traumatic hair loss
25.1 Introduction
Hair transplantation is one of the most frequently performed
aesthetic surgery procedures in men today. The goal is hair
restoration that is natural and virtually imperceptible. A poorly
designed or executed procedure will result in a highly visible and
unnatural hairline. Despite its popularity, this procedure often
results in unsatisfactory aesthetic outcomes. The causes of these
problems and solutions for addressing them are the focus of this
chapter.
Before defining the problems that create bad results in hair
transplantation, one must identify the components of a natural
hairline. ithout knowledge of what defines the normal, it is dif-
ficult to discuss the abnormal. A successful hair transplant should
look totally natural, with a hairline that is irregular, feathered, and
age-appropriate.
When considering a patient for hair transplantation, the
surgeon must realize that hair loss is progressive. Probably no
single factor is as important or has led to so many poor results as
270
m i i n
when the progressive nature of hair loss is ignored. The location
of the frontal hairline is another key factor. hat looks good
in an 18-year-old young man will usually not be appealing in a
45-year-old. Therefore, it is important to design a frontal hairline
that will be aesthetically acceptable over a long period as the
patient’s face matures and hair loss continues. High hairlines
rarely look bad, but extremely low hairlines can be a disaster. One
of the most critical anatomic components of a natural hairline
is the frontotemporal angle. Rounding off this angle with hair
transplants usually leads to a bizarre appearance, especially as
the patient ages.
Aesthetic surgeons frequently place a high premium on obtain-
ing symmetrical results in most procedures. However, in hair
transplantation, a perfectly straight, symmetrical hairline, even
with the use of micrografts, is destined to look artificial, as can
be seen in the patient in Fig. 25.1, who had a large number of
transplants placed in an extremely straight line. Irregularity and
asymmetry are the hallmarks of a natural-appearing hairline.
25.2 Common Problems Requiring
Reoperation
Unsuccessful hair transplants generally share similar charac-
teristics:
• The hairline is too even and straight.
• The frontotemporal angle has been blunted.
• Large plug grafts have been used.
• The transplanted hair fails to grow.
• The hairline is too low.
• The hair has been transplanted at an incorrect angle.
Transplants done with large plug grafts represent a major
problem (Fig. 25.2; Fig. 25.3). Unfortunately, many individuals
have undergone these procedures over the past three decades.
Careful analysis is required to correct or improve these difficult
cases. Often there is significant scarring in the donor site, because
a coring device was used to remove grafts containing 10 to 40
hairs at a time. Frequently the donor site was allowed to heal by
secondary intention, resulting in significant scarring. Many of
these patients have little if any available donor hair remaining for
further grafting.
In individuals with adequate donor hair, a significant improve-
ment can be achieved by excising the old plugs, recutting and
recycling this hair, and using small one- to three-hair grafts for
further transplantation. This improvement, however, can be
accomplished only if sufficient residual donor hair is available.
Scalp excisions and forehead advancement procedures are
important adjuncts in these difficult secondary cases.
 e er i n e nemen
Another problem is the failure of transplanted grafts to take.
In healthy patients, the graft-take rate should exceed 90 . Small
one- to three-hair grafts, properly created, will rapidly undergo
neovascularization, and in a healthy patient most of this hair
should grow. However, if the grafts are poorly prepared, the
success rate falls off drastically. It takes a considerable amount of
time and experience for a surgeon to be able to create these small
grafts, and a well-trained team is critical for a successful outcome.
One of the most difficult problems to correct successfully is
a hairline that has been placed too low. As the patient ages, the
hair recedes, leaving a bizarre, isolated frontal hairline. Often the
only solution is an aggressive procedure that involves resection
of these grafts combined with a forehead lift with regrafting
(Fig. 25.4).
Finally, there is the group of patients who have had cosmetic
surgery and experienced secondary hair loss, such as after a
facelift or a coronal brow lift. In a patient who has undergone a
Fig. 25.1 A perfectly straight, symmetrical hairline, even with the use
of micrografts, is destined to look artificial.
Fig. 25.3 A common problem when a young patient undergoes a
hair transplantation procedure at too early an age is the creation of a
permanent frontal fringe with extensive baldness behind it. The use of
large plug grafts makes the deformity even more noticeable.
nd re men m i i n er ir r n n i n
facelift, temporal hair loss is the most common; it is caused by
either excess skin tension or superficial undermining with direct
damage to the hair bulbs. Hair loss is usually related to tissue isch-
emia. In many of these patients, the hair will regrow after 6 to 9
months, and a conservative approach is best. In some individuals
the hair fails to regrow, and transplantation is an ideal solution.
Traumatic alopecia, which usually occurs from hair bulb ischemia,
may be caused by factors other than cosmetic surgery. Prolonged
pressure on the scalp, such as in a comatose patient, can also
lead to hair loss without ischemia of the scalp. The skin is more
tolerant of ischemia than the hair bulbs are.
25.3 Evolution of Technique
In 1959 Orentreich published a landmark report on the use of
punch grafts to treat male pattern baldness, thereby establishing
punch grafts as the standard treatment for almost three decades.
Fig. 25.2 This patient had plug grafts to thicken his frontal hairline in
his early 20s. As the hair surrounding the unsightly plugs fell out with
aging, the large plug grafts became exposed, creating this noticeable
deformity.
Fig. 25.4 One of the most difficult problems to correct successfully is
a hairline that has been placed too low. As the patient ages, the hair
recedes, leaving a bizarre, isolated frontal hairline. Often the only
solution is an aggressive procedure that involves resection of these
grafts combined with a forehead lift with regrafting.
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 IV Hair Transplantation
Although results achieved with this technique may have been
reasonable at that time, the abnormal cornrow appearance they
produced was far from aesthetic. These grafts were harvested
with a 3.5- to 5.0-mm punch, producing plugs containing a large
number of hairs. This technique created two major problems: (1)
a severely scarred donor site in the posterior scalp, because the
donor holes were allowed to heal by secondary intention, and (2)
an unnatural recipient site with the classic cornrow appearance.
Eventually, smaller plugs containing six to eight hairs were
used, but this still resulted in an unnatural appearance. It was
not until the early 1990s that physicians began to recognize that
donor grafts containing the follicular units (naturally occurring
clusters in which hair grows) of one to three hairs were the key
to producing natural results. By transplanting the hair in these
smaller units, the cornrow appearance is avoided.
The other great advance in the evolution of hair transplantation
occurred with the development of the technique for transplanting
large numbers of hairs in one session. Pioneers such as Carlos
Uebel and others developed techniques whereby 1,000 to 2,000
follicular units could be transferred at one time. Thus, the com-
bination of small grafts composed of anatomically correct one- to
three-hair units and the ability to transfer a large number of grafts
rapidly in a single megasession produced a revolution in hair
transplantation.
25.4 Indications and
Contraindications
The patient’s age, family history of hair loss, current hair pattern,
amount of hair remaining, and expectations are all important
factors in selecting potential candidates for reoperative hair
transplantation. Patients with minimal hair loss are the best
candidates for primary and, in particular, secondary hair
transplantation procedures and are much more likely to be
satisfied after hair transplantation.
Patients in their late or early 20s and those in their teens are
rarely appropriate candidates. These young patients often develop
a receding hairline later in life and may wish to fill in the anterior
hairline they previously had. Such a procedure is usually a major
mistake, because with progressive hair loss the patient will be
left with an isolated frontal fringe with balding areas behind the
transplanted rows. An attempt to create a juvenile hairline by
rounding off the temporal recession is also a mistake in a young
patient. Patients who demand an inappropriate hairline should be
excluded from surgery; otherwise, both the patient and the doctor
at some time in the future will regret the procedure (Fig. 25.2).
Another common problem when a young patient undergoes a
hair transplantation procedure at too early an age is the creation of
a permanent frontal fringe with extensive baldness behind it. The
use of large plug grafts makes the deformity even more noticeable
(Fig. 25.3). However, in this patient, even if small natural grafts
had been inserted originally, the effect would still look unnatural
because of the extensive baldness that evolved over the years
behind the grafts. The major point demonstrated by this case is
not to perform transplantations too early.
A patient with extensive hair loss with only a thin posterior and
lateral remaining fringe is also a poor candidate for reoperative
hair transplantation. Such a patient can be given a frontal hairline,
272
but if complete coverage of the area of alopecia is the goal, the
patient will likely be disappointed after the procedure. Caution
should also be exercised when attempting hair transplantation
in the occipital area. In young patients or those with extensive
hair loss, overly aggressive transplantation in this region can
lead to a strange halo pattern, with a permanent tuft of central
occipital hair surrounded by a bald ring or halo that progresses
as the patient ages and hair recedes. It is important to explain to
the patient the possible ramifications of overly aggressive hair
transplantation in this area. Thus, in younger patients it is prudent
to graft the frontal and superior regions of hair loss initially and
to observe over time the evolution of the patient’s hair loss. If a
young patient with fairly extensive hair loss rejects a high hairline
with temporal recession, this patient is not a good candidate for
transplantation.
As in all aesthetic surgery procedures, it is essential that the
patient be fully informed to ensure ultimate patient satisfaction.
This is even more important in an unhappy patient who has had
a poor result and wants revision. Realistic expectations must be
established before the surgeon considers reoperating on such
patients, based on the results of previous surgery and what
available donor hair tissue remains. The patient with a poor result
from 20 years ago who expects a miracle should be excluded from
surgery. Some of these patients must resign themselves to wearing
a hairpiece either to cover up a poor result in the recipient area or
to cover excessive scarring in the donor site from previous punch
grafting. In other areas of cosmetic surgery, such as a facelift, the
procedure can be repeated over time. However, a patient with
male pattern baldness has limited donor hair; therefore, it is crit-
ical to set appropriate goals with the patient based on this simple
anatomic fact.
25.5 Preoperative Assessment
Preoperative assessment focuses on the recipient site to evaluate
the results of the transplantation, as well as the donor site to
assess residual scarring and the amount of available donor hair.
The recipient site should be examined to determine whether the
hairline was placed in the correct location not too high or too
low and whether it was properly created. That means it has
an irregular line with a natural temporal recession. A common
problem after hair transplantation, especially in the past, was
creation of a straight hairline. Hairlines need to be irregular;
even a properly located hairline with small grafts in the correct
location will look unnatural if it is perfectly straight.
After assessing the recipient area, the physician must critically
evaluate the potential donor site if further grafting is to be con-
sidered. In the past, donor grafts were harvested with punches,
and the residual donor area was allowed to heal by secondary
intention, creating a significant amount of scar tissue. Eventually,
physicians began to use linear excision of the donor site with
primary closure. This became the standard, which significantly
reduced scarring in the donor area. Unfortunately, in the past and
even today, some surgeons make multiple parallel incisions each
time they harvest donor hair, which results in multiple transverse
scars in the posterior recipient area. This technique is rarely
necessary. Most patients can undergo at least two or three repeat
procedures over time using a single donor site and creating a
 e er i n e nemen nd re men m i i n er ir r n n i n

single scar. If multiple transverse parallel donor scars are too close
together, further excisions run the risk of tissue devascularization
and scalp necrosis.
The course of hair loss should also be considered. Hair loss is
both progressive and unpredictable. It is this unpredictability
that is the single most important issue in evaluating patients as
candidates for these procedures. In designing the hair pattern to
be transplanted, the surgeon must take into consideration the
patient’s progressive postoperative hair loss over the ensuing
decades.
The individual characteristics of the patient’s hair and skin
color must also be examined. The less the contrast between skin
and hair color, the more natural the final result will appear after
transplantation. Thus, light hair with fair skin or dark hair with
dark skin will have a low contrast. Dark hair on light skin, how-
ever, has a high contrast, and grafts with several hairs will look
more unnatural in these high-contrast patients.
The phenomenon called compression is particularly noticeable
in patients with a high-contrast situation. Compression is a
condition in which there are too many hairs exiting a single hole,
thereby creating a bouquet appearance, with the hair spreading Fig. 25.5 Compression is a condition in which there are too many hairs
exiting a single hole, thereby creating a “bouquet” appearance, with
out distally from a central site (Fig. 25.5). To avoid compression the hair spreading out distally from a central site.
of individual grafts, it is particularly important to use small
micrografts or follicular units in dark-haired patients. The texture,
density, and straightness versus curliness of the hair should also
be assessed. Curly hair provides better coverage of the scalp than Proper angulation or direction of the transplanted hair is
straight hair after transplantation. Fine hair gives less coverage another key anatomic factor in producing a natural result. Hair
than thick hair. grows at different angles at different locations on the scalp. Along
the frontal hairline, the hair should be angled in a slightly anterior
direction. Too much anterior angulation appears abnormal, as
25.6 Preoperative Planning does posterior angulation. Hair in the temporal area needs to be
angled downward, whereas hair on top is directed straight upward
In secondary hair transplantation, as in other types of revision
and hair in the posterior scalp is directed downward. Incorrectly
surgery, planning is as important as the execution of the sur-
angled hair requires revision surgery (Fig. 25.6; Fig. 25.7).
gery itself. In patients with adequate donor hair who have had
previous unnatural-looking plug grafts, a two-step procedure is
suggested. First, the plug grafts are excised, recut, and replanted 25.6.1 Options for Reoperative Hair
as small, natural-looking grafts; then donor hair is harvested Transplantation
from the posterior scalp and implanted as small follicular units
in between the previous plug grafts to fill in the spaces. There is no single operation for management of poor results or
There is no consistent pattern to follow when planning inci- complications from previous hair transplantation. Management
sions in this group of patients. hen large, unsightly grafts are of these complex cases requires a combination of techniques. In
visible, they need to be excised, and wherever there is residual some cases, simple excision of unsightly plugs alone can yield a
donor hair, it needs to be harvested. For more extensive cases, a reasonable improvement, especially in a patient who wishes no
more aggressive approach may be necessary, with radical excision further grafting procedures or one who no longer has any usable
of the previous recipient plugs, followed by secondary grafting. donor hairs.
Badly scarred donor areas can be improved in selected patients as However, in most patients with unsightly plugs, it is necessary
long as there is adequate hair in the area to cover up scarring from to excise the plugs and recut and recycle them as small follicular
further excisions. ide donor scars can frequently be improved units or micrografts (Fig. 25.8). Excision of old plugs is performed
by simple reexcision with primary closure. In more extensive under loupe magnification (2.5 or 3.5 ) using a o. 11 blade or
cases, tissue expansion or flap rotations can be used to improve a 1- or 2-mm biopsy punch. It is important to keep the tip of the
unsightly donor scars. blade parallel with the hair shaft and follicle to avoid injury to
The goal of reoperative hair transplantation is to produce an the entire hair unit. Improper angulation of the knife blade will
overall hairline that is both natural and undetectable. Therefore, damage the follicle or may leave it in its original location, only to
when planning revision surgery, the surgeon should avoid placing regrow another unsightly plug. Once the entire plug is removed,
the transplanted hair too low and rounding off the temporal it is carefully recut into small individual units for regrafting.
recession. The emphasis should be on creating a high hairline Typically, only 50 to 75 of the hairs removed in the old plugs
at least 8 to 10 cm above the glabella with a natural-appearing can be made into new, acceptable small grafts because of scarring.
frontotemporal angle. However, in patients with limited donor hair, every hair counts.

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 IV Hair Transplantation

Fig. 25.6 In this case, hair was transplanted along the patient’s right b c
frontal hairline at the wrong angle. Even though the grafts were small
and natural-appearing, because of their incorrect angulation, they
created a strange appearance. This patient requested correction,
which required excision of the scalp in the area marked by the ellipse.
After this area healed, grafts were inserted at the correct angle,
solving the problem.

d e
Fig. 25.8 Treatment of patient with unsightly previous plug grafts.
(a) Partial plug removal. (b) Plugs removed to be recycled into
minigrafts; (c) Additional micrografts and minigrafts. (d,e) Immediate
postoperative result.

not solve the problem. These grafts must be excised carefully,

as previously discussed; regrafting of the entire area is the best
solution using both the old recut grafts along with new ones. In
patients whose hairlines are too low, more aggressive treatment
may require scalp excision and a forehead lift in addition to plug
excision and graft recycling (Fig. 25.9).

Avoiding Donor Site Problems in Patients

with Previous Transplant Procedures
• The tension in the donor site closure should be minimized.
Fig. 25.7 This patient’s hair grafts were inserted at too acute an angle.
The hairs are growing straight forward from the scalp, yielding a very
• Scalp elasticity should be evaluated in patients with multiple
unnatural appearance. To correct this problem, excision, recycling, and donor site scars.
new grafting were all required. • The closer the previous scars are to the lower neck hairline,
the better the elasticity, because it is possible to recruit neck
skin.
• The higher the previous donor site scars and the closer to the
The best solution is to combine this technique with further har-
fixed occipital scalp, the less elasticity will be available. This
vesting of posterior scalp donor hair to create more small grafts
makes further donor site excisions more difficult to close.
for filling in between previous grafts.
• Patients who had previous plug grafts harvested from the
Patients with unnatural hairlines may present special prob-
donor area have stiffer donor tissue, making closure of strip
lems, such as improper angulation of the original grafts, or
excisions more difficult.
hairlines placed too low, too high, or too straight. Again, a proper
• Multiple previous transverse strip excision donor sites should
preoperative evaluation is critical, depending on which of these
be noted because of the risk of tissue devascularization asso-
four problems is present. In a patient with improper angulation
ciated with further harvesting of donor tissue.
of previous grafts, simply filling in between with new grafts will

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Fig. 25.9 Management of secondary cases.
25.7 Patient Examples
25.7.1 Cornrow Plugs
A case in which the techniques previously described were used
to correct a cornrow appearance due to the use of large plug
grafts in a patient with light skin and dark hair is summarized
in Fig. 25.10.
25.7.2 Isolated Frontal Forelock
Some patients develop an isolated frontal forelock as they age
(Fig. 25.11). hen connecting this forelock with the hair poste-
riorly, it is important not to drop the hairline too low. It may be
necessary to begin transplanting behind the frontal forelock.
25.7.3 Temporal Alley Defect
In patients who have had previous transplants along the superior
scalp and occipital area, a gap or alley may develop as the hair
recedes inferiorly along the sides of the head (Fig. 25.12). In this situ-
ation, a combination of procedures is required, including excision of
the scalp as well as further grafting (Fig. 25.13; Fig. 25.14; Fig. 25.15).
A common problem after scalp excision, however, is the phe-
nomenon of stretch back. This refers to the progressive widening
over time of the excised area as a result of tissue relaxation (Fig.
25.16).
25.7.4 Abnormally Low Hairline
One of the most difficult problems to correct is a hairline that has
been placed too low, especially if unsightly plugs were used. In
this situation, the old plugs must be carefully excised and recut
into small grafts. Scalp excision and forehead lift may also be
nd re men m i i n er ir r n n i n
a b
c d
Fig. 25.10 (a,c) This patient presented with noticeable plug grafts along
the hairline. Because the patient had a high-contrast component with
dark hair and light skin, the plugs seemed even more obvious. Correction
of this common problem was accomplished using three different
techniques. First, the old plugs along the outer edge were excised; next,
the plugs were cut into small follicular units to be reinserted. At the same
time, an ellipse of posterior scalp measuring 1.8 cm wide and 16 cm
long was excised and cut into 1,200 follicular units. These small grafts
plus those that were recycled were then placed between and in front of
the remaining plugs. The excised plug sites, which usually measure 5 to
6 mm in diameter, were closed with a single 5–0 nylon suture that was
left in for approximately 1 week. (b,d) One year postoperatively, the
patient is healed and has had complete correction of the artificial plug
look. The results here demonstrate that hair transplants should not be
recognizable but should resemble natural hair.
a
b c
Fig. 25.11 (a,b) This patient demonstrates the appearance of an
isolated frontal forelock. He has two isolated tufts of hair on his head,
creating a bizarre, unnatural appearance. To correct this problem,
a single session of 1,500 follicular grafts was used to connect the
two isolated forelocks with the hair posteriorly. (c) This approach
produced improved framing of the face and a much more normal
appearance to the hairline. Also, the hair was placed in an irregular
pattern, which produced a more natural appearance.
required. In these complex cases, multiple stages are frequently
required (Fig. 25.17; Fig. 25.18; Fig. 25.19; Fig. 25.20).
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Fig. 25.13 The skin containing the temporal alley defect in the patient
Fig. 25.12 This patient presented with a temporal alley defect after an in Fig. 25.12 was excised and a hole was created for the Mitek suture
unsuccessful attempt at hair transplantation. fixation device, which was placed on either side of the defect.

Fig. 25.14 The edges of the excised defect shown in Fig. 25.13 were pulled together, thereby reducing the amount of stretch.

Fig. 25.16 A common problem after scalp excision,

Fig. 25.15 At a separate session with the patient in Fig. 25.14, 4 months later, approx- however, is the phenomenon of “stretch back.” This
imately 1,200 follicular grafts were placed in the area, completing the restoration and refers to the progressive widening over time of the
significantly improving the appearance in the temporal area. excised area as a result of tissue relaxation.

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 e er i n e nemen nd re men m i i n er ir r n n i n

Fig. 25.17 This patient presented with an abnormally transplanted hairline, with the grafts placed too low in the temporal region. Besides the
original transplanted hairline being too low, the grafts had also been placed incorrectly in a curved line so that the temporal area was rounded off,
thus losing a normal frontotemporal angle.

a b c
Fig. 25.18 (a) A more aggressive approach was required for revision of the case in Fig. 25.17. A radical excision of the previous plug grafts was done,
along with excision of a segment of scalp along the frontal and temporal areas. (b,c) Holes were then made at multiple sites for insertion of Mitek
devices.

a b
Fig. 25.19 (a) The Mitek device with 2–0 Ethibond sutures attached was inserted into the defect shown in Fig. 25.18. The sutures were tied with
significant elevation of the forehead in both the midline and the temporal area. (b) The incision was allowed to heal for several months, and then the
patient underwent micrografting to the area.

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Correction of a Low Hairline:

Operative Overview
1. The frontal hairline scalp, including the old unsightly plugs,
is excised as a circumlinear ellipse.
2. The galea is left intact and the ellipse of skin with its old plug
a b
grafts is recycled, as described earlier, creating new, small,
one- to two-hair grafts for replanting.
3. Next, a forehead lift is performed while the excised hair is
being recut.
4. Unlike a traditional forehead lift, in which the goal is
elevation of the eyebrows and upper lids, this forehead
lift advances the forehead skin superiorly to raise the new
c d
future hairline, leaving the eyebrows alone. This is accom-
plished by not dissecting below the superior orbital ridges Fig. 25.20 Postoperatively in the patient shown in Fig. 25.19 (a,c)
and releasing these tissues. a significant elevation of the forehead is evident, with creation of a
normal frontotemporal angle in contrast to the preoperative condi-
5. The frontal forehead is stretched superiorly by making tion. (b,d) The patient has a visible scar in the temporal area from the
numerous parallel, horizontal releases in the periosteum in forehead lift. However, this scar could not be avoided, because further
a subperiosteal dissection or in the galea in a subcutaneous grafting in this area would have re-created the abnormal appearance.
dissection.
6. Next, deep sutures of 3–0 Ethibond (Johnson Johnson,
New Brunswick, NJ) are used with the Mitek fixation device
two-hair grafts in an irregular pattern in front of the previously
(Mitek Products, Westwood, MA), outer table drill holes, or
grafted areas. It is easier to improve the hairline in patients
the Endotine device (Coapt Systems, Palo Alto, CA) to fix
with light skin and light-colored hair, because the color contrast
the forehead in an elevated position. (I have used all three
is less obvious than in patients with dark hair and light skin.
techniques with excellent results.)
In high-contrast patients with dark hair and light skin or light
7. The suture fixation device is placed several centimeters
hair and dark skin, a greater number of grafts will be required
above the new future hairline to allow maximal elevation
to mask the previous procedure and create irregularity. This is
while it is being tied.
true for all corrective procedures. Color contrast is a subtle but
8. Once the forehead has been adequately elevated along its
important issue when performing secondary hair restorations.
superior aspect, the skin is closed with 3–0 polyglactin 910
(Vicryl, Johnson Johnson, New Brunswick, NJ) sutures and
a running 3–0 or 4–0 poliglecaprone 25 (Monocryl, Johnson
Johnson, New Brunswick, NJ) suture. 25.7.7 The Noticeable Donor Site Scar
9. The old plugs, which have been recut into small grafts, are
now reinserted behind the suture line. Independent of the problems associated with the recipient
10. After the skin is adequately healed in 3 to 4 months, large- site is the problem of a noticeable linear donor site scar. With
volume grafting is begun to create a new, natural hairline. the development and refinement of follicular unit extraction
(FUE), a technique of camouflaging the linear donor site scar is
available.
25.7.5 High Hairline The FUE grafts are harvested above and below the previous
linear scar and are primarily used for further grafting in the areas
In men, hairlines that are too high are rarely a problem, and as of general hair loss. However, a small percentage of the grafts are
long as donor hair is available, further sessions of grafting, using retained to be placed directly into the previous linear scar.
small grafts with an appropriate irregular hairline, solve these Typically, the FUE grafts cannot be placed as close together in
patients’ problems. However, in women who have had an overly scar as in the normal recipient areas but must be placed farther
aggressive forehead lift, a high hairline can create an abnormal apart because of the characteristics of scar tissue. Scar tissue may
appearance, especially if it also creates a masculinizing acute have decreased blood supply compared to normal scalp, and spac-
temporal recession. ing the follicular grafts farther apart than the traditional spacing
in the scalp ensures their viability. Also, it is more difficult to place
grafts into scar tissue compared to normal scalp because the scar
25.7.6 Straight Hairline does not have the elasticity of normal tissue (Fig. 25.21).
Another problem that presents a reoperative challenge is a
transplanted hairline that is extremely straight. Hairlines need
to be irregular; even in patients with small grafts, straight hair-
lines are noticeable. Obviously, if the straight hairline includes 25.7.8 Traumatic Hair Loss
unsightly plugs, these must be excised and recycled, as previ-
One of the most common causes of traumatic hair loss is aes-
ously described. In many of these patients, as long as the hairline
thetic facial surgery. This can be caused either by direct damage
is not too low, it can be improved by placing small one- to
to the follicles from superficial elevation of the skin flaps or by

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excessive tension leading to ischemia. The skin may not visibly
show signs of ischemia after aesthetic surgery, but there may
be enough relative decrease in tissue perfusion to damage the
follicles. In most patients, the hair regrows after 4 to 6 months,
but in some cases the hair loss is permanent.
In some patients, simple excision of the non-hair-bearing scar
can be successful. However, this maneuver often fails, because
the new scar may also lose its hair, and reexcision, because of the
risk of undue tension, will lead to ischemia and further hair loss.
For these reasons, many patients with traumatic hair loss require
hair transplantation to fill in the defect (Fig. 25.22). Remarkably,
small hair transplants placed directly into scar tissue consistently
grow. The problem with placing small grafts into scar tissue is
mechanical. Unlike normal scalp, which is relatively thick, areas of
hair loss with or without scar tissue are frequently thin, and it can
be difficult to insert the grafts in these areas. Using a tumescent
technique in the recipient areas is particularly helpful in this sit-
uation. The tumescent fluid creates the depth necessary for graft
insertion. In some of these patients the grafts cannot be placed as
close together, because the scar is thin and relatively ischemic. In
these patients several sessions performed over a period of time
may be more useful.
Fig. 25.21 This patient had a strip harvesting procedure 5 years
previously and requested a follicular unit extraction (FUE) procedure
for his second hair transplantation. FUE grafts were placed directly into
the previous linear scar, as seen on the right side, prior to insertion on
the left. The grafts are spaced far enough apart to ensure viability.
nd re men m i i n er ir r n n i n
Most patients with traumatic hair loss have their hair restored
in two sessions of grafting. Combining excision with grafting may
be the ideal situation, because excising a portion of the non-hair-
bearing area produces a smaller area requiring grafting. hen
combining these two procedures, the surgeon should excise the
skin conservatively, because further tension and ischemia will
lead to more hair loss and may create a relatively hypoxic environ-
ment in which few of the transplanted grafts survive.
One of the benefits of today’s micrografts or follicular grafts is
their high success rate. These small grafts have fewer metabolic
demands than the larger grafts previously used and usually do
well in areas of scar tissue and even in skin grafts. The older-style
plugs, especially those with 10 to 20 hairs in each plug site, had
less tolerance for ischemia. Frequently, patients with old plugs
have sites or areas within the plugs with poor hair growth.
One also sees scars from the old plugs creating a cobblestone
appearance, with little or no hair growth. This occurs because
the skin of the plug graft was neovascularized and survived, but
the follicles within never successfully grew hair. This cobblestone
look is unsightly, and excision of the non-hair-bearing skin plugs
is frequently the best solution, followed by further grafting when
possible.
25.8 Postoperative Care
Of all the areas of aesthetic surgery, hair transplantation,
whether primary or secondary, is one of the easiest procedures
to deal with in the postoperative period. Every physician has his
or her own protocols. I put patients in a protective head dressing,
a b
c d
Fig. 25.22 (a,c) This woman had posttraumatic hair loss in both the
preauricular temporal area and the posterior neck–postauricular area
after a facelift. In one session, 350 grafts were placed in the temporal
area and 400 in the posterior neck–postauricular area. Care was taken
to angulate the hair grafts properly; this maneuver is essential to
achieving a natural result. In the temporal area, hair naturally grows in
a downward and slightly posterior direction. In the posterior neck, the
hair needs to grow downward and slightly backward. (b,d) Following
these guidelines, significant improvement can be achieved in a patient
with traumatic hair loss after aesthetic surgery.
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 IV Hair Transplantation

similar to a facelift dressing, for 24 hours and then remove it.
Where there is a donor site closure with sutures, the patient
washes this area in a normal manner. here the grafts have
been inserted, I instruct patients that after the first 24 hours,
they should blot a mild shampoo on the recipient site once a day
and rinse the area using a cup, avoiding a direct shower stream
hitting the recipient grafts. After 6 days patients can wash the
recipient areas without any restrictions, since the small grafts
are well fixed at this time. I usually leave sutures in for 10 to 12
days in the linear donor site area and where a forehead lift has
been performed because of significant tension. Otherwise, noth-
ing unique is required in the immediate postoperative period for
management of these patients.
25.9 Concluding Thoughts
Many factors go into creating a successful hair transplant.
Avoiding complications before they occur is obviously the opti-
mal situation. Many of the problems associated with less than
satisfactory results after hair transplantation are more often
associated with mistakes in judgment and less likely the result
of errors in surgical technique. To avoid an unnatural result, the
surgeon must realize that hair loss is progressive in nature. It is
important to design a hairline that will be aesthetically accept-
able over time as the patient matures and hair loss continues.
Suggested Reading
1 Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting. St.
Louis, MO: uality Medical Publishing; 2002
2 Barrera A. The use of micrografts and minigrafts for the treatment of burn alope-
cia. Plast Reconstr Surg 1999;103(2):581–584
3 Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
4 Bernstein RM, Rassman R. Follicular transplantation. Patient evaluation and
surgical planning. Dermatol Surg 1997;23(9):771–784, discussion 801–805
5 Bernstein RM, Rassman R. The aesthetics of follicular transplantation. Derma-
tol Surg 1997;23(9):785–799
6 Epstein S. Revision surgical hair restoration: repair of undesirable results. Plast
Reconstr Surg 1999;104(1):222–232, discussion 233–236
7 Greco M, Raposio E, Raposio E, et al; ordstr m REA. The ordstrom suture to
enhance scalp reductions. Plast Reconstr Surg 2001;107(2):577–582, discussion
583–585
8 Orentreich . Autografts in alopecias and other selected dermatological condi-
tions. Ann N Y Acad Sci 1959;83:463–479
9 Uebel CO. Hair Replacement Surgery: Micrografts and Flaps. ew ork, :
Springer-Verlag; 2000
10 Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann
Plast Surg 1991;27(5):476–487
11 Vogel E. Correction of the cornrow hair transplant and other common problems
in surgical hair restoration. Plast Reconstr Surg 2000;105(4):1528–1536, discus-
sion 1537–1541
12 Vogel E. Advances in hair restoration surgery. Plast Reconstr Surg
1997;100(7):1875–1885, discussion 1886–1889

Clinical Caveats
• The following four characteristics are associated with unsuc-
cessful hair transplantation: (1) large, unnatural plug grafts,
(2) an extremely straight hairline, (3) a blunted frontotempo-
ral angle, and (4) a hairline that is too low.
• Surgical correction of large, unnatural plug grafts requires
graft excision, recutting into individual one- and two-hair
grafts, reimplantation of new small grafts, and closure of
individual donor sites with single small sutures.
• Surgical correction of a hairline that is too straight involves
removal of periodic grafts along the hairline if plugs are pres-
ent, with recycling farther back, and use of small single-hair
grafts to create a feathered, irregular hairline.
• Surgical correction of a blunted frontotemporal angle includes
removal of hair grafts and elevation of the temporal skin, with
advancement superiorly and posteriorly.
• Surgical correction of an abnormally low transplanted hairline
requires excision of frontal grafts, with reimplantation farther
back, excision of skin along the transplanted hairline, and a
forehead lift and closure of the defect.
• Color contrast is a subtle but important consideration when
performing secondary hair restorations.

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Brow Lift

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26 Clinical Decision Making in Brow Lift: Brow Rejuvenation

Foad Nahai

noted. e also note how thick the hair is and areas where the
Abstract
hairline is receding (Fig. 26.1).
There are a variety of surgical and nonsurgical procedures for
rejuvenation of the brow. Clinical applications of each and its role
in periorbital rejuvenation including brow lift are discussed. 26.1.2 Evaluation of the Aging Forehead
and Brow
Keywords
Features to Assess
neuromodulators/toxins, coronal brow lift, endoscopic brow lift,
temporal lift, direct brow lift brow pexy • Brow position lateral and medial
• Rhytids horizontal and vertical, at rest and on animation

26.1 Evaluation • Crows’ feet

• Lateral orbital crowding
e evaluate the entire face rather than isolated zones. The
• Skin
hallmark of a youthful face is the smooth transition from zone
Evaluation should include an assessment of the position of the
to zone; for example, brow to eyelid, eyelid to cheek, cheek to
brow laterally and medially, the relationship of the brow to the
perioral area, perioral area to jawline, jawline to neck. For best
upper eyelid, and the distance from the upper lid sulcus to the
results, procedures are planned to rejuvenate all of these areas
hair-bearing brow. Horizontal and vertical forehead and gla-
and to restore a harmonious transition from zone to zone.
bellar rhytids are assessed at rest and on animation, as are the
It comes as a surprise for a patient seeking an eyelid lift to
crow’s feet. (Horizontal forehead rhytids are more common in
be advised that in addition to blepharoplasty, a brow lift is also
men.) The quality, elasticity, and thickness of the forehead skin
recommended. Most patients will accept the surgeon’s recom-
are also evaluated. Lateral orbital bunching or crowding is noted
mendation, yet others resist, saying they want only to remove
with the eyebrow at rest and when elevated (Fig. 26.2).
the excess skin or bags from their eyelids. For some it becomes a
financial consideration, with concerns that each added procedure
will increase the cost. Regardless, we explain to the patient that Evaluation of Brow Position
regional or full facial rejuvenation would be the best option rather The medial brow is usually lower than the lateral brow, with
than localized, isolated procedures. e leave the final decision to a variable arch in between. The position of the brow is judged
the patient. based on the relationship of the hair-bearing brow to the supra-
In my practice, an isolated brow lift is a rarity. I consider a brow orbital rim. A lower brow position is typically seen in men; in
lift to be one component of periorbital rejuvenation, encompass- fact, brow position varies with sex, age, and ethnic background.
ing the brow, upper and lower eyelids, eyelid–cheek junction, and The ideal brow position also varies according to fashion and cul-
midface. o brow or forehead rejuvenation is complete without ture. High, arched brows are more common and more desirable
considering rejuvenation of at least the upper eyelids, if not the among those of Hispanic, Latin, and Mediterranean origins. Low
entire periorbital area. hen evaluating a patient’s face, I make brow position is associated with a tired, unhappy appearance,
note of the morphologic structure and anatomic features; then I whereas excessive brow elevation is associated with a frightened
evaluate the changes resulting from the aging process. Morphology or surprised look.
refers to the study of the shape or form of an anatomic structure;
thus it is the morphologic structure of the face, breast, and body,
rather than the anatomy, that we change through aesthetic sur-
gery. et a detailed knowledge of the anatomy of the structures
themselves is essential in aesthetic surgery. This includes bony
prominences, eye prominence, nasal prominence, and hairline
shape, whereas aging changes include changes in the skin, subcu-
taneous tissues, deeper soft tissues, and even the bones.

26.1.1 Anatomic Features

The convexity of the forehead and any supraorbital bony prom-
inence is noted. The thickness of the retro–orbicularis oculi fat
(ROOF) is assessed. The hairline and height of the forehead are Fig. 26.1 Factors to consider when anatomically evaluating the face.

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Brow height does not necessarily signal youth. Brow fullness

and shape are far more important than height, as indicated by the
three images of young women shown in Fig. 26.3.

Evaluation of Rhytids, Crow’s Feet, and the

Lateral Orbital Area
The patient is asked to frown, elevate the brow, and tightly close
his or her eyes so that the glabella, forehead, and crow’s-feet
rhytids can be assessed. Brow position and the lateral orbital
area are also evaluated during each of these facial movements. By
observing these muscle contractions in relation to brow, eyelid,
and lateral orbital movement, the surgeon can assess muscular
interactions. Success in relocating the brow to the desired posi-
tion will largely depend on modification of this muscle balance.

Evaluation of Skin
The quality and quantity of the skin on the forehead, upper eyelid,
and lateral orbital area are evaluated for thickness, elasticity,
and the presence of rhytids. The depth of the rhytids and the
skin texture are noted. Any excess skin is also noted, including
determining whether the skin excess is real or apparent, with
particular attention to whether there is excess skin in the gla-
bella over the nasal radix (Fig. 26.4).

26.2 Treatment Options
There are a variety of surgical and nonsurgical options as pri-
mary procedures. Adjunctive treatments such as resurfacing
may be performed at the same time to enhance the results.
Fig. 26.2 Comparison of a youthful and aged forehead and brow
region: the brow position (medial and lateral) needs to be evaluated
along with location and direction of rhytids of the forehead, brow, and
periorbital regions.

Fig. 26.3 Brow height does not necessarily signal youth. Brow fullness and shape are far more important than height, as indicated by the three
images of young women shown here.

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Treatment options range from toxin injections to the traditional

open coronal forehead lift.

26.2.1 Options for Forehead

Rejuvenation
The goals of forehead rejuvenation are to reposition or reshape
the brow into a more youthful position or desired shape. Brow
shape is far more important than brow elevation. Injection of
toxins is effective not only in elevation of the brow, but also
Fig. 26.4 Factors to consider when evaluating the forehead include
in reshaping. Surgical rejuvenation of the brow leads to brow both anatomic features related to the shape and framing of the
repositioning or shaping through a combination of steps, forehead and brow and age-related changes.
including mobilization of the brow and modification of muscles
to assist in maintaining brow position and ameliorating rhytids.
The open coronal lift was for years considered the standard
brow as desired and enhance its shape. The extensive incision
procedure; now, with several options available, it is considered
involved, together with the risk of sensory changes, including
the benchmark procedure to which all others are compared. In
dysesthesias, numbness, and alopecia, is perceived as a deterrent
Table 26.1, I have compared the various procedures, including
by patients who decline this approach. Since the introduction of
injectables, in terms of ease of exposure of the anatomic
the endoscopic approach in 1993, I have not performed an open
structures, muscle excision, and forehead mobilization. Scalp
coronal brow lift. Before 1993, only 10 to 15 of the patients
excision is included, because at one time it was the only option
undergoing facial rejuvenation in my practice would accept
for fixation. I have found the endoscopic approach to be as effec-
the open coronal lift. Today almost all of my facial rejuvenation
tive as the coronal, and in selected patients the combination of
patients undergo brow rejuvenation through one of the four
a lateral approach with transpalpebral muscle excision has also
preferred procedures listed previously.
proved satisfactory.
There is no question that the coronal approach is the best option
Selection of a technique is based on aging changes and the
for some patients. These are patients in whom a high hairline
patient’s anatomy. As important in this selection process is the
and a convex frontal bone would make the endoscopic approach
surgeon’s familiarity and experience with each procedure, and
rather challenging. In such individuals, I prefer a combination of
in the final analysis, we will each select a procedure that in our
the lateral approach with transpalpebral muscle excision. Those
hands will produce the best result with minimal morbidity (Fig.
with a high forehead also present a challenge to the endoscopic
26.5).
approach, making it technically very difficult, if not impossible. An
My preferred surgical options and the frequency with which
alternative would be an open coronal biplanar approach to fore-
each is performed are as follows (Fig. 26.6):
head rejuvenation, allowing shortening of the forehead height.
• Full endoscopic (1 )
• Lateral-temporal (30 ) Endoscopic Forehead Lift
• Transpalpebral muscle excision (5 ) The endoscopic forehead lift (Fig. 26.8) is not without its limita-
• Combination lateral-temporal plus transpalpebral muscle tions. Although it can be uniformly applied in every patient, the
excision (64 ) results will vary according to the patient’s anatomic features as
well as the aging changes present. There are certain anatomic
features that make the endoscopic approach rather challenging.
Open Coronal Forehead Lift Patients with those features are best served by one of the alter-
The open coronal approach affords excellent exposure and native approaches (Fig. 26.9; Table 26.2).
facilitates release of adhesions, muscle excision, and brow mobi- The endoscopic approach affords excellent exposure for release
lization (Fig. 26.7). The scalp excision is tailored to elevate the of the periorbital adhesions and septa; the magnification offered

Table 26.1 Options for forehead rejuvenation

Exposure ee e d e i n Muscle excision re e d m ii i n Scalp excision
Open coronal ++++ ++++ +++ ++++ ++++
Endoscopic ++ ++++ ++++ ++++ +
Direct approach +++ +++ + +++ ++++

Transpalpebral ++ + +++ +++ —

Lateral approach +++ +++ — +++ +++
Toxins NA NA Temporary paralysis +++ NA
Degree of effectiveness indicated by the number of pluses. NA, not applicable; —, not possible.

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 V Brow Lift

Fig. 26.5 Various approaches for brow rejuvenation. One must weigh the advantages and disadvantages of these approaches when deciding on a
treatment plan.

Full endoscopic Transpalpebral

1% muscle excision
5%

Lateral–temporal
30%
Combination—
lateral–temporal+
transpalpebral
muscle excision
64%

Fig. 26.6 The author’s preferred surgical approaches and their
frequencies. The author’s most frequent approach is combination of
treatments to include a lateral temporal brow lift with a transpalpebral
muscle excision.
Fig. 26.7 An open coronal brow lift can provide excellent exposure
and mobilization of the brow along with an ability to perform muscle
excision. Shown is a peak centered at the midline (bicoronal brow lift).
Variations of this incision can be made to help better camouflage the
incision depending on the patient’s hairline.

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through the endoscope facilitates muscle excision and nerve Lateral–Temporal Brow Lift
preservation. Scalp excision is rather limited with the endoscopic
The lateral–temporal approach affords excellent repositioning
approach, so elevation and maintenance of brow position rely
and elevation of the lateral brow through a temporal incision
primarily on muscle balance and fixation techniques compared
(Fig. 26.10). Suturing of the temporoparietal fascia to the deep
with the open coronal approach, in which scalp excision main-
temporal fascia provides permanent fixation.
tains brow position. Even 26 years after the endoscopic approach
Muscle modification, although theoretically possible, especially
was introduced, there is still no consensus on endoscopic fixation.
with an endoscope, is not usually performed with this approach.
Opinions range from muscle balance is all that counts; fixation
This approach is best combined with a transpalpebral excision of
is not necessary to the other extreme: that fixation must be per-
manent. I individualize the need for fixation, whether permanent,
temporary, or not at all. e must bear in mind that toxins provide
a way to reposition the brow effectively through altering muscle
balance without any surgical fixation.

Fig. 26.8 An endoscopic approach to brow lifting through the central
port to access corrugator excision.
Fig. 26.9 The shape of the forehead and hairline can have significant
implications on access and visualization for an endoscopic approach.
The patient at left has a shorter forehead with a flatter contour,
making it more favorable for an endoscopic approach. Hair thickness,
skin thickness, and depth of rhytids are other considerations to take
into account.

Table 26.2 Endoscopic forehead lift: favorable and unfavorable

candidates
An mi e ure r e n r e
re e d
Height Short High
Convexity Flat Convex

Hairline
Height Short High
Receding Nonreceding Receding
Hair quality Thick Thin
S in

Fig. 26.10 Lateral–temporal brow lift approach, which allows for Thickness Normal Thick
repositioning and elevation of the lateral brow. Rhytids Superficial Deep

287
 V Brow Lift

the corrugator supercilii and division of the procerus muscles for

an effective brow lift.
The best candidates for this combined approach are patients
with little if any excess skin at the nasal radix, those requiring
little if any medial brow repositioning, and those who are candi-
dates for upper lid blepharoplasty. Advantages are the minimally
invasive approach and the minimal risk of sensory changes.

Direct Approach
The direct approach is effective in elevating the lateral brow,
but it is rarely performed, because it leaves a scar directly over
the hair-bearing brow or in a transverse forehead line. The
best candidates are elderly patients or those with pronounced
lower forehead transverse creases where the scar can be Fig. 26.11 Direct brow lift incisions as shown are best for older
concealed. This approach offers excellent brow elevation and patients or those with pronounced lower forehead transverse creases
access to the muscles. Traditionally, the excision has not been as shown.
combined with muscle excision. The advantages of this method
are that it is simple and quick, it can be performed with local
anesthesia in many instances, and it carries minimal risk to
the sensory nerves. The scar is the only potential disadvantage
(Fig. 26.11).

Transpalpebral Browpexy
Minimal lateral brow elevation is possible through this approach,
in which the lateral brow is repositioned through the upper
eyelid incision and sutured down to the periosteum (Fig. 26.12).
The limited elevation achieved with this approach restricts this
procedure to patients with mild lateral brow ptosis without any
medial brow ptosis or excess skin at the nasal radix.

Transpalpebral Excision of Corrugator and Fig. 26.12 Transpalpebral brow pexy approach.

Procerus Muscles
Modification of the glabellar muscles through the upper eyelid
results in improvement of glabellar lines with minimal medial
elevation of the brow (Fig. 26.13). Lateral brow elevation is per-
formed through the lateral–temporal lift. The best candidates are
individuals with glabellar frown lines with minimal if any medial
or lateral brow ptosis. In combination with a lateral–temporal
brow lift, this is my preferred choice for brow rejuvenation in
patients requiring minimal or no medial brow elevation.
The patient with brow asymmetry, glabellar frown lines, and
aging of the upper and lower lids shown in Fig. 26.14 underwent
upper and lower lid blepharoplasty with transpalpebral excision
of the corrugator and division of procerus muscles. Postoperative
views and a split-face view 18 months postoperative show elim-
ination of glabellar frown lines, improvement of asymmetry, and
Fig. 26.13 Transpalpebral brow approach for corrugator and procerus
appropriate brow position. muscle excision.

Injection of Toxins
Toxin injections are the most popular procedure for brow reju-
venation, representing a safe and effective method for mild to
moderate brow elevation through alterations to muscle balance.
Advantages include the fact that this treatment is nonsurgical
and less expensive in the short run. Limitations include the
temporary nature of the correction, the necessity for repeated
injections, and the expense over time (Fig. 26.15).
26.2.2 Ancillary Procedures
The surgical procedures described so far reposition the brow
and improve forehead and glabellar lines. Frequently, additional
ancillary procedures are needed to improve the result further.
These include peels, laser resurfacing, and fillers. e will
often improve the vertical frown lines by threading a piece of

288
 ini e i i n ing in r i r e u en i n

a b c
Fig. 26.14 (a) Before and (b) after results, (c) with a split-face comparison, of a patient who underwent an upper and lower blepharoplasty and
transpalpebral approach for muscle excision.

Fig. 26.15 Botulinum toxin being administered in the area of the corrugator supercilii to treat vertical and oblique rhytids of the glabellar region.

autologous temporal fascia or orbicularis muscle just deep to

the dermis. If the temporal fascia is exposed during the brow lift
procedure, my preference is to harvest the temporal fascia and
use it as a filler. If an upper eyelid incision is made, the orbicu-
laris oculi muscle would be an alternative source of autologous
tissue. In my practice, laser resurfacing and autologous fillers for
forehead and glabellar lines are the two most common ancillary
procedures in forehead lifting.
The split-face view in Fig. 26.16 demonstrates preoperative and
5-year postoperative results after an endoscopic brow lift with
external screw fixation and laser resurfacing. Other procedures
performed in this patient included upper and lower lid blepharo-
plasties, face lift, neck lift, and perioral laser resurfacing.

26.3 Choosing the Best Option

Guidance for choosing the best option for brow lifting is given in
Fig. 26.16 Split-face view demonstrating preoperative and 5-year Table 26.3.
postoperative results after an endoscopic brow lift with external screw
fixation and laser resurfacing. Other procedures performed in this
patient included upper and lower lid blepharoplasties, facelift, neck
lift, forehead, and perioral laser resurfacing.

289
 V Brow Lift

Table 26.3 Choosing a brow lift option

Morphology and Coronal Endoscopic er r n e r er em r r Direct r e y Ancillary
aging changes em r r eru i r n e r
corrugator r eru rrug r Laser Autologous
excision excision i er
re e d
High
Low

Flat
Convex
Hairline
High
Low
Receding
S in e
Lateral
Medial
S in
Thick
Normal
Deep rhytids
Superficial rhytids
r ii n
Lateral
Normal
Low
Medial
Normal
Low

Suggested Reading
1 Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term
results. Plast Reconstr Surg 2006;117(4):1137–1143, discussion 1144
2 Byrd HS, Burt D. Achieving aesthetic balance in the brow, eyelids, and midface.
Plast Reconstr Surg 2002;110(3):926–933, discussion 934–939
3 Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech-
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200
4 Carruthers A, Carruthers . Eyebrow height after botulinum toxin type A to the
glabella. Dermatol Surg 2007;33(1 Spec o.):S26–S31
5 Farkas LG, olar C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
6 nize DM. Reassessment of the coronal incision and subgaleal dissection for
foreheadplasty. Plast Reconstr Surg 1998;102(2):478–489, discussion 490–492
7 nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
8 Mahmood U, Baker L r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624
9 Pelle-Ceravolo M, Angelini M. Transcutaneous brow shaping: a straight-
forward and precise method to lift and shape the eyebrows. Aesthet Surg J
2017;37(8):863–875
10 Sweis IE, Hwang L, Cohen M. Preoperative use of neuromodulators to optimize
surgical outcomes in upper blepharoplasty and brow lift. Aesthet Surg J
2018;38(9):941–948
11 Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit
2006;25(4):261–265

290

27 Temporal Brow Lift
Foad Nahai
Abstract
The temporal approach for repositioning of the central and lat-
eral brow is described. It may be combined with transpalpebral
excision of the corrugator and procerus muscles.
Keywords
temporal lift, corrugator excision, procerus modification
27.1 Introduction
Our goals for brow rejuvenation include repositioning the
eyebrows according to cultural norms and individual tastes,
eliminating or at least improving lines at rest or on animation,
reducing lateral orbital crowding, and correcting excess gla-
bellar skin over the nasal radix. Very often brow rejuvenation
is combined with an upper lid blepharoplasty. In these patients
the upper eyelid will be the gateway to the brow, as the lower
eyelid has become an important gateway for rejuvenating the
lid-cheek junction and the midface. In this chapter I will discuss
the role of the upper eyelid as a gateway to the brow and its role
in periorbital rejuvenation.
ith the many options for brow repositioning and rejuvena-
tion, selection of a procedure based on the patient’s individual
needs is the key. ot every patient requires, nor should every
patient undergo, an endoscopic or coronal brow lift to achieve an
ideal result.
Through a limited temporal incision similar to that for the
three-incision endoscopic brow lift, the periorbital septa and
adhesions are easily divided, and subperiosteal dissection almost
to the midline is also possible. Although challenging, even glabel-
lar muscle modification is possible through this incision. However,
my preference is to modify the glabellar muscles through the
upper eyelid in this combination approach. Lateral brow elevation
and fixation are easily achieved with this approach.
Injectable toxins and this combination approach have signifi-
cantly reduced the number of endoscopic brow lifts in my prac-
tice. Today I undertake an endoscopic brow lift only in patients
who would benefit from medial brow elevation as well as lateral
brow repositioning.
27.2 Indications and
Contraindications
The lateral brow lift is best for patients with no medial brow
ptosis, no glabellar skin excess above the nasal radix, and
forehead aging limited to the lateral brow. For patients with
glabellar lines, modest medial brow depression, and no excess
skin above the nasal radix, the combination approach, includ-
ing transpalpebral modification of the glabellar muscles, is an
em r r i
excellent option, with results matching those achieved with
endoscopic and even open coronal techniques. I often combine
this approach with an upper lid blepharoplasty and midface
rejuvenation or a full facelift. This is not an effective procedure
for patients with significant medial brow ptosis, excess glabellar
skin over the nasal radix, or deep forehead lines at rest. Those
individuals are better suited for an endoscopic or coronal
approach.
27.3 Preoperative Planning
27.3.1 Brow Markings
The patient is instructed to clench the teeth while contracting
the temporalis muscle, so the surgeon can palpate the muscle
the temporal crest–temporal line of fusion is marked along the
anterior border of the contracted muscle. If the sentinel vein is
readily visible with the patient in a sitting position, it is marked
(Fig. 27.1).
Otherwise, the patient is asked to lie supine, and the sentinel
vein is marked. The temporal incision is marked 2 to 3 cm behind
the temporal hairline, extending no higher than the temporal crest
to avoid injury to the lateral branch of the supraorbital nerve. The
incision is planned directly over the muscle to facilitate anchoring
of the temporoparietal fascia to the deep temporal fascia. Incisions
beyond the extent of the temporalis muscle should be avoided
(Fig. 27.2).
27.3.2 Eyelid Markings
The upper eyelid is marked for blepharoplasty with the upper
eyelid crease at the level of the midpupillary line, usually 8 to 10
mm above the lashes in women and a little lower in men. The lat-
eral marking should be at least 6 mm above the lateral canthus,
with a lateral extension within one of the crows’ feet, if present.
At least 10 mm of skin should be preserved between the upper
marking and the hair-bearing brow. In addition, I ask the patient
to frown so that I can mark the extent and bulk of the corrugator
muscle. If there are any horizontal glabellar lines, indicating pro-
cerus hyperactivity, those are marked as a reminder to section
the procerus muscles (Fig. 27.3).
27.4 Operative Technique
27.4.1 Anesthesia
The procedure may be performed with the patient under local
or general anesthesia. In my practice, because most of these
procedures are combined with full facial rejuvenation, I prefer
a general anesthetic. I always infiltrate the surgical field with a
combination of lidocaine and epinephrine.
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 V Brow Lift
I prefer to start with the lateral temporal brow lift first, simulate
the new brow position to confirm the upper eyelid skin excision, and
then proceed with the upper eyelid component of the operation.
27.4.2 Lateral Temporal Brow Lift
I perform this portion of the operation exactly as I do for an endo-
scopic brow lift. The incision is placed coronally or horizontally or
anywhere in between, depending on the desired final brow posi-
tion. The incision is made and continued through the temporopa-
rietal fascia onto the deep temporal fascia. The initial dissection is
made bluntly, with the scissors pushing along the deep temporal
fascia toward the lateral orbital rim to establish an optical cavity.
From this point on, the dissection can continue under endoscopic
control or, my preference, direct vision with the aid of a lighted
retractor or an Aufricht retractor and a headlight (Fig. 27.4).
The endoscope is introduced, and dissection proceeds rapidly
with an endoscopic dissector in this avascular plane toward the
lateral orbital rim. The sentinel vein is easily identified, and I prefer
Fig. 27.1 Marking out the anterior border of the temporalis muscle.
Fig. 27.2 The patient is supine with the temporal incision marked 2 to 3 cm behind the hairline below the temporal crest. The sentinel vein is marked
as well at this point if it was not already identified in the upright position.
292
to preserve it. The septa and adhesions are released, usually with
the endoscopic dissector. To ensure complete release and thus
mobilization of the lateral brow, I make a point of skeletonizing
the sentinel vein (Fig. 27.5).
Some of the septa and adhesions, especially beyond the vein,
may require division with endoscopic scissors. Following the
skeletonizing of the sentinel vein, dissection continues minimally
beyond the orbital rim and then laterally through the temporal
crest and into the subperiosteal space.
The extent of the medial subperiosteal dissection varies from
patient to patient and depends on brow shape and the desired
final result (Fig. 27.6).
At this stage the lateral brow is tested with upward traction at
the skin edge to ensure mobility by observing the upward and
medial rotation of the lateral brow. If the lateral brow moves only
minimally, further dissection must be performed; otherwise,
there may be no brow elevation. The brow is not fixed at this stage.
I then proceed with upper lid blepharoplasty and glabellar muscle
modification.

Fig. 27.3 The temporal dissection is similar to that of the endoscopic approach and easily completed without the endoscope.
Fig. 27.4 The lateral brow is elevated and the sentinel vein skeletonized for better mobilization.
Fig. 27.5 After lateral mobilization and skeletonizing of the sentinel
vein, a variable amount of medial dissection is performed.
27.4.3 Transpalpebral Glabellar Muscle
di i n
I perform the glabellar muscle modification with loupe magnifi-
cation. The upper eyelid skin and muscle are excised as marked.
em r r i
The dissection proceeds superiorly deep to the orbicularis oculi,
facilitated by two Blair retractors suspending the upper edge
of the resected orbicularis. I prefer to operate with the cutting
current of the Colorado eedle (Stryker CMF, alamazoo, MI).
Alternatively, the dissection can be performed easily with a pair
of scissors. At this stage, even if I am planning to resect upper
eyelid fat, I leave the orbital septum intact, and any planned fat
removal is delayed until after the glabellar muscle is excised, thus
facilitating dissection of the orbicularis off the orbital septum.
Laterally, the dissection is continued along the deep surface of
the orbicularis until the lateral orbital dissection through the
eyelid is continuous with the endoscopic dissection from above.
Once the communication between the eyelid and brow plane
of dissection has been established, I make a number of radial cuts
into the lateral orbicularis, not to permanently weaken it but
rather to weaken it temporarily to prevent the downward pull
of the orbicularis during the early postoperative phase to help
maintain lateral brow position. The radial cuts are made in the
muscle with the Colorado eedle and with a finger placed behind
the hair-bearing brow pushing the muscle forward to facilitate
scoring (Fig. 27.7).
Medially, the dissection approaches the supraorbital rim. The
orbicularis fibers running horizontally must be divided to reach
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 V Brow Lift

Fig. 27.6 The patient has both the upper eyelid blepharoplasty and associated glabellar bulk/creases caused by the corrugator or procerus muscles
marked. The lateral extension of the blepharoplasty should be placed within one of the crow’s feet.

the diagonally running muscle fibers of the corrugator supercilii
muscle (Fig. 27.8). Branches of the supratrochlear nerve may also
be visible at this stage (Fig. 27.9).
The orbicularis muscle is divided with the Colorado eedle or
by spreading with the tips of scissors or a fine mosquito clamp.
This immediately brings the corrugator muscle and a branch or
two of the supratrochlear nerve into view (Fig. 27.10).
Although the corrugator muscle can be divided in stages, I
prefer to insert the tips of the fine mosquito clamp around the
entire muscle belly if possible; otherwise, I insert the tips partially
through it, spread the tips, and resect the intervening segment of
muscle. I often encounter a branch or two of the supratrochlear
nerve coursing through the muscle. The supraorbital nerve is
usually lateral to this dissection (Fig. 27.11).
Removal of a segment of the muscle reveals one or more intact
branches of the supratrochlear nerve (Fig. 27.12). These nerves
are often accompanied by blood vessels that can bleed. I make
every attempt to avoid these vessels. If they bleed, I cauterize
them with a bipolar cautery rather than a unipolar coagulating
current. The muscle division/excision should be complete to pre-
vent postoperative recurrence of glabellar function and lines. At
the completion of the procedure, there should be a significant gap

Fig. 27.7 Medially, exposure of the corrugator supercilii via a transpalpebral approach through a window in the medial orbicularis.

Fig. 27.8 Branches of the supratrochlear nerve are identified through the medial orbicularis window.

294
 em r r i

Fig. 27.9 The orbicularis muscle window is made with a fine mosquito clamp.

Fig. 27.10 Exposure and isolation of the corrugator muscle belly.

Fig. 27.11 Excision of the corrugator muscle segment and exposed branches of the supratrochlear nerve.

in the muscle with preservation of the supratrochlear and supra-
orbital branches. Theoretically, dissection in the upper medial
corner of the orbit may injure the trochlear or superior oblique
muscles. Such injuries are very rare and are easily avoided by
limiting the dissection behind the origin of the corrugator muscle.
It is rare that any contour deformities result from this excision
of the corrugator; however, if there is any concern, fascia and
periorbital fat serve well as filler between the cut ends of the
corrugator muscle.
In patients who have transverse glabellar or dorsal nasal skin
lines resulting from procerus muscle activity, the procerus is
transversely divided through the blepharoplasty incision by ele-
vating the orbicularis and then pushing a pair of scissors deep to
the skin toward the nasal radix, cutting the fibers off the procerus

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 V Brow Lift
Fig. 27.12 Radial cuts are made through the lateral orbicularis to weaken it temporarily and prevent downward pull while the lateral brow heals in its
new position.
under the skin. If necessary, periorbital fat is excised at this time
(Fig. 27.13).
The next step is brow fixation. The brow is rotated upward and
medially, and the temporoparietal fascia is anchored down to
the deep temporal fascia. I usually place two 2–0 polydioxanone
sutures (PDS) between the temporoparietal fascia and the deep
temporal fascia in a diagonal or vertical vector. More medial screw
fixation may be necessary, but this is rare. A minimal amount of
excess scalp is excised, and the scalp incision is closed with sta-
ples. The upper eyelid incision is closed (Fig. 27.14).
27.4.4 Postoperative Care
To minimize swelling, the patient’s head is kept elevated, and ice
packs are applied to the periorbital area.
27.5 Results
The middle-aged woman shown in Fig. 27.15 underwent a
temporal brow lift, transpalpebral corrugator excision, a nasal
compartment orbital fat flap to correct the A-frame deformity of
the upper lids, transconjunctival lower blepharoplasty with fat
distribution, and a facelift.
Fig. 27.13 Sharp division of the procerus muscle off its skin insertion.
296
The 50-year-old woman shown in Fig. 27.16 exhibited
aging of the upper and lower lids, lid–cheek junction, and face.
Rejuvenation of the periorbital area and lower face was planned.
She underwent a lateral temporal lift, upper and lower blepha-
roplasty, and a short-scar blepharoplasty. Four years postopera-
tively, the improved lateral brow position has been maintained.
27.6 Problems and Complications
Infection and bleeding are rare. Alopecia may be seen along the
temporal incision line. This risk is minimized by avoiding exces-
sive tension in the scalp closure and limiting the use of coagulat-
ing current along the cut edges of the incision. Inadequate lateral
temporal release may lead to relapse or recurrence of brow
ptosis. The upper-eyelid procedure increases the risk of bleeding
and swelling beyond that of a standard upper-eyelid blepha-
roplasty. Hemostasis in the corrugator muscle bed is essential.
Unless combined with lower-lid procedures, ecchymosis and
other blepharoplasty complications are rarely seen.
Fig. 27.14 Anchoring of the temporoparietal fascia to the deep
temporal fascia.

a b
c c
Fig. 27.15 (a,c) This middle-aged woman underwent a temporal brow
lift, transpalpebral corrugator excision, a nasal compartment orbital fat
flap to correct the A-frame deformity of the upper lids, transconjuncti-
val lower blepharoplasty with fat distribution, and a facelift. (b,c) She is
shown several months postoperative.
27.7 Concluding Thoughts
Combining a lateral/temporal lift with an upper-lid blepharo-
plasty and transpalpebral excision of the corrugator muscle
through the upper eyelid is a safe and effective option for reju-
venation of the brow. It requires no special equipment beyond a
pair of loupes. The best candidates have moderate lateral brow
ptosis, appropriate medial brow position, and moderate vertical
glabellar frown lines.
Clinical Caveats
• The temporal incision must be kept over the temporalis muscle.
This not only eliminates the risk of injury to the lateral branch
of the supraorbital nerve but also ensures that the temporopa-
rietal fascia can be anchored down to the deep temporal fascia.
• Complete release of the lateral orbital attachments, adhe-
sions, and septa is essential; otherwise, the lateral brow
cannot be successfully elevated.
• Dissecting instruments should be kept firmly down over the
deep temporal fascia to avoid frontal branch injury.
• Vertical spreading in the vicinity of the sentinel vein should be
avoided to minimize the risk of stretch injuries to the frontal
branch.
• Loupe magnification greatly facilitates the transpalpebral
excision of the corrugator muscle.
em r r i
a b
Fig. 27.16 (a,c) This patient underwent rejuvenation of the periorbital
area and lower face with a lateral temporal lift, upper and lower
blepharoplasty, and a short-scar blepharoplasty. (b,c) Her 4-year
postoperative photo shows that her improved lateral brow position has
maintained.
• Connecting the lateral upper-lid and brow dissections through
the lower-lid dissection facilitates lateral brow elevation.
• Serial scoring of the lateral orbicularis oculi muscle minimizes
downward pull of the orbicularis during the postoperative
period, which assists fixation of the lateral brow position.
Suggested Reading
1 Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech-
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200
2 Farkas LG, olar C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
3 Guyuron B, Michelow B . Refinements in endoscopic forehead rejuvenation. Plast
Reconstr Surg 1997;100(1):154–160
4 Guyuron B, Michelow B , Thomas T. Corrugator supercilii muscle resection
through blepharoplasty incision. Plast Reconstr Surg 1995;95(4):691–696
5 nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
6 nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
7 Mahmood U, Baker L r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624
8 iechajev I. Transpalpebral browpexy. Plast Reconstr Surg 2004;113(7):2172–
2180, discussion 2181
9 Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr
Surg 2001;108(5):1409–1424
10 Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit
2006;25(4):261–265
297
 V Brow Lift
28 Endoscopic Brow Lift
Foad Nahai
Abstract
There have been many modifications to the original three-port
Emory endoscopic brow lift since 1993. The indications, instru-
mentation, and fixation options have all evolved. Those modifi-
cations and the author’s current indications for the endoscopic
approach are discussed.
Keywords
brow lift, brow shaping, endoscopic brow lift
28.1 Introduction
For too long we have focused on brow position rather than brow
shape and fullness as representing beauty and youth. Perhaps our
emphasis on brow height during the early days of endoscopic brow
lifting was not only a carryover of the thinking in the early 1990s
but also a desire to establish that endoscopic brow lifting could
elevate and maintain brow height. Since then, our understanding
of facial aging and the role of volume and deflation has been
advanced significantly through the work of Lambros and Coleman.
umerous publications have also established the efficacy of the
endoscopic brow lift for elevating and maintaining brow position.
Our current view is that a youthful or beautiful brow is related
more to volume and shape than to height (Fig. 28.1).
Endoscopic procedures have been modified with these ideals
in mind. Repositioning the brow with amelioration of forehead
and glabellar lines is an integral part of periorbital and full facial
rejuvenation. In a balanced, youthful face, the eyebrow is lower
medially and higher laterally, with a variable arch in between.
Several publications have attempted to describe the youthful or
Fig. 28.1 Comparison of brow positions show that both a low and high
brow can maintain a youthful appearance through fullness and brow
shape.
298
beautiful brow through numeric measurements and formulas.
However, there are many youthful and beautiful women without
high eyebrows. Given these variations of beauty and normalcy,
neither aging nor the success of rejuvenation in the periorbital
area should be judged by brow height; brow shape and volume
are far more important than brow height.
Early signs of brow and periorbital aging include deflation and
brow ptosis with a lowering of the medial and lateral hair-bearing
brow and development of vertical glabellar and horizontal forehead
lines. These changes often result in alterations to facial expression,
producing a tired, concerned, or even angry look. There is also real
or apparent excess skin on the upper eyelid. A variety of techniques
are available to reposition and reshape the brow and to soften ver-
tical and horizontal frown lines. Most involve mobilization, repo-
sitioning, and fixation of the forehead and brow with modification
of the forehead musculature. The open standard coronal brow lift
was for many years the only option for forehead rejuvenation; it
remains an effective, proven operation, the benchmark against
which other techniques are measured (Fig. 28.2).
In 1992 Isse and V sconez independently pioneered what we
refer to today as the endoscopic brow lift. Since that time, this
technique has evolved significantly: it has been simplified, the
instrumentation minimized, and the anatomy defined. It has
Fig. 28.2 Side-by-side comparison of the characteristics seen in a
more youthful (left) versus aging (right) brow and periorbital region.
 nd i r i

steadily gained in popularity and was once, without doubt, the

most common endoscopic procedure, not only in aesthetic sur-
gery but also in all of plastic surgery. However, the popularity and
effectiveness of toxins in reshaping and repositioning the brow
and the effectiveness of transpalpebral glabellar muscle modifica-
tion combined with a temporal brow lift have affected the number
of endoscopic brow lifts performed. Despite these recent devel-
opments, the procedure continues to enjoy tremendous patient
acceptance. Before endoscopic forehead lifts were introduced,
approximately 1 in 10 of my patients undergoing a facelift would
accept a coronal brow lift. Today some form of brow lift, whether
endoscopic, transpalpebral, or lateral temporal, is my routine for
almost all patients undergoing facial rejuvenation.
My experience with several hundred endoscopic brow lifts over
18-plus years has been favorable. Patient acceptance has been
high, morbidity has been low, and my results have compared
favorably with those of the coronal brow lift.
The endoscopic approach affords excellent exposure for release
of periorbital adhesions; muscle excision and nerve preserva-
tion are facilitated through the endoscope’s magnification. The
approach results in shorter scars and reduces the risks of sensory
denervation of the scalp and alopecia. However, scalp excision is
limited with this approach, so elevation and maintenance of brow
position must rely on muscle balance and fixation techniques,
compared with the open coronal method, in which scalp excision
maintains brow position.
Fig. 28.3 Side-by-side comparison of a good and a poor candidate
for endoscopic brow lift. The left shows a good candidate for an
endoscopic brow lift, with a short, flat forehead, nonreceding and
Advantages and Disadvantages of the thick hairline, normal skin, moderate rhytids, and minimal skin excess
Endoscopic Brow Lift medially over the nasal radix and laterally.

Advantages:
• Excellent exposure for release of periorbital adhesions
• Shorter scars
• Endoscopic magnification
• Reduced risk of alopecia and scalp sensory changes
Disadvantages:
• Initial cost of equipment and special instrumentation
• Technology-dependent nature of the procedures—equipment
failure may prevent completion of the procedure
• Learning curve involved
• Need for additional fixation
28.2 Indications and
Contraindications
The best candidates for an endoscopic forehead lift are patients with
short, flat foreheads who have nonreceding, thick hairlines and
normal skin, moderate rhytids, and minimal true skin excess lat-
erally and over the nasal radix. Poor candidates have a high convex
forehead, a high, receding hairline with thin hair, thick skin, deep
rhytids, and true excess skin on the forehead and brow (Fig. 28.3).
Forehead height and shape are limiting factors for a rigid
endoscope. In a patient with a short, flat forehead, it is relatively
easy for the surgeon to maneuver the endoscope to visualize the
glabellar musculature and orbital rim. A convex forehead makes
it difficult to maneuver the rigid, straight endoscope, and a high
forehead places limitations on the reach of the endoscope.
28.3 Pertinent Anatomy
ey anatomic points include the sentinel vein, the temporalis
muscle and temporal crest, periorbital septa and adhesions, gla-
bellar muscles, and the supratrochlear and supraorbital nerves.
28.3.1 Sentinel Vein
De La Plaza and coworkers described and named perforating
vessels in the temporal region and sentinel vessels of the lateral
wall of the orbit. These zygomaticotemporal veins are communi-
cating veins between the superficial and deep systems. There are
usually two zygomaticotemporal veins, one medial and the other
lateral; the medial is larger and is referred to as the sentinel vein.
The endoscopic view in Fig. 28.4 shows the medial and lateral
zygomaticotemporal veins. The smaller, or lateral one, is often
accompanied by the zygomaticotemporal nerve.
The sentinel vein (Fig. 28.2, top) is a useful landmark for preop-
erative planning (Fig. 28.2, bottom) and a key point for the release
of the periorbital septa and adhesions during the operation.
In most patients in the recumbent position, the sentinel vein is
located 1.5 cm above and lateral to the lateral canthus. The lowest
of the frontal nerve branches usually passes approximately 1 cm
above the level of the sentinel vein. Thus the sentinel vein defines
a danger zone for the frontal branch. I can operate rapidly toward
the zone with safety; however, when approaching the vein, the

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Fig. 28.4 Endoscopic view showing the medial and lateral zygoma-
ticotemporal veins, which are communicating veins between the
superficial and deep systems.
dissection is slowed under endoscopic control to prevent any
direct damage or stretching of the nerve.
28.3.2 Temporalis Muscle and Temporal
Crest
The temporal crest marks the transition from the dissection to
the temporoparietal fascial (subfascia) to the subperiosteal plane
by elevating the temporal line of fusion at the temporal crest. The
temporal crest also marks the lateralmost course of the lateral
branch of the supraorbital nerve. Preoperatively I ask patients to
clench their teeth, and I mark the temporal crest, as seen in Fig.
28.5. My left hand rests over the contracting muscle while the pen
held in my right hand outlines the temporal crest just anterior to
the contracting muscle. The sentinel vein is also marked.
28.3.3 Periorbital Septa and Adhesions
Although several authors have referred to ligaments in the perior-
bital area, Moss and coworkers pointed out that rather than true
ligaments, there are multiple septa and adhesions in the perior-
bital area. To mobilize the brow, especially the lateral periorbital
brow, all of the septa and adhesions must be completely divided. I
have found that skeletonizing the sentinel vein effectively releases
septa and adhesions, allowing elevation of the brow (Fig. 28.6).
28.3.4 Glabellar Muscles
The corrugator supercilii is the first muscle encountered with
the endoscopic approach in the glabellar region. Medial to the
corrugator are fibers of the orbicularis oculi muscle, called the
depressor supercilii. More superficially and in the midline lie the
procerus muscles. The supratrochlear nerves run within or just
superficial to the corrugator. The bulk of the orbicularis muscle
lies superficial to the corrugator and is viewed only once the
corrugator has been excised (Fig. 28.7).
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Fig. 28.5 Preoperative marking of the temporal crest, performed by
asking the patient to clench the teeth and feeling the edge of the muscle.
28.3.5 Supratrochlear and Supraorbital
Nerves
The supratrochlear nerves are several small filamentous nerves
lying within or just superficial to the depressor supercilii
and corrugator muscles. These nerves almost always emerge
through notches in the supraorbital rim. Injury to one or more
of these small filaments is inevitable during excision of the cor-
rugator muscle and is of relatively little significance. A useful
clinical landmark for the supratrochlear nerves is the vertical
glabellar frown line if present; it is usually 1.5 to 2 cm from the
midline.
The supraorbital nerve is much larger than the supratrochlear
nerves; it is usually one single large nerve, although occasionally
two or three branches may be seen. It emerges from the orbit
through a definite notch or occasionally through a foramen that
may be up to 2 to 4 cm above the supraorbital rim. Although the
supratrochlear nerves lie within the fibers of the corrugator, the
supraorbital nerve is usually deep to the corrugator. The lateral
branch of the supraorbital nerve may course as far lateral as the
temporal line of fusion. Any incision in the scalp that is medial to
the temporal line of fusion runs the risk of dividing this branch,
resulting in sensory loss in the forehead. A useful landmark for
this nerve is the midpupillary line, or a distance of 3 to 4 cm from
the midline (Fig. 28.8).
 nd i r i

Fig. 28.6 ones of adhesion in the brow and periorbital region. (Modified with permission from Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy
of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000; 105:1475-1490.)

Fig. 28.7 Anatomic relationships of the muscles in the glabellar region, with the corrugator muscles being the first encountered through the endoscope.

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• The necessary training

• Appropriate mechanical equipment
• nowledge of equipment troubleshooting and safety measures
• The technical skills to perform the procedure

Today endoscopic equipment, including the endoscope, camera,

monitors, and so on, has become standard in operating rooms where
aesthetic surgery is performed. Operating room personnel are now
quite familiar with this equipment and its maintenance (Fig. 28.9).

Team Preparation
The Surgeon

• Take a CME-approved endoscopic plastic surgery teaching

course.
• Familiarize yourself with the endoscope and camera.
• Study a DVD or videotape of the procedure.
Fig. 28.8 The relationship of the various nerves in the periorbital
• Watch a colleague perform the procedure.
region. The supratrochlear nerves are medial with smaller-caliber • If possible, have an experienced endoscopic surgeon assist
fibers, which run more superficially than the larger supraorbital nerve. you with your first case.
• Practice setting up the equipment.
e er ing mS

28.4 Preoperative Assessment • Receive in-service instruction from experienced operating

room personnel or a manufacturer’s representative.
Patient evaluation includes an assessment of the medial and lat-
• Dismantle and set up equipment.
eral brow position, position of the brow in relation to the upper
• Learn troubleshooting techniques.
eyelid, assessment of glabella and forehead lines at rest and on
• Be aware of the location of backup equipment.
animation, and assessment of frontal bone convexity, forehead
• Stage a dress rehearsal before performing an actual procedure.
height, and hairline. This evaluation influences the surgeon’s
• Learn the names of the endoscopic instruments.
choice of procedure. If the endoscopic brow lift is chosen, this
• Arrange endoscopic instruments in the order in which the
evaluation influences the location of the incisions, extent of surgeon will use them.
muscle modification, and fixation techniques, if any are needed.
• Watch a DVD or videotape of a procedure.
In patients with normal or minimal medial brow descent,
• Visit an operating room where these procedures are routinely
minimal or no glabellar skin excess over the radix, modest lateral performed.
brow ptosis, and superficial forehead lines at rest, I prefer the
combination of a lateral temporal brow lift and transpalpebral Minimum Equipment Needs
corrugator excision.
• Endoscope—4- or 5-mm 30° angle Hopkins rod
The surgeon advises the patient about the following:
• Endoscopic cannula or endoretractor—4 or 5 mm
• The number, location, and length of the incisions and, if fixation • Endoscopic cart
is required, the type of fixation (for example, external screws or Monitor
an Endotine Forehead fixation device MicroAire, Charlottesville, Light source
VA ) and any additional incisions required for fixation • Camera (at least three-chip)
• Although the risk is minimal, the possibility of alopecia at the • Endoscope warmer
Defogging solution
incision sites and around the external screw fixation sites
• Electrocautery
• Possible temporary or even permanent sensory changes in the • Instrumentation
scalp
Curved elevators (two or three)
• To expect some downward movement of the brow within the Endoscopic scissors
first few months after the procedure, as well as that over the Insulated graspers
long term the brow will not be as high as the initial result • Fixation devices

28.5 Preoperative Planning Originally, up to 25 special instruments were designed and

marketed for the endoscopic brow lift. Today most of us have our
As with any technology-dependent technique, the surgeon must
own half-dozen or more favorite instruments for this procedure
have a basic understanding of the principles. In endoscopic aes-
(Fig. 28.10).
thetic surgery, the surgeon needs to have the following:

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Fig. 28.9 An example of the video tower for endoscopic brow lift.
As a safeguard, it is important to have a backup system avail-
able, including a second endoscope, camera, and light source.
These are readily available in a large hospital or surgical center but
perhaps not in a small office-based operating room. Before every
operation, either the surgeon or the operating room nurse should
not only test the system but also inspect all of the instruments,
especially the endoscopic graspers. I specifically look for breaks
in the insulation of the graspers. Because we use the graspers for
cauterization, any break in the insulation could cause a burn.
28.5.1 Markings
The major landmarks for this procedure include the sentinel vein,
the temporal crest, and fixation vectors. If the sentinel vein is
readily visible with the patient sitting down, I put a mark over it
and then draw the likely course of the frontal branch of the facial
nerve 1 cm or so above the sentinel vein. If the sentinel vein is not
visible with the patient in the sitting position, I ask the patient to lie
flat, and in most patients the vein is then visible (Fig. 28.11). I then
ask the patient to clench his or her teeth firmly. This enables me to
palpate the muscle with my left hand as my right hand outlines the
temporalis muscle and the temporal crest on the forehead just ante-
rior to the contracting muscle (Fig. 28.12). I then mark the access
incision 1 or 2 cm behind the temporal hairline, making certain that
I am over the temporalis muscle. This will facilitate fixation of the
temporoparietal fascia down to the deep temporal fascia.
These markings are made symmetrically on both sides of the
head. The orientation of this temporal incision varies from radial
to coronal. I individualize this based on the patient’s anatomy
and our goals. I prefer a coronal or horizontal incision to a radial
incision, because with the radial incision I am limited to one
fixation suture, whereas the other approach allows me to put in a
minimum of two fixation sutures.
I then ask the patient to frown, which outlines the origin and
insertion of the corrugator muscle. ext I mark the glabellar frown
line and the course of the muscle lateral to it to be a guide for muscle
nd i r i
Fig. 28.10 Standard instruments for an endoscopic brow lift.
excision. I also mark the midpupillary line, indicating the course of
the supraorbital nerve. Another mark is placed 2 to 4 cm above the
orbital rim in the midpupillary line, indicating a danger zone where
the supraorbital nerve could emerge through a foramen.
Finally, the vectors for fixation are marked. For temporal fixation,
I routinely rely on vector from the alar base to the lateral canthus
projected onto the forehead. An alternative line is drawn from the
oral commissure to the lateral canthus and then onto the forehead.
This vector provides a more vertical and upward elevation of the
lateral brow. If extra fixation is planned, such as with a screw or an
Endotine Forehead device, I individualize these vectors. In general,
I place them on the scalp in line with the most convex arch of the
brow. The projection of the most convex part of the brow onto the
scalp is marked as the site for additional fixation (Fig. 28.13).
The patient is shown in Fig. 28.14 with all of the final markings.
28.5.2 Patient Positioning
The patient is placed supine on the operating table with the head
extending slightly beyond the headpiece. This facilitates maneu-
vering of the endoscope and endoscopic instruments. The pro-
cedure can be performed with the patient under local or general
anesthesia. I prefer a general anesthetic because in my practice,
endoscopic brow lift procedures are almost always performed
in combination with other periorbital and facial rejuvenation
procedures (Fig. 28.15).
Operative Sequence
1. Hair preparation
2. Infiltration
3. Right temporal incision and dissection
4. Left temporal incision and dissection
5. Central access incision
6. Subperiosteal dissection
7. Division of periosteum from one lateral orbital rim to the other
8. Muscle modification
9. Drain placement
10. Closure of central access incision
11. Placement of temporal fixation sutures
12.Additional fixation, if needed
13.Tying of temporal fixation sutures
14. Temporal scalp excision, if needed
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Fig. 28.11 (a) Endoscopic view of the sentinel vein. (b) The sentinel vein can help as a preoperative landmark both for a key point to release perior-
bital septa and also to define a danger zone for the frontal nerve, whose lowest branch runs approximately 1 cm above the sentinel vein.

Fig. 28.12 Preoperative marking of the temporal crest, performed by asking Fig. 28.13 Preoperative marking of the most convex part of the brow
the patient to clench the teeth and feeling the edge of the muscle. onto the scalp as site for additional fixation.

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Fig. 28.14 Final preoperative markings for an endoscopic brow lift.
Fig. 28.15 Operative setup for an endoscopic brow lift.
nd i r i
28.6 Operative Technique
28.6.1 Hair Preparation
With the patient under general anesthesia, I cleanse the hair
with a soapy solution and braid the hair to expose the proposed
incision sites. Braiding keeps the hair out of the way during the
procedure; alternatively, the hair may be stapled on each side of
the proposed incisions (Fig. 28.16).
28.6.2 n r i n
The brow area is infiltrated with a solution of 1 lidocaine
(Xylocaine, Astra eneca, Cambridge, U ) and epineph-
rine 1:100,000, encompassing the entire area that will be
undermined.
28.6.3 Temporal Incisions and Dissection
I begin the procedure on the right side; the incision is made
through the scalp down to the deep temporal fascia over the
temporalis muscle.
ith a hook elevating the lower edge, I dissect in the plane
between the temporoparietal fascia and the deep temporal fascia.
This is a bloodless field, and the dissection proceeds rapidly
toward the lateral orbital rim (Fig. 28.17).
Once the dissection is started, I switch from Metzenbaum
scissors to a Ramirez no. 4 dissector. I dissect rapidly toward
the orbital rim, without the endoscope but under direct vision,
with an Aufricht retractor and a headlight, keeping the tip of
the dissector firmly down on the deep temporal fascia. This
avoids any possible risk of damage or stretching of the frontal
branch. The dissection is stopped within 1 cm of the sentinel
vein. This nonendoscopic dissection is continued medially
through the temporal line of fusion and then in a superior
direction so that the temporal line of fusion is elevated and
the subperiosteal space is entered. At this stage the endoscope
is introduced, and with the same dissector the dissection is
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Fig. 28.16 Preparation of hair and incision sites.
continued toward the sentinel vein and the lateral orbital rim
(Fig. 28.18).
The sentinel veins are easily identified. In most patients I am
able to divide the septa and adhesions around the sentinel vein
Fig. 28.17 Temporal incision made and dissection taken down to the
deep temporal fascia.
306
and extend the dissector into the upper eyelid, deep to the orbicu-
laris and the retro–orbicularis oculi fat (ROOF; Fig. 28.19).
If the adhesions around the sentinel vein cannot be taken
down with the dissector, I complete their division with the
endoscopic scissors under direct endoscopic control (Fig. 28.20).
I make every effort to preserve and skeletonize the sentinel vein
(Fig. 28.21).
At this stage I place traction on the lower edge of the inci-
sion, pulling the brow upward. This confirms whether all of
the adhesions have been released and that the lateral brow is
now mobile. Failing to release the lateral brow limits the result.
The procedure is then repeated in exactly the same way on the
left side.
28.6.4 Central Access Incision
The central access incision is made in the midline, approximately
1 cm behind the hairline. This is a radial incision extending
straight through to the periosteum.
The subperiosteal dissection is initiated with a straight
periosteal elevator and extended toward the glabella, later-
ally toward the temporal incisions, and posteriorly for 3 or
4 cm. This dissection is fairly rapid, and I progress through
 nd i r i

Fig. 28.18 Blunt dissection performed in the avascular plane on top of the deep temporal fascia.

b
Fig. 28.19 (a) Endoscopic view of a dissected sentinel vein, lateral zygomaticotemporal vein, and nerve. (b) Endoscopic view with the sentinel vein
dissected free circumferentially assuring release of all sepra and adhesions.

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Fig. 28.21 Fully skeletonized sentinel vein.

Fig. 28.20 Dividing the periorbital adhesions with endoscopic scissors,

allowing dissection to extend into the upper eyelid, deep to the
orbicularis oculi and retro–orbicularis oculi fat.

two other periosteal elevators with increasing curvature

(Fig. 28.22).
The subperiosteal dissection is connected with both temporal
dissections and extended in the midline to the glabella and to a
level approximately 2 to 4 cm above the supraorbital rim. This
subperiosteal dissection is performed blindly (Fig. 28.23).
The endoscope is then introduced through this central access
incision so that the subperiosteal dissection, which is completed
down to the supraorbital rim, is continued under endoscopic
control to permit identification and easy preservation of the
Fig. 28.22 Central access incision with subperiosteal dissection with
supraorbital nerve if it emerges through a foramen above the progressively curved elevators.
supraorbital rim (Fig. 28.24).

28.6.5 Division of the Periosteum

At this stage the periosteum is divided from one lateral orbital
rim to the next (Fig. 28.25). This periosteal division serves two
purposes:
1. To allow further brow elevation laterally; the medial brow and
glabellar periosteum may be left intact if medial brow elevation
or separation is not desired.
2. To permit access to the glabellar musculature.

28.6.6 u e di i n
After the periosteum is divided, the corrugator, procerus,
and depressor supercilii are easily seen. The direction of the
muscle fibers aids in identifying each individual muscle. The Fig. 28.23 Subperiosteal dissection is connected with both temporal
dissections.
procerus fibers have a slightly deeper color, with the fibers
running vertically. The depressor fibers are lighter in color and
are vertically oriented also, whereas the corrugator fibers run
diagonally. grasper; I grasp a little muscle at a time and tease it upward (Fig.
I have tried various instruments for muscle modification, 28.26).
including Takahashi forceps, coagulating current, a laser, and I have found that the muscle tears very easily, but the branches
even a periosteal elevator. My preference now is the endoscopic of the supratrochlear nerve are more resilient. Depending on the

308
 nd i r i

b c
Fig. 28.24 (a–c) Endoscopic view of the central access subperiosteal dissection.

b c
Fig. 28.25 (a–c) Endoscopic division of the periosteum at the level of the orbital rim.

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Fig. 28.26 Takahashi forceps to resect the corrugator muscle.
Fig. 28.27 Endoscopic grasper to resect the corrugator muscle.
bulk of the muscle and the severity of the patient’s glabellar lines,
I vary the extent of muscle division and the amount of muscle I
remove (Fig. 28.27).
At the end of the muscle modification, the branches of the
supratrochlear nerve should lie bare within the optical field.
Sometimes with a heavy muscle I extend the dissection laterally,
superficial to the supraorbital nerve (Fig. 28.28).
The supraorbital nerve and a separate lateral branch are
shown after muscle excision in Fig. 28.29. I rarely need to
cauterize any vessels. The combination of the slight elevation
of the head of the table and epinephrine infiltration yields a
relatively bloodless field. Occasionally bleeding is encountered
from veins accompanying the supratrochlear and supraorbital
nerves; this bleeding is easily controlled by holding the vein
with the endoscopic grasper, pulling it away from the skin, and
then gently cauterizing it. It is important to pull the vein away
from the skin and to set the electrocautery on a low level to
310
avoid injury to the surrounding nerves and even the overlying
skin. If there is bleeding in the field, I have found neurosurgical
patties to be very useful for drying up the field. I also like to
have a 10-mL syringe filled with saline solution attached to the
endoscopic sheath for irrigation. This irrigation is useful for
clearing the field, if needed, but most of all to eliminate fogging
of the endoscope.
28.6.7 Drain Placement
I routinely drain all endoscopic brow lifts for up to 24 hours.
Although there is minimal drainage, 20 to 25 mL at most, I believe
this makes a big difference with regard to upper lid swelling and
ecchymosis, especially when the endoscopic brow procedure is
combined with upper-lid blepharoplasty. I prefer to place a 10
French drain directly along the supraorbital rim with the tubing
exteriorized behind the ear on one side (Fig. 28.30).
 nd i r i

Fig. 28.28 Endoscopic views of the relation between the supratrochlear and supraorbital nerves with its corresponding veins after corrugator muscle excision.

Fig. 28.29 Endoscopic view of the supraorbital nerve and the lateral Fig. 28.30 Routine placement of a 10 French drain along the supraor-
branch of the supraorbital nerve. bital rim after endoscopic brow lift.

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28.6.8 Closure
The central access incision is closed first. I routinely fix the brow
in the temporal area with one or two 2–0 polydioxanone sutures,
anchoring the temporoparietal fascia down to the deep temporal
fascia. If additional paramedian fixation is needed (between the
temporal crest and the central access incision), I place temporal
fixation sutures, but I do not tie them until the paramedian
fixation is performed. Currently my choices for paramedian fix-
ation include external screw fixation or an absorbable Endotine
Forehead device. The Endotine Forehead device affords perma-
nent fixation and multidirectional vectors or modified Emory
taping. It does require a separate incision and a special drill bit.
hether it is an Endotine device, an external screw, a single
hook is placed on the scalp behind the planned fixation site. The
scalp is then lifted, pulled upward, and rotated medially.
External screw fixation using a hand drill and screw holder is
shown in Fig. 28.31. The drill has a 5-mm stop. With the assistant
b c
Fig. 28.31 (a) A hand drill and screw holder are used for (b,c) external
screw fixation through a stab incision.
Fig. 28.33 Drill hole placement and Endotine Forehead device being
fixated to the calvarium.
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maintaining the brow in the desired position through the hook,
a stab incision is made in the scalp, and a drill hole is made with
the hand drill. A self-tapping screw, 16 mm in length with a 5-mm
thread, is placed in the drill hole and secured. A staple is placed
behind this screw, maintaining the brow position.
For insertion of the Endotine Forehead device, a separate 2-cm
incision is made according to the preoperative vectors (Fig. 28.32).
The brow is then pulled close to its desired position. The Endotine
Forehead device has five prongs or tines to engage the periosteum and
hold it in the new position. ext, with a power or hand drill, a drill
hole is made, into which the device is placed with the tines pointing
backward. The Endotine Forehead device is inset into the drill hole.
The device may be rotated according to the fixation desired (Fig.
28.33). The scalp is pulled upward and rotated medially. Then the
scalp is pushed down onto the device to engage the tines (Fig. 28.34).
Once the paramedian fixation has been completed, the temporal
fixation sutures are tied, minimal scalp excision in the temporal
area is performed if needed, and the temporal incisions are closed.
28.6.9 Fixation Choices
Currently there is no consensus among surgeons regarding the
preferred method of brow fixation. In fact, there is even some
debate about whether any fixation is needed, because the muscle
balance between the glabella and the frontalis is altered, and
therefore brow position will likely be maintained.
a b
Fig. 28.32 (a) A 2-cm incision is made based on predetermined
vectors (b) for placement of the Endotine Forehead device.
Fig. 28.34 Fixation of the scalp on the Endotine Forehead device.
 nd i r i

ho needs fixation, and which methods work Temporal
fixation anchoring of temporoparietal fascia down to the deep
temporal fascia is universally applied to every patient in my
practice. Paramedian fixation between the temporal crest and
midline with an upward and medial rotation is selectively applied
on the basis of the patient’s aging changes, brow position, brow
shape, sex, and desired results.
I am more likely to use permanent paramedian fixation in a man
with heavy forehead skin and significant brow ptosis than in a woman
with moderate or minimal brow ptosis and normal forehead skin.
A variety of methods for brow fixation are available. I have had
experience with all of the fixation methods listed in Table 28.1,
except for the Mitek anchors. The fixation methods can be further
divided into temporary and permanent fixation. How long does
it take for brow position to become fixed How long does the
periosteum take to adhere Opinions vary from 8 days to as long
as 6 weeks. The only study available, which was in a rabbit model,
showed that it took the periosteum 6 weeks to stick back down. The
general consensus is that to be effective, the fixation should last at
least a couple of weeks. Based on this information, I consider the
external screws, which we normally take out at 1 week to 10 days,
to be temporary and the Endotine Forehead device to be permanent.
just deep to the dermis. I have found this method to be rapid,
effective, and relatively free of problems or complications. The
volume of the transferred tissue is preserved over time.
The woman in her 30s shown in Fig. 28.35 had brow ptosis and
very deep, established glabellar frown lines. She was a candidate
for endoscopic brow lift and autologous temporal fascia grafts to
the grade 5 rhytids in her glabellar area.
During the endoscopic brow lift for this patient, a 1 3-cm
piece of deep temporal fascia was harvested. The fascia was split
in half longitudinally into equal 0.5 3-cm strips (Fig. 28.36).
ith a no. 57 Beaver blade, a subdermal tunnel was made
under the left glabellar rhytid. In this procedure the blade not only
creates the tunnel but also releases the deep dermal attachments.
The blade exits the lower end of the rhytid, making a small inci-
sion in the skin (Fig. 28.37).

28.7 Ancillary Procedures

Frequently ancillary procedures are performed in combination Fig. 28.36 Temporal fascial grafts harvested during the endoscopic
with an endoscopic brow lift to improve the result further. These brow lift.
include peels, laser resurfacing, and injection of tissue fillers. In
patients with deep vertical frown lines at rest in whom muscle
modification alone will not eradicate the lines, I thread a piece
of autologous tissue, temporal fascia, or orbicularis muscle

Table 28.1 Endoscopic brow fixation methods

em r ry erm nen
Emory tapes Vertex sutures Mitek anchors
Bolster sutures Internal screws Permanent
Fibrin glue Permanent Absorbable Fig. 28.37 A subdermal tunnel being made with a Beaver blade.

External screws Absorbable Cortical tunnels

Endotine device

Fig. 28.38 Placement of temporal fascial grafts in a subdermal tunnel

Fig. 28.35 Patient with brow ptosis and grade 5 glabellar rhytids. for glabellar rhytids.

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A fine grasper is passed through the tunnel from above and
out through the lower incision. The grasper firmly holds the
fascial strip, which is pulled into the tunnel. The procedure is
repeated on the right side. ith both strips placed subdermally,
the protruding fascia is trimmed flush with the skin, and the stab
incisions are closed with 6–0 suture material. My preference is
6–0 rapid-absorbing catgut (Fig. 28.38).
Comparing the preoperative view with the patient’s postop-
erative results 1 year after treatment demonstrates improved
brow position, improved upper eyelids without an upper
eyelid blepharoplasty, and effective elimination of the glabellar
frown lines. The split-face image confirms the improvement
(Fig. 28.39).
28.8 Postoperative Care
Because most endoscopic brow procedures in my practice are
performed in conjunction with other aesthetic facial procedures,
these patients usually spend the night in our overnight facility.
They are kept comfortable, with the head elevated and an ice
pack over the eyes. Every effort is made to alleviate nausea and
to monitor blood pressure and keep it under control.
Antihypertensive medication and sedatives are administered
routinely in men and as needed in women. The drain is usually
removed the next morning, before the patient goes home. The
patient is advised to keep his or her head elevated and to avoid
strenuous activity for up to 3 weeks and is scheduled to return for
follow-up within 3 to 6 days.
28.9 Outcomes
Patient acceptance of this procedure has been high. There
have been few problems such as alopecia, dysesthesias, and
temporary nerve paralysis. In a personal series of approximately
700 patients, there was no permanent facial nerve paralysis.
a b
c
Fig. 28.39 (a,c) Pre- and (b,c) 1-year postoperative results showing
improved brow position, upper eyelids, and glabellar frown lines after
endoscopic brow lift and temporal fascia grafts for the glabella.
314
Temporary facial nerve paralysis was seen in less than 1 of
patients, and alopecia at the screw fixation site was seen in 4 .
The preoperative view of the woman shown in Fig. 28.40
demonstrates brow asymmetry, brow ptosis, glabellar and trans-
verse forehead rhytids (grade 4), and aging of the upper and lower
eyelids with crow’s feet. The patient underwent an endoscopic
brow lift with external screw fixation and upper and lower lid
blepharoplasty. The early postoperative view and a split-face
image demonstrate improvement of brow asymmetry, elevation
of the brow position, and improvement of rhytids. A close-up of
the left side of her scalp (Fig. 28.41) shows a 1 1.5-cm area of
alopecia at the site of the external screw fixation. This area was
excised to eliminate the bald spot.
Most patients experienced mild temporary dysesthesias. I have
personally reoperated on only one of my earliest endoscopic brow
patients for recurrent brow ptosis.
28.10 Results
The woman in her late 40s shown in Fig. 28.42 had brow ptosis,
grade 5 glabellar lines, and full facial aging; she underwent
an endoscopic brow lift with no paracentral fixation. She also
had upper and lower eyelid blepharoplasty, facelift, and neck
a b c
Fig. 28.40 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent correction of brow asymmetry, brow ptosis, glabellar and
transverse forehead rhytids (grade 4), and aging of the upper and
lower eyelids with crow’s feet. She underwent an endoscopic brow lift
with external screw fixation and upper and lower lid blepharoplasty.
Fig. 28.41 A close-up of the left side of the scalp of the patient in Fig.
28.40 shows a 1 × 1.5-cm area of alopecia at the site of the external
screw fixation. This area was excised to eliminate the bald spot.
 nd i r i

a b c a b c
Fig. 28.42 (a,c) Pre- and (b,c) postoperative photos of a patient who Fig. 28.43 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent correction of ptotic brows with grade 5 glabellar lines and underwent correction of heavy, ptotic brows with grade 4 glabellar
facial aging. She underwent an endoscopic brow lift with upper and rhytids.
lower lid blepharoplasty, facelift, and neck lift.

central scalp excision because it led to these exaggerated medial

lift. Her postoperative result at 18 months demonstrates an brow elevations.
elevated brow position with significant improvement in the The woman in her late 40s shown in Fig. 28.45 had heavy
glabellar lines. This is most readily apparent in the split-face brows and brow ptosis. She had an endoscopic brow lift with
image, demonstrating elevation of the medial and lateral brow. Emory taping. She is shown at 7 years and 8 years postoper-
The woman in her early 50s shown in Fig. 28.43 had heavy, atively, demonstrating maintenance of the elevated brow
ptotic brows with grade 4 glabellar rhytids. She underwent an position.
endoscopic brow lift with external screw fixation as well as a
lower lid blepharoplasty and transpalpebral midface lift. Her
postoperative result demonstrates improvement of brow position,
amelioration of rhytids, and improvement of the lower lid–cheek
junction and midface area.
The man in his 40s shown in Fig. 28.44 had a heavy ptotic brow
and deep grade 5 transverse forehead lines. He underwent an
endoscopic brow lift with Emory taping, upper lid blepharoplasty,
and transconjunctival removal of fat from the lower eyelids.
Postoperative results at 4 months and at 7 years demonstrate
maintenance of brow elevation, including the exaggerated medial
brow elevation that was typical of our early endoscopic brow lifts
with the central Emory T to V scalp excision. I abandoned the

Fig. 28.45 Pre- and postoperative photos of a patient who underwent

an endoscopic brow lift with Emory taping.

a b c
Fig. 28.44 Pre- and postoperative photos of a patient who underwent Fig. 28.46 (a,c) Pre- and (b,c) postoperative photos of a patient who
an endoscopic brow lift with Emory taping, upper lid blepharoplasty, underwent an endoscopic brow lift, lower lid blepharoplasty with
and transconjunctival removal of fat from the lower eyelids. transpalpebral midface lift, and endoscopic neck lift.

315
 V Brow Lift
The 40-year-old woman shown in Fig. 28.46 had brow ptosis, 4 Coleman SR. Structural Fat Grafting. St. Louis: uality Medical Publishing, 2004.
5 Core GB, V sconez LO, Askren C, et al. Coronal face-lift with endoscopic tech-
grade 4 glabellar lines, and aging of the midface and neck. Despite
the high forehead, she elected to have an endoscopic brow lift, a 6 Daniel R , Tirkanits B. Endoscopic forehead lift. Aesthetics and analysis. Clin Plast
lower lid blepharoplasty with transpalpebral midface lift, and
an endoscopic neck lift. The postoperative view demonstrates 7 Daniel R , Tirkanits B. Endoscopic forehead lift: an operative technique. Plast
repositioning of the brow, amelioration of the glabellar lines,
8 De La Plaza R, Valiente E, Arroyo M. Supraperiosteal lifting of the upper two-
improvement of the upper eyelids (without an upper eyelid bleph-
aroplasty), and improvement of the lower lid and midface area. 9 Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift. Basics and options.
10
28.11 Concluding Thoughts
Although the use of neurotoxins and even less invasive brow 11
rejuvenation techniques have gained in popularity, and the
12
overall numbers of coronal and endoscopic brow lifts are in
decline, there is still a role for the endoscopic approach. Based on 13
my 16-plus years of experience, during which I have performed
several hundred endoscopic brow lifts, I conclude that the pro- 14
cedure is effective and safe, with lasting results. ith technical
15
modifications, the exaggerated medial brow elevation has been
eliminated. The need for fixation, if any, and the type of fixation 16
remain a matter of debate, and we each have our own thoughts
based on experience. 17
18
Clinical Caveats
19
• An endoscopic brow lift is a technology-dependent procedure. 20
The surgeon and operating room personnel should be familiar
with the endoscopic equipment and be able to troubleshoot 21
problems involving the camera, light source, and monitor.
• The success of this procedure depends on adequate release of 22
the periorbital septa and adhesions.
• Vertical spreading should be avoided during the temporal 23
dissection to prevent stretch injury of the frontal branch of
the facial nerve. 24
• Keeping the dissector firmly down on the deep temporal
fascia and temporalis muscle prevents any injury to the fron-
25
tal branch of the facial nerve.
• Release of the periosteum is essential for brow elevation. 26
• While resecting the glabellar musculature, the surgeon
should avoid removal of subcutaneous fat, which could result 27
in a depression.
28
• Every attempt should be made to preserve the sentinel vein.
Sacrifice of the vein leads to engorgement of the superficial veins, 29
which will become readily visible in thin-skinned individuals.
30
• If medial brow elevation is not desired, subperiosteal dissec-
tion should be avoided in the medial brow area.
31
Suggested Reading 32
1 Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term
results. Plast Reconstr Surg 2006;117(4):1137–1143, discussion 1144 33
2 Chajchir A. Endoscopia en cirugía plástica y estética. In Gonzalez Montaner L ,
Huriado Hoyo E, Altman R, et al, eds. El Libro de Oro en Homenaje al Doctor Carlos 34
Reussi. Buenos Aires: Asociaci n M dica Argentina; 1993:74–78
3 Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg
1994;18(3):269–274
316
niques. Plast Surg Forum 1992;25:227–229
Surg 1995;22(4):605–618
Reconstr Surg 1996;98(7):1148–1157, discussion 1158
thirds of the face. Br J Plast Surg 1991;44(5):325–332
Clin Plast Surg 1997;24(2):309–327
Elkwood A, Matarasso A, Rankin M, Elkowitz M, Godek CP. ational plastic
surgery survey: brow lifting techniques and complications. Plast Reconstr Surg
2001;108(7):2143–2150, discussion 2151–2152
Farkas LG, olar C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
Guyuron B. Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards.
Plast Reconstr Surg 2006;117(4):1121–1133, discussion 1134–1136
Hamas RS. An endoscopic brow lift that does not raise the hairline. Aesthet Surg J
1997;17(2):127–129
Hamas RS. Reducing the subconscious frown by endoscopic resection of the
corrugator muscles. Aesthetic Plast Surg 1995;19(1):21–25
Isse G. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case
reports. Aesthetic Plast Surg 1994;18(1):21–29
Isse G. Endoscopic forehead lift. Presented at the Annual Meeting of the Los
Angeles County Society of Plastic Surgeons, Los Angeles, September 12, 1992.
Isse G. Endoscopic forehead lift. Evolution and update. Clin Plast Surg
1995;22(4):661–673
nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg
2007;120(5):1367–1376, discussion 1377
Mackay G , ahai F. The endoscopic forehead lift. Oper Tech Plast Reconstr Surg
1995;2:137
Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar creases.
Dermatol Surg 1995;21(8):695–700
Moss C , Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous
attachments in the temple and periorbital regions. Plast Reconstr Surg
2000;105(4):1475–1490, discussion 1491–1498
ahai F, Saltz R. Endoscopic Plastic Surgery, 2nd ed. St Louis: uality Medical
Publishing; 2008
assif PS, okoska MS, Homan S, Cooper MH, Thomas R. Comparison of subperi-
osteal vs subgaleal elevation techniques used in forehead lifts. Arch Otolaryngol
Head Neck Surg 1998;124(11):1209–1215
Oslin B, Core GB, Vasconez LO. The biplanar endoscopically assisted forehead lift.
Clin Plast Surg 1995;22(4):633–638
Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg
1996;20(2):129–134
Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr Surg
1995;95(6):993–1003, discussion 1004–1006
Ramirez OM. Endoscopically assisted biplanar forehead lift. Plast Reconstr Surg
1995;96(2):323–333
Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann
Plast Surg 1996;37(6):577–584
Roberts TL III, Ellis LB. In pursuit of optimal rejuvenation of the forehead:
endoscopic brow lift with simultaneous carbon dioxide laser resurfacing. Plast
Reconstr Surg 1998;101(4):1075–1084
Rohrich R , Beran S . Evolving fixation methods in endoscopically assisted
forehead rejuvenation: controversies and rationale. review Plast Reconstr Surg
1997;100(6):1575–1582, discussion 1583–1584
Rosenberg G . The subperiosteal endoscopic laser forehead (SELF) lift. Plast
Reconstr Surg 1998;102(2):493–501
Trinei FA, anuszkiewicz , ahai F. The sentinel vein: an important reference
point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32
V sconez LO. The use of the endoscope in brow lifting. A video presentation
at the Annual Meeting of the American Society of Plastic and Reconstructive
Surgeons. ashington, DC, 1992
 nd i r i y er n A r

29 Endoscopic Brow Lift: My Personal Approach

H. Devon Graham III

Abstract
ith the adaptation of endoscopic techniques from sinus sur-
gery to aesthetic surgery a new era was ushered into our field in
the mid 1980s. The endoscopic brow lift procedure has evolved
over time as refinements have been made with increased
surgical experience and better understanding of the surgical
anatomy of the upper face. This chapter is the culmination of
25 years of practice with plenty of errors and triumphs along
the way. It includes my surgical technique as it stands today
as well as patient selection and representative results. The
endoscopically assisted brow lift procedure is an invaluable
option for brow rejuvenation. It is not, however, the end-all
for every patient. Excellent results can be achieved only with
proper patient selection and proper execution by the surgeon.
Communication, in any relationship, is paramount, and the
doctor–patient partnership is no exception. ith the proper
patient, realistically addressed expectations, and meticulous
Fig. 29.1 Ptosis of the brow/forehead complex contributing to a tired,
execution this technique can achieve superior, lasting results sad, even angry appearance at rest.
with minimal morbidities.

Keywords
a result with which both the patient and surgeon are happy.
endoscopic, brow lift, arcus marginalis, conjoined tendon, senti- Best candidates for the endoscopic approach are the patients
nel vein, ptosis, rejuvenation, suspension with bilateral brow ptosis and a relatively short forehead as
well as deeper-set eyes (Fig. 29.2; Fig. 29.3). Less ideal candi-
dates for endoscopic approach are those patients with a long
29.1 Introduction forehead and high hairline (Fig. 29.4; Fig. 29.5) or patients
The advent of endoscopic techniques for sinus surgery in the with thick, heavy, or sun-damaged skin (Fig. 29.6; Fig. 29.7).
mid-1980s ushered in a new era in the field of facial rejuvenation. oncandidates include patients with frontal branch paralysis
Soon afterward these instruments were adopted by innovative (Fig. 29.8).
surgeons performing facial cosmetic surgery, with the goal
being, as it was with sinus surgery, to reduce the morbidity of the
procedures performed while maintaining or improving results.
hen meeting someone, the first thing we see is his or her
eyes. The eyes and brow/forehead complex are under the control
of many sets of muscles that are completely expressive in nature.
They are considered by some to be the windows to the soul ;
however, aging, gravitational forces, and genetic factors all can
contribute to ptosis of the brow/forehead complex and a tired,
sad, or even angry appearance at rest (Fig. 29.1). This may not
be how the individual feels, but it is what is conveyed to those
around him or her. These are the patients who present to us for
upper facial rejuvenation.

29.2 Indications and

Contraindications: Patient
Selection
Fig. 29.2 Patient with bilateral brow ptosis and a relatively short
Early on in my career I learned from one of my mentors, Dr.
forehead as well as deeper-set eyes.
Gene Tardy, that patient selection is paramount to achieving

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 V Brow Lift

Fig. 29.3 Type I: Ideal candidate: thin-skinned, deep-set eyes; minimal Fig. 29.4 Type II: Excellent candidate: relatively thin-skinned; mostly
rhytids. medial brow ptosis; minimal to moderate rhytids.

Fig. 29.5 Type III: Good candidate: relatively thin-skinned; more lateral Fig. 29.6 Type IV: Good candidate for experienced surgeon: moder-
brow ptosis; some hypertrophy of corrugators; moderate rhytids. ately thick skin; bilateral brow ptosis with asymmetry.

Fig. 29.8 Type VI: Not an appropriate candidate: facial nerve paralysis,
Fig. 29.7 Type V: Less desirable candidate: thick, sebaceous skin; no brow elevator muscle; will need renervation procedure or static
heavy brows with deep rhytids. sling and skin excision for brow repositioning.

318
 nd i r i y er n A r

29.3 Pertinent Anatomy point above the lateral canthus; in men the brows should lie in a
more horizontal position. These relations are shown in Fig. 29.9.
Prerequisite for any facial aesthetic procedure is a working
knowledge of the functional and static anatomy of the forehead.
The functional anatomy of the brow/forehead complex consists 29.5 Preoperative Assessment
of paired muscles that act in conjunction or opposition, leading
to a myriad of facial expressions. These muscles are divided into 29.5.1 Patient Evaluation
elevators and depressors. As previously discussed, prospective patients fall into the following
The major elevator of the brow/forehead complex is the paired types with respect to their candidacy for endoscopic brow lifting:
frontalis muscles, which, along with the paired occipital muscles
and the interconnecting galea aponeurotica, form the epicranium. • Type I: Ideal candidate; thin-skinned, deep set eyes; minimal
The galea is a tendinous inelastic sheet that connects the frontalis rhytids (Fig. 29.3)
muscle to the occipitalis muscle and merges laterally with the • Type II: Excellent candidate; relatively thin-skinned; mostly
temporoparietal fascia (TPF), which is continuous with the super- medial brow ptosis; minimal to moderate rhytids (Fig. 29.4)
ficial musculoaponeurotic system (SMAS) in the lower face. The • Type III: Good candidate; relatively thin-skinned; more lateral
frontalis muscle originates from the galea, inserts in the forehead brow ptosis; some hypertrophy of corrugators; moderate
skin, and acts as the primary elevator of the brow. These muscles, rhytids (Fig. 29.5)
acting in concert, draw the scalp superiorly to raise the eyebrows.
• Type IV: Good candidate for experienced surgeon; moderately
Motor nerve supply to the frontalis muscle is via the frontal branch thick skin; bilateral brow ptosis with asymmetry (Fig. 29.6)
of the facial nerve. The frontalis muscle is by far the major elevator
of the brow, although the corrugator muscles have a very small
• Type V: Less desirable candidate; thick sebaceous skin; heavy
brows with deep rhytids (Fig. 29.7)
role in elevation of the medial portion of the brow upon contrac-
tion. The antagonistic depressor muscles of the brow include the • Type VI: ot an appropriate candidate; for example, facial
paired corrugator supercilii muscles, the orbicularis oculi, and the nerve paralysis (Fig. 29.8).
depressor supercilii muscles. The corrugator supercilii muscles are
the primary muscles responsible for the often deep vertical rhytids
of the glabella that trouble most patients. The procerus muscle,
originating from the nasal bones, produces the transverse rhytids
in the nasion. An excellent anatomic study of the function of these
muscles can be found in the work of G.-B. Duchenne from 1862.
The static forehead anatomy includes the skin, subcutaneous
tissue, and adnexa as well as the underlying layers of fascia that
overlie, underlie, or envelop the facial musculature. Also included
in the static anatomy are the sensory and motor nerves along
with the accompanying arterial and venous supply to these mus-
cles and the overlying soft tissue. An excellent description and
demonstration of these structures, as well as their pertinence and
relationships in terms of surgical procedures, may be found in the
work of Larrabee and Maeielski.
Understanding the anatomy for surgical dissection is often
distinguished from that encountered in the gross anatomy lab.
The same principle must be altered to facilitate anatomic findings
encountered during the endoscopic approach to the brow as well.
During the subperiosteal endoscopic forehead lift, the frontalis
muscle is not usually visualized, as the dissection is in the sub-
periosteal plane. Through the endoscope, familiar structures are
viewed in an unfamiliar manner; therefore, a thorough grasp of
the anatomy and the fascial planes is indispensable.

29.4 Aesthetics of the Brow

The classic eyebrow position has gone through various phases
over the years, but the basic tenets remain the same. The medial
origin should lie along a vertical line drawn through the nasal alar–
facial junction. The lateral brow should end on the same horizontal
plane as the medial brow and on its intersection with a line drawn
from the nasal alar–facial junction through the lateral canthus. In
women the brow arcs softly above the orbital rim with the high
Fig. 29.9 The “classic” eyebrow has gone through various phases over
the years but the basic tenants remain the same. The medial origin
should lie along a vertical line drawn through the nasal alar–facial
junction. The lateral brow should end on the same horizontal plane as
the medial brow and on a line drawn from the nasal alar–facial junction
through the lateral canthus. In women the brow arcs softly above the
orbital rim with the high point above the lateral canthus. In men the
brows should lie in a more horizontal position.

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 V Brow Lift

hen evaluating a patient for forehead and brow rejuvena-

tion, there are several factors to consider. As stated earlier, a
shorter forehead and lower hairline are ideal. If the patient has
deeper-set eyes, then an endoscopic brow lift could be the only
rejuvenation procedure needed. If the patient has upper lid der-
matochalasis, then it is imperative that the brow be addressed
first and then the upper lid. Thicker-skinned patients are not a
contraindication; however, the range of skin slide in the galeal
layer is greater than that of a thin-skinned individual, and thus
some degree of initial overcorrection is needed. hen exam-
ining patients, I ask them to completely relax their brow with
their eyes closed. This simple task is often quite difficult, as
they have been contracting their frontalis muscles constantly
for so long in order to bring their brows to a good position that
it is difficult to relax them. I will assist them by pushing down
on the brow until I feel it relax (Fig. 29.10). At this point I have
them open their eyes just enough to see straight ahead in the
mirror (Fig. 29.11). Here you can demonstrate to them their
ptotic brow position at rest and can show them, by raising
the brow with your fingers, what a brow lift could achieve
(Fig. 29.12).

29.6 Preoperative Planning

29.6.1 Surgical Markings and Positioning
The first step for preop markings is to locate the supraorbital Fig. 29.11 Examination of a patient before surgery. The patient is
notch or depression (Fig. 29.13). This corresponds to the asked to open her eyes just enough to see straight ahead in the mirror.

Fig. 29.12 Examination of a patient before surgery. The author

Fig. 29.10 Examination of a patient before surgery. Patient is asked to demonstrates to the patient her ptotic brow position at rest and shows
relax her brows. her what a brow lift could achieve by raising the brow with his fingers.

320

supraorbital neurovascular bundle, which is imperative to
preserve to avoid numbness of the forehead and scalp. Once
these are marked (Fig. 29.14), the desired vectors of elevation
are determined (Fig. 29.15) and the central pocket incisions
Fig. 29.13 Palpation for the supraorbital notch.
a b
Fig. 29.15 Determine (a) the intended displacements and (b) the vectors of pull desired to elevate and support the brows.
Fig. 29.16 Planned incisions for central ports are marked inside the
hairline along the required vectors.
nd i r i y er n A r
are marked a centimeter or so inside the hairline (Fig. 29.16).
The temporal elevation and support are then determined (Fig.
29.17), and those planned incisions are also marked within the
temporal hairline (Fig. 29.18).
Fig. 29.14 Bilateral notches are marked.
29.6.2 Injections
Injections are begun just lateral to the supraorbital neurovascu-
lar bundles along the orbital rim medially to the midline (Fig.
29.19). Through the same injection site the needle is pivoted
laterally and injection is made along the orbital rim to the level
of the lateral canthus (Fig. 29.20). The portal incisions are then
injected individually (Fig. 29.21).
The temporal pocket is then injected with a 22-gauge spinal
needle, and the local with epinephrine is fanned across this
area. It is critical here that the patient not have any paralytic
on board from anesthesia staff, as the injector should watch
for any stimulation of the frontal nerve branch. If that occurs,
then adjustment of the plane and angle of injection is required
(Fig. 29.22).
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 V Brow Lift

a b
Fig. 29.17 Lateral vectors of pull are likewise (a) planned and (b) marked: more upward in women and more horizontal in men.

a b
Fig. 29.18 Artist’s rendition of portal incisions: (a) central; (b) temporal.

Fig. 29.19 Injection just lateral to the supraorbital neurovascular Fig. 29.20 Lateral injection along the orbital rim through the same
bundles along the orbital rim medially to the midline. injection site used for the medial injection.

322

Fig. 29.21 After the orbital rim has been injected, the portal incisions
are then injected individually.
Fig. 29.22 The temporal pocket is then injected with a 22-gauge spinal
needle, and the local anesthetic with epinephrine is fanned across this
area, taking care to avoid any stimulation of the frontal nerve branch.
Fig. 29.24 Elevating the periosteum around the portal gently with a
Cottle elevator, taking great care to keep the periosteum intact.
nd i r i y er n A r
29.7 Endoscopic-Assisted Brow Lift
Operative Technique
29.7.1 Central Portal and Subperiosteal
Dissection
The central portal incisions are made first and carried down to and
through the periosteum with one complete incision (Fig. 29.23).
The periosteum around the portal is then gently elevated with
a Cottle elevator, taking great care to keep the periosteum intact
(Fig. 29.24).
A larger, flat elevator is then introduced into the portal, and
elevation is made inferiorly in the subperiosteal plane (Fig. 29.25).
The elevation progresses blindly to a point one fingerbreadth
above the orbital rim (Fig. 29.26).
The 30 endoscope is then introduced into the adjacent portal,
and the elevation is visualized (Fig. 29.27). As a left-handed
Fig. 29.23 The central portal incisions are made first and carried down
to and through the periosteum with one complete incision.
Fig. 29.25 Elevation inferiorly in the subperiosteal plane using a larger,
flat elevator.
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 V Brow Lift

surgeon, I set up with assistant holding the scope and camera on

the patient’s left and me on the right (Fig. 29.28).
The first step after introducing the endoscope is to identify
the supraorbital neurovascular bundles (Fig. 29.29). Of note, 1 in
10 patients will have this neurovascular bundle exiting the skull
from a true foramen rather than a notch (Fig. 29.30).
Once the neurovascular bundles have been identified and
preserved, attention is turned to the corrugator and procerus
musculature. I separate these fibers bluntly, though in some cases
sharp excision or laser lysis is warranted (Fig. 29.31).
A key component of this procedure is the complete release of the
arcus marginalis, where the periosteum of the frontal bone attaches
just inside the orbital rim. Externally, this lies below the eyebrow at
the orbital rim. For the brow to be elevated, it is imperative that this
release take place so that the periosteum can be advanced superi-
orly. Upon release of the arcus, the surgeon will immediately see Fig. 29.26 Elevation progresses blindly to a point one fingerbreath
retro–orbicularis oculi fat (ROOF) exposed (Fig. 29.32; Fig. 29.33). above the orbital rim.

Fig. 29.28 Setup for the author as a left-handed surgeon with

Fig. 29.27 The 30° endoscope is then introduced into the adjacent assistant holding the scope and camera on patient’s left and the author
portal and the elevation is visualized. on the right.

Fig. 29.30 Supraorbital neurovascular bundles exiting the skull from a

Fig. 29.29 Identification of supraorbital neurovascular bundles. notch (9 in 10 patients) and from a true foramen (1 in 10 patients).

324
 nd i r i y er n A r

29.7.2 Temporal Incisions

Incision is made beveled with the hair follicles (Fig. 29.34; Fig.
29.35). Sharp dissection is carried down through the temporopa-
rietal fascia to, but not through, the fixed temporalis fascia (Fig.
29.36).
Initial elevation is carefully made with the back of the knife
handle (Fig. 29.37). Utilizing a 0 scope, the temporal pocket is
joined to the central pocket from lateral to medial across the
temporal line (Fig. 29.38; Fig. 29.39).
An endoscopic view of the elevator coming from lateral to
medial is shown in Fig. 29.40. Elevation of the temporal pocket
then proceeds inferiorly (Fig. 29.41).
In a standard brow lift, the temporal elevation ends at the level
of the sentinel (medial zygomaticotemporal) vein (Fig. 29.42).
Fig. 29.31 Once the neurovascular bundles have been identified and
preserved, attention is turned to the corrugator and procerus muscu-
lature. The author separates these fibers bluntly, though in some cases
sharp excision or laser lysis is warranted.

a b
Fig. 29.32 (a) Arcus marginalis, where frontal periosteum attaches just inside the orbital rim, must be completely released. (b) Release of the arcus
marginalis reveals retro–orbicularis oculi fat (ROOF).

Fig. 29.33 Artist’s rendition of arcus marginalis release. Fig. 29.34 Artist’s rendition of temporal incisions.

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 V Brow Lift

Fig. 29.35 Temporal incision is made beveled with the hair follicles.
Fig. 29.36 Sharp dissection is carried down through the temporopari-
etal fascia to, but not through, the fixed temporalis fascia.

Fig. 29.37 Initial elevation is carefully made with the back of the knife
handle.

Fig. 29.38 Utilizing a 0° scope, the temporal pocket is joined to the

central pocket from lateral to medial across the temporal line.

Fig. 29.39 Artist’s rendition of elevation of temporal pocket across

temporal line. Fig. 29.40 Endoscopic view of elevator coming from lateral to medial.

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 nd i r i y er n A r

A key component of the elevation is release of the conjoined

tendon at the inferiormost aspect of the central and temporal
pockets (Fig. 29.43).

29.7.3 Temporal Fixation

The temporoparietal fascia is suspended along the planned vector
to the temporalis fascia using 3–0 PDS (Fig. 29.44; Fig. 29.45).

29.7.4 Central Fixation

My technique utilizes two Endotine Forehead fixation devices
(MicroAire Surgical Instruments, Charlottesville, VA; Fig. 29.46; Fig. 29.41 After the temporal pocket is joined to the central pocket,
elevation of the temporal pocket then proceeds inferiorly.

Fig. 29.42 In a standard brow lift, the temporal elevation ends at the Fig. 29.43 A key component of the elevation is release of the conjoined
level of the sentinel (medial zygomaticotemporal) vein. tendon at the inferiormost aspect of the central and temporal pockets.

Incision

3-0 PDS suture

r
cto
Ve

Bone
X’
X

Temporalis muscle

Incision
Deep temporal fascia Skin and
Skin (superficial layer) temporoparietal
fascia lifted

Temporoparietal fascia
(superficial layer)

Fig. 29.44 Artist’s rendition of the temporal suspension suture. The temporoparietal fascia is suspended along the planned vector to the temporalis
fascia using 3–0 polydioxanone suture (PDS).

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 V Brow Lift

a b

c d

Fig. 29.45 (a–e) Temporal suspension suture. The temporoparietal fascia is suspended along the planned vector to the temporalis fascia using 3–0
polydioxanone suture (PDS).

328
 nd i r i y er n A r

Fig. 29.47). The first step in this technique involves hand drilling
of the outer cortex of the frontal bone at the desired position
(Fig. 29.48; Fig. 29.49). The drill hole is irrigated to remove bone
shavings (Fig. 29.50; Fig. 29.51). The Endotine Forehead is then
placed (Fig. 29.52; Fig. 29.53) and snapped into position using
moderate force (Fig. 29.54). At this point the device can be

Fig. 29.47 Endotine Forehead fixation device.

Fig. 29.46 Artist’s rendition of Endotine fixation.

Fig. 29.49 Hand drilling of outer cortex, close-up view.

Fig. 29.48 Hand drilling of outer cortex.

Fig. 29.50 Irrigation of drill hole to remove bone shavings. Fig. 29.51 Irrigation of drill hole to remove bone shavings, close-up view.

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 V Brow Lift

rotated to the desired vector of pull before removing the driver

(Fig. 29.55). The mobilized forehead flap is then pulled upward
to affect the desired brow elevation (Fig. 29.56) and then pressed
down on the device prongs to hold it in place, producing a palpa-
ble and audible crackle (Fig. 29.57). The scalp incision is then
closed with staples (Fig. 29.58).

29.8 Ancillary Procedures

29.8.1 Eyelid
Ptosis of the brow/eyelid complex is one of the earliest signs of
aging. Patients often present saying that people close to them are
constantly asking whether they are tired or don’t feel well. hen
we meet someone, the first thing we see is the person’s eyes. If
these are ptotic, it can make the person look tired, sad, or even
Fig. 29.52 Endotine Forehead fixation device held in insertion tool
angry. In patients with deep-set eyes, endoscopic brow lift is some- ready for placement.
times the only procedure needed for rejuvenation of the brow/lid
complex. More often than not, however, the brow lift is performed

Fig. 29.53 Placement of Endotine Forehead fixation device through Fig. 29.54 Moderate force applied to snap Endotine Forehead device
incision. in place.

Fig. 29.55 Endotine Forehead device in place. Fig. 29.56 Forehead scalp is pulled up to achieve desired brow elevation.

330

Fig. 29.57 Pressure is applied directly over Endotine Forehead device
prongs, and a palpable and audible “crackle” occurs.
in conjunction with an upper-lid blepharoplasty for complete
rejuvenation. In such a case, it is imperative that the brow lift be
performed first to set the correct position before the upper bleph-
aroplasty is undertaken. Otherwise the brow is pulled down with
removal of upper lid skin, causing a foreshortening of the natural
space between the brow position and the upper lid crease.
29.8.2 Myomodulators
Myomodulators such as botulinum toxin are often used in the brow
and forehead region. Early in the development of the endoscopic
brow procedure, it was postulated that the depressor muscles
should be treated before the brow lift to avoid their downward pull
on the brow postoperatively while healing was occurring. This had
some validity in the earlier techniques, which were performed in
the subgaleal plane. In the more modern technique, however, the
elevation is in the subperiosteal plane and the depressor muscles
have been released, allowing in essence a bipedicled subperiosteal
flap that will readhere in an elevated and supported position to
the underlying bone in approximately 12 days.
29.9 Postoperative Care
After the procedure is completed, I place a head wrap consisting of 4
in. 4 in. dressings, erlex (Cardinal Health, Dublin, OH), and ling
conforming bandage ( ohnson ohnson, ew Brunswick, ) to
keep pressure on the elevated forehead flap to prevent seroma
or hematoma formation. This will typically stay on for 24 hours.
e have the patient avoid heavy lifting, straining, or bending and
sleep with head elevated at 30 . At approximately 1 week postop,
patients will return for staple removal. At this point patients may
have their hair washed, but it is critical that they not run a brush or
comb through their hair, as doing so may disrupt the suspension
to the Endotine Forehead device. Based on our laboratory studies,
the periosteal readhesion of the forehead approaches preopera-
tive values at 12 days. Thus, posterior traction on the scalp must
be avoided throughout this period. e place our patients on the
nd i r i y er n A r
Fig. 29.58 Staple skin closure.
SinEcch regime (Alpine Pharmaceutical, San Rafael, CA) pre- and
postop to minimize bruising and swelling. They are also told to
avoid aspirin, ibuprofen, vitamin E, and other platelet inhibitors for
2 weeks before and after surgery. Some numbness and tightness
feelings are normal postoperatively and will resolve with time.
Rarely there will be some temporary alopecia at the incision sites,
though this has always resolved in my experience. At 1 month
postop, when patients return for follow-up, most of the swelling is
resolved, and they are typically looking good and happy with their
results. At this point they may have their hair colored, which is
the most common question. I then see them back at 1 year postop,
though they may return at any time with questions or concerns.
29.10 Results/Outcomes
Results with this procedure are quite positive, with 1-year
follow-ups showing excellent maintenance of brow position
and few postoperative issues. A couple of instances early on of
frontal branch neuropraxia both resolved completely in a few
weeks. Two cases in which the Endotine device (made of poly-
L-lactic acid) caused a cyst formation as it absorbed required a
local procedure for removal. My experience with patient overall
satisfaction with the procedure is excellent.
29.10.1 Brow Lift Alone
Fig. 29.59 shows pre- and postop views of a patient with brow
lift alone. ote the unfurling of the brow to a more natural and
classical position above the orbital rim.
Fig. 29.60 shows the result of a brow lift alone in a patient with
brow ptosis and deep-set eyes.
29.10.2 Brow Lift and Upper
Blepharoplasty
Fig. 29.61 shows a patient who received a combination brow lift
and upper blepharoplasty.
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 V Brow Lift

b
Fig. 29.59 (a) Frontal and (b) lateral before (left) and after (right) views of results with brow lift alone.

a b
Fig. 29.61 (a) Pre- and (b) postoperative views of a patient who
a received a combination brow lift and upper blepharoplasty.

procedure for all patients. Those with higher hairlines are often
better served with a trichophytic approach, which can also be
utilized to lower the frontal hairline. Though the endoscopic
technique will raise the hairline in relation to the skull, it does not
raise it in relation to the brows, unlike the older coronal technique.

b
Fig. 29.60 (a) Pre- and (b) postoperative views for brow lift alone in a
patient with brow ptosis and deep-set eyes.
29.11 Concluding Thoughts
The endoscopically assisted brow lift is one tool in the arma-
mentarium of the facial plastic surgeon. In measurement studies
the actual lift averages 0.5 cm. This procedure is really more an
unfurling and support of the ptotic brow back to a natural posi-
tion above the orbital rim. The advantages of this approach are
minimal incisions, though the wound is the same as with open
techniques. One of the bigger advantages is decreased incidence of
nerve injury and alopecia due to long incisions and tissue removal.
Long-term results have proven to be excellent and comparable to
more traditional open approaches. It is not, however, the correct
Clinical Caveats
• Proper patient selection is key to any rejuvenation procedure.
• A thorough understanding of the surgical anatomy is vital to
achieving the best results.
• During the subperiosteal elevation the periosteum must be
kept intact throughout in order for it to be elevated as essen-
tially a bipedicled flap and for secure suspension superiorly.
• Inferiorly below the level of the brow at the arcus marginalis
the periosteum must be completely released for a full eleva-
tion to occur.
• I do not believe that its possible to overcorrect at the lateral
temporal suspension; however, it is possible to overcorrect
the central suspension.
• If combining an endoscopic brow lift and an upper blepha-
roplasty, I believe that it is imperative that the brow lift be
performed first before the upper eyelid can be properly
marked and the blepharoplasty performed.

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 nd i r i y er n A r

Suggested Reading 8 Graham HD. Methods of soft tissue fixation in endoscopic surgery. Facial Plast
Surg Clin North Am 1997;5:145–154
1 Brodner DC, Downs C, Graham HD III. Periosteal readhesion after brow-lift in 9 Graham HD, uatela V, Sabini P. Rejuvenation of brow and midface. In: Papel ID,
ew ealand white rabbits. Arch Facial Plast Surg 2002;4(4):248–251 Frodel L, Holt GR, et al, eds. Facial Plastic and Reconstructive Surgery, 2nd ed.
2 Core GB, V sconez LO, Graham HD III. Endoscopic browlift. Clin Plast Surg ew ork, : Thieme Medical Publishers; 2002; 171–184
1995;22(4):619–631 10 Graham HD, houry EP. Preoperative analysis, diagnosis, and evaluation of the
3 Duchenne de Boulogne G-B. The Mechanism of Human Facial Expression. forehead and brow. Facial Plast Surg Clin North Am 2003;11(3):319–326
Cuthbertson RA, ed. Cambridge, U : Cambridge University Press; 1990 11 eller GS, Graham HD, Freeman GS, eds. Endoscopic Facial Plastic Surgery. St.
4 Graham HD, Core GB. Endoscopic forehead lifting using fixation sutures. Oper Louis, MO: Mosby Publishers; 1997.
Tech Otolaryngol—Head Neck Surg 1995;6(4):245–252 12 im C, Crawford Downs , Azuola ME, Graham HD III. Time scale for periosteal
5 Graham HD, Core GB. Endoscopic forehead lifting using fixation sutures. In: readhesion after brow lift. Laryngoscope 2004;114(1):50–55
Keller GS, ed. Endoscopic Facial Plastic Surgery. St. Louis, MO: Mosby Publishers; 13 Larrabee F, Makielski H. Surgical Anatomy of the Face. ew ork, : Raven
1997:82–96 Press Ltd; 1993
6 Graham HD. (Guest editor on endoscopic surgery.) Facial Plast Surg Clin North 14 Pearlman S , Graham HD. Forehead rejuvenation in head and neck surgery. In:
Am 1997;5:2 DeSouza C, ed. Head & Neck Surgery. St. Louis, MO: aypee Brothers Medical
7 Graham HD, Freeman MS. Endoscopic surgery of the forehead and midface. Publishers; 2009:451
Facial Plast Surg Clin North Am 1997:5:113–132

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 V Brow Lift
30 Other Approaches to Brow Lift
Foad Nahai
Abstract
Beyond endoscopic and temporal brow lifts, the direct brow lift,
coronal lifts, internal brow pexy, and toxins offer other options
for brow repositioning. These, their indications, operative details,
and alternate procedure are all described in this chapter.
Keywords
Coronal brow lift, direct brow lift, brow pexy, neurotoxins
30.1 Introduction
A variety of options are available for rejuvenation/repositioning
of the brow and forehead, ranging from the open coronal fore-
head lift to neurotoxins and including the following:
• Coronal brow lift
• Endoscopic forehead lift
• Lateral–temporal brow lift
• Transpalpebral excision of corrugator and procerus muscles
• Lateral–temporal brow lift combined with transpalpebral
excision of corrugator and procerus muscles
• Direct brow lift
• Transpalpebral brow pexy
• Injection of neurotoxins
Successful rejuvenation of the brow and forehead includes
repositioning of the hair-bearing brow, improvement of vertical
glabellar and horizontal forehead lines, reversal of the brow
descent, and conversion of a tired or angry expression into a
rested and contented look.
As surgeons we look for safe and efficacious procedures that
render lasting results, whereas our patients look for an effective
procedure with minimal scarring and a short recovery time.
The coronal lift remains the benchmark against which the
results, morbidity, and longevity of the other procedures can
be compared. ot everyone undergoing facial rejuvenation is
a candidate for or will consent to a coronal brow lift. Therefore
alternatives must be sought to provide the desired result without
the coronal incision.
ot all the alternatives will match the results of the coronal
brow lift; however, they are all far less invasive. Each alternative
has its own benefits and limitations. Careful patient evaluation
facilitates matching the patient to the best option.
30.2 Coronal Brow Lift
Despite the popularity of the endoscopic forehead lift, the coro-
nal brow lift is still an excellent option. Many surgeons consider
it the method of choice for all patients; some surgeons limit the
334
coronal lift to patients who are not candidates for an endoscopic
approach.
This approach affords excellent exposure, facilitating release
of periorbital septa and adhesions, muscle excision, and brow
mobilization. Through scalp excision, the desired preplanned
brow elevation and brow shaping can be achieved.
30.2.1 Indications and Contraindications
The coronal brow lift may be applied universally to anyone who
is a candidate for forehead rejuvenation. It is my opinion that the
best candidates are those who are not suitable for the endoscopic
approach; these include patients with high foreheads, significant
frontal bone convexity, a high or receding hairline, extremely
thick skin or deep lines, and significant brow ptosis with excess
skin over the lateral brow and glabella. Patients who would have
similar results with less invasive procedures would not be candi-
dates for the coronal approach.
30.2.2 Preoperative Planning
Markings
As with other brow lift procedures, the coronal brow lift is rarely
performed in isolation. It is typically combined with other peri-
orbital procedures or full facial rejuvenation. This is a full, open
procedure; therefore, preoperative markings are not as critical as
the markings for the endoscopic approach. However, it is useful
to mark the sentinel vein, the temporal crest, and the course of
the supraorbital and supratrochlear nerves.
Incisions
The incision will vary, depending on the patient’s hairline and
the desired results. There are three options for planning the
incision: (1) a standard coronal incision, (2) a modified coronal
incision, and (3) an anterior hairline incision (Fig. 30.1). The
standard coronal incision is placed 6 to 8 cm behind the frontal
hairline. It is easily concealed within the hair in patients with
normal hair thickness. The modified coronal incision is curved
anteriorly in the frontal area. This is best for individuals who
have a normal temporal hairline but a very high frontal hair-
line. By modifying the incision and bringing it to the hairline
in the frontal area, the height of the forehead may be reduced.
The frontal portion of the incision may be visible. The anterior
hairline incision is best reserved for an individual with a high
forehead and a receding hairline in both the temporal and fron-
tal areas. In such individuals this incision allows reduction in
the forehead height and temporal hairline. This entire scar may
be visible, and most surgeons and patients prefer to avoid this
incision. Any or all of these incisions, particularly the anterior
hairline incision, may be made in a zigzag fashion to break up
the resultant scar.
 er A r e r i

Fig. 30.1 Three possible incisions for a coronal approach depending Fig. 30.2 Vectors for fixation should be determined and marked to
on the patient’s hairline and goals: standard bicoronal, modified, and help guide scalp excision and brow positioning.
anterior hairline incision.

Vectors of fixation are also marked on the forehead; these will

include a line projected onto the head from the most convex por-
tion of the hair-bearing brow. These vectors are a guide to scalp
excision and brow positioning (Fig. 30.2).

30.2.3 Operative Technique

Although the procedure can be performed with either a local or a
general anesthetic, our preference is general anesthesia, because
other procedures are usually performed in combination. ith
the patient lying supine on the operating table, with the head
slightly elevated to decrease venous engorgement, the hair is
washed with soap and braided, and the proposed area of scalp
excision may be shaved. The entire area is infiltrated with 0.5
lidocaine and epinephrine 1:200,000. The field is then prepared
with povidone–iodine (Betadine) and draped. Fig. 30.3 Once the incision is made, the flap is raised in the bloodless
After allowing sufficient time (8–10 minutes) for the epinephrine plane between the galea/aponeurotic system and periosteum.
to take effect, the surgeon makes the incision through the scalp,
down to the deep temporal fascia in the temporal area, and more
centrally down to the periosteum. The knife blade is beveled so that
it runs parallel with the hair roots to preserve as many hair follicles as
possible. This is more critical with the modified and anterior hairline
incisions. The anterior hairline incision is not made anterior to the
hairline, as its name indicates, but must be made 1 or 2 mm behind
the hairline so that some hair follicles are left within the cut edges.
Once the incision is made, the elevation of the forehead flap
proceeds very rapidly in a bloodless field between the temporo-
parietal fascia and deep temporal fascia laterally and the subperi-
osteal plane centrally. The flap is elevated to the orbital rims. This
elevation will release the periorbital septa and allow easy access
to the glabellar musculature (Fig. 30.3).
The anterior hairline approach will allow dissection in the
subcutaneous plane. This subcutaneous plane is directly over the
frontalis muscle. This allows significant reduction of transverse
forehead lines through the release of the fibrous septa that run
between the muscle and the overlying skin. An added advantage Fig. 30.4 The anterior hairline approach is performed in the subcuta-
of this approach is better preservation of the scalp’s sensory neous plane above the frontalis muscle, allowing release of the fibrous
innervation (Fig. 30.4). septa, and preserves the scalp’s sensory innervation.

335
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Once the flap is elevated, the corrugator, procerus, and
depressor supercilii muscles are easily identified. These muscles
are divided, avulsed, or cauterized, according to the surgeon’s
preference (Fig. 30.5). To weaken the frontalis muscle, the lowest
portions of the muscle are incised. The surgeon notes the course
of the supratrochlear and supraorbital nerves and divides the
frontalis muscle, carefully avoiding the nerves. A variety of
techniques have been used to weaken the frontalis in this area,
including horizontal division, crisscross division, and even a 1-cm
strip excision. The scalp flap is then retracted superiorly and the
degree of elevation is adjusted.
ext the scalp is incised at key sites, and fixation sutures or
staples are placed. Usually the scalp is fixed at three sites: one
centrally and one on each side, according to the preoperative
vectors (Fig. 30.6).
The intervening scalp is excised and closed in two layers with
sutures and staples (Fig. 30.7).
30.2.4 Postoperative Care
The patient’s head is elevated, ice packs are placed over the eyes,
and measures are taken to prevent an elevation in blood pressure
and nausea and vomiting. Most patients undergoing a brow
lift with additional procedures are kept overnight. Staples and
sutures are removed 5 to 7 days postoperatively, and physical
activities are restricted for 2 to 3 weeks.
Fig. 30.5 Direct excision of the procerus and corrugator muscles is performed while avoiding injuring the supratrochlear and supraorbital nerves.
336
30.2.5 Outcomes
This procedure has proved effective, with acceptable morbidity.
The results have stood the test of time. Complications include
alopecia, dysesthesias, and sensory loss in the scalp.
30.3 Direct Brow Lift
A direct brow lift is an effective method for elevating the brow,
particularly the lateral brow. However, the direct lift is rarely
used, because it may leave a visible scar. This approach offers
excellent brow elevation through direct excision of the redun-
dant skin. It will also allow access to the muscles. It is a quick,
simple procedure that can be performed with a local anesthetic
and carries minimal risk to the sensory nerves.
30.3.1 Indications and Contraindications
The best candidates are older individuals with heavy lateral
brows and deep transverse forehead creases where the scar can
be hidden. This is a relatively quick procedure and may be an
acceptable alternative for patients who are not candidates for
other options that require lengthier operations. The disadvan-
tage is the scar.
30.3.2 Preoperative Planning
The incision choices include an incision directly above the
hair-bearing brow, which follows the shape of the brow, or an
incision higher up, within a pre-existing crease (Fig. 30.8).

Fig. 30.6 The scalp is fixed centrally and laterally according to the
predetermined vectors.
Fig. 30.8 Preoperative markings for incisions. A direct brow lift
should be made directly overlying the hair bearing brow or higher in a
pre-existing crease.
a b
Fig. 30.9 Excision directly above the brow should be designed based on the movement desired: (a) directly above for upward brow elevation and (b)
laterally for lateral elevation.
er A r e r i
Fig. 30.7 Once set in the desired position, the scalp is serially excised
and closed in layers with suture and staples.
For the incision along the hair-bearing brow, a mark is made
that follows the upper border of the hair-bearing brow. The skin
above is then pinched to bring the brow into the proposed posi-
tion, and the upper border of the skin excision is marked.
The design is varied to allow direct upward elevation of the
brow (Fig. 30.9a) or lateral elevation (Fig. 30.9b). The incision
within the crease is marked with the patient actively elevating the
brow. The amount of forehead skin to be excised is then assessed
and marked by pinching the forehead skin.
30.3.3 Operative Technique
The procedure is performed with a local anesthetic unless it is
combined with other procedures.
Following the markings for a central brow elevation, the surgeon
excises the predetermined skin. This is limited to a skin excision
to avoid injury to the frontal branch of the facial nerve and the
sensory nerves (Fig. 30.10). It is possible through the transverse
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Fig. 30.10 Direct excision of only the skin being performed to mobilize the brow upward.

incision to access the glabellar musculature as well; however, this
is not commonly performed. This operation is usually limited to
skin excision.
The wound is then closed in two layers with 5–0 poliglecaprone
(Monocryl, ohnson ohnson, ew Brunswick, ) sutures to
the dermis, and the skin is closed with intracuticular Monocryl
or simple 6–0 polypropylene (Prolene, ohnson ohnson, ew
Brunswick, ) sutures (Fig. 30.11).
30.3.4 Postoperative Care
Postoperative swelling is prolonged and noticeable. To minimize
this, it is important to keep the patient’s head elevated, with ice
packs on the eyelids. e also consider the use of diuretics and a
short course of methylprednisolone (Medrol DosePak; Upjohn,
alamazoo, MI).
30.3.5 Outcomes
The direct brow lift is an effective way of elevating the
lateral brow. In carefully selected patients, the scar may be
imperceptible.
30.3.6 Results
The elderly man shown in Fig. 30.12 underwent a direct brow
lift with upper and lower lid blepharoplasties. His postoperative
result shows lateral brow elevation with an imperceptible scar.
30.4 Transpalpebral Brow Pexy
The transpalpebral approach offers minimal lateral brow elevation
through an upper lid blepharoplasty and is best as an adjunct to upper
lid blepharoplasty rather than as a primary brow lift procedure.
30.4.1 Indications and Contraindications
The limited elevation seen with this approach limits its applica-
tion to patients with mild lateral brow ptosis and with no medial
brow ptosis or excess skin at the nasal radix.
30.4.2 Preoperative Planning
The brow is held in the projected position, and the upper eyelid
is marked for an upper lid blepharoplasty.

Fig. 30.11 A layered closure of the direct brow lift is performed after excision of the skin.

338
 er A r e r i

a b
Fig. 30.12 (a) Pre- and (b) postop images following a direct excision
and quad blepharoplasty. Courtesy Clinton D. McCord, Jr., MD.
b
Fig. 30.13 (a) The technique for a transpalpebral brow pexy through
an upper blepharoplasty incision. Dissection is continued through
the orbicularis oculi, along the periosteum for 2 to 3 cm, clearing
adhesions. (b) Calipers are used to mark a point 10 to 15 mm above the
orbital rim.

30.4.3 Operative Technique

The incisions are made and the skin–muscle excision for the
blepharoplasty is completed. The orbicularis muscle is retracted
upward with two Blair retractors and with the cutting current
and a Colorado eedle (Stryker CMF, alamazoo, MI). The dissec-
tion is continued deep to the orbicularis to the lateral orbital rim,
staying above the periosteum. The dissection continues upward
laterally for 2 to 3 cm. Care should be taken to preserve the
sentinel vein (medial zygomaticotemporal vein), which is easily
identified. This dissection releases some of the adhesions and
septa of the lateral orbital area. The plane of dissection is deep to
the course of the frontal branches of the facial nerve (Fig. 30.13).
The calipers are then used to mark a point 5 to 10 mm above the
orbital rim. Then a 5–0 absorbable polydioxanone suture (PDS) or
a
permanent clear nylon suture is used to fix the hair-bearing brow
to the periosteum. The suture is first placed through the orbicularis,
the retro–orbicularis oculi fat (ROOF), and the deep layers of the
dermis, right in the middle of the hair-bearing brow. ext, the needle
is passed through the previously marked periosteum. The suture is
then tied, moving the brow upward. The eyelid skin is closed (Fig.
30.14). Dimpling may result if the suture through the orbicularis and
ROOF extends too far into the skin. Skin redundancy may result above
the point of fixation if the lateral brow is inadequately undermined.
b c
30.4.4 Postoperative Care
Postoperative care is the same as for upper lid blepharoplasty.

30.4.5 Outcomes
Only minimal elevation is possible with this technique. The
results have been effective and maintained over time.

30.4.6 Results
The patient shown in Fig. 30.15 was seen in consultation for upper
and lower lid blepharoplasty. He requested improvement of the
heaviness of his upper eyelids and the excess skin and bags of his
lower eyelids. In addition to excess skin in the upper lids and aging
d e
Fig. 30.14 (a,c) For pexy of the brow, the central hair bearing area is
chosen to place a suture through the orbicularis oculi and (b) retro–
orbicularis oculi fat (ROOF) to the new position on the periosteum.
(d) Once pexy is tied down, (e) the eyelid skin is then closed.

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of the lower lids, he had lateral brow ptosis. He underwent upper

and lower lid blepharoplasty with an internal transpalpebral brow
pexy. The split-face image shows his result at 2 years. ote the
elevation of the brow through the internal brow pexy suture.

30.5 Concluding Thoughts

The popularity and effectiveness of injectable neurotoxins has led
to a decline in the number of brow lifts performed. Despite that,
there is still a role for these alternative procedures. Patient selec-
tion and matching the procedure to the patient is the key. Although
coronal brow lifts and direct brow lifts have limited application in
my practice, the transpalpebral brow pexy has proved very useful.

Clinical Caveats
Coronal brow lift:

• The surgeon can avoid creating a surprised look by limiting
traction and scalp excision.
• The incision line is beveled to preserve hair follicles.
• The anterior hairline incision should be placed 1 to 2 mm
behind the hairline to preserve hair roots rather than in front
of the hairline.
• Supraorbital and supratrochlear nerve branches should be
preserved while dividing the frontalis muscle.
Direct brow lift:
• Incisions are best placed within pre-existing creases.
Fig. 30.15 Split-face comparison of pre- and postoperative views of
upper and lower lid blepharoplasty with internal transpalpebral brow
pexy for lateral brow ptosis
7 nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
8 nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
9 Mahmood U, Baker L r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624

• The excision should be limited to skin only to avoid nerve injury. 10 Matarasso A, Terino EO. Forehead-brow rhytidoplasty: reassessing the goals.
Plast Reconstr Surg 1994;93(7):1378–1389, discussion 1390–1391
Transpalpebral brow pexy: 11 McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplas-
• Dimpling can be avoided by limiting the suture placement to ty. Plast Reconstr Surg 1990;86(2):248–254
12 Mc inney P, Mossie RD, ukowski ML. Criteria for the forehead lift. Aesthetic
the deep dermis.
Plast Surg 1991;15(2):141–147
• An overhang can be avoided by adequately undermining the 13 Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr
lateral brow. Surg 2001;108(5):1409–1424
14 Pelle-Ceravolo M, Angelini M. Transcutaneous brow shaping: a straight-
forward and precise method to lift and shape the eyebrows. Aesthet Surg J
2017;37(8):863–875
Suggested Reading 15 Pitanguy I. Section of the frontalis-procerus-corrugator aponeurosis in the cor-
rection of frontal and glabellar wrinkles. Ann Plast Surg 1979;2(5):422–427
1 Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech- 16 Riefkohl R, osanin R, Georgiade GS. Complications of the forehead-brow lift.
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200 Aesthetic Plast Surg 1983;7(3):135–138
2 Casta ares S. Forehead wrinkles, glabellar frown and ptosis of eyebrows. Plast 17 Sweis IE, Hwang L, Cohen M. Preoperative use of neuromodulators to optimize
Reconstr Surg 1964;34(4):406–413 surgical outcomes in upper blepharoplasty and brow lift. Aesthet Surg J
3 Connell BF, Lambros VS, eurohr GH. The forehead lift: techniques to avoid com- 2018;38(9):941–948
plications and produce optimal results. Aesthetic Plast Surg 1989;13(4):217–237 18 Tirkanits B, Daniel R . The biplanar forehead lift. Aesthetic Plast Surg
4 Friedland A, acobsen M, Ter onda S. Safety and efficacy of combined upper 1990;14(2):111–117
blepharoplasties and open coronal browlift: a consecutive series of 600 patients. 19 Vinas C, Caviglia C, Cortinas L. Forehead rhytidoplasty and brow lifting. Plast
Aesthetic Plast Surg 1996;20(6):453–462 Reconstr Surg 1976;57(4):445–454
5 aye BL. The forehead lift: a useful adjunct to face lift and blepharoplasty. Plast 20 Vogel E, Hoopes E. The subcutaneous forehead lift with an anterior hairline
Reconstr Surg 1977;60(2):161–171 incision. Ann Plast Surg 1992;28(3):257–265
6 latsky SA. Foreheadplasty for facial rejuvenation. Aesthet Surg J 21 olfe SA, Baird L. The subcutaneous forehead lift. Plast Reconstr Surg
2000;20:416–427 1989;83(2):251–256

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 Part VI
Eyelid Surgery

VI

31 Eyelid and Periorbital Anatomy
Amy Patel and Guy G. Massry
Abstract
A fundamental understanding of the anatomy of the eyelid and
periorbital region is critical to achieve an optimal aesthetic
outcome and maintain appropriate function. Sound surgical
technique can be achieved only with a thorough understanding
of the intricate details of the periorbital structures. With this
foundation, appropriate surgical intervention can lead to satisfied
patients and avoid significantly adverse events that can threaten
vision and impair quality of life. This chapter thoroughly reviews
eyelid anatomy and critical principles while emphasizing sur-
gical pearls to help guide an aesthetic surgeon. In addition, it
outlines the anatomy of the forehead, temples, and midface in
relation to the periorbital region, as well as details how these
anatomic areas transition together. The goals of this chapter are
to lay a foundation for the aesthetic surgeon and provide a better
understanding of the anatomic nuances of the periorbital region
and adjacent structures.
Keywords
periorbital anatomy, midface, forehead, temples, eyelid anatomy,
upper eyelid, lower eyelid, levator, blepharoplasty, temporal
fascia
31.1 Introduction
The fundamental basis of surgery starts and ends with a
detailed knowledge of anatomic constructs. This is especially
true in reference to the delicate eyelid and periorbital regions.
In these areas sound surgical technique and principles can be
• Superior temporal line (STL) at level
of bone
• Superior temporal septum (STS)
= fusion of supertemporal fascia (STF)
and deep temporal fascia (DTF)
• Conjoint tendon (CT)
= STS with periosteum of frontal bone STL/STS/CT
Upper temporal quadrant
Lower temporal quadrant
Inferior temporal septum (ITS)
Frontal nerve (TFN)
Zygomatico temporal nerves (ZTN)
Zygomatico facial nerves (ZFN)
a b
Fig. 31.1 (a) Important anatomic quadrants and landmarks of the temple and forehead region. (b) Cross-sectional view of the layers of the temple region.
ye id nd eri r i An my
applied only with a thorough comprehension of the various
anatomic structures that make up this aesthetic subunit
of the face. This basic premise allows maintenance of form
and function, both of which are critical to attaining optimal
outcomes, achieving high patient satisfaction, and avoiding
adverse events. This chapter is presented as an overview of
what the authors have identified as clinically relevant concepts
of eyelid and periorbital anatomy. In addition to the eyelids,
the adjacent forehead, temples and midface are included, as
these adjacent structures are in continuity with the eyelids,
making them critically relevant anatomically and surgically
to the aesthetic eyelid surgeon. The authors’ goal is that upon
completion of this chapter, the reader will understand the
anatomic nuances of these facial subregions and how their five
tissue layers transition with each other. Each chapter section
will include highlighted “clinical pearls,” in italics and bold,
emphasizing how knowledge of anatomy directs surgical tech-
nique and enhances surgical proficiency.
31.2 Temple and Brow
The upper third of the face can be subdivided into two regions:
the forehead, which is centrally based, and the temples laterally.
Externally, without animation, the two regions blend together
without a discrete boundary. hen the frontalis muscle con-
tracts, horizontal rhytids are noted within the forehead to its
lateral extent. here these rhytids end, the temple begins. The
subcutaneous transition of these facial structures is more com-
plicated. At the level of bone, this occurs at the superior temporal
line (STL), a concave, curvilinear bony groove composed of the
zygomatic, frontal, and parietal bones (Fig. 31.1). The STL forms
Superior temporal septum (STS)
Lateral temporal fat compartment (LTFC)
Upper temporal compartment (UTC)
Deep temporal fascia (DTF)
Temporal ligamentous
adhesions (TLA)
Supertemporal fascia (STF)
Inferior temporal septum (ITS)
Lower temporal
compartment (LTC)
Sentinel vein (SV) Lateral orbital fat
compartment (LOFC)
Skin
Lateral orbital
thickening (LOT)
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 VI Eyelid Surgery

the superior medial boundary of the temporalis fossa, where

the temporalis muscle resides. The deep temporal fascia (DTF),
a dense fascial layer overlying the temporalis muscle, inserts on
this landmark. The DTF also fuses with the more superficial and
flimsier superficial temporal fascia (STF) at this point. This line of
fusion forms one of two septa in the temple, this one called the
superior temporal septum (STS). The name given to the continu-
ity of the STF/DTF (STS) and the periosteum of the frontal bone is
the conjoint tendon (CT) or the area of fusion between the fascial
layers of the temple and the soft tissue of the forehead (Fig. 31.1).
The CT is an important landmark in brow lifting surgery, as its
division makes the surgical planes of the temple and forehead
continuous.
Fig. 31.2 Upper temporal quadrant dissection. The dissection
proceeds easily in a blunt fashion. It demarcates superficial temporal
31.2.1 Temple fascia above, deep temporal fascia below.

The temple is externally bounded by the hairline superolaterally,

the STL medially, and the zygomatic arch below. Like all regions
of the face, it is composed of 5 layers (Fig. 31.1b):
1. Skin
2. Subcutaneous tissue/fat
3. Superficial fascia (STF, also known as the temporoparietal fascia,
TPF)
4. Loose areolar tissue (a potential space)
5. The DTF overlying the temporalis muscle

As described, the STS is the medial fusion of the STF and DTF,
which overlies the transition of the temple and forehead.
Similarly, there is a second and inferior septum of the temple
region, the inferior temporal septum (ITS), which is also a
fusion of the STF and DTF. The ITS traverses a dense adhesion
above the lateral brow, referred to as the temporal ligamentous
adhesion (Fig. 31.1a), and continues to the helix of the ear. It
divides the temple anatomically into two separate superficial
and deep compartments. In superficial Layer 2 of the temple,
the ITS divides the subcutaneous fat into an upper temporal
fat compartment and the lateral orbital fat compartment (Fig.
31.1b). In the deeper Layer 4 of the temple, the ITS divides this
plane into the upper temporal compartment (UTC) and the
lower temporal compartment (LTC). This space between the
STF and DTF of the temple is the surgical plane for endoscopic
brow lifting surgery. The UTC is an extension of the sublegal
plane of the forehead, is a true potential space, and is defined Fig. 31.3 Surgical endoscopic view of the conjoint tendon. Dissection
medially by the STS and inferiorly by the ITS. The UTC is proceeds in a subperiosteal manner.
composed of loose areolar tissue, and surgical dissection can
proceed bluntly and easily to its boundaries (Fig. 31.2). At its
boundaries, more meticulous dissection is required to avoid can be inadvertently entered, with subsequent damage to the
complications. At the medial boundary of the UTC, dividing frontal branch of the facial nerve. Of note, while motor nerve
the CT is a necessary step in endoscopic brow lift surgery injury has greater functional and aesthetic implications than
(Fig. 31.3). During this step, if an elevator is used to divide sensory injury during endoscopic brow lift surgery, sensory
the CT, it is critical to divide the tendon from the temporal deficit is far more common.
subaponeurotic space to the central subperiosteal space. Inferiorly, below the ITS, the LTC, which is functionally an
The deep lateral branch of the supraorbital nerve runs just extension of the midface below, is bounded by denser adhesions.
above the frontal periosteum, parallel and medial to the CT Dissection in this area to access the lateral brow or midface
(Fig. 31.4). Dissection must be subperiosteal over the frontal requires caution so as to avoid injury to critical neurovascular
bone to protect this nerve. If this nerve is damaged, prolonged structures. These include the frontal branch of the facial nerve
scalp numbness/paresthesia or itching can occur. Also, if the and both the sentinel (medial zygomaticotemporal) vein and
inferior release of the CT proceeds medial to lateral, the STF various branches of the zygomaticotemporal nerves. Preserving

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 ye id nd eri r i An my

Deep branch of
supraorbital
nerve

Conjoint tendon

Superficial branches
of the supraorbital
nerve

Fig. 31.4 The deep branch of the supraorbital nerve runs just above the frontal bone periosteum, parallel and medial to conjoint tendon. Dissection must
be subperiosteal to prevent sensory deficit. (Reproduced from Pu L. Aesthetic Plastic Surgery in Asians. Principles & Techniques. New ork, N : Thieme; 2015.)

the sentinel vein during endoscopic brow lift and midface sur-
gery is important to prevent the development of new and vis-
ible postoperative periorbital veins and prolonged edema (Fig.
31.5). Of all these structures, understanding the course of the
frontal branch of the facial nerve is most important. Externally, Superficial fascia

the nerve courses along the Pitanguy line, from a point 0.5 cm
below the tragus to a point 1.5 cm lateral to the supraorbital Sentinel vein
rim (Fig. 31.1a). Internally, it lies in the roof of the LTC in the
innermost aspect of the STF.
Of note, just above the ITS the DTF divides into two lami-
nae, with a fatty layer between (the superficial temporal fat). Deep fascia

Disruption of this fat pad during surgery can lead to postop-

erative temporal wasting. Below this division the superficial
layer of the DTF is known as the innominate or intermediate
fascia. The two layers of the DTF insert on the zygomatic arch.
The superficial layer of the DTF continues beyond the zygomatic
arch and blends with the parotideomasseteric fascia of the face.
The arterial supply of the temple is from the superficial temporal
artery (STA), which courses in the STF in this location. Care must
be taken with filler and fat injections superficially within the
temple, as the STA communicates within the forehead with the
supraorbital artery. Inadvertent intra-arterial injection can
lead to vision loss via this route. Venous drainage is from the
superficial temporal vein, while lymphatic drainage is via the
preauricular nodes. Motor innervation of the temporalis muscle
is from branches of the mandibular division of the trigeminal
Fig. 31.5 Surgical endoscopic view of the sentinel vein, which should
be preserved in surgery to avoid new and visible postoperative
periorbital veins and prolonged edema.
nerve (cranial nerve V3). These branches are called the deep
temporal nerves. Sensory innervation of the temple is from the
zygomaticotemporal nerve, a branch of the maxillary division
(V2) of the trigeminal nerve that exits the lateral orbit to arrive
at the temple, and the auriculotemporal nerve, a branch of the
mandibular division (V3) of the trigeminal nerve that runs supe-
riorly with the superficial temporal artery and veins to ascend to
the temple.

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 VI Eyelid Surgery
31.2.2 Forehead
The forehead is delineated superiorly by the hairline; inferiorly
by the glabella, frontonasal groove, and eyebrows; and laterally
by its boundary to the temple as already described. It is also
composed of five layers, which include the following (Fig. 31.6):
1. The skin
2. Subcutaneous tissue/fat
3. Galea aponeurotica
4. Loose areolar tissue
5. Periosteum
The main retractor of the forehead is the paired and ver-
tically oriented frontalis muscles, which tighten the scalp,
raise the eyebrows, and create horizontal forehead rhytids.
The frontalis is encased by the superficial and deep layers of
the galea aponeurotica as part of layer 3 (Fig. 31.6). It fuses
with the occipitalis muscle posteriorly (some consider it part
of the occipitofrontalis muscle), is continuous (as part of the
galea) with the STF of the temple, and interdigitates with the
procerus, corrugator supercilii, and orbicularis oculi muscles
inferiorly, before inserting into the dermis underlying the
eyebrows. As the frontalis has no bony origin or attachment,
it serves only to provide facial expression. Finally, the lateral
forehead and eyebrows receive their blood supply from the STA,
while the medial forehead is supplied by terminal branches of
the ophthalmic artery, including the supraorbital and supra-
trochlear arteries. Venous drainage for the forehead is via the
supraorbital, supratrochlear, and superficial temporal veins,
while lymphatic drainage is to the preauricular and parotid
lymph nodes. The forehead (frontalis muscle) receives motor
innervation from the frontal branch of the facial nerve and
sensory input from the supraorbital and supratrochlear nerves,
both terminal branches of the ophthalmic division (V1) of the
Skin
Subcutaneous tissue
Superficial temporal fascia
Deep temporal fascia
Temporalis muscle
Pericranium
Superficial temporal fat pad
Frontal branch of facial nerve
a b
Fig. 31.6 Layers of the forehead. (a) Frontal view. (Reproduced from Sokoya M, Inman J, Ducic . Scalp and forehead reconstruction. Semin Plast Surg
2018;32(02):90–94.) (b) Parasagittal section through eyeball. (Reproduced from Codner M, McCord C, eds. Eyelid & Periorbital Surgery, 2nd ed. New
ork, N : Thieme; 2016.)
346
trigeminal nerve. The supraorbital nerve has two branches (see
Fig. 31.4):
1. A medial superficial branch, which pierces the corrugator super-
cilii muscle before supplying the central forehead
2. A deep lateral branch that runs just above the periosteum lat-
eral to the conjoint tendon, supplying the lateral forehead and
posterior scalp
This deep lateral branch should be protected in endoscopic
brow lifting surgery (dissect subperiosteally below it) to prevent
protracted postoperative sensory deficit.
At the level of the brow, the deep layer of the galea splits and
envelops the brow fat pad, also called the retro–orbicularis oculi
fat (ROOF). The ROOF continues into the eyelid proper as the
postorbicularis fascia in Caucasians and the preseptal fat in Asians.
The lateral extent of frontalis is bounded by the STL. Beyond
this landmark the tail of the brow has no elevator. Therefore,
neuromodulation of the lateral brow depressors (lateral orbi-
cularis oculi muscle) is a common intervention for chemical
lateral brow lifts. In addition, the ROOF descends and deflates
with age. Elevating (with brow lifts or suspension sutures) or
chemical filling (i.e., hyaluronic acid gel) of the ROOF can also lift
and/or project the tail of the brow. The authors prefer the term
brow recontour rather than brow lift, as in their view it is the
shape, arch, and contour of the brow that are more important
than height. A detailed knowledge of anatomy is what allows
consistent and reproducible results to these interventions.
hile there is one elevator of the eyebrows, there are multiple
depressors. These include the glabellar muscles medially, consisting
of the corrugator supercilii and procerus muscles, and the orbicularis
oculi muscle laterally. Unlike the frontalis, these muscles do have
bony attachments. The frontal branch of the facial nerve innervates
the orbicularis and corrugator muscles, while the buccal and zygo-
matic branches of the facial nerve innervate the procerus muscle.
Deep galea
Superficial galea
Anterior leaf
of deep galea
Frontalis muscle
Deep (lateral) branch Posterior leaf
of deep galea
of supraorbital nerve
Superficial (medial) branch Brow fat
of supraorbital nerve
Supratrochlear nerve
Postseptal
preaponeurotic fat
 ye id nd eri r i An my

31.3 Eyelid Anatomy 31.3.2 Key Points

31.3.1 General Considerations
The supraorbital ridge marks the transition of the upper to the
middle third of the face. The upper and lower eyelids are, thus,
in the middle third. They are complicated, multilayered, and
dynamic structures that act to protect the ocular surface and
preserve vision. Failure to maintain the anatomic integrity and
biomechanics of the eyelids during surgery can lead to aesthetic
and functional disability, including visual compromise. They
span the lateral to medial canthi, with the upper eyelid bounded
by the brows above and the lower eyelids by the midface below.
These transitions are not distinct but rather blend together,
so that the brows and upper eyelids and the lower eyelids and
midface behave, and are considered, as individual functional
and aesthetic facial subunits (Fig. 31.7). The area between the
brows and upper lids at their junction is called the superior
sulcus. Avoiding hollowing of this area by overresection of
skin, muscle, and fat is an important paradigm of upper bleph-
aroplasty for aesthetic enhancement.
Externally, the eyelids are topographically subdivided into a
palpebral (pretarsal and preseptal) and an orbital segment, based
on the internal anatomic structure underlying the eyelid skin and
muscle in this area (Fig. 31.7). Internally, the eyelids are composed
of three distinct lamellae: anterior, composed of thin skin and
orbicularis muscle; middle, defined by the orbital septum; and
posterior, made up of conjunctiva, tarsus, and retractors depend-
ing on topographic location on the eyelid (Fig. 31.8). Eyelid closure
is controlled in both the upper and lower eyelids by the orbicularis
oculi muscle, the only protector of the eyelids. Conversely, eyelid
opening is driven by separate and differing structures in the upper
and the lower eyelids, generally referred to as eyelid retractors,
discussed hereafter. Finally, the eyelids are internally separated
from the orbit proper by a thin connective tissue structure called
the orbital septum. The orbital septum is a critical landmark
in eyelid surgery, as the eyelid/orbital fat, which is excised or
transposed in blepharoplasty, is always posterior to the septum.
The orbicularis oculi is a concentric muscle that, depending on
its subdivision, originates and inserts on the orbital rim, lateral
raphe, or canthi. As it is a circular sphincter, it requires counterfix-
ation at the canthi to allow appropriate vertical eyelid excursion.
Poor canthal stability after blepharoplasty surgery can lead to
a biomechanical deficit in eyelid closure, medialization of the
lateral canthus, with subsequent shortening of the horizontal
palpebral fissure, collectively referred to as “fishmouthing.” The
pretarsal orbicularis lies above the tarsal plate and is thought to
contribute (with the preseptal orbicularis) to involuntary upper
eyelid excursion such as blink. The muscle continues to the eyelid
margin, where it can be seen as the grey line, also referred to as
the muscle of Riolan. The muscle has both superficial and deep
components that contribute to the medial and lateral canthal
tendons. The preseptal orbicularis overlies the orbital septum;
is mobile as compared with its pretarsal counterpart, which is
fixed to the tarsus; and also has superficial and deep segments,
which contribute to the canthal tendons. Both these segments of
orbicularis contribute to the lacrimal pump mechanism for tear
drainage. As the eyelids close, the orbicularis muscle contracts.
The pretarsal component compresses the canaliculi, driving
tears to the lacrimal sac. As the preseptal orbicularis (which
inserts into the lacrimal sac) contracts, it expands the lacrimal
Orbital Orbital
orbicularis segment
Preseptal
orbicularis
Middle lamella
septum
Palpebral
segment

Pretarsal
Posterior lamella orbicularis
(tarsus, conjunctiva)
Anterior lamella
a (skin, orbicularis)
Upper lid crease
Upper lid fold

Canthal tilt
(2 mm higher Superior sulcus
laterally)
Lateral canthus Medial canthus Inferior tarsal muscle
Tarsal platform
show Nasojugal Capsulopalpebral fascia
groove
Lower lid crease Inferior oblique muscle

Inferior rectus
Eyelid–cheek muscle Lockwood’s inferior
junction b suspensory ligament

Fig. 31.7 Normal eyelid surface anatomy. Fig. 31.8 (a) Upper lid cross section. (b) Lower lid cross section.

347
 VI Eyelid Surgery

originates at a periosteal fusion site at the orbital rim called the

Orbital orbicularis muscle arcus marginalis and inserts onto the LA on the upper lid and the
Superior preseptal eyelid retractors of the lower lid (Fig. 31.11).
orbicularis muscle

Superior pretarsal 31.3.3 S e i er ye id An my

orbicularis muscle
The critical layers of the upper lid are the anterior lamellae (skin
and orbicularis muscle), the middle lamella (orbital septum), and
the posterior lamella (conjunctiva, retractors, and tarsus). The
Inferior pretarsal
orbicularis muscle anterior lamella overlies the tarsus and orbital septum, which, as
stated, separates superficial eyelid tissue from the deeper orbit
Inferior preseptal proper. The orbital septum, which originates at the arcus margin-
orbicularis muscle
alis of the superior orbital rim, fuses with the LA approximately
2 to 3 mm above the tarsal plate in Caucasians and below the
Fig. 31.9 Orbicularis oculi muscle is classically divided into three
portions: orbital, preseptal, and pretarsal.

Whitnall’s ligament

sac, creating a negative pressure that draws the tears into the Posterior reflection
Lateral
sac. As the eyelid opens, the orbicularis muscle relaxes, which canthal
of medial canthal
tendon
in turn opens the puncta and collapses the lacrimal sac, and the tendon
cycle repeats. The bottom line is that normal eyelid function is Anterior reflection
of medial canthal
critical to prevent postsurgical tearing. The orbital orbicularis tendon
is the largest segment of the orbicularis muscle and controls Lockwood’s
inferior
voluntary upper eyelid closure as well as medial and lateral brow suspensory Lacrimal sac fossa
depression. Fig. 31.8 and Fig. 31.9 demonstrate the anatomic ligament
Posterior lacrimal crest
subdivision of the orbicularis muscle.
The eyelids are anchored medially and laterally by the medial and Anterior lacrimal crest
Arcuate
lateral canthal tendons. The medial canthal tendon is formed by expansion
fibrous extensions of the orbicularis muscle and has both anterior
and posterior crura, which attach to the anterior and posterior lac-
rimal crests, respectively. The anterior lacrimal crest is an extension Fig. 31.10 Critical structures and landmarks in canthal anatomy.
of the frontal process of the maxilla. The posterior lacrimal crest is
part of the lacrimal bone. The lacrimal sac lies between the anterior
Müller’s muscle
and posterior crura of the medial canthal tendon and within the Superior orbital rim
Levator palpebrae
lacrimal fossa. The lateral canthal tendon is similarly formed by
Eyebrow superioris muscle
fibrous extensions of the orbicularis muscle that connect the tarsal
plate to the lateral orbital rim, and it also has anterior and posterior Brow fat pad (ROOF)

crura. The anterior crus attaches to the anterior orbital rim, while Postseptal fat
the posterior crus attaches to hitnall’s tubercle, a bony promi- Orbital septum
nence 3 mm posterior to the lateral orbital rim and 10 mm below Levator aponeurosis
the frontozygomatic suture. Four anatomic structures attach to Dermal insertions forming
Whitnall’s tubercle (the 4 Ls): the lateral rectus check ligament, upper eyelid crease
the levator aponeurosis (LA), Lockwood’s suspensory ligament, Conjunctiva
and the lateral canthal tendon. In addition, the lateral canthal Superior tarsal plate
tendon sits approximately 2 mm higher than the medial canthal Pretarsal orbicularis muscle
tendon. This is known as the normal canthal tilt (Fig. 31.7). It is
Inferior tarsal plate
critical to re-create this posterior/superior attachment of the LCT
Inferior pretarsal muscle
in surgery, as it allows appropriate apposition of the lid to the
Capsulopalpebral fascia lid retractors
globe and directionality of the horizontal palpebral fissure. Fig.
Postseptal fat
31.10 shows critical structures and landmarks in canthal anatomy.
Inferior septum
The upper and lower tarsal plates are dense connective tissue Inferior oblique
Orbitomalar ligament
structures that provides structural integrity and support to the muscle

eyelids. The upper tarsus measures approximately 10 mm in SOOF

height and 25 mm in width. It tapers medially and laterally and
tends to decenter temporally with age. The lower tarsal plate
measures 4 mm in height and is approximately the same width.
Finally, in both the upper and lower eyelids, the orbital septum
Inferior orbital rim
Arcus marginalis
Fig. 31.11 Relevant anatomic structures for upper and lower lid anat-
omy. ROOF, retro–orbicularis oculi fat; SOOF, sub–orbicularis oculi fat.

348

superior border of the tarsal plate in Asians (Fig. 31.12). Dermal
attachments of this fusion point create the eyelid crease (Fig.
31.11). Posterior to the septum, the upper eyelid has two fat pads:
1. Nasal or medial
2. Central or preaponeurotic fat (PAF)
The fat pads are separated by the trochlea, the tendinous sling of
the superior oblique muscle (Fig. 31.13). In contrast to the lower
eyelid, there is no lateral fat pad in the upper lid, but a prolapsed
lacrimal gland can clinically appear as a full lateral upper lid. It
is important to familiarize oneself with the appearance of the
lacrimal gland in surgery so as not to resect it in error, assum-
ing that it is eyelid/orbital fat. The nasal fat pad, which is paler
than the more yellow PAF, is an extension and in continuity with
deeper orbital fat. Conversely, the PAF lies above the LA, which
separates it from the deeper orbital fat. The nasal fat, as compared
with PAF, tends to be relatively stem cell rich and becomes more
prominent clinically with age. As the nasal fat pad is laterally
bounded but not divided by the LA, it can be accessed from a
transconjunctival approach. Also, as the nasal fat pad is richer
in progenitor cells and tends toward prominence with age, it can
be transposed centrally within the eyelid to potentially maintain
volume and prevent postoperative superior sulcus hollowing
during blepharoplasty. While there is no distinct lateral fat pad in
the upper lid, the PAF can have lateral extensions that mimic this
appearance. The PAF is a critical landmark in eyelid surgery, as
it overlies the LA, which must be preserved in blepharoplasty to
avoid postoperative ptosis. Do not continue dissection through
the eyelid if fat is not identified.
The levator palpebrae superioris (LPS) muscle is the main
retractor of the upper eyelid (Fig. 31.11). It is skeletal muscle,
under voluntary control, and originates within the orbital apex
just above the optic foramen, from the lesser wing of the sphenoid
bone, and inserts on the anterior tarsal plate and the orbicularis
muscle and skin (to form the eyelid crease). It is innervated by the
ASIAN
ROOF
Levator
Levator muscle
muscle Preseptal fat
Müller’s Pre-aponeurotic
muscle fat
Fig. 31.12 Asian eyelids are fuller than those of non-Asians, as preaponeurotic fat rides lower in the lid and there is a preseptal fat layer, which is
continuous with the brow fat pad. Also, note potentially blunted attachments of the levator to the dermis, which can lead to an incomplete or absent
crease in many patients.
ye id nd eri r i An my
superior division of the oculomotor nerve (OM ; cranial nerve
III) and is composed of a muscular portion measuring 40 mm in
length and a tendinous portion (aponeurosis) measuring 14 to 20
mm in length. hitnall’s ligament (the superior transverse liga-
ment) lies at the junction of the muscular and tendinous portions
of the levator complex, is partially formed by the fascia of the
levator muscle, and inserts medially at the trochlea of the superior
oblique tendon and laterally at the lacrimal gland pseudocapsule
and frontal bone of the lacrimal sac fossa, 10 mm above hitnall’s
tubercle (Fig. 31.10). Whitnall’s ligament, interestingly, does not
attach to Whitnall’s tubercle. The ligament acts as a fulcrum to
change direction of the LPS from anterior to posterior to superior
and inferior. This allows the levator muscle to function as an
eyelid elevator and helps maintain eyelid/globe apposition. As
the levator aponeurosis continues inferiorly, it expands to medial
and lateral horns. The lateral horn divides the lacrimal gland into
orbital and palpebral and inserts on the lateral orbit at Whitnall’s
tubercle. Some of its fibers contribute to the lateral canthal
tendon. The medial horn inserts into the posterior reflection of
the medial canthal tendon and posterior lacrimal crest. These
horn insertions are important to maintain optimal lid contour.
Projections of the distal LA continue anteriorly to the orbicularis
muscle and skin to form the eyelid crease (Fig. 31.11). With age,
the levator aponeurosis tends to attenuate and/or dehisce from
its insertion. This leads to the characteristic clinical presentation
of ptosis, a hollow sulcus (recessed PAF), and an elevated eyelid
crease (levator recession)
The second upper eyelid retractor is M ller’s muscle (Fig.
31.11). This smooth muscle is responsible for involuntarily lift-
ing the eyelid approximately 2 mm (i.e., during the fight or flight
response), is sympathetic innervated, and loosely adheres to the
levator aponeurosis anteriorly and tightly connects to the con-
junctiva posteriorly. It originates from the undersurface of the
levator muscle and inserts onto the superior tarsal plate. In the
presence of ptosis, topical phenylephrine drops can be placed in
NON-ASIAN
Müller’s
muscle
Attachments of
levator to the dermis
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 VI Eyelid Surgery

orbicularis muscle and skin. The lower-riding fat is also one of

Central fat pad Interpad septum
under trochlea
the factors predisposing to fuller eyelid in Asians. The other
factor is that in Asians there is a preseptal fat layer in the eyelid,
Lacrimal gland
which is a continuation of the brow fat pad (ROOF). In Caucasians
the brow fat pad continues into the upper lid as postorbicular
Nasal fat pad fascia. Finally, Asians often have a shorter vertical tarsal height.
Lateral canthal
tendon Medial canthal 31.3.4 Lower Eyelid Anatomy
Lateral fat pad tendon
Lower eyelid anatomy can be more challenging to conceptualize
Nasal fat pad
Arcuate expansion three-dimensionally than the anatomy of its upper lid coun-
of Lockwood’s terpart. This anatomy often wreaks havoc on novice surgeons,
Inferior oblique
ligament
muscle especially when performing surgery transconjunctivally. In
addition, lower lid blepharoplasty is fraught with more frequent
and potentially disabling functional and aesthetic complications
Central fat pad than similar upper lid surgery. Accordingly, familiarization with
the complex and delicate nature of lower lid structure is critical
Fig. 31.13 Fat pads of the upper and lower eyelids. The trochlea sepa- to maintain both form and function after surgery (Fig. 31.11).
rates the upper nasal and preaponeurotic fat pad. The inferior oblique
separates the nasal and central fat pad of the lower eyelid. The arcuate As in the upper eyelid, the anterior lamella of the lower lid con-
expansion separates the lateral fat pad of the lower eyelid. sists of skin and orbicularis muscle subdivided into orbital and pal-
pebral (preseptal and pretarsal) segments, and the middle lamella
is composed of orbital septum. While it can be safe to excise
preseptal orbicularis during lower blepharoplasty surgery, care
the affected eye to potentially stimulate muscle contraction and
must be taken to preserve the pretarsal orbicularis muscle during
accordingly plan posterior approach ptosis repair surgery based
this procedure so as to avoid lower eyelid malposition. What is
on a predetermined algorithm. Posterior approach ptosis
different in the lower lid is that the retractors are structured differ-
repair (müllerectomy) requires no patient cooperation and
ently and are composed of both the capsulopalpebral fascia (CPF)
less detailed knowledge of anatomy, is technically easier, and
and the inferior tarsal muscle (ITM). The orbital septum fuses
is more consistent and reproducible than levator-dependent
with the retractors approximately 5 mm below the tarsal plate.
ptosis surgery.
This fusion point is important when performing transconjunctival
blepharoplasty, as it allows both a preseptal and a postseptal surgi-
Asian Upper Eyelid Anatomy Variations cal dissection plane, depending on where the incision is made (Fig.
It is important to recognize the differences in Asian upper eyelid 31.14). It has been shown with transconjunctival surgery that
anatomy (Fig. 31.12). Approximately 50 of Asian eyelids have both pre- and postseptal surgery lead to a negligible incidence of
a partial or no eyelid crease. This occurs because the orbital lower lid malposition. In addition, with the postseptal approach,
septum can attach lower on the LA. This more inferior attach- an incision 6.5 mm below the tarsus has been shown to attain
ment of the septum allows PAF to ride lower in the eyelid and direct fat access in 82% of cases. Posterior to the orbital septum
potentially blunt the terminal attachments of the LA to the are three fat pads: nasal, central, and lateral. The nasal and central

Conjunctiva

Lower lid
retractors

Orbital
septum
Orbicularis
oculi muscle

Transconjunctival Transconjunctival
pre-septal approach post-septal approach

Fig. 31.14 Preseptal versus postseptal transconjunctival blepharoplasty.

350

fat pads are superficially divided by the inferior oblique muscle
(IOM), which originates from the medial orbital floor and courses
superolaterally to insert on the posterior aspect of the globe. It is
responsible for extorsion, abduction, and elevation of the globe,
and iatrogenic trauma to the muscle during blepharoplasty can
lead to postoperative diplopia (Fig. 31.13).
Like the upper lid, the lower lid also has a suspensory structure,
called Lockwood’s ligament (Fig. 31.10). It functions as a ham-
mock below the globe to support it and prevent its downward dis-
placement. It is attached to the medial and lateral orbit (laterally
inserts on hitnall’s tubercle), is a thickening of Tenon’s capsule
(bulbar sheath) and is intimately associated with both the IR
muscle and IOM. The arcuate expansion of Lockwood’s ligament
is a projection of the ligament that inserts on the inferolateral
orbital rim and separates the central and lateral fat compartments
of the eyelid (Fig. 31.13). Surgically, the nasal and central fat pads
typically override the IOM as the muscle arises deep to the orbital
rim. Conversely, the central and lateral fat pads do not override
the arcuate expansion, which is a more superficial structure.
Accordingly, during clinical evaluation of a patient for lower
blepharoplasty, the nasal and central fat pads appear as one fat
pad, while a demarcation is often noted between the central and
lateral fat pads. These findings are more pronounced when the
patient looks up. hile the IOM and the arcuate expansion are
structural landmarks that separate the lower lid fat pads, these
fat pads are continuous, as can be seen when pulling in opposite
directions sequentially on the nasal and central fat pad under the
IOM. This maneuver has been called the “inverse shoeshine sign.”
The posterior lamella of the lower lid is composed of the tarsus
and conjunctiva for the first 5 mm below the lashes (where the
tarsus ends). Below the level of the tarsus, the posterior lamella
consists of the lower eyelid retractors, including the CPF, ITM, and
conjunctiva (Fig. 31.8b). The lower lid retractors are intimately
associated with the conjunctiva. The capsulopalpebral head orig-
inates from the fascia of the IR muscle, then envelopes the IOM
to become the CPF, which fuses with the orbital septum to insert
on the inferior tarsal border. The ITM, similar to M ller’s muscle
of the upper eyelid, is a sympathetically driven smooth muscle
that lies posterior to the CPF. The lower eyelid crease is formed by
small fibrous attachments of the CPF to the skin of the lower lid
a few millimeters below the tarsus. As the lower lid retractors
have origins at the IR muscle, strabismus surgery involving the
IR muscle can change eyelid position.
31.3.5 Neurovascular Supply of the
Eyelids
Arterial Supply
The arterial supply of the eyelids is derived from both the inter-
nal carotid artery (ICA) and the external carotid artery (ECA).
The ophthalmic artery (OA), the first branch of the ICA, gives off
multiple orbital branches including the lacrimal and supraorbital
arteries. These terminal branches primarily contribute to the
marginal and peripheral arcades of the eyelids. In the upper
eyelid, the marginal arterial arcade lies 2 mm superior to the
eyelid margin and anterior to the tarsal plate. The peripheral
marginal arcade lies superior to the tarsus between the levator
ye id nd eri r i An my
aponeurosis and M ller’s muscle. In the lower eyelid, there is only
one arterial arcade, which is located at the inferior tarsal border.
From the ECA the STA gives off three branches that contribute
to eyelid arterial blood supply. These include the frontal branch,
which communicates with both the lacrimal and supraorbital
arteries; a zygomatico-orbital branch, which in part supplies the
upper lid; and a transverse facial branch, which anastomoses
with the infraorbital arteries supplying the lower lids. Finally,
the infraorbital artery (a branch of the internal maxillary artery,
from ECA) provides a rich arterial supply to the peripheral lower
lid. It is important to understand the varied communication of
the ICA and ECA. These connections provide potential access of
facial injections of filler, fat, or particulate material into the
ICA circulation via retrograde flow with injection pressure.
The subsequent antegrade flow to the ophthalmic artery, when
injection pressure is released, can lead to blindness via infarc-
tion of arterial branches to the anterior and posterior optic
nerve or retinal circulation. Refer to Fig. 31.15 for vascular
supply of the eyelids.
Venous and Lymphatic Drainage-
The venous drainage of the eyelids is divided into pretarsal
and posttarsal components. The pretarsal tissue drains into
the angular veins medially and the superficial temporal vein
laterally. The posttarsal drainage is into the orbital veins and
the deeper branches of the anterior facial vein and pterygoid
plexus. Lymphatic vessels that serve the medial eyelid drain into
the submandibular lymph nodes, while those serving the lateral
portions of the eyelids drain first into the superficial preauricular
nodes and then into the deeper cervical nodes.
Eyelid Innervation
Motor eyelid innervation is supplied by branches of the facial
nerve (F ; cranial nerve VII), the OM (cranial nerve III), and
sympathetic nerve fibers. The OM and sympathetic fibers
are responsible for eyelid retraction (opening), while the F is
responsible for eyelid protraction (closing). The superior branch
of the OM innervates the main upper eyelid retractor, the levator
palpebrae superioris. Sympathetic nerve fibers innervate the
ancillary eyelid retractors, including M ller’s muscle of the upper
eyelid and the ITM of the lower eyelid. First-order neurons of the
sympathetic pathway begin centrally at the hypothalamus and
descend caudally to the cervical spinal cord. Second-order neu-
rons exit the cervical cord and travel with the brachial plexus as
part of the cervical sympathetic chain and synapse in the superior
cervical ganglion. Third-order neurons leave the superior cervical
ganglion and travel into the cranium, entering in proximity to the
internal carotid artery (internal carotid nerve), after which they
enter the orbit with the optic nerve and ophthalmic artery through
the optic foramen. Disruption of the sympathetic pathway can
lead to Horner’s syndrome, which presents with a combination of
the classic findings of ptosis, miosis, and anhidrosis.
Eyelid protraction is controlled by various branches of the F ,
including the frontal, zygomatic, and buccal branches. The frontal
branch innervates the upper eyelid orbicularis, while the lower
lid orbicularis is innervated by both the zygomatic and buccal
branches. Recent cadaveric dissections have demonstrated that
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 VI Eyelid Surgery

Supratrochlear artery Terminal branches of V1 that innervate the upper eyelid include
Supraorbital artery the lacrimal, supraorbital, and supratrochlear nerves from lateral
Superior arcade to medial. Similarly, in the lower lid, sensory branches emerge
from V2 and include the zygomaticofacial and infraorbital nerves,
Marginal arcade
lateral to medial (Fig. 31.16).
Dorsal nasal
artery
Lacrimal artery
31.4 Midface Anatomy
Medial palpebral
Superficial The midface, which transitions from the lower eyelid at the
artery (superior)
temporal
artery
infraorbital rim, completes the middle third of the face. It
Medial palpebral has been traditionally bounded superiorly by the lid–cheek
artery (inferior)
Angular artery
junction and inferiorly by a line from the inferior tragus to the
oral commissure. It is also divided into a lateral and more central
Lateral
anterior compartment by a line from the lateral canthus to the
nasal oral commissure. This lateral/central division has anatomic and
artery
Zygomatico- clinical relevance, as laterally the five tissue layers of the face
facial artery
are thin and functionally fused over the muscles of mastication;
thus, there is little facial expression in this location. In the central
(anterior) midface, by contrast, the five tissue layers are robust
Transverse Angular artery and act in consort to convey facial expression.
facial artery
The layers of the midface are the same as in other regions of the
a
Infraorbital face and include the following (Fig. 31.17):
artery
1. Skin
Superior Supraorbital vein 2. Subcutaneous tissue
palpebral vein
3. A fibrous layer investing the muscle of facial expression: the
Nasofrontal vein superficial musculoaponeurotic system (SMAS)
4. A loose areolar tissue plane
Supratrochlear
vein 5. Periosteum or deep fascia

Medial palpebral
Superficial
vein (superior)
temporal
vein Nasal vein Supraorbital nerve

Medial palpebral Supratrochlear

vein (inferior) Zygomaticotemporal nerve
nerve
Angular vein

Infraorbital vein

b Anterior facial vein

Fig. 31.15 (a) Arterial and (b) venous supply of the eyelid.

the lower orbicularis is not innervated by multiple vertically

oriented motor nerve fibers as had been thought. In fact, it was
shown that these vertical fibers emerge from the infraorbital
foramen, indicating that they are sensory nerves. Furthermore,
Infraorbital nerve
it has been shown that the zygomatic branch of the facial nerve,
with buccal branch contribution, travels obliquely through the
anterior cheek and supplies the orbicularis oculi of the lower Zygomaticofacial
eyelid and the medial portion of the upper eyelid. nerve
Sensory innervation to the eyelids is supplied by the ophthal-
mic (V1) and maxillary (V2) divisions of the trigeminal nerve. Fig. 31.16 Sensory innervation to the eyelids.

352
 ye id nd eri r i An my

Nasojugal groove

Skin
Orbital septum

Orbital retaining ligament

Malar
Preperiosteal fat Superficial fat mound

Prezygomatic space
Orbicularis oculi muscle

SOOF
Bone Zygomatic
cutaneous
ligament

Fig. 31.17 Layers of the midface from skin to periosteum with associated grooves and mounds which develop with age.

As stated, in the lateral midface, all tissue layers are essentially
fused. Accordingly, they cumulatively act as one structural retain-
ing ligament. In the anterior midface, there are three prominent
ligamentous attachments, which traverse all five facial tissue
layers (deep fascia to dermis) to support the dynamic midfacial
soft tissue in this location. These include the orbicularis retaining
ligament (ORL), the zygomaticocutaneous ligament ( CL), and the
masseteric ligament (Fig. 31.17, Fig. 31.18). Critical to eyelid and
midfacial aging changes are the ORL and CL. At the medial lower
lid/cheek junction, there is a dense attachment of orbicularis
fibers to the upper maxilla. This is a true ligament, which has been
called the tear trough ligament. With age, a multitude of factors,
including volume loss, orbital septal attenuation, and midface
ptosis, create a topographic depression over this area, which has
been called the tear trough or nasojugal groove (Fig. 31.17, Fig.
31.18). At the midpupil the ligamentous attachment of the infe-
rior orbital rim to the dermis becomes less dense and longer as it
traverses thicker tissue planes including fat. At this point the lig-
ament is called the ORL, and its associated age-related depression
above the orbito- or palpebromalar groove. In combination, the
nasal-to-lateral age-related lid–cheek depression is often referred
to as a prominent lid–cheek junction (Fig. 31.19). Effacement
of periorbital hollows, including the tear trough, has been
attempted by filling with synthetic materials, autologous fat or
allografts, native fat transposition, and a variety of tissue lift-
ing techniques. Familiarization with lower eyelid and midface
anatomy is critical to attaining successful results and avoiding
sometimes permanent complications with these innervations.
The CL, like the ORL, is an osteocutaneous ligament that
originates from the periosteum of the zygoma and/or the anterior
and lateral border of the zygomatic arch (posterior to the origin
of the zygomaticus minor muscle) and insets into the dermis of
the cheek. As with the lid–cheek junction, age-related volume loss
and tissue descent lead to a characteristic groove (malar groove)
overlying the ligament, with tissue bulges or bags around the
groove (malar mound, Fig. 31.17, Fig. 31.19). As a general rule,
potential spaces are present in the loose areolar plane of the
anterior midface, and these spaces are bounded by the ligaments
described. These spaces are glide planes between the muscles of
facial expression above (within the SMAS) and the periosteum or
deep fascia below. These glide planes allow the facial soft tissue to
move freely over fixed tissue. With age, differential laxity occurs
between these spaces and their accompanying ligament-sup-
ported boundaries. These differences account for much of what
we see in facial aging (bags and depressions).
Volume is an essential part of midface structure. Much of this
volume is attained from the midface fat pads. These fat pads are
critical to facial shape and appearance, involute with age in a
nonuniform way, and are target sites for facial volumization with
synthetic fillers or autologous fat. These fat pads can be divided
into two groups. The first is subcutaneous or superficial in depth
and above the SMAS, while the second is deep and sub-SMAS in
location. The superficial fat has nasolabial, medial, middle, and lat-
eral temporal compartments. The deep fat is divided into the sub–
orbicularis oculi fat (SOOF), which has both a medial and lateral
segment; a deep medial cheek fat, also with a medial and lateral
segment; and a deeper medial fat in a location called Ristow’s space
(lateral to piriform aperture, medial to deep medial fat).
The midface musculature functions to elevate the lip and the
corner of the mouth. These include the levator labii superioris

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 VI Eyelid Surgery

(LLS), levator labii superioris alaeque nasi (LLSA ), and the leva-
tor anguli oris (LAO) medially, and the zygomaticus major ( M)
and minor ( m) laterally. The LLS originates on the medial infe-
rior orbital rim, courses over the infraorbital foramen to insert
on the orbicularis oris, and functions to elevate the lip vertically.
The LLSA originates on the frontal process of the maxilla course
inferiorly and splits into a medial and lateral head, inserting
onto the skin of the lateral nostril and upper lip. It functions to
flare the nostril and raise the lip. The LAO originates 1 cm below
the infraorbital foramen and inserts on the modiolus and outer
edge of the lip. It functions to elevate the angle of the mouth.
The M originates at the zygomatic arch, inserts on the modiolus
of the mouth, and serves to move the lip laterally and vertically.
Finally, the m originates on the maxillary process of the zygoma,
inserts on the lip just lateral to the LLS, and also functions as a
lip elevator.

OL
31.4.1 Innervation
ZL All midface muscles described above are primarily innervated
MCL by the buccal branch of the facial nerve, with some overlap with
the zygomatic branch (Fig. 31.20). Damage to the facial nerve
with subsequent aesthetic and functional impairment has been
a major concern to surgeons operating in the midface. For this
reason, subperiosteal midface lifts gained popularity as to avoid
neuroinjury. However, in the midface, the facial nerve branches
run outside the walls of the glide planes described near the
Fig. 31.18 Osseocutaneous ligaments of the midface. OL, orbicularis
retaining ligament (ORL in text); L, zygomaticocutaneous ligament retaining ligaments. Accordingly, surgical dissection is safe with
( CL in text); MCL, masseteric ligament. appropriate knowledge of anatomy. The sensory innervation

A B

Orbital rim Tear trough and

indentation nasojugal fold

Malar mound

Nasolabial
crease
Midfacial fold

a b

Fig. 31.19 Common aging changes in the periorbital and midface region. (a) The aged face with associated changes. (b) The youthful face.

354
 ye id nd eri r i An my

Superficial temporalis fascia

(temporoparietal fascia)

Deep temporalis fascia

Temporal branch (frontal)

Zygomatic branch
Postauricular nerve
Buccal branch
Parotid duct
Marginal mandibular branch
Great auricular nerve
External jugular vein Cervical branch

Fig. 31.20 Illustration of the facial anatomy, including motor innervation of the midface via the zygomatic and buccal branches of the facial nerve.

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31.4.2 Vasculature
The arterial supply of the midface is primarily from the ECA via
its terminal branches, including the infraorbital artery (from
the maxillary branch) and transverse facial artery (from the
STA). There is also a small contribution from the ICA through its
zygomaticofacial branch.
31.4.3 Venous and Lymphatic Drainage
The venous drainage of the midface is via the inferior ophthalmic
vein into the pterygoid plexus and from various facial veins that
drain into the external jugular vein. The lymphatic drainage can
be variable, with medial drainage to the submental and subman-
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32 Clinical Decision Making in Aesthetic Eyelid Surgery
Foad Nahai
Abstract
There are numerous surgical and nonsurgical options for rejuve-
nation of the eyelids. Our clearer understanding of loss of volume/
deflation in the aging process has led to the more common,
almost routine addition of volume to the eyelids, be it fat or filler.
All surgical and nonsurgical options are presented and through
patient selection, the indications for each is presented.
Keywords
fat grafting, skin muscle flap, transconjunctival blepharoplasty,
skin pinch, canthopexy
32.1 Evaluation
The hallmark of youthful-appearing eyelids (Fig. 32.1) is a
smooth contour that extends from the brow to the upper lid
and from the lower lid to the cheek and midface. The lid–cheek
junction lies over the infraorbital rim and is usually 5 to 12 mm
below the lid margin. The skin is tight and the tissues are full.
There is an upward slant from the medial canthus to the lateral
canthus, and eyelid tone is normal: a snapback test results in
rapid lid recovery, and lid distraction will be 6 mm or less.
In contrast, the aged eye (Fig. 32.2) appears hollow, with a
definite demarcation from the brow to the upper lid and the lower
lid to the cheek and midface. In most individuals, the eye fissure
becomes smaller and rounder with age. The lid–cheek junction
lies well below the infraorbital rim, 15 to 18 mm from the lid
margin. There is a downward slant from the medial canthus to
Fig. 32.1 Youthful-appearing eyelids. Fig. 32.2 Aged eyelid.
ini e i i n ing in Ae ei ye id Surgery
the lateral canthus, and eyelid tone is significantly reduced, with
a very slow result to the lid snapback test and a lid distraction of
6 mm or greater.
These aging changes, which develop gradually over time, are a
combination of volume loss, loss of skin elasticity, and downward
descent of the tissues. These changes are classified into the follow-
ing four types (Fig. 32.3):
• Type I: Aging confined to the lower lid, with skin and muscle
laxity and pseudoherniation of the fat
• Type II: Aging no longer confined to the lower lid; in addition
to skin and muscle laxity, there is skin excess and minimal
descent of the lid-cheek junction
• Type III: Lower lid aging with volume loss, descent of the
lid–cheek junction, and malar eminence; skeletonization of
the orbital rim, deepening of the nasolabial fold, loss of skin
elasticity, and lid laxity are also common findings
• Type IV: Further volume loss and descent of the lid–cheek
junction; deepening of the nasojugal groove; presence of malar
bags; further loss of skin elasticity, lateral canthal descent, and
lid laxity with scleral show
This classification is most useful in selecting appropriate
procedures to address specific problems for each patient type. In
addition to addressing the lower eyelid, it also demonstrates that
aging of the lower lid and aging of the midface are intertwined.
Rejuvenation of one without the other will lead to a suboptimal
or patchwork result. Concomitant with the aging changes of the
lower lid and lid–cheek junction, there is a real or apparent loss of
volume that must be addressed (Fig. 32.4).
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Fig. 32.3 The four types of eyelid aging changes.

A component evaluation of the eyelids to determine aesthetic

options will also minimize complications. Components of eyelid
evaluation are discussed next.

Decision-Making Factors in Eyelid Surgery

Aesthetic factors:
a b
• Skin
uality
uantity
• Muscle
• Fat
• Lid–cheek interface
• Scleral triangles
Medial c d
Lateral
Safety factors: Fig. 32.4 (a) Type I; (b) Type II; (c) Type III; (d) Type IV.
• Upper lid ptosis
• Lid tone
• Eye prominence
• Canthal position

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32.1.1 Skin 32.1.5 Lid Tone

As an individual ages, the elasticity of eyelid skin diminishes,
causing the skin to appear loose and wrinkled. There is real
and apparent skin excess. The physician evaluates the quality
and quantity of the skin. In assessing upper eyelid skin excess,
the brow should be held in its ideal position. The eyelids should
always be evaluated with the eyes open as well as with them shut.
32.1.2 Muscle
Muscle activity and morphology are noted. ith aging, the
orbicularis oculi muscle may become lax and hypertrophic,
especially in the pretarsal area. Infratarsal fullness may also be
present. Although this fullness is often associated with a youth-
ful eye, some patients are concerned about infratarsal fullness.
32.1.3 Fat
Lower eyelid tone is evaluated with the lid distraction test and
lid snapback test previously described. Routine correction of
lower lid laxity is essential to minimize complications.
32.1.6 Eye Prominence
(Hertel Measurement)
Eye prominence is assessed by means of the Hertel ophthalmom-
eter, which measures the distance between the cornea and the
lateral orbital rim (Fig. 32.5).
ormal eye prominence, which is seen in 65 of the population,
ranges from 15 to 17 mm. Deep-set or anophthalmic eyes mea-
sure less than 15 mm, and any measurement of 18 mm or greater
indicates a prominent eye. These measurements play a significant
role in determining risk, procedure selection, and lid-anchoring
techniques (Fig. 32.6).

Two pockets of periorbital fat are contained within the upper

lid, with three in the lower lid. The surgeon notes these and 32.1.7 Canthal Position
decides whether to preserve, redistribute, or remove this fat. In
The surgeon notes the position of the lateral canthus in relation
addition, the retro–orbicularis oculi fat (ROOF) lying along the
to the medial canthus. The lateral canthus should normally be
lateral orbital rim between the orbicularis oculi muscle and the
higher than the medial canthus. A lateral canthus at the same
periosteum is also assessed. Under rare circumstances, some of
level or lower than the medial canthus indicates significant lid
this fat will need to be resected to improve the contour of the
laxity, requiring horizontal lid shortening (canthoplasty) (Fig.
lateral orbital rim.
32.7).

32.1.4 Upper Lid Ptosis 32.1.8 Scleral Triangles

The presence or absence of upper lid ptosis should always be
The triangle between the cornea and the medial canthus is
recorded. If present, it is pointed out to the patient, and plans are
called the medial scleral triangle, and the triangle between the
discussed to correct it at the time of blepharoplasty.

Fig. 32.5 Use of the Hertel ophthalmometer to measure eye prominence.

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cornea and lateral canthus is called the lateral scleral triangle.
ith increasing lid laxity and age, these triangles, especially the
lateral scleral triangle, are lost. Eye shape is judged by the shape
and size of the lateral scleral triangle. The tighter the triangle,
the more almond-shaped the eye; conversely, the looser the
triangle, the rounder the shape of the eye (Fig. 32.8).
32.1.9 Signi n e u i n
Components
Evaluation of skin, muscle, and fat plays a role in selecting the
best treatment option. However, of more importance is evalu-
ation of the lid–cheek interface and midface aging for lower lid
options. For the upper eyelid, the relationship between the upper
lid and the brow is an important determining factor.

Fig. 32.6 Normal eye prominence, which is seen in 65% of the population, ranges from 15 to 17 mm. Deep-set or anophthalmic eyes measure less
than 15 mm, and any measurement of 18 mm or greater indicates a prominent eye.

Fig. 32.7 Canthal position in the youthful and aged eye.

Fig. 32.8 Scleral triangles in the youthful and aged eye.

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Evaluation of lid tone, eye prominence, and canthal position
plays a pivotal role in determining which lid-anchoring procedure
is appropriate to minimize the potential for complications.
32.2 Preoperative Planning
32.2.1 Treatment Options
A variety of surgical and nonsurgical options are available
for treating upper and lower eyelid aging. Fat grafting and
injectables offer volume restoration of the upper lid and the
lid–cheek junction. Surgical options include transcutaneous
and transconjunctival approaches. Procedures range from the
simple transconjunctival removal of fat from both upper and
lower lids to complex procedures, including transpalpebral pro-
cerus and corrugator muscle modification, brow pexy through
the upper eyelid, and transpalpebral midface lift through the
lower eyelid.
32.2.2 Options for Fat Management
In recent years there has been a tremendous revolution in our
thinking about and approach to facial rejuvenation. This is espe-
cially true for concepts of fat preservation and augmentation,
not only in face lifts but even more so in blepharoplasty. Gone
is the standard skin, muscle, and fat excision blepharoplasty
that I was taught many years ago. Our current choices are to
preserve or redistribute the periorbital fat and occasionally
remove or even augment the fat. For augmentation, options
include autologous fat, autologous dermis, fillers, and even
alloplastic materials.
I base my options for fat management on evaluation of the
lid–cheek junction and choose a procedure to improve this area.
Although most surgeons continue to rejuvenate the lower lid
surgically, including fat grafting, injectable fillers are a safe and
effective option for lower lid rejuvenation, especially for correc-
tion of the tear-trough area (Fig. 32.9). I feel that the results of
surgical procedures are better, last longer, and are in the long run
more cost-effective than injectables.
Fig. 32.9 Although most surgeons continue to rejuvenate the lower lid
surgically, injectable fillers are being established as a safe and effective
option for lower lid rejuvenation, especially for correction of the
tear-trough area.
ini e i i n ing in Ae ei ye id Surgery
Options for Fat Management
• Preserve
• Redistribute
• Augment
• Remove
If the patient has an adequate volume of fat, my preferred
technique for improving the lid–cheek junction is a combi-
nation of fat redraping and a transpalpebral midface lift with
orbicularis muscle flap redraping. If the patient does not
have fat herniation or enough fat for redraping, I plan no fat
manipulation, I do not open the periorbital septum, and I rely
on the transpalpebral midface lift and on orbicularis muscle
flap redraping.
If I think that these approaches are not adequate for correction
of the lid–cheek junction, I consider autologous tissue augmen-
tation. I have no experience with alloplastic implants around
the orbital rim, and I think that autologous tissue is better and
as effective. Occasionally, I do resect fat from the lower lid, most
often from the lateral compartment when the fat bulges out. The
patient shown in Fig. 32.10 had no fat removal from either lower
eyelid. The patient shown in Fig. 32.11 had fat removed only from
the lower left eyelid.
A previous review of a personal series of 100 consecutive
blepharoplasties revealed 49 with fat redraping, 38 with no
fat manipulation, 9 with fat excision, and 4 with autologous
grafting in the lower lid (Fig. 32.12). More recently, fat graft-
ing of the lower lid and lid cheek junction, with or without
skin excision, has become more common in my practice (Fig.
32.13). In the upper eyelid in the same series, I resected fat
from the medial nasal pocket in 76 and from the lateral
pocket in only 24 of cases (Fig. 32.12). Today it is very rare
that I resect fat from the central compartment. Those num-
bers were indicative of my practice a few years ago. Today fat
Fig. 32.10 Periorbital rejuvenation without fat removal.
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Fig. 32.11 This patient’s bulging lower left eyelid required resection of fat on that side only.
Fig. 32.12 Frequencies of fat management approaches in the author’s
practice in lower and upper blepharoplasties.
preservation and augmentation are far more common in my
practice.
Resection of the ROOF was very popular a decade or two ago
and was part of my approach to the upper eyelid and lateral brow
in selected patients. Today, with a better understanding of the
aging process and the role of volume, I do not resect the ROOF.
Patients with a full subcutaneous pocket, deep to the lateral
hair-bearing brow, who would benefit from ROOF resection are
few and far between (Fig. 32.14).
ith the current interest in fat preservation and adding
volume to the lower eyelid, it is possible that the surgeon may
injudiciously inject excessive amounts of autologous fat into the
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a b
Fig. 32.13 Woman aged 64 (a) before and (b) after face- and neck lift
with fat grafting of cheeks and upper and lower eyelids.
periorbital area, as had been done to the patient shown in Fig.
32.15. Given the unpredictability of the survival of the grafted
fat, this is not an uncommon finding. Injecting deep and limiting
overcorrection will reduce or eliminate the chances of overinjec-
tion of fat. Transconjunctival and transcutaneous fat removal has
proved to be a relatively straightforward and effective procedure
for correction of this problem. The injected fat bears little resem-
blance to the periorbital fat and maintains the appearance and
morphologic character of the area from which it was harvested.
The transcutaneous approach was chosen for this patient so that
her lid retraction and skin excess could be addressed, along with
removal of the excess injected fat (Fig. 32.16).
Transconjunctival fat removal is shown in another patient in
Fig. 32.17.
32.2.3 Upper Eyelid
Options for upper eyelid rejuvenation are fewer than those for
the lower eyelid. Most upper eyelids are approached through a
standard skin–muscle incision. Rarely, the transconjunctival
approach is an option to resect excess fat in the medial pocket.
 ini e i i n ing in Ae ei ye id Surgery

Fig. 32.14 Lower lid fat management.

Fig. 32.15 Patient who had undergone injection of an excessive amount of autologous fat in the periorbital area.

a b
Fig. 32.16 The transcutaneous approach was chosen for the patient
in Fig. 32.15 so that her lid retraction and skin excess could be
addressed, along with removal of excess injected fat. (a) Pre- and (b)
postoperative images are shown here following the removal of the
excess fat, canthopexy, and transpalprebral mid facelift. Fig. 32.17 Transconjunctival fat removal.

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A skin excision with muscle preservation may sometimes be
the best option to preserve orbicularis muscle so as to maintain
volume in the upper eyelid.
Options for Upper Eyelid Rejuvenation
• Transconjunctival fat removal from the medial pocket
• Skin and muscle excision
Gateway to the lateral brow
Gateway to the glabellar muscles
Ptosis repair
• Skin excision with muscle and fat preservation
Options for rejuvenating the upper eyelid include transconjunc-
tival and transcutaneous approaches (Table 32.1). The transcon-
junctival approach has a limited role, confined to excision of fat
from the medial or nasal fat pocket. The most versatile approach
to the upper lid is excision of skin and muscle (the open-sky
approach), which allows access to the periorbital fat, ROOF, lateral
brow, glabellar muscles, and levator muscle. Recently the skin
excision with muscle preservation approach to the upper eyelid
has been popularized. ith this volume-preserving procedure,
the orbicularis is preserved to increase the volume of the upper
eyelid. Access deep to the orbicularis is possible by merely divid-
ing the muscle rather than resecting it.
The advantage of this transconjunctival approach is that it
eliminates the need for an incision in the upper eyelid skin. This
approach has been free of complications in my hands, and I have
not seen any ptosis. The limitation of this approach is that only one
aspect of upper eyelid aging medial fat herniation is addressed.
Skin-Muscle Excision
Skin–muscle excision is the most versatile approach to the upper
eyelid, allowing manipulation and excision of fat from both
periorbital fat pockets; excision of ROOF, if indicated; access
to the lateral brow; and access to the glabellar muscles. The
skin–muscle excision approach also affords exposure of the leva-
tor and its aponeurosis for ptosis repair. It is a proven approach
with minimal morbidity. Potential problems include inadvertent
disruption of the levator aponeurosis, leading to postoperative
ptosis, and misplaced scars.
Skin Excision
In keeping with recent trends to preserve and restore volume in
facial rejuvenation, a volume-preserving upper lid skin excision
has been described (Fagien). If access deep to the orbicularis
is needed, the orbicularis is divided rather than resected. It is
thought that the small amount of orbicularis that is spared with
this approach adds volume to the upper lid.

Transconjunctival Approach 32.2.4 Lower Eyelid

The transconjunctival approach has limited application for
My approach to the lower eyelid is based on management of fat,
removal of the medial or nasal fat pocket only. I have found this
skin, muscle, and the lid–cheek junction. Options include the
to be a safe, efficacious technique in primary as well as second-
transconjunctival and transcutaneous approaches. A detailed
ary fat removal from the medial pocket. Ideal candidates have
evaluation of the eyelid and periorbital area helps determine
a bulging medial fat pocket of the upper eyelid with no excess
the appropriate selection of surgical technique. A variety of
upper eyelid skin.
procedures are available to manage the skin laxity and excess,
The lateral fat pocket, preaponeurotic fat, in the upper eyelid
periorbital fat, muscle, and the lid–cheek interface and lid laxity.
lies anterior to the levator aponeurosis, whereas the medial or
Some are relatively straightforward, with minimal if any mor-
nasal fat pocket lies medial to the aponeurosis. The insertion of
bidity (for example, skin-pinch blepharoplasty and transcon-
the levator aponeurosis into the tarsal plate prevents herniation
junctival fat removal), whereas others, especially those designed
of the lateral fat pocket (Fig. 32.18); however, the medial horn
to improve on the lid–cheek junction, not only are complex and
of the levator aponeurosis is much higher than the lateral horn.
technically demanding but also may lead to lid retraction and
This allows herniation of the medial fat as well as access to the
exposure. Correction of lid laxity and routine lid anchoring at
medial fat through the conjunctiva. The incision is made in the
conjunctiva medial to the medial border of the tarsal plate.

Table 32.1 Options for upper eyelid rejuvenation

m nen r n n un i S in nd S in
mu e excision
excision
Skin — ++++ ++++
Muscle — ++++ —
Fat ++++ ++++ —
(medial pocket only)
Lateral brow — ++++ —
Glabellar muscles NA ++++ —
Ptosis repair NA ++++ — Fig. 32.18 The insertion of the levator aponeurosis into the tarsal plate
Degree of effectiveness indicated by the number of plus signs. NA: not applicable. prevents herniation of the lateral fat pocket.

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 ini e i i n ing in Ae ei ye id Surgery

the time of the primary procedure are prerequisites to minimize Fillers

these potential complications.
Autologous fat as a filler in the periorbital area is increasing in
The lid–cheek junction can be improved and the lower lid reju-
popularity and effectiveness. A variety of hyaluronic acid fillers
venated through augmentation with fillers or fat and manipulation
(nonanimal stabilized hyaluronic acid fillers, or ASHAs), are
of the superficial musculoaponeurotic system (SMAS) with open
available for volume restoration of the lower lid, especially the
facelift procedures, such as the high SMAS technique, SMASectomy,
nasojugal groove.
and the extended minimal-access cranial suspension (MACS) lift
technique with a skin-pinch blepharoplasty. Although all of these
will improve on the lower lid, in my experience the results do not Pinch Blepharoplasty
match those of a skin-muscle flap blepharoplasty approach. The pinch technique is safe and effective for removal of excess,
inelastic eyelid skin without disturbing the underlying orbicu-
laris muscle. Although it has a role as a stand-alone procedure,
Options for Lower Eyelid Rejuvenation a pinch blepharoplasty is most often combined with transcon-
• Fillers and fat junctival fat removal from the lower lid. It may also be used as
• Pinch blepharoplasty an adjunct to facelift procedures such as the extended MACS lift
• Transconjunctival fat removal and high-SMAS procedures that elevate the midface, resulting in
• Transconjunctival fat redistribution excess lower lid skin. Although a canthopexy can be performed
• Transcutaneous: with a skin pinch blepharoplasty, it is not imperative.
Skin flap In this procedure, the excess eyelid skin is pinched with one
Skin–muscle flap pair of forceps in the left hand while the second pair of forceps in
Fat management the right hand progressively pinches and squeezes the extra skin,
Orbicularis redraping proceeding from lateral to medial (Fig. 32.19). This pinched skin
• Midface lift: is then trimmed with a pair of scissors (Fig. 32.20).
Full open approach The skin excision is completed (Fig. 32.21). Because the skin has
Limited or endoscopic approach been pinched, there is very little bleeding after the skin excision.
• Certain facelift techniques By spreading the skin, the extent of the resection can be seen, and
bleeding points can be cauterized with bipolar cautery (Fig. 32.22).

Fig. 32.19 Pinch blepharoplasty. The excess eyelid skin is pinched with one pair of forceps in the left hand while the second pair of forceps in the right
hand progressively pinches and squeezes the extra skin, proceeding from lateral to medial.

Fig. 32.20 Pinch blepharoplasty. Once pinched, the excess skin is trimmed with a pair of scissors.

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Fig. 32.21 Pinch blepharoplasty. The skin excision is completed.
Transconjunctival Approach
The transconjunctival approach offers two treatment options:
preseptal and postseptal (Table 32.2). The postseptal approach is
the most popular, as well as the safest and easiest route to access
the periorbital fat compartments. This approach generally is pre-
ferred for fat excision. The incision is made 4 to 5 mm below the
tarsal border at the level of the vascular arcade. The conjunctiva
and lid retractors are incised together, and the fat pockets are
immediately identified and excised as needed.
The preseptal approach affords the opportunity to resect fat as
well as the option to redrape the fat; it also provides access to
the midface region. The incision is made along the tarsal border
through the conjunctiva and lid retractors, then over the perior-
bital septum toward the orbital rim.
These transconjunctival approaches obviously will not allow
excision of skin or muscle. Some have advocated approaching
the fat and the midface through the transconjunctival approach
and adding a simple skin-pinch excision to deal with the excess
lower eyelid skin. Laser resurfacing with transconjunctival
blepharoplasty is another option. The major advantage of the
transconjunctival approach is that no incisions are made in the
orbicularis, thus minimizing, if not totally eliminating, the risk
of lid retraction. I have found the transconjunctival approach
for fat excision to be safe and effective with minimal, if any, risk
of lid retraction. I have also found that it is much more difficult
to manipulate fat and to access the midface through a preseptal
transconjunctival approach. I prefer to manipulate the fat and
approach the midface through a transcutaneous muscle–skin flap.
Transcutaneous Approach
The traditional transcutaneous skin–muscle flap is still my
preferred approach to the lower eyelid in a patient who requires
more than simple fat excision. This approach, especially any
Fig. 32.22 Pinch blepharoplasty. Because the skin has been pinched,
there is very little bleeding after the skin excision. By spreading the
skin, the extent of the resection can be seen, and bleeding points can
be cauterized with bipolar cautery.
incision in the orbicularis, has come under considerable attack
and scrutiny over the past few years. Some believe that any
incision within the orbicularis will lead to its denervation and
result in lid retraction. However, the cause of lid retraction is
multifactorial, with orbicularis denervation merely one of the
many potential causes.
Causes of Lid Retraction
• Anterior lamellar insufficiency
• Middle lamellar scarring
• Lid laxity
• High-risk patient
• Orbicularis muscle excision/denervation
The anterior lamella is composed of skin and the orbicularis
muscle. Overresection of skin and muscle will lead to lid retraction.
This is easily avoided through judicious skin excision. The middle
lamella is composed of the periorbital septum and periorbital fat.
ithout doubt, scarring of the middle lamella is a major cause of
lid retraction, and any procedure requiring manipulation within
the middle lamella will increase the risk of lid retraction. This risk
is minimized through meticulous dissection and hemostasis in
the middle lamella and aggressive treatment of any postoperative
bleeding or hematoma.
Unrecognized or untreated lid laxity is also a major cause of
lid retraction. The routine application of lid-anchoring techniques
in patients undergoing the transcutaneous skin–muscle flap
approach and middle lamellar manipulations significantly reduces
the risk of lid retraction. Horizontal lid shortening, if indicated,
is also my routine. This is particularly appropriate for high-risk
patients, including those with prominent or enophthalmic eyes,

Table 32.2 Options for lower eyelid rejuvenation

m nen r n n un i r n n un i r n n un i nd er S in-mu e S in-mu e Trans-
preseptal postseptal re ur ing r in in nd r i u ri e r
mid e i
Skin + + ++ ++++ ++++ ++++
Muscle + + + ++++ ++++ ++++
Fat ++++ ++++ ++++ ++++ ++++ ++++
Lid-cheek interface ++++ +++ ++++
Degree of effectiveness indicated by the number of plus signs.

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and for anyone undergoing a secondary blepharoplasty. There is
no question that true and complete denervation of the orbicu-
laris, especially the pretarsal portion, will lead to lid retraction.
Similarly, there is no question that a 5-mm rim of innervated
orbicularis should remain on the tarsal plate.
The question of denervation is currently a topic of much
debate. The orbicularis is innervated by the zygomatic and buccal
branches of the facial nerve. The bulk of the orbicularis muscle,
the extracanthal orbicularis, is innervated by the zygomatic
branches; classically, these branches run from below upward,
almost perpendicular to the tarsal plate, and there is no ques-
tion that division of the orbicularis as in the skin–muscle flap
approach will divide these branches. The extracanthal orbicularis
is responsible for squeezing the eyelid, whereas the inner canthal
orbicularis (that part of the orbicularis within 5 to 10 mm of the
medial canthus) is responsible for eyelid closure, blinking, lower
lid tone, and the tear pump.
This extracanthal portion of the muscle is innervated by the
buccal branches and is usually preserved with the standard
skin–muscle incision unless the incision in the muscle is contin-
ued all the way to the medial canthus. Leaving a 5-mm segment
Fig. 32.23 Motor innervation in the periorbital region.
Fig. 32.25 If fat redraping or dermis fat augmentation is planned, then the orbicularis incision is extended to within 10 to 15 mm of the medial
canthus with a full-access incision.
ini e i i n ing in Ae ei ye id Surgery
of pretarsal muscle on the tarsal plate and limiting the incision in
the orbicularis to within 10 to 15 mm of the medial canthus will
preserve a functioning, fully innervated portion of the orbicularis
with adequate lid tone and closure (Fig. 32.23).
I individualize the extent of the incision in the orbicularis
muscle. I approach the lower eyelid through the skin incision and
elevate a small skin flap; the orbicularis muscle is then divided
separately and elevated as a combined skin–muscle flap. The
extent of the incision I make in the orbicularis depends on my
plans for the middle lamella, as follows.
If I do not plan any middle lamellar manipulations, such as
fat excision or redraping, I make a limited-access incision in the
orbicularis starting 10 mm lateral to the lateral canthus and
extending up to 10 mm medial to the lateral canthus. This short
incision allows access to the entire midface complex. It also
enables release of the arcus marginalis all the way to the medial
canthus, identification and preservation of the infraorbital nerve,
and full subperiosteal dissection of the midface. I prefer to do the
dissection with a headlight and a slim retractor, although others
have advocated the use of the endoscope (Fig. 32.24).
If fat redraping or dermis fat augmentation is planned, however,
then the orbicularis incision is extended to within 10 to 15 mm
of the medial canthus with a full-access incision. Both of these
incisions allow me to excise as much skin as needed, elevate and
fix the midface, redrape the orbicularis, and resect any orbicularis
excess. Occasionally, in a patient who has excess periorbital fat,
the limited-access incision may be combined with transconjunc-
tival fat removal (Fig. 32.25).
Fig. 32.24 Limited-access incision in the orbicularis starting 10 mm
lateral to the lateral canthus and extending up to 10 mm medial to the
lateral canthus.
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Orbicularis Flap
All of the transcutaneous skin–muscle flap procedures on the
lower lid include orbicularis oculi muscle flap redraping. This
serves two purposes: functional and aesthetic. The orbicularis
is redraped so that it sits snugly against the lower lid tarsus and
adds extra support to the lower lid. Redraping with a vertical or
combined diagonal and vertical vector will elevate the midface
complex, especially the diagonal vector, and will further enhance
the youthful appearance of the lower lid (Fig. 32.26).
32.2.5 Transpalpebral Midface Lift
Many approaches are available to rejuvenate the midface area.
I prefer this combined approach, because it allows the lower lid
and midface to be treated as a single unit. I make a limited-access
or full-access incision, depending on the need for middle lamella
manipulation. Through either approach, a full subperiosteal
dissection and elevation of the midface are performed. I include
some subperiosteal dissection below the infraorbital rim on all
blepharoplasties in type II, III, and IV patients.
32.2.6 Regional Procedures
Blepharoplasty is one component of periorbital rejuvenation.
Often upper lid blepharoplasty is combined with some type of
brow or forehead rejuvenation. The lower lid is so intimately
involved with the midface complex that I think of the lower lid
and cheek as one entity. Therefore, in almost all blepharoplasties
for type II, III, and IV patients, I perform a midface lift; the extent,
of course, is individualized, depending on the degree of aging
and our goals for the patient. These regional procedures reflect
the approach to facial rejuvenation, addressing facial zones or
the entire face rather than individual components, such as the
eyelids, brow, or midface.
32.3 Ancillary Procedures
The surgical procedures just described will rejuvenate the upper
and lower eyelids, improve the relationship of the upper lid and
brow, and improve the lower lid–cheek junction and midface.
Frequently, additional ancillary procedures are performed
to enhance the result. These include peels, laser resurfacing,
alloplastic implants, and fat grafting or fillers as an adjunct.
Laser resurfacing or peeling of sun-damaged, wrinkled skin at
the time of blepharoplasty is a safe procedure, because the skin
has been elevated as a reliable musculocutaneous flap with a full
blood supply.
Fat is the filler material of choice around the eyelids and cheek.
Although autologous fat injections are frequently the primary
treatment for aging in the periorbital area, they also have a signif-
icant role as an adjunct to lower lid blepharoplasty and midface
lift. As discussed previously, dermis fat is placed along the orbital
rim to enhance the results in patients who have a deficiency in
this area. Alloplastic materials, especially cheek implants, may
also enhance the results.
368
Fig. 32.26 Orbicularis flap.
32.4 Results
32.4.1 Short-Term Results
The woman shown in Fig. 32.27 in her mid-40s exhibited type
II aging of the lower lid–cheek junction. She also had lid laxity,
a round eye, and scleral show bilaterally. She underwent upper
and lower lid blepharoplasties with a transpalpebral midface lift
and lid anchoring to correct the lid laxity and scleral show. She
also had a facelift and neck lift. Her postoperative result shows
correction of the aging changes of the lower lid and correction of
the lid laxity and round eye.
The middle-aged woman shown in Fig. 32.28 had type II aging
of the lower lids, brow ptosis, grade IV glabellar and forehead
lines, and grade III aging of the lower lid–cheek junction and
nasolabial folds. She was treated with an endoscopic brow lift,
upper and lower lid blepharoplasties with a transpalpebral
midface lift, and erbium laser resurfacing of the forehead and
glabella. Postoperative views show an improved brow position,
lidcheek junction, midface, and nasolabial folds. The split-face
view more dramatically demonstrates the rejuvenative effect of
these procedures.
The woman in her late 40s shown in Fig. 32.29 had type II aging
changes of the lower lids, midface, and jowls. She underwent a
short-scar facelift, rhinoplasty, and lower lid blepharoplasty, with
fat redistribution and orbicularis redraping. She was very pleased
with the improvement in the lower lid–cheek junction, nasolabial
folds, and perioral area.
The woman shown in Fig. 32.30, who is in her 60s, had type III
aging of the lower lids, as well as lid laxity, tear-trough deformity,
nasojugal grooves, and early development of malar bags. Upper
and lower lid blepharoplasties with a transpalpebral midface lift,
orbicularis redraping, and canthopexy were performed. She also
underwent concomitant erbium laser resurfacing of the perior-
bital area. The postoperative result shows improvement in the
lid–cheek junction, with amelioration of the malar mound and
early festoons.
More severe aging changes are evident in the 60-year-old
woman shown in Fig. 32.31, who had type IV aging of the lower
eyelids. She had lid laxity; the lateral canthus was significantly
lower than the medial canthus. She also had malar mounds and
 ini e i i n ing in Ae ei ye id Surgery

Fig. 32.27 This woman in her mid-40s exhibited type II aging of the lower lid–cheek junction. She also had lid laxity, a round eye, and scleral show
bilaterally. She underwent upper and lower lid blepharoplasties with a transpalpebral midface lift and lid anchoring to correct the lid laxity and scleral
show. She also had a short scar facelift and neck lift. Her postoperative result shows correction of the aging changes of the lower lid and correction of
the lid laxity and round eye short scar.

Fig. 32.28 This middle-aged woman had type II aging of the lower lids, brow ptosis, grade IV glabellar and forehead lines, and grade III aging of the
lower lid–cheek junction and nasolabial folds. She was treated with an endoscopic brow lift, upper and lower lid blepharoplasties with a transpalpe-
bral midface lift, and CO2 laser resurfacing of the forehead and glabella. Postoperative views show an improved brow position, lid–cheek junction,
midface, and nasolabial folds. The split-face view more dramatically demonstrates the rejuvenative effect of these procedures.

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 VI Eyelid Surgery

Fig. 32.29 This woman in her late 40s had type II aging changes of the lower lids, midface, and jowls. She underwent a short-scar facelift, rhino-
plasty, and lower lid blepharoplasty, with fat redistribution and orbicularis redraping.

Fig. 32.31 This 60-year-old woman had type IV aging of the lower
eyelids. She had lid laxity; the lateral canthus was significantly lower
than the medial canthus. She also had malar mounds and festoons. To
address these problems, she underwent lower lid blepharoplasty with
a transpalpebral midface lift, horizontal lid shortening with cantholysis
and canthoplasty, and a facelift and neck lift. Her postoperative
result shows significant improvement in the lower lid–cheek junction,
Fig. 32.30 This woman, who is in her 60s, had type III aging of the amelioration of the festoons, and improved eyelid position.
lower lids, as well as lid laxity, tear-trough deformity, nasojugal
grooves, and early development of malar bags. Upper and lower
lid blepharoplasties with a transpalpebral midface lift, orbicularis
redraping, and canthopexy were performed. She also underwent
concomitant erbium laser resurfacing of the periorbital area. The
postoperative result shows improvement in the lid–cheek junction,
with amelioration of the malar mound and early festoons.

festoons. To address these problems, she underwent lower lid

blepharoplasty with a transpalpebral midface lift, horizontal lid
shortening with cantholysis and canthoplasty, and a facelift and
neck lift. Her postoperative result shows significant improvement
in the lower lid–cheek junction, amelioration of the festoons, and
improved eyelid position.
The 40-year-old woman shown in Fig. 31.32 had prominent
eyes with a Hertel measurement of 23 mm, thus making her
a high-risk blepharoplasty patient. She underwent lower lid
blepharoplasty with fat redistribution and placement of a pri-
mary spacer graft with AlloDerm (Allergan, Dublin, Ireland) and
canthopexy and a short-scar facelift. Fig. 32.33 shows release of Fig. 32.32 This 40-year-old woman had prominent eyes with a Hertel
the lower lid retractors, placement of an AlloDerm spacer, and measurement of 23 mm, thus making her a high-risk blepharoplasty
redistribution of fat. The split-face view of this patient, shown in patient. She underwent lower lid blepharoplasty with fat redistribution
and placement of a primary spacer graft with AlloDerm and cantho-
Fig. 32.34, demonstrates the postoperative improvement in the
pexy and a short-scar facelift.
lower lid–cheek junction, with normal lid position.

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 ini e i i n ing in Ae ei ye id Surgery

a b c
Fig. 32.33 (a) Release of the lower lid retractors, (b) placement of the primary AlloDerm spacer, and (c) redistribution of the fat (right).

a b

Fig. 32.34 This split-face view of the patient in Fig. 32.32

demonstrates the postoperative improvement in the lower lid–cheek
junction, with normal lid position.

32.4.2 Long-Term Results

The type II patient in Fig. 32.35 is shown 9 years after an
endoscopic brow lift, upper and lower blepharoplasty with fat
redistribution, orbicularis redraping, and canthopexy.
Another type II patient demonstrates a typical result; she is c d
shown 3 months, 5 months, and 5 years after a skin–muscle flap
blepharoplasty with fat redistribution, orbicularis redraping, and Fig. 32.35 This type II patient is shown (a,c) before and (b,d) 9 years
after an endoscopic brow lift, upper and lower blepharoplasty with fat
canthal anchoring (Fig. 32.36).
redistribution, orbicularis redraping, and canthopexy.

32.5 Choosing the Best Option

Guidance for choosing the best option for the upper eyelid is
given in Fig. 32.37. Guidance for choosing the best option for the
lower eyelid is given in Fig. 32.38.

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 VI Eyelid Surgery

a b

Fig. 32.36 Type II patient demonstrates a typical result; she is shown (a) before, 3 months after, (b) 5 months after, and 5 years after a
skin–muscle flap blepharoplasty with fat redistribution, orbicularis redraping, and canthal anchoring.

Fig. 32.37 Options for upper eyelid blepharoplasty.

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Fig. 32.38 Options for lower eyelid blepharoplasty.

Suggested Reading
1 anuszkiewicz S, ahai F. Transconjunctival upper blepharoplasty. Plast Reconstr
Surg 1999;103(3):1015–1018, discussion 1019
2 Hester TR r, Codner MA, McCord CD, ahai F, Giannopoulos A. Evolution of
technique of the direct transblepharoplasty approach for the correction of lower
lid and midfacial aging: maximizing results and minimizing complications
in a 5-year experience. Plast Reconstr Surg 2000;105(1):393–406, discussion
407–408
3 Hester TR r, McCord CD, ahai F, Sassoon EM, Codner MA. Expanded appli-
cations for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg
2001;108(1):271–272
4 Codner MA, Day CR, Hester TR, ahai F, McCord CD. Role of fat in the lower
eyelid. Perspect Plast Surg 2001;15(1):1–13
5 Codner M, Day CR, Hester TR, ahai F, McCord CD. Management of mundane to
complex blepharoplasty problems. Perspect Plast Surg 2001;15(1):15–32
6 Hirmand H, Codner MA, McCord CD, Hester TR r, ahai F. Prominent eye: oper-
ative management in lower lid and midfacial rejuvenation and the morphologic
classification system. Plast Reconstr Surg 2002;110(2):620–628, discussion
629–634
7 McCord CD, Ford DT, Hanna , Hester TR, Codner MA, ahai F. Lateral canthal
anchoring: special situations. Plast Reconstr Surg 2005;116(4):1149–1157
8 Pacella S , ahai FR, ahai F. Transconjunctival blepharoplasty for upper and
lower eyelids. Plast Reconstr Surg 2010;125(1):384–392
9 Alghoul M. Blepharoplasty: anatomy, planning, techniques, and safety. Aesthet
Surg J 2019;39(1):10–28
10 Tonnard PL, Verpaele AM, eltzer AA. Augmentation blepharoplasty: a review of
500 consecutive patients. Aesthet Surg J 2013;33(3):341–352
11 eltzer AA, Tonnard PL, Verpaele AM. Sharp-needle intradermal fat grafting
(SNIF). Aesthet Surg J 2012;32(5):554–561
12 Pelle-Ceravolo M, Angelini M. Properly diluted fat (PDF): an easy and safe
approach to periocular fat grafting. Aesthet Surg J 2019;sjz039: Epub ahead of
print 10.1093/asj/sjz039
13 ilson SC, Daar DA, Maliha SG, Abdou SA, Levine SM, Baker DC. Lower eyelid
blepharoplasty: does the literature support the longevity of this procedure
Aesthet Surg J 2018;38(12):1289–1297
14 Barmettler A, ang , Heo M, Gladstone G . Upper eyelid blepharoplasty: a novel
method to predict and improve outcomes. Aesthet Surg J 2018;38(11): P156–
P164
15 Little , Hartstein ME. Simplified muscle-suspension lower blepharoplasty by
orbicularis hitch. Aesthet Surg J 2016;36(6):641–647
16 Pascali M, Avantaggiato A, Brinci L, Cervelli V, Carinci F. Tarsal sling: an
essential stitch to prevent scleral show in lower blepharoplasty. Aesthet Surg J
2015;35(1):11–19

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33 Upper Eyelid Blepharoplasty

Ted Wojno

Therefore, any cut placed on the face of the patient for any reason
Abstract
has an aesthetic component.
Upper eyelid blepharoplasty is perhaps the most commonly per- Often patients are reluctant to express their desires for aes-
formed aesthetic surgery worldwide. This chapter will outline thetic surgery for fear of being labeled as vain by family mem-
the evaluation of patients for this procedure, discuss the relevant bers or even the physician. Many have spent considerable time
anatomy, and describe the surgery in detail. Avoidance of com- searching the Internet to educate themselves as to exactly what
plications is stressed. to say to communicate that their vision is functionally impaired,
in hopes of obtaining insurance coverage for the procedure. In
an age where one can easily access web-based data on any topic,
Keywords
we should assume that patients have acquired at least a cursory
blepharoplasty, ptosis, eyelid crease, eyelid fold, ptosis field, education in how to present themselves at the initial consultation.
dermatochalasis, orbital septum A simple inquiry by the physician, such as How important is it to
you that the result look attractive can open the discussion up
to the aesthetic component of surgery and reassure the patient
33.1 Indications and that the physician is also concerned that the patient experience
a favorable cosmetic outcome. I typically tell such patients that
Contraindications I expect that, upon completion of surgery, not only will they will
see a significant improvement in their visual function but they
33.1.1 Functional Upper Eyelid should look better too.
Blepharoplasty
Patients who present for upper eyelid blepharoplasty can be 33.1.2 Aesthetic Upper Eyelid
thought of as falling into two categories that often overlap. Many
older individuals are interested in functional improvement
Blepharoplasty
to alleviate complaints of visual obstruction from redundant The second group of patients are those who are primarily seeking
upper eyelid tissues. Such patients complain of difficulties with aesthetic improvement. On the whole, this is a younger group of
activities of daily living such as driving and reading but will patients than those who come for functional improvement and
often add comments related to tasks performed on their jobs is predominantly female. I continue to be impressed by the fact
that are unique to their own situations. hen severe, they may that this group often presents shortly after the conclusion of a
complain of a frontal headache by day’s end due to constant use major negative life event such as severe illness or divorce. They
of the frontalis muscle in an unconscious effort to open the eyes may be seeking cosmetic surgery to help lift their spirits, as a
to improve the superior and lateral fields of vision. Symptoms reward for battling through medical problems, or as a prelude
are often vague, such as my eyes feel tired, I cannot seem to getting back into social dating. It is important to understand
to get enough light in, or I have trouble reading. Patients
frequently state that the upper lids feel heavy, especially by the
end of the day. They will pull up on the eyebrow to demonstrate
how vision improves when the brow and forehead are lifted,
since they usually do not distinguish between upper eyelid skin
redundancy and brow ptosis (Fig. 33.1). Pointing this out to the
patient gives the physician the opportunity to explain the signif-
icant difference between upper eyelid blepharoplasty and brow
or forehead lifting. hen patients realize that these are two
distinct but related procedures, they are sometimes confused
as to what is the best way to alleviate the functional problem.
Thus, it is the duty of the physician to help them to decide on
the best surgical option. This does not imply that patients who
seek functional improvement in their visual field are not inter-
ested in cosmesis. Although the patient may state, I only want
to see better, the aesthetic appearance is usually a very close
second, if often unspoken, goal of the surgery. This is true even
for those individuals in their ninth or tenth decade of life. Simply Fig. 33.1 Patient demonstrating how vision is improved by pulling up
put, no one wants to look bad after eyelid or facial surgery. on the eyebrow.

374

the underlying motivations of this group, since they are more
likely to be suffering emotional turmoil and are less likely to be
satisfied with results that they view as not achieving the desired
outcome. The desired outcome, of course, is sometimes not
totally related to the ultimate appearance after surgery.
ust as functional patients may be secondarily interested in
aesthetic improvement, those patients who present for what they
regard as purely cosmetic interests often notice that their vision
has improved after upper eyelid blepharoplasty. It is important
to inform them prior to surgery that insurance coverage may be
possible.
33.1.3 General Considerations
I always ask my patients what type of work they do, since this
may have a bearing on how long it takes for them to recover and
return to full activity. A desk worker can often return to full
activity on the next day, whereas someone who performs heavy
manual labor may need to be off the job for two weeks or more.
The patients must realize that there will be a variable and unpre-
dictable period of bruising and swelling, during which they may
feel that they do not want to appear in public. The answer to the
question How bad will I look after surgery is very different
from one person to the next, and the physician needs to have this
discussion with each patient.
I also inquire as to whether the patient is seeking surgery prior
to a major social event, such as a family wedding or class reunion.
The patient may not have allowed enough time between the
proposed date of surgery and the social event to permit adequate
healing. I caution patients to allow 2 weeks for bruising and 2
months for swelling to resolve. I tell them that we may need to
do additional touch-ups in the months that follow in order for
them to get as close to normal and symmetric as possible and
that they should take all of this into consideration when planning
the timing of the procedure. This not infrequently results in
the patient deciding to wait until after the social event to have
surgery.
Some patients will plan a vacation immediately after surgery so
as to give themselves time to return to work or social engagements
without others noticing that they had surgery. They are often
surprised to find that they have significantly underestimated the
time needed to return to work. Some patients assume that the
surgeon will use those stitches that just fall out by themselves,
so this too needs to be discussed in the preoperative evaluation
and reiterated on the day of surgery. Some patients may travel a
long distance to have a procedure by a particular surgeon and will
ask, hy can’t my doctor at home take out my stitches This as
well should be discussed in advance of the procedure.
I caution all patients that upper eyelid blepharoplasty always
leaves a scar that will be noticeable to some degree. I advise
women that the incision in the upper eyelid frequently results in
a degree of numbness in the pretarsal skin and eyelashes for at
least 6 to 12 months, caused by cutting the sensory nerve fibers
that run vertically from below the brow inferiorly to the lash line.
Some women find that this temporary anesthesia is bothersome
when applying eye makeup due to the lack of tactile feedback
from the makeup brush.
There are few absolute contraindications to upper eyelid bleph-
aroplasty. Patients with disorders such as thyroid eye disease,
33 Upper Eyelid Blepharoplasty
blepharochalasis syndrome (angioneurotic edema), rosacea, dry
eye syndrome, and essential blepharospasm may safely undergo
surgery if appropriately counseled and surgery is tailored to the
individual patient. Indeed, these can be some of the happiest
patients after surgery.
Likewise, patients with pre-existent lagophthalmos, for any
reason, should be carefully evaluated, since removal of additional
upper eyelid tissue would very likely exacerbate the problem.
Methods of lagophthalmos correction could be considered as an
adjunct to blepharoplasty surgery in such cases.
Perhaps the only absolute contraindications to upper bleph-
aroplasty are an uncontrolled coagulopathy or an inability to
discontinue anticlotting medications adequately for enough time
to minimize the risk of orbital hemorrhage. I caution patients
to discontinue all medications prescription, over-the-counter,
or herbal that can interfere with the coagulation system. For
prescribed medications, the patients must supply written docu-
mentation from their physician that the medications can be safely
discontinued and if so, for how long. If the patient’s physician is
unwilling to hold such medications for a sufficient length of time
to return the clotting status to normal, then the patient should
be informed of the relative risk of vision-threatening hemorrhage
depending on the individual circumstances. Obviously, the greater
the degree of anticoagulation, the greater the threat to vision.
hen informed of this possibility, no matter how remote, some
patients will decide not to have the surgery.
As with any procedure, unreasonable expectations will
invariably lead to dissatisfaction with the results and the sur-
geon. Unfortunately, underlying psychopathology is not always
obvious in the preoperative period but becomes manifest only
postoperatively.
33.2 Pertinent Anatomy
33.2.1 Skin and Crease/Fold Complex
The eyelid skin is often the thinnest in the body, but this does
vary considerably amongst individuals and ancestries. ith age,
the subcutaneous blood vessels are often noticeable and some-
times a source of dissatisfaction to patients. The upper eyelid fold
overlaps the upper eyelid crease. The crease is formed by elastin
fibers from the levator aponeurosis that penetrate through the
orbicularis oculi and insert into the underside of the dermis
(Fig. 33.2). In general, the fold is lowest in Asians, midrange
in Caucasians and highest in African populations (Fig. 33.3). A
lower fold generally gives the impression of having more skin,
while a higher fold gives the impression of less skin. The amount
of pretarsal show (the vertical height of visible skin below the
fold) preferred by the patient should be determined prior to
the surgery. The position and shape of the fold must always be
considered in surgery of the upper eyelid, since asymmetry of
the fold is quite noticeable.
33.2.2 Orbicularis Oculi Muscle
The orbicularis oculi muscle is divided into pretarsal, preseptal,
and orbital parts (Fig. 33.4a). The orbicularis is the protractor
muscle of the eyelids, functioning as a sphincter to blink for
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Fig. 33.2 Cross-sectional view of the upper eyelid showing the elastin
fibers given off by the levator to insert into the dermis thus forming
the upper eyelid crease. ROOF, retro–orbicularis oculi fat; SOOF,
sub–orbicularis oculi fat. (Reproduced from Nahai F, ed. The Art of
Aesthetic Surgery: Principles and Techniques, 2nd ed. New ork, N : c
Thieme; 2011.)
Fig. 33.3 Variations in upper eyelid crease height with ancestral
group. (a) Asian, very low crease. (b) Caucasian, intermediate crease.
(c) African, relatively high crease.

maintenance of the precorneal tear film, close the eye for pro-
tection, and pump tears down the lacrimal system. The pretarsal
and preseptal parts of the orbicularis oculi insert medially into
the medial canthal tendon and then to the anterior and poste-
rior lacrimal crests, respectively. Laterally they insert into the
lateral canthal tendon and then into Whitnall’s orbital tubercle
(which most often is not a discernable structure) just inside the
orbital rim. The orbicularis oculi muscle interdigitates with
the frontalis muscle under the eyebrow and the corrugator and
procerus muscles in the medial brow. The motor innervation
to the orbicularis oculi comes from the frontal and zygomatic
branches of the facial nerve (Fig. 33.4b). Note that the buccal
branch separately innervates the medial aspect of the orbicularis
in the lower eyelid.
Any loss of function of the orbicularis oculi, whether due to
disease, injury or surgery, is significantly debilitating. Despite
this fact, remarkable amounts of the orbicularis muscle can be
removed in upper eyelid surgery with no discernable loss of its
function. This is evidenced by the fact that patients who have
undergone orbicularis oculi myectomy for essential blepharo-
spasm have surprisingly few problems with lagophthalmos.
33.2.3 Tarsal Plate
The tarsal plates are composed of dense collagen and function
as the skeleton of the eyelids (Fig. 33.5). They contain the

a b
Fig. 33.4 (a) The muscular anatomy of the periorbital region. (b) The motor innervation to the orbicularis oculi from the frontal and zygomatic
branches of the facial nerve. (Reproduced from Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques, 2nd ed. New ork, N : Thieme;
2011.)

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meibomian glands, which produce the outer, oily component of
the precorneal tear film, which prevents evaporation of the aque-
ous component of tears. Any incision through the tarsal plates can
decrease function of these glands and thus disrupt the tear film.
33.2.4 Orbital Septum and Lacrimal Gland
The orbital septum forms the anterior border of the orbit and con-
tains the two fat pockets of the upper eyelid. The medial pocket
is whiter and contains the medial palpebral artery, a terminal
branch of the ophthalmic artery. It is important to recognize this
artery when resecting this fat pocket, since if not adequately
cauterized, it can cause significant bleeding after retracting back
into the orbit. The lateral fat pad of the upper eyelid (referred to
by some authors as the middle pocket) is more yellow, due to
the greater amount of beta carotene compared with the medial
pocket. The significance of this difference is unclear (Fig. 33.6).
The lateralmost part of the upper eyelid contains the orbital
portion of the lacrimal gland, which with age can prolapse out
of the orbit from its attachment inside the superior orbital rim
and present as a distinct bulge in the lateral upper eyelid. Care
should be taken to avoid resection of the gland during surgery of
the upper eyelid. The palpebral lobe of the lacrimal gland lies just
under the lateral upper eyelid.
must be judiciously avoided in upper eyelid blepharoplasty
and carefully handled during ptosis repair. The levator muscle
arises from the lesser wing of the sphenoid bone superior to the
annulus of inn. In the orbit it lies above, but is closely applied
to, the superior rectus muscle. It inserts into the medial canthal
tendon, the lateral canthal tendon (after dividing the orbital
and palpebral lobes of the lacrimal gland), the superior tarsal
border, the anterior face of the tarsus, the pretarsal orbicularis,
and overlying skin. The striated portion of the levator muscle is
40 mm long, while the aponeurotic component is 15 mm long,
although this varies considerably based on individual anatomy.
The levator muscle contains hitnall’s superior transverse liga-
ment at the level of the equator of the globe (Fig. 33.7). This is a
condensation of fascia typically 15 to 20 mm above the superior
tarsal border that attaches to the trochlea, the levator horns, the
lacrimal gland, and the lateral orbital wall. Whitnall’s ligament
functions as a suspensory ligament of the upper eyelid and a
pulley or fulcrum around which the levator changes direction

33.2.5 The Levator and Müller’s Muscle

Virtually all surgery performed on the upper eyelid must take
into account the levator palpebrae superioris muscle. This muscle

Orbital lobe
of lacrimal gland Fig. 33.6 The medial and lateral preaponeurotic fat pockets in the left
upper eyelid. Note that the lateral pocket is distinctly more yellow in
Palpebral lobe color .
of lacrimal gland
Gland of Krauss
Gland of Wolfring

Gland of Manz
Levator aponeurosis

Crypts of Henle

Gland of Moll

Meibomian
gland
Gland of Zeis

Fig. 33.5 Detailed anatomy of the upper eyelid. (Reproduced from

Codner MA. Eyelid and Periorbital Surgery. New ork, N : Thieme;
2016.) Fig. 33.7 Whitnall’s superior transverse ligament (arrow).

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 VI Eyelid Surgery
from an anterior–posterior direction to a superior–inferior
direction.
The adrenergic M ller’s muscle arises from the posterior sur-
face of the levator muscle and inserts onto the superior border
of the tarsal plate. It is approximately 10 mm long. The plane
between the levator muscle and M ller’s muscle is relatively
easy to open surgically, while that between the conjunctiva and
M ller’s muscle is typically very tightly adherent and more diffi-
cult to separate.
33.2.6 The Conjunctiva
The conjunctiva is the inner, mucous membrane surface of the
eyelids (palpebral conjunctiva), which is reflected onto the sur-
face of the globe (bulbar conjunctiva) in the superior and inferior
fornices or culs-de-sac. The conjunctiva contains numerous
accessory lacrimal glands and mucin-producing glands, which
contribute to the precorneal tear film.
33.2.7 The Lacrimal Apparatus
The lacrimal puncta are found medially in the upper and lower
eyelid margins. They lead to the upper and lower canaliculi, each
being about 8 mm long. In 90 of patients, the upper and lower
canaliculi combine to form a 1- to 2-mm common canaliculus
that enters the upper part of the lacrimal sac just under the
medial canthal tendon. Care is necessary when any dissection is
performed medial to the puncta.
33.2.8 The Trochlea and Superior
Oblique Muscle
ust medial to the supraorbital notch and 2 to 4 mm inside the
superior orbital rim is the trochlea. This is a U-shaped piece
of fibrocartilage that acts as a pulley to transmit the superior
oblique tendon, which passes inferiorly, posteriorly, and laterally
from the trochlea. The superior oblique passes under the superior
Fig. 33.8 The superior oblique tendon just lateral to the medial fat
pocket (arrow).
378
rectus muscle to insert on the posterior superior surface of the
globe. It functions to depress the globe in adduction and second-
arily to intort and abduct the globe. The tendon can be damaged
when dissecting through the nasal fat pocket (Fig. 33.8).
33.2.9 Blood and Lymphatic Supply to
the Upper Eyelid
The blood supply to the upper eyelid comes from the lacrimal
artery and the medial palpebral artery with anastomotic con-
tributions from the angular, supraorbital, and supratrochlear
arteries and the frontal branch of the superficial temporal artery.
The marginal arcades lie just under the orbicularis muscle 2 to 3
mm from the lid margin, while the superior branch (sometimes
just called the superior arcade) is 10 to 11 mm from the lid
margin. The upper branch lies between the levator aponeurosis
and M ller’s muscle at the superior tarsal border and can cause
bothersome bleeding when dissecting under the levator (Fig.
33.9). The lymphatic drainage from the upper eyelid is usually to
the preauricular nodes.
33.3 Preoperative Assessment
33.3.1 Past Medical and Ophthalmic
History
As stated in the Indications and Contraindications section,
the physician should determine the patient’s goals and expec-
tations for both cosmetic and functional improvement after
surgery. In addition to the usual medical history, it is necessary
to know about the presence of any ophthalmologic disease and
surgery in the patient’s past history. Patients often fail to men-
tion prior refractive surgery such as laser in situ keratomileusis
(LASI ) and radial keratotomy unless specifically asked. This
is important to know, since refractive and intraocular surgery
may weaken the globe and thus require extra caution during
Fig. 33.9 The superior arcade at the upper border of the tarsal plate
(arrow).
 33 Upper Eyelid Blepharoplasty

subsequent periocular procedures. It is worth pointing out to Measure the levator function. This is the excursion of the upper
patients that any eyelid surgery may cause a few months of eyelid from downgaze to upgaze with the brow fixated as mea-
blurred vision due to temporary changes in the refractive error sured at the center of the pupil (Fig. 33.11). ormal levator func-
induced by eyelid edema. In rare cases, the refractive change tion is greater than 12 mm. If the levator function is less, suspect
may be permanent. that the patient may have had prior upper eyelid surgery (which
Inquire as to whether the patient uses artificial tears or lubri- can restrict the motility of the upper eyelid) or has congenital
cating ointment for dry eye, takes medications for ocular allergies, ptosis (wherein levator function is always decreased).
or suffers from rosacea. Such conditions are notorious for worsen- Look for upper eyelid retraction, which is most commonly
ing in the months after eyelid surgery. This seems to be especially secondary to thyroid eye disease. Such patients often appear to
true for those patients with ocular rosacea manifestations such have greater skin excess than is actually the case. This is due to
as chalazia or posterior lid margin disease (meibomianitis). For the fact that the skin and orbicularis muscle become thicker in
patients with severe dry eye (keratoconjunctivitis sicca), the thyroid eye disease, leading to the false perception of significant
surgeon may consider performing a more conservative bleph- redundancy. These patients are at risk for lagophthalmos in the
aroplasty to minimize the risk of exposure in the postoperative postoperative period from overzealous skin excision and relative
period. Likewise, when there is a history of severe rosacea, treat- exophthalmos. If indicated, perform exophthalmometry readings.
ment with low doses of an oral tetracycline (50 mg/day) before A reading above 21 mm is indicative of exophthalmos in white
and after surgery may be beneficial. Unfortunately, there are large patients or above 25 mm in black patients.
numbers of patients who are overdiagnosed and misdiagnosed Consider performing the basic secretion tear test to determine
as having dry eye or blepharitis. Such patients often show whether there is a clinically significant dry eye. Instill a drop of
up with a bag full of prescription and over-the-counter drops,
ointments, and lid hygiene products. If there is any doubt, an
ophthalmologic evaluation may be useful.
Does the patient use glaucoma medication, or has the patient
had glaucoma surgery Topical glaucoma drops can cause consid-
erable ocular irritation, erythema, and contact dermatitis, which
may worsen in the postoperative period. Glaucoma filtering
procedures often have a noticeable bleb at the limbus, or the
patient may have hardware in the subconjunctival space on the
superior part of the globe to facilitate lowering of intraocular
pressure. Likewise, scleral buckling procedures performed for ret-
inal detachment may have a noticeable, globe-encircling silicone
band at the equator of the eye. Obviously, caution is needed, since
these procedures may be associated with decreased thickness and Fig. 33.10 Measurement of the palpebral fissure.
strength of the sclera. Fortunately, contemporary cataract surgery
involves very small incisions that are typically watertight and are
not prone to complications from the pressures exerted on the
eyelid during blepharoplasty.

33.3.2 Physical Examination

Evaluate the amount of redundant skin and fat in the upper
eyelid with the patient in a sitting position and looking straight
ahead. Prominent eyelid fat pockets are less obvious when the
patient is in a recumbent position. ote the position and level
of the eyelid crease and lid fold. Compare with the opposite eye
a
for symmetry. ote the position of the eyebrow and whether the
patient is using excessive frontalis force to lift the lids. hen
necessary, encourage the patient to relax the frontalis muscle
to appreciate the full extent of any brow ptosis and redundant
upper eyelid skin. It may be necessary to push down gently on
the forehead and brow to nullify the effect of the frontalis.
ext, measure the height of the palpebral fissure. This is the
distance from the lower eyelid to the upper eyelid at the center
of the pupil with the patient looking straight ahead (Fig. 33.10).
ote the position of the upper eyelid relative to the pupil to detect
any ptosis. The normal upper eyelid rests 3 to 4 mm above the b
center of the pupil and 2 mm below the superior limbus. Visually
significant ptosis is typically any lid that rests 2 mm or less above Fig. 33.11 Levator function is the change in millimeters of the upper
eyelid margin from (a) downgaze to (b) upgaze.
the center of the pupil.

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 VI Eyelid Surgery
topical ophthalmic anesthetic and then several seconds later
a drop of 1 to 4 lidocaine to obtain adequate anesthesia. The
topical ophthalmic anesthetic is placed first, since lidocaine is sig-
nificantly uncomfortable but does more thoroughly anesthetize
the eye. Insert a Schirmer tear strip at the lateral canthus for 5
minutes (Fig. 33.12). Any reading of less than 10 mm is considered
indicative of dry eye.
Examine the anterior segment of the eye and fornices with
a penlight. This is an easy way to spot any major ocular surface
pathology. Significant cataract is also easily visualized with a
penlight and is characterized by an opacity in the pupil. If there is
any doubt as to the health of the eye, ophthalmologic consultation
is appropriate.
Gently push on the upper and lower eyelids with a finger and
observe whether there is significant discharge from the meibo-
mian glands (Fig. 33.13). If noted, the patient is more likely to have
increased swelling and irritation after surgery and, as explained
previously, may require treatment with low dose, oral tetracycline.
ith the patient looking in a mirror, I attempt to simulate the
postoperative appearance that the patient may have by elevating
the upper eyelid skin with a cotton-tipped applicator. I often speak
in terms of small, medium, and large resections of upper
eyelid tissue in an attempt to determine what will make patients
happiest. Frequently, they have not considered the possibility that
the amount of skin and fat removal can, to a degree, be tailored
to their preference. This sometimes leads to confusion and might
end with the patient saying, ust do what you think is best for
me. I typically respond by asking them to think about this after
our visit, simulate the skin excision in the mirror at home, and, if
available, consult with their spouse or partner. The vast majority
of patients will come to a small, medium, or large decision on
their own.
Fig. 33.12 Basic secretion tear test (Schirmer test).
Fig. 33.13 Digital pressure on the lower eyelid margin to check for
excessive meibomian gland discharge.
380
Patients frequently bring old photos of themselves from their
youth. Many patients never had a significant amount of pretar-
sal skin visible between the lash line and the upper eyelid fold.
Although a full upper eyelid with a low fold may be perceived as
attractive when a person is in the 20s, a postoperative result in
which the upper eyelid fold rests just above the lash line will usu-
ally be judged by patients as an inadequate correction. Although
an old photo may represent an idealized result, I stress that we
simply cannot replicate the eyelid of youth. Instead we aim to
make the patient look better for their age, awake and refreshed.
Surgeons’ perceptions of an optimum postoperative result have
also evolved with time. A hollow superior sulcus was once the
norm. Fat preservation and fat grafting techniques now empha-
size fullness of the upper lid and orbital rim to emulate a youthful
appearance better. Despite this, many patients still want aggres-
sive skin and fat removal and desire the hollow superior sulcus.
Again, communication between patient and surgeon is essential.
As with any surgery, emphasize that secondary procedures or
touch-ups may be needed to obtain desired results.
33.3.3 Documentation of Functional
vs. Cosmetic
If the dermatochalasis is severe enough, the surgery may be cov-
ered by insurance, and predetermination of benefits is usually
required. Insurance requirements differ significantly based on
the company, but some generalizations apply. A letter of medical
necessity accompanies a copy of the exam detailing the patient’s
specific complaint of visual field interference from the redun-
dant skin. Supply photographic documentation of the patient
in primary position and from each side. Some insurers require
this be done with flash to demonstrate the pupillary light reflex.
A visual field (automated Humphrey or manual Goldmann) is
required with taped and untapped eyelids, demonstrating the
improvement in the peripheral vision with taping (Fig. 33.14).
The exact visual field criteria needed to qualify vary from one
carrier to the next.
Fig. 33.14 Goldmann ptosis field of the right eye, indicating improve-
ment of 30° with taping of the upper eyelid.

33.4 Preoperative Planning,
Including Markings
Mark the incision lines in the upper eyelid with the patient in the
recumbent position. There are no universally agreed-upon mea-
surements for the height and shape of the upper eyelid incision
line, but this typically varies between 8 and 12 mm above the
center of the eyelid margin. Most surgeons feel that the incision
line should be lower for male than for female patients to prevent
feminization of the male eyelid. I have not found this to be true
and use the same measurement on men and women. I typically
place the lower incision at 10 mm centrally, 9 mm above the lat-
eral canthus, and 8 mm above the punctum in Caucasian patients
(Fig. 33.15). Generally, this line will be significantly lower for
Asian blepharoplasty and higher in patients with relative exoph-
thalmos who already have a physiologically high eyelid crease.
ith the patient gently closing the eyes, pinch the skin together
with a Green’s forceps or similar device centrally, medially, and
laterally to determine the excess and mark the upper edge of the
incision line (Fig. 33.16). hile doing this, be certain that the eye
can still close. The degree of skin excision will have been agreed
Fig. 33.15 Measurements for the lower edge of the incision.
a b
Fig. 33.17 (a) Outline of skin excision. (b) Lower eyelid blepharoplasty incision is 10 mm from the upper eyelid incision.
33 Upper Eyelid Blepharoplasty
upon by the patient and physician prior to the surgery based
on the desired result. An often-quoted rule of thumb is that the
upper edge of the skin excision should be at least 10 mm from
the lower edge of the eyebrow to allow for closure. This is not an
absolute rule, since some patients with low eyebrows and rela-
tive enophthalmos can have a slightly more aggressive removal,
while those with exophthalmos may need to have much more
than 10 mm of skin left between the upper edge of the incision
and the brow to prevent lagophthalmos.
The medial extent of the incision should go no further than
the medial canthus to prevent webbing or an epicanthal fold.
Laterally, however, it may have to go significantly further than the
lateral canthus to remove lateral hooding. hen going beyond the
lateral canthus, angle the incision upward by 20 to 30 following
a crow’s foot line (Fig. 33.17a). Be certain that the upper eyelid
and lower eyelid incisions are separated by at least 10 mm from
each other to prevent a lateral web (Fig. 33.17b). Compare both
sides for symmetry in terms of skin removal and the horizontal
length of the incision. Scars that extend beyond the lateral orbital
rim are usually well tolerated, but the left and right must be
identical in terms of their length and position to be perceived as
aesthetically acceptable.
Fig. 33.16 Determination of the amount of skin excision with a Green’s
forceps.
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 VI Eyelid Surgery
The choice of general anesthesia versus sedation versus
straight local is dependent upon the needs of the patient and the
preferences of the surgeon. Even with general anesthesia, local
infiltration with lidocaine and/or bupivacaine with epinephrine
is helpful in maintaining hemostasis and comfort after surgery.
The addition of hyaluronidase to the local greatly facilitates the
spread and duration of the anesthetic and decreases the swelling
of tissues during surgery, thus minimizing distortion.
33.5 Operative Technique
33.5.1 Skin, Orbicularis,
and Fat Resection
The choice of skin only versus skin/orbicularis excision versus
skin/orbicularis/fat excision is purely a choice of the surgeon
based on the desired result. Obviously, the more tissue removed,
the greater the magnitude of change. The following assumes that
all three are resected.
Incise the skin with a blade and remove with sharp scissors,
monopolar cautery, or laser or radiofrequency device as preferred
by the surgeon (Fig. 33.18). The exposed orbicularis muscle
Fig. 33.18 Skin incision with a blade.
Fig. 33.19 Removal of additional orbicularis muscle.
382
may now be trimmed according to the surgeon’s judgment as to
whether it is better to debulk the eyelid or leave it to preserve
fullness (Fig. 33.19). A substantial amount of the upper eyelid
orbicularis can be removed if necessary without causing problems
with closure. Exercise caution at the lower edge of the incision to
prevent inadvertent resection of the levator aponeurosis, which
is in close proximity to the undersurface of the orbicularis at this
point.
If resecting preaponeurotic fat, now open the orbital septum.
ith the fingers of one hand, push inferiorly on the upper eyelid
near the lid margin. ith the other hand, retract the upper skin
edge superiorly while applying light pressure against the globe.
This maneuver pushes the globe posteriorly into the socket, dis-
placing the fat anteriorly, where it now visibly bulges out under
the septum. hile still applying pressure as just described, cut
the septum, causing the fat to bulge through (Fig. 33.20). Cut
the septum across the eyelid to expose the remaining fat (Fig.
33.21). ext separate the fine fibrous attachments between
the fat and the levator (Fig. 33.22). Anteriorly, the fat can be
separated from the orbicularis up to the orbital rim if needed.
Resect the fat as planned and, if using scissors, clamp the fat
pockets with a small hemostat, cut the fat, and cauterize the
stump. Inspect for bleeding before releasing the fat. It is often
necessary to give a supplemental injection of local into the fat
pockets, especially the medial, to obtain complete anesthesia
(Fig. 33.23).
Do not resect fat above the level of the superior orbital rim.
Doing so can result in an adhesion between the levator muscle
and the bone, with resultant mechanical ptosis and restriction of
motility of the upper eyelid.
An alternative method to contour fat is simply to apply multi-
ple, small points of cautery across the orbital septum. This shrinks
and tightens the septum, thus pushing the fat posteriorly into the
orbit, decreasing its prominence (Fig. 33.24). Caution is advised
with this technique, since excessive septal contraction can lead to
lagophthalmos.
Fig. 33.20 Retraction of the brow superiorly with one hand while
placing pressure on the upper lid margin to cause the fat to bulge
through the cut septum.

Fig. 33.21 Opening the orbital septum with scissors.
Fig. 33.23 Additional injection of local anesthetic into the medial fat
pocket.
33.5.2 Crease Fixation
ow is the time to create an upper eyelid crease. Although a
crease will usually form spontaneously at the incision line,
crease fixation techniques reliably ensure this. Tissue excision
may be completely symmetric between right and left eyes, but if
the crease and fold do not match, the final result will not be even.
Historically, crease techniques have come from the Asian liter-
ature and so called double eyelid procedures. These practices
have been modified by numerous authors and are applicable to
estern eyelids.
All crease fixation techniques work by establishing an adhesion
between the skin and the levator. hen the upper eyelid opens,
the levator muscle pulls superiorly, invaginates the overlying
attached skin, and thus generates the upper eyelid fold from the
skin above the crease. Crease fixation is generally not required if
a hollow, deep superior sulcus is the goal. Crease fixation should
not be performed if the lower edge of the incision is more than 12
mm from the eyelid margin, since this usually leads to a mechani-
cal ptosis. This occurs because the crease essentially suspends the
33 Upper Eyelid Blepharoplasty
Fig. 33.22 Cutting the fine attachments between the orbital fat and
the levator.
Fig. 33.24 Cautery to contract and tighten the orbital septum. Arrow
identifies the site of a spot of cautery.
skin and orbicularis muscle that is inferior to the point of fixation
to the levator. If performed above 12 mm from the lid margin, the
tissue is generally too heavy for the levator, resulting in ptosis.
The simplest way to form a crease is to close the skin with a
running, monofilament suture and incorporate a bite of the leva-
tor aponeurosis just above the lower skin edge with every other
throw (Fig. 33.25). The disadvantage of this method is that the
crease is sometimes lost after the suture is removed.
A more secure method of fixation is to use a 6–0 fast or 6–0
silk suture to take a bite of the lower skin edge, then a bite of the
levator aponeurosis, and then the upper skin edge (Fig. 33.26).
This is done in two or three locations across the upper eyelid. The
inflammatory nature of these sutures creates a spot weld and
thus forms the crease.
The most reliable technique for crease fixation is to use a 6–0
polyglactin or 6–0 polyester suture to take a bite of the levator
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 VI Eyelid Surgery
aponeurosis just above the lower skin edge and then a bite of the
orbicularis on the underside of the lower skin edge (Fig. 33.27).
Again, this is done in two or three places across the incision (Fig.
33.28). Although a bit more time-consuming, this procedure
forms a crease that is reliable and long-lasting. The disadvantage
is that this suture may in time cause a reaction and need to be
removed. Removal of an occasional extruding suture is, however,
simpler than having to reform the crease in the months following
surgery, as may be needed with the other techniques.
Fig. 33.25 Creation of the eyelid crease by taking a bite of the levator
with every other throw of the running, monofilament skin suture.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New ork, N : Thieme; 2019.)
a b
Fig. 33.26 (a) Creation of the eyelid crease with an interrupted 6–0 silk suture passed between the lower skin edge, the levator aponeurosis, and the
upper skin edge. (b) Cross-sectional diagram of the suture placement. (Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair
Manual. New ork, N : Thieme; 2019.)
384
33.5.3 Skin Closure
The skin is then closed according to the surgeon’s preference.
Running, monofilament suture can be removed as soon as the
fifth postoperative day and can be delayed for up to 2 weeks with
no problem.
33.6 Ancillary Procedures
Extensive brow procedures, fat grafting, and skin resurfacing can be
performed at the same time but are covered in separate chapters.
There is now considerable thought given to procedures that increase
rather than decrease the volume of the periocular tissues. This may
be as simple as preservation of the orbicularis oculi muscle, less
resection of orbital fat or the addition of hyaluronic acid fillers. Even
more extensive is concomitant fat grafting to the brows. All of these
modalities serve to give a fuller look to the periocular area, with
the thought that the result is more representative of the natural,
youthful state of these tissues. This is in contrast to an aggressive
removal of tissue, which leads to a very hollowed-out appearance
(sometimes referred to as the post-blepharoplasty look ) that for
so long was the goal of the procedure. Again, the surgeon needs to
educate patients in regards to the options available and help them
to make an informed decision so that they will be pleased with the
outcome. The concept of what is beautiful and pleasing continues
to evolve in the minds of both the physician and the patient.
33.6.1 Lacrimal Gland Resuspension
Prolapse of the orbital lobe of the lacrimal gland is seen as a
distinct bulge in the lateral part of the upper eyelid (Fig. 33.29).
If the prolapse is not severe, the application of bipolar or unipolar
 33 Upper Eyelid Blepharoplasty

a b c
Fig. 33.27 (a) Creation of the eyelid crease with a 6–0 polyester. First, the suture takes a bite of the levator aponeurosis. (b) Then the suture takes
a bite of the orbicularis at the lower edge of the incision. (c) Cross-sectional diagram of the suture placement. (All parts reproduced from Nahai F,
Wojno T. Problems in Periorbital Surgery: A Repair Manual. New ork, N : Thieme; 2019.)

Fig. 33.28 Frontal diagram of the suture placement. (Reproduced

from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual.
New ork, N : Thieme; 2019.)

cautery to the capsule of the gland will shrink it and effectively b

reposit the gland back into the orbit. This will not affect the
function of the gland to any measurable degree.
If the prolapse is severe, it must be surgically repositioned.
Dissect anterior to the gland down to the level of the orbital rim
arcus marginalis. Take a bite of the lacrimal gland and then a bite
of the arcus marginalis with a nonabsorbable suture, and tie (Fig.
33.30). A second suture may be necessary to reposition the gland
adequately. This procedure does not affect the function of the gland.
33.6.2 Resection of Brow Fat
The brow fat, or ROOF (retro–orbicularis oculi fat) may some-
times need to be thinned if it is too prominent and has descended
into the upper eyelid. This is especially common in patients who
have had thyroid eye disease. This tissue is visible as a distinct
Fig. 33.29 (a) Prolapse of the right lacrimal gland is visible as a distinct
bulge in the lateral upper eyelid. (b) A different patient demonstrating
mild prolapse of the lacrimal gland inferior to the orbital rim (arrow).
layer of firmer fat with smaller lobules just anterior and superior
to the preaponeurotic fat (Fig. 33.31a). This can be trimmed with
scissors or unipolar cautery to decrease the anterior projection
of the eyelid between the upper edge of the incision and the eye-
brow (Fig. 33.31b). Conservative resection is recommended, and
a thin layer of fat must remain between the skin and the orbital
rim. Excessive resection can result in a secondary lid crease due
to adhesion of the skin to the orbital rim.

385
 VI Eyelid Surgery

a b
Fig. 33.30 Repositioning of a prolapsed lacrimal gland. (a) First, take a bite of the gland (arrow) with a nonabsorbable suture. (b) Next, take a bite of
the arcus marginalis, and tie.

a b
Fig. 33.31 (a) The retro–orbicularis oculi fat (ROOF, white arrow) is seen just superior to the orbital septum (black arrow). (b) Trimming excess ROOF
with scissors.

33.6.3 Lateral Brow Pexy downward for the desired effect and symmetry, pull the end of the
suture though from the skin side, and tie. Brow pexy performed
If needed, the lateral brow can be fixated to the lateral orbital rim in this fashion will result in temporary, mild swelling and extra
via the upper eyelid incision (Fig. 33.32). Dissect below the orbicu- discomfort in this area.
laris under the lateral third of the brow to a point 2 cm above the
orbital rim. Place a 4–0 polyester suture full-thickness through
the skin at the inferior border of the brow. ext, take a bite of the 33.7 Postoperative Care
periosteum 1 cm superior to the orbital rim and then through the
Patients are advised to avoid strenuous physical activity and
tissue under the flap at the exit point of the original pass, which is
heavy lifting to prevent orbital hemorrhage and broken sutures.
the lower border of the eyebrow. Adjust the placement upward or

386
 33 Upper Eyelid Blepharoplasty

a b c

d e f
Fig. 33.32 Lateral brow pexy. (a) Dissection under the orbital orbicularis (arrow marks the orbital rim). (b) Placement of a 4–0 polyester suture
through the skin at the inferior border of the brow. (c) The needle of the 4–0 polyester suture emerging through the orbital orbicularis (arrow).
(d) Measuring 1 cm superior to the orbital rim. (e) Taking a bite of the periosteum 1 cm superior to the orbital rim (arrow). (f) The needle now taking
a bite of the orbital orbicularis at the point where the suture emerged at the lower border of the brow (arrow).

Frequent use of cool compresses helps minimize swelling, bruis-

ing, and pain. Twice-daily application of a bland ophthalmic
33.9 Results
ointment keeps the suture line clean and more comfortable. Three patients are shown before and 2 months after upper eyelid
Patients should be cautioned that even though the ointment is blepharoplasty. The patients, respectively, requested a small
applied to the sutures, some of it will melt, get into the eyes, amount (Fig. 33.33), a moderate amount (Fig. 33.34), and a
and cause some blurring of vision for 24 hours after the last large amount (Fig. 33.35) of skin and fat removal.
application. Any ophthalmic drops normally prescribed for
the patient are continued uninterrupted. The patients may get
the sutures wet and may read and watch television as desired.
They may return to work the following day if desired. They
are instructed to call immediately if they develop significant,
uncontrolled bleeding or loss of vision. Acetaminophen usually
suffices for pain control, but a small minority will require the
addition of a mild narcotic. Patients are instructed as to when
to resume medications that interfere with the clotting system
on an individualized basis. Sutures are removed 5 to 7 days after
surgery, and the patient is seen 1 to 2 months later, after most of
a
the edema has resolved.

33.8 Outcomes
As with any other procedure, patients are generally satisfied
with the overall results and pleased with the improved field of
vision. Touch-up procedures to remove small amounts of addi-
tional skin or fat for symmetry can be done as soon as 1 month
after surgery. Even 1 mm of asymmetry is very noticeable in the
upper eyelids and is not well accepted by most patients. In most b
cases, patients should not require a repeat procedure for at least
Fig. 33.33 Patient who requested a “small” amount of tissue removal.
10 years. (a) Before surgery. (b) Two months after surgery.

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 VI Eyelid Surgery
b
Fig. 33.34 Patient who requested a “moderate” amount of tissue
removal. (a) Before surgery. (b) Two months after surgery.
33.10 Concluding Thoughts
Functional and cosmetic blepharoplasties are some of the most
frequently performed aesthetic surgical procedures. Satisfied
patients become a source of referral for friends and associates
and a portal of entry for other aesthetic treatments. Results are
generally gratifying for the patient and surgeon. Careful consid-
eration of the underlying structures, individual differences in
anatomy and ethnicity, the patient’s medical condition, and the
patient’s desires will minimize postoperative problems.
Clinical Caveats
• No upper eyelid blepharoplasty is purely functional or purely
cosmetic.
• The surgeon needs to understand the patient’s expectations
and explain what can and cannot be accomplished.
• The surgeon must appreciate how individual differences in
anatomy and ethnicity will affect outcome.
• The major decisions are placement of the incision lines, how
much tissue is resected versus how much tissue is preserved,
and method of formation of the eyelid crease-fold complex.
• The notion that this is “simply a little tuck” must be avoided.
388
b
Fig. 33.35 Patient who requested a “large” amount of tissue removal.
(a) Before surgery. (b) Two months after surgery
Suggested Reading
1 Cohen BD, Reiffel A , Spinelli HM. Browpexy through the upper lid (BUL): a new
technique of lifting the brow with a standard blepharoplasty incision. Aesthet
Surg J 2011;31(2):163–169
2 Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics
of the upper periorbita. Plast Reconstr Surg 2002;110(1):278–291, discussion 292
3 Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in
optimizing results in aesthetic upper blepharoplasty: a new look at the surgical
treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr Surg
2010;125(2):653–666
4 Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty.
Clin Plast Surg 1993;20(2):193–207
5 Massry GG. asal fat preservation in upper eyelid blepharoplasty. Ophthal Plast
Reconstr Surg 2011;27(5):352–355
6 Mendelson BC, Luo D. Secondary upper lid blepharoplasty: a clinical series using
the tarsal fixation technique. Plast Reconstr Surg 2015;135(3):508e–516e
7 Pang HG. Surgical formation of upper lid fold. Arch Ophthalmol 1961;65:783–784
8 Putterman AM. Treatment of upper eyelid dermatochalasis with reconstruction
of upper eyelid crease: skin-muscle flap approach. In: Fagien S. Putterman’s
Cosmetic Oculoplastic Surgery. 4th ed. Philadelphia, PA: Saunders Elsevi-
er;2008:79–86.
9 Sheen H. Supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg
1974;54(4):424–431
 34 Upper Blepharoplasty in the Asian Patient

34 Upper Blepharoplasty in the Asian Patient

H. Joon Kim

The most commonly referenced anatomical difference between

Abstract
Asian blepharoplasty, or double-eyelid surgery, is one of the
most common cosmetic procedures performed in Asia. hile it
encompasses the fundamental concepts of a traditional bleph-
aroplasty, the anatomical and aesthetic differences of Asian
eyelids necessitate a distinct procedure. A specialized preoper-
ative evaluation and understanding of patient expectations are
required for a successful outcome. Countless surgical techniques
exist, each with their set of advantages and disadvantages, that
are outlined in this chapter.
Keywords
Asian blepharoplasty, double-eyelid surgery, preoperative evalu-
ation, incisional techniques, nonincisional techniques
34.1 Background
Double-eyelid surgery can be dated back to apan near the end
of the Edo period, when estern influences prevailed. Although
the initial documented surgery was performed by Mikamo
during this time in 1896, the term Asian blepharoplasty was
popularized by illiam Chen in 1987 to highlight the differences
in anatomy and technique from the traditional blepharoplasty.
Today, the procedure remains the most frequently performed
cosmetic procedure in Asia. It is important to note that while
the term Asian blepharoplasty has become nearly synonymous
with double-eyelid surgery, it can encompass the fundamental
concepts of skin and/or orbicularis excision and fat contouring
that define a traditional blepharoplasty.
Asian and Caucasian lids is the point of fusion between the septum
and the levator palpebrae superioris aponeurosis. For Caucasian
lids, the fusion occurs between 5 and 10 mm above the superior
border of the tarsal plate, while for Asian eyelids the fusion occurs
below the superior tarsal border (Fig. 34.2). This difference, along
with the shorter tarsal height and an inferior displacement of
the preaponeurotic fat, give a fuller appearance of the eyelids in
Asians and a lower or absent lid crease. Additionally, the absence
of the terminal interdigitations of the levator aponeurosis to the
orbicularis and dermis have been described, which results in the
lack of a lid crease.
The upper eyelid crease in Asians exists about 50 of the time
and tends to be approximately 6 to 8 mm from the lid margin, as
compared to that in Caucasians, which often exists 9 to 11 mm
from the lid margin. Crease morphology can also vary, particularly
nasally, where it can be tapered or parallel (Fig. 34.3). A tapered
crease gradually converges to blend in with the medial epicanthal
fold, whereas a parallel crease will remain parallel medially and
remain above the epicanthal fold.
34.3 Preoperative Evaluation
As with any other cosmetic surgery, the initial consultation
is critical in arriving at a mutual understanding of desires and
expectations. For Asian blepharoplasty, understanding their
motive for surgery is important. Are they seeking surgery to just
obtain a double eyelid crease Do they desire to make their eyes
look bigger Do they just want to improve their vision It is also
vital to understand whether they already have an ideal height

34.2 Anatomy
Significant anatomical differences can exist between Asians and
Caucasians, even down to the bony anatomy. Anthropometric
studies have shown that Asian orbits tend to be more round,
whereas Caucasian orbits tend to be more square with a more
prominent superior orbital rim and deeper lateral orbital rim.
Despite the variation in the shape, the entrance height and width
remain similar.
The epicanthal fold, most notably epicanthus tarsalis, where
folds are most prominent from the upper lid to the medial canthus,
is another common feature of an Asian eyelid (Fig. 34.1). Several
traditionally accepted theories exist to explain this feature, which
include a combination of a low nasal bridge, Z-shaped kinking
of the orbicularis oculi muscle fibers, excess of orbicularis oculi
muscle, and an absence of dermal attachment to the medial can-
thal tendon. More recent cadaver studies by akizaki showed that
the main etiologic factor for epicanthal tarsalis depends on the
fibers of the oblique direction of the preseptal orbicularis muscle Fig. 34.1 An example of an epicanthal tarsalis with the prominent
folds from the upper lid to the medial canthus.
rather than those of the pretarsal orbicularis.

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 VI Eyelid Surgery

Preaponeurotic fat Orbital fat Preaponeurotic fat Orbital fat

Orbicularis
oculi muscle

Orbital septum
Orbital septum
Levator aponeurosis

Müller’s muscle

Superior tarsus
Levator aponeurosis
Terminal
interdigitations

Conjunctiva

Inferior tarsus

a Caucasian b Asian

Fig. 34.2 Comparison of (a) Caucasian and (b) Asian eyelid anatomy.

and shape of the crease in mind. It is often the case that they
desire to look natural but are unsure as to the details of what
this implies.
A comprehensive medical history should be obtained, with
special attention to the ocular history, including previous eye
and/or eyelid surgeries and injectables such as botulinum toxin
and fillers around the eyes, as these can impact the eyelid height
and shape. Also, asking about symptoms and conditions of dry
eye or ocular surface surgery such as laser in situ keratomileusis
(LASI ) is prudent. Safe discontinuation of anticoagulants is also
recommended to minimize intraoperative bleeding and to reduce
the risk of postoperative complications such as a retrobulbar
hemorrhage.

a
34.4 Physical Examination
A thorough examination of the periocular region and of the eyes
should be performed. Brow position and shape with associated
temporal hooding should be assessed. Determine any brow/fore-
head ptosis that may need to be corrected to augment the out-
come of the blepharoplasty. Measurement of the marginal reflex
distance (MRD1) is important (Fig. 34.4). This measurement in
millimeters is from the corneal light reflex in the center of the
pupil to the upper eyelid margin and will help to differentiate
true blepharoptosis from dermatochalasis. An average MRD1
in Caucasians is about 4 mm. For Asian patients the average
MRD1 can vary slightly from 2 to 4 mm, presenting another
level of challenge to the necessary surgical procedure. Again,
the discussion of the desired outcome with the patient will be
critical. The presence or absence of a natural crease should be
noted along with its contour and shape, especially medial in
relation to the epicanthal fold. In addition to the natural fullness b
of the Asian eyelid, older patients can also have fat prolapse that Fig. 34.3 Variations in crease morphology with (a) showing a tapered
can be simultaneously present with superior sulcus hollowing. crease and (b) showing a parallel crease.

390

Fig. 34.4 Demonstration of the technique for measuring the marginal
reflex distance 1 (MRD1) from the corneal light reflex to the upper lid
margin for determining ptosis.
Determination of how much fat to contour and/or excise while
maintaining the natural fullness of an Asian eyelid can add
another level of complexity to the surgery. A full eye exam
should be performed with close attention to visual acuity and
ocular surface changes to suggest dry eye or lagophthalmos.
To demonstrate the appearance of the patient’s lids with a
crease, a double-eyelid curved probe simulator (Fig. 34.5), or even
a straightened paper clip, could be used during the preoperative
consultation. Double-eyelid tape (Fig. 34.6), which has gained
popularity in Asia, can also be used to simulate a crease in the
office, with the caveat that the outcome could slightly vary.
Fig. 34.5 Double-eyelid curved probe simulators.
34 Upper Blepharoplasty in the Asian Patient
34.5 Surgical Techniques
Asian blepharoplasty can be performed either in the office minor
room with local anesthesia or in the operating room under moni-
tored anesthesia care with intravenous sedation. In the office setting,
preoperative benzodiazepines can be prescribed as an anxiolytic.
Typical local anesthetic consists of 1 to 2 lidocaine with 1:100,000
dilution of epinephrine, either alone or in combination with a lon-
ger-lasting anesthetic, such as 0.5 to 0.75 bupivacaine in a 1:1 ratio.
Hyaluronidase can additionally be added to this local mixture for
rapid dispersion of the infiltrate with minimal turgor and distortion
of the tissue. Some surgeons also may add sodium bicarbonate to
minimize the burning sensation of the anesthetic. After instillation
of 0.5 proparacaine into both eyes, 5 povidone–iodine is often
used to prep the entire face prior to draping.
34.5.1 Nonincisional Techniques
Since there is no manipulation of the skin or fat in the noninci-
sional technique, it is ideal for young patients with minimal or no
redundant skin or fat seeking a double-eyelid crease. The nonin-
cisional suture technique has remained popular due to its short
operative time, minimal scarring, and quick recovery. Countless
variations in technique and suture preference have developed
over the years, to the extent that a comprehensive description
of every modification would prove challenging. Practically
speaking, this procedure can be subcategorized depending
on the suture placement: buried versus nonburied tech-
niques and continuous versus interrupted techniques. The
suture can then be passed full-thickness or near full-thickness
through the eyelid, either through the tarsal plate or through
M ller’s and levator muscle immediately superior to the tarsus.
Fig. 34.6 Double-eyelid tape.
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 VI Eyelid Surgery

Mini-incision techniques also exist that serves as a hybrid
between the nonincisional and incisional techniques.
Interrupted Technique
Mikamo’s technique in 1896 was a nonburied, interrupted tech-
nique that required removal of the sutures 6 to 8 days postoper-
atively. He placed three 4–0 silk sutures full-thickness through
the eyelid medially, centrally, and laterally approximately 6 to 8
mm from the lashline (Fig. 34.7). The depth of the fold depended
on the day of the suture removal. Since then, buried techniques
have become increasingly favorable in an effort to minimize the
loss of the surgically created crease, one of the major failures
of the suture technique. One of the earliest buried techniques,
presented by Uchida in 1926, utilized the same three placements
of the sutures as Mikamo but instead used catgut. Song has also
utilized a similar technique but employed nylon sutures.
More recently, a single-suture technique has also been described
by Baek, which includes making a mark along the lid skin 6 to 8 mm
from the lash line (Fig. 34.8a). Two stab incisions are made with a
no. 11 blade along the marked line as points of entry for the sutures
(Fig. 34.8b). The eyelid is then everted, and one of the needles of a
double-armed 6–0 Prolene suture is passed through the conjunctiva
in the corresponding point of one of the stab incision sites and exits
through the conjunctiva corresponding to the second stab incision
site (Fig. 34.8c). Each of the two needles is then passed anteriorly
to exit through the skin where its stab incision was created (Fig.
34.8d). One needle is then passed subcutaneously to the other
stab incision site so that both needles are then exiting from the
same incision site (Fig. 34.8e). A knot is tied and buried beneath
the orbicularis. The stab incision sites are closed with interrupted
6–0 Prolene (Fig. 34.8f). u describes a similar method but utilizes
four to seven sutures that are passed closer together.

6–8 mm

Fig. 34.7 Artist’s rendition of the first reported double-eyelid surgery, performed by Mikamo in 1896.

6–8 mm

B C D
b c d

a e f
E F
Fig. 34.8 Artist’s rendition of a single-suture nonincisional technique by Baek. (a) Marking of the lid 6 to 8 mm from the lash line. (b) Two stab
incisions on the marked line serve as (c) entry and exit points for double-armed suture. (d) Each needle is passed back out through its incision. (e)
One suture is led subcutaneously to the other stab incision site. (f) The sutures are joined with a buried knot, and the stab incisions are closed.

392
 34 Upper Blepharoplasty in the Asian Patient

Continuous Technique skin through each incision. A 7–0 nylon suture is then passed
from the lateralmost stab incision and advanced medially,
In an effort to create a more durable crease, numerous con-
alternating between dermis bites and partial-thickness tarsal
tinuous methods have also been described. One of the initial
bites (Fig. 34.9b). The suture is then reversed from medial
techniques was described by Maruo in 1929 as a two-way
to lateral, again alternating between dermal and tarsal bites
continuous buried-suture method that has been illustrated
in the opposite intervening segments (Fig. 34.9c), and tied
by Chen, im, Song, ong, and more recently in a modified
buried within the incision laterally. It is important to note,
version by Fan. In both Maruo’s and Fan’s methods, seven to
as ong emphasized in his report, that with each intratarsal
nine stab incisions are created along the designated crease
bite, the lid should be everted to ensure that the suture does
starting from about 5 mm lateral to the medial canthus and
not pass full-thickness through the tarsal plate where it may
ending 10 mm medial to the lateral canthus (Fig. 34.9a).
cause corneal damage. Most authors believe that continuous
Modifying Maruo’s technique in a way first reported by im et
techniques result in a longer-lasting crease because of the
al in 2000, Fan excises an approximately 1-mm-long piece of
numerous points of fixation to the underlying tissue, but some
argue that it is more difficult to control the crease contour and
deal with revisions, still making the interrupted techniques
Stab incisions more superior.

34.5.2 Incisional Techniques

The traditional incision methods were described by Maruo in
3 4 5
2 6
1 7 1929 and popularized during the 1950s and 1960s by Sayoc,
6–8 mm Fernandez, and Boo-Chai. ey points from their methods include
marking the crease approximately 5 to 8 mm from the lid
margin, followed by conservative excision of ellipse of skin and/
or orbicularis oculi with dissection down to expose the levator
aponeurosis. Usually minimal or no fat resection is performed.
Crease fixation differs between authors: some will separately
form the crease and close the skin independently, while others
a Medial Lateral will incorporate tarsal or levator bites with skin closure, usually
A in an interrupted fashion. One or more sutures are then passed
from either the levator or the tarsal plate (depending on the
desired crease height) and through the dermis of the inferior skin
edge (Fig. 34.10). The skin is closed with a nonabsorbable suture
Skin 3 4 5
2
1
6
7 that is typically removed within 3 to 10 days. Results are shown
Fat in Fig. 34.11 and Fig. 34.12.
Orbicularis

Aponeurosis

Tarsus

Conjunctiva

b Cornea
B Preaponeurotic
Orbicularis oculi fat
muscle
Orbital septum

2 3 4 5 6
Upper eyelid skin
1 7 Levator palpebrae
superioris
Superior tarsal
plate
Conjunctiva

c Cornea
C
Fig. 34.9 Artist’s rendition of a continuous nonincisional technique by
Fan. (a ) Seven to nine stab incisions are made along the marked line.
(b ) A 7–0 nylon suture is passed from incision to incision from lateral
to medial, alternating between dermis bites and tarsal bites. (c) Suture
is passed back from medial to lateral, taking dermis bites and tarsal Fig. 34.10 An artist’s rendition of the crease fixation suture placed via
bites opposite to those in the first pass. an incisional technique reported by Boo-Chai.

393
 VI Eyelid Surgery
a
b b
Fig. 34.11 Results of an incisional technique with a natural-appearing
“medium” crease. (a) Preoperative photo. (b) Three-month postoper-
ative photo.
Due to the prolonged edema and hypertrophic scarring
that can be associated with Asian eyelids, the classic methods
have evolved to mini-incision techniques that in theory yield
minimal scarring and fast recovery associated with the suture
techniques and also with the longevity of the open methods (Fig.
34.13, Fig. 34.14). Lam reported 1,500 cases in which he utilized
a 1- to 1.8-cm incision along the desired crease height with
resection of the septum and preaponeurotic fat. He then placed
five to seven interrupted 7–0 nylon sutures from the levator apo-
neurosis to the inferior edge of the incision. Chen illustrates a
technique that adopts a single 1-cm incision centrally along the
desired crease height, with or without fat removal, and utilizes
three 6–0 Prolene sutures to secure the crease from the levator
aponeurosis to the dermis along the inferior incision. His method
also allowed for simultaneous ptosis correction by adjusting the
suture placement on the levator. Ma describes making two 2- to
3-mm incisions along the marked crease, debulking the pretar-
sal tissue, and fixating the crease by passing a 7–0 nylon suture
from the pretarsal levator to the dermis along the inferior edge
of the incision.
394
a
Fig. 34.12 Results of an incisional technique with a minimally visible
“low” crease. (a) Preoperative photo. (b) Three-month postoperative
photo.
34.6 Complications
Problems with the crease are undoubtedly the most frequently
encountered complications. They can include an incomplete crease,
an asymmetric crease, multiple creases, or an excessively high
or low crease (Fig. 34.15), and various corrective methods have
been described. Aggressive fat excision can result in a sunken
upper eyelid or a superior sulcus deformity that can be difficult
to restore. Due to the thicker dermis and a more exuberant fibro-
blastic response during wound healing, persistent erythema and
hypertrophic scarring have also been an anticipated problem in
Asian patients, and thus it would be prudent to have a postoperative
algorithm for managing the scar. Excessive skin removal can result
in an ectropion (lid margin turning outward) and/or lagophthalmos
(incomplete closure of the eyelid). These complications are not
unique to Asian eyelids but can occur in any eyelid where the skin
has been aggressively resected. Additional surgery is often neces-
sary to correct these issues. Although Asian blepharoplasty can be a
straightforward procedure to perform, it can be riddled with com-
plications and should be approached with appropriate planning and
strategies for managing the common postoperative problems.
 34 Upper Blepharoplasty in the Asian Patient

a b c

d e f

g h i
Fig. 34.13 An example of a “mini-incision” technique. (a) A 1- to 2-cm incision is marked. (b,c) Dissection is carried down to the superior border of
the tarsal plate. (d) A 5–0 polyester suture is passed partial-thickness along the superior border of the tarsal plate. (e) The lid is everted to ensure that
the polyester has not passed full-thickness through the tarsal plate. (f) The polyester is then passed through the inferior cut edge of the orbicularis
oris muscle from deep to superficial, then (g) reversed and passed superficial to deep in a horizontal mattress fashion, then (h) tied down securely. (i)
The resulting invagination of the lid forms the lid crease.

Fig. 34.15 A patient showing a high crease with a “sunken” appear-

ance of both upper lids after an Asian blepharoplasty. The left upper lid
has an additional complication of having multiple creases

b
Fig. 34.14 Results of “mini-incision” technique with a natural
appearing “medium” crease. (a) Preoperative photo. (b) Three-month
postoperative photo.

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 VI Eyelid Surgery

34.7 Concluding Thoughts
hile Asian blepharoplasty can be a challenging operation, the
exponentially growing demand for a double eyelid necessitates
its inclusion in the fundamental armamentarium of surgeries
for a plastic surgeon. A thorough understanding of the distinct
anatomy and subtle nuances of the various techniques can make
this a very rewarding and successful procedure.
Clinical Caveats
8 Fan , Low D . A two-way continuous buried-suture approach to the creation of
the long-lasting double eyelid: surgical technique and long-term follow-up in 51
patients. Aesthetic Plast Surg 2009;33(3):421–425
9 Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr
Surg Transplant Bull 1960;25:257–264
10 eong S, Lemke B , Dortzbach R , Park G, ang H . The Asian upper eyelid:
an anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol
1999;117(7):907–912
11 ordan DR, Anderson RL. Epicanthal folds. A deep tissue approach. Arch Ophthal-
mol 1989;107(10):1532–1535
12 akizaki H, Ichinose A, akano T, Asamoto , Ikeda H. Anatomy of the epicanthal
fold. Plast Reconstr Surg 2012;130(3):494e–495e
13 Goold LA, Casson R , Selva D, akizaki H. Tarsal height. Ophthalmology

• Absence of the eyelid crease in individuals of Asian ancestry 2009;116(9):1831–1831.e2

stems from a subtle yet significant difference in anatomy, with
a lower fusion point of the septum with inferiorly displaced
preaponeurotic fat.
• Be aware of the various crease heights and morphology and
reach a mutual understanding with patients preoperatively
regarding their expectations.
• Distinguish brow ptosis, blepharoptosis, and dermatochalasis
to determine the appropriate surgery.
• Be familiar with the numerous techniques that exist for an
Asian blepharoplasty, each with its unique pros and cons.
• Anticipate and prepare for potential complications, such
as asymmetry, high “sunken” crease, multiple creases, and
hypertrophic scarring.
14 im BG. Multiple suture technique. In: Park I, Toriumi DM, eds. Asian Facial
Cosmetic Surgery. Philadelphia, PA: Saunders Elsevier; 2006:24–32
15 im , wan D, Oh S. Double eyelid operation with three tiny incisions. Arch
Plast Surg 2000;27(3):195–198
16 im , Park H , im S. Secondary correction of unsatisfactory blepharoplasty:
removing multilaminated septal structures and grafting of preaponeurotic fat.
Plast Reconstr Surg 2000;106(6):1399–1404, discussion 1405–1406
17 im S, Choi TH, Liu , Ogawa R, Suh S, Mustoe TA. Update on scar man-
agement: guidelines for treating Asian patients. Plast Reconstr Surg
2013;132(6):1580–1589
18 Lam SM, im . Partial-incision technique for creation of the double eyelid.
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eyelid by fascia-fat graft. Plast Reconstr Surg 2001;107(1):15–19
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2017;70(12):1768–1775
21 Ma F , Cheng MS. Mini-incision double eyelidplasty. Aesthet Surg J
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2004;114(5):1270–1277, discussion 1278–1279 continuous tarsal stitch. Facial Plast Surg Clin N Am 2007;15:337–341e3
7 Duke-Elder S. The eyelids. In: System of Ophthalmology. Vol II. London, U : Henry 30 u . A two-way continuous buried-suture approach. Aesthetic Plast Surg
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35 Ptosis Surgery in the Blepharoplasty Patient
Ted Wojno
Abstract
Ptosis repair may be an integral part of upper eyelid blepharo-
plasty. If ptosis goes unrecognized and untreated during upper
eyelid blepharoplasty, secondary surgery will likely be needed. If
the surgeon is familiar with the anatomy, this is a straightforward
addition to the procedure. The evaluation of the ptosis patient is
discussed, as is the surgical repair in both patients under local
and general anesthesia. Management of complications of ptosis
repair is reviewed.
Keywords
levator muscle, levator aponeurosis, m llerectomy, acquired
ptosis, congenital ptosis
35.1 Indications and
Contraindications
Ptosis repair is easily combined with upper eyelid blepharoplasty,
since the levator palpebrae superioris aponeurosis and muscle
are already exposed in the surgery. The addition of functional
ptosis repair should be considered when the upper eyelid margin
rests 2 mm or less above the center of the pupil, which is gener-
ally considered to be the point at which ptosis is visually signif-
icant. Ptosis repair should also be considered if there is greater
than 1 mm difference in the upper eyelid position between the
two eyes in primary position. This magnitude of asymmetry,
although seemingly small, is surprisingly noticeable. Such a
difference may not, however, be discerned by patients if they are
focused on the redundant skin and fat of the upper eyelid. Often,
pre-existent ptosis is only noticed by patients after the swelling
from upper eyelid blepharoplasty has resolved.
There is no absolute contraindication to ptosis repair at the
time of upper eyelid blepharoplasty in an otherwise normal
patient. If, however, the patient has preoperative lagophthalmos
from any etiology, then ptosis repair would exacerbate symptoms
of exposure and thus should be carefully considered. As with
upper eyelid blepharoplasty, the only real contraindication is a
patient who has an uncontrolled coagulopathy or one who cannot
discontinue anticoagulant medication for a sufficient length of
time to return the clotting system to a level that minimizes the
risk of vision-threatening orbital hemorrhage.
35.2 Pertinent Anatomy
The anatomy of the upper eyelid was discussed at length in
the chapter on upper eyelid blepharoplasty, and the reader is
referred there for this discussion.
35 Ptosis Surgery in the Blepharoplasty Patient
35.3 Preoperative Assessment
Examine the eyes with the patient sitting in front of and level
to the examiner. Have the patient look straight ahead over the
examiner’s shoulder to the end of the room. Be certain that the
frontalis muscle is relaxed. It may be necessary to gently push the
brow and forehead down to the normal position to achieve this.
35.3.1 Palpebral Fissure
The palpebral fissure (PF) is the vertical gap in millimeters
between the upper and lower eyelid margins as measured at
midpupil (Fig. 35.1). Again, the patient should have the frontalis
muscle relaxed and looking toward the end of the room. This
measure will vary depending on the position of both the upper
and lower eyelids but is usually between 8 and 10 mm.
hen measuring the palpebral fissures, remember the influ-
ence of Hering’s law of equal innervation (also known as Hering’s
law of motor correspondence of yoked muscles). The two levator
muscles receive their motor innervation from a single, unpaired
nucleus in the brain. This means that both levator muscles receive
the same amount of neural stimulation no matter what the
anatomic state of either muscle may be. If the patient attempts to
compensate for a unilateral ptosis or an asymmetric ptosis (either
consciously or unconsciously), there will be an equal increase
in the innervation to both levator muscles. If the patient has a
bilateral, asymmetric ptosis, the more ptotic eye may appear to
have only a mild ptosis while the opposite eye appears to rest at a
normal level. In such a case, a unilateral ptosis repair of the more
severely ptotic eye will result in the opposite eye displaying ptosis
postoperatively, since the neurologic stimulation of both muscles
is now lessened somewhat. Also, in some cases of unilateral ptosis,
the ptotic eye may appear normal while the opposite (normal eye)
may actually appear retracted.
Fig. 35.1 Measurement of the palpebral fissure.
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 VI Eyelid Surgery
To detect whether this exists, the examiner should elevate the
ptotic (or more ptotic) eyelid with a fingertip (thus decreasing the
need for excessive stimulation of the levator muscles) and observe
any drop in the resting level of the opposite upper eyelid. If the
opposite upper eyelid is now ptotic, both eyelids will require
ptosis repair in conjunction with blepharoplasty (although the
amount of repair will likely differ).
Although not 100 reliable, the demonstration of Hering’s law
will apply in the vast majority of ptosis cases. There will still be an
occasional patient who will not exhibit ptosis of the opposite eye
until sometime in the postoperative period.
35.3.2 rgin e e i n e
ith a penlight centered on the cornea, the marginal reflex
distance (MRD) is the vertical gap between the pupillary light
reflex and the upper eyelid margin (Fig. 35.2). This is typically
3 to 4 mm. This measurement is independent of the position of
the lower eyelid and is thus a more accurate gauge than the pal-
pebral fissure for the presence and degree of ptosis. By conven-
tion, 1 to 2 mm of ptosis is considered mild, 3 mm is moderate,
and 4 mm or greater is severe.
35.3.3 Levator Function
The levator function is the vertical excursion of the upper eyelid
as measured at midpupil from downgaze to upgaze (Fig. 35.3).
The examiner should hold a finger over the eyebrow to nullify
any contribution from the frontalis muscle. ormal levator func-
tion is 12 mm or greater.
35.3.4 Acquired (Age-Related) Ptosis
The vast majority of patients who present with both upper eyelid
dermatochalasis and ptosis will have acquired, age-related
Fig. 35.2 Measurement of the marginal reflex distance.
398
ptosis. This is also referred to as aponeurotic ptosis, since it is
best conceptualized as a thinning and/or stretching of the levator
aponeurosis. Although many authors assert that the aponeurosis
is disinserted from its attachment to the tarsus, careful inspec-
tion at the time of surgery will almost always reveal an intact,
albeit thinned, aponeurosis (Fig. 35.4). Most cases of aponeurotic
disinsertion found at surgery are most likely iatrogenic, having
been caused by inadvertent excision of the diaphanous inferior
aponeurosis during removal of skin and orbicularis or after
opening the orbital septum.
Age-related, acquired ptosis is due to degenerative changes and
thinning of the levator aponeurosis. It can be exacerbated by or
unmasked by prior intraocular surgery, an episode of lid edema/
swelling, long-term contact lens wear, or direct trauma. These
patients will have excellent levator function ( 12 mm), a higher
than normal or absent eyelid crease (due to loss of the fibrous
attachments from the levator to the underside of the skin), and,
in severe cases, visibility of the iris through the thinned eyelid
tissues (Fig. 35.5). Such ptosis is characteristically worse in the
evening as the levator, M ller’s, and frontalis muscles tire of sup-
porting the drooping eyelids. Since this is best conceptualized as a
stretched-out levator aponeurosis, if unilateral, the involved lid
will descend to a lower level than the opposite lid on downgaze.
Often the thinning of the levator is more remarkable medially,
and in some instances the aponeurosis and muscle are essentially
non-existent here (Fig. 35.6). This nasal atrophy is responsible
for the frequently noted observation that acquired ptosis may be
much worse medially.
b
Fig. 35.3 Measurement of levator function from (a) downgaze to (b)
upgaze. In this example it is 14 mm.

Fig. 35.4 Intact levator aponeurosis demonstrating extreme thinning
at the time of ptosis repair.
Fig. 35.6 Photo of the left upper eyelid demonstrating almost
complete atrophy of the nasal portion of the levator muscle and
aponeurosis in the medial region.
There also exists a much less common form of age-related,
acquired ptosis that is characterized not by thinning but rather by
thickening of both the levator aponeurosis and muscle (Fig. 35.7).
These changes are quite obvious at surgery, and pathology reveals
that the tissues display fat infiltration and fibrosis. Although
sometimes unilateral, most cases are bilateral. This variant is
poorly understood and underappreciated as a cause of ptosis. It is
perhaps best conceptualized as an adult onset dystrophy specific
to the levator. Some cases display a remarkable family history
of significant ptosis that develops in the age range of 20 to 40
years. For all purposes, it behaves as, and can be treated just like,
aponeurotic ptosis in terms of surgery. Repeat surgery is often
necessary over a period of years, since in some patients the degen-
erative process seems to continue.
35 Ptosis Surgery in the Blepharoplasty Patient
Fig. 35.5 The dark iris can be subtly visualized through the thinned
upper eyelid tissues in this patient with ptosis.
Fig. 35.7 Grossly thickened levator muscle with fibro-fatty infiltration.
35.3.5 Other Causes of Acquired Ptosis
Myasthenia Gravis
An infrequent cause of ptosis is the neuromuscular disorder
myasthenia gravis. A classic symptom in myasthenia is worsen-
ing by day’s end, which, although present in most other cases
of ptosis, is typically much more dramatic in this disorder. It
is sometimes accompanied by diplopia, as other extraocular
muscles may be involved. Although an intravenous injection of
edrophonium is the classic way of making the diagnosis, this test
is inconvenient and has significant side effects. A much simpler
and very reliable test is the ice test, whereby the examiner
places an ice cube (usually in a disposable exam glove) over the
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 VI Eyelid Surgery

patient’s closed upper eyelid for 2 minutes. In myasthenia, the is a mitochondrial myopathy accompanied by a retinal pigmen-
ptosis (and diplopia if present) will reverse for about 30 seconds tary dystrophy and cardiac conduction abnormalities.
after removal of the ice (Fig. 35.8). The test may have some
false positives but rarely has false negatives. Alternatively, the
Oculopharyngeal Muscular Dystrophy
examiner can have the patient look repetitively from extreme
Oculopharyngeal muscular dystrophy is a progressive disorder
downgaze to upgaze for 1 minute. In myasthenia, the ptosis will
of bilateral, severe ptosis and difficulty swallowing that most
become much worse. If myasthenia is suspected, referral to a
often arises in patients with French-Canadian ancestry (Fig.
neurologist is appropriate. It is important to know that if myas-
35.11). The symptoms of dysphagia are usually quite marked. If
thenia gravis is isolated in the levator muscle, antibody testing
suspected, a referral to a neurologist is indicated.
will usually be negative.

Horner’s Syndrome Mechanical Ptosis

Acquired Horner’s syndrome is also very uncommon and is
characterized by 1 to 2 mm of ptosis accompanied by the very
distinctive sign of a miotic pupil (Fig. 35.9). The pupillary asym-
metry is worse in dim light than in regular light. There is also a
1- to 2-mm elevation of the lower eyelid (upside-down ptosis)
compared with the opposite side due to the lack of sympathetic
innervation to the adrenergic muscle of the lower eyelid.
Ipsilateral facial anhidrosis may also be noted. If suspected, the
patient should be referred to a neuro-ophthalmologist or neurol-
ogist for additional testing, since Horner’s syndrome has many
causes, many of which have significant consequences.
Chronic Progressive External Ophthalmoplegia
Very uncommon as a cause of ptosis is chronic progressive
external ophthalmoplegia (CPEO). This is a bilateral disorder of
the levator and all the extraocular muscles that begins in ado-
lescence and is characterized by severe ptosis and limitation of
ocular motility (Fig. 35.10). The earns-Sayre form of the disease
Mechanical ptosis is due to any lesion that weighs down the
upper eyelid. The cause of such cases is typically obvious on
exam (Fig. 35.12). The notable exception is the rare case of a
lost contact lens that becomes embedded in the eyelid tissues
of the superior fornix. Treatment of mechanical ptosis is aimed
at correction of the underlying pathology, which often must be
combined with levator surgery.
Acquired Third-Nerve Palsy
Acquired third-cranial-nerve palsy is easily diagnosed given that
the ptosis is usually complete and accompanied by severe exo-
tropia of the involved eye (Fig. 35.13). Repair requires a frontalis
sling procedure and extensive strabismus surgery. Results are
most often unsatisfying since diplopia is rarely alleviated.
Traumatic Ptosis
Traumatic ptosis is any that is due to injury to the levator muscle
or its innervation. Repair of traumatic ptosis is best delayed for
at least 6 months after the injury, since many cases will sponta-
neously improve (Fig. 35.14). Many instances of traumatic ptosis

Fig. 35.9 Patient with ptosis of the right upper eyelid in Horner’s
syndrome.

b
Fig. 35.8 (a) Patient with ptosis of left upper eyelid due to myasthenia
gravis. (b) Patient immediately after the ice test demonstrating
complete resolution of ptosis. Fig. 35.10 Patient with chronic progressive external ophthalmoplegia.

400

Fig. 35.11 Patient with oculopharyngeal muscular dystrophy.
b b
Fig. 35.13 (a) Patient with complete ptosis secondary to a
third-cranial-nerve palsy. (b) The severe exotropia due to medial rectus
paralysis in third-cranial-nerve palsy.
are simply thinning of the levator aponeurosis due to eyelid
edema from the injury and behave as acquired, aponeurotic
ptosis of aging.
Orbital Pathology
Acquired ptosis is rarely due to orbital pathology such as a neo-
plasm or inflammation. Look for subtle signs of proptosis, globe
dystopia, and strabismus. An inexplicable decrease in levator
function should arouse suspicion of orbital pathology.
Pseudoptosis
Pseudoptosis may be due to contralateral lid retraction and is
most frequently seen with thyroid eye disease. It is common for
such patients to present complaining of unilateral ptosis, since
the lower of the two lids is often perceived as the abnormal
one (Fig. 35.15). Look for other signs of thyroid eye disease such
as eyelid and conjunctival edema, injection over the medial and
lateral recti, and exophthalmos. Pseudoptosis is also seen with
unilateral enophthalmos caused by orbital disease, injury, or a
microphthalmic globe (Fig. 35.16). Unilateral hypotropia (down-
ward deviation of the globe) may also give the appearance of
ptosis. This is because the upper eyelid follows the movement of
the globe and thus simply appears to be lower than the opposite
side.
35 Ptosis Surgery in the Blepharoplasty Patient
Fig. 35.12 Patient with mechanical ptosis secondary to
neurofibromatosis.
Fig. 35.14 (a) Patient with traumatic ptosis 1 month after injury. (b)
The same patient 6 months later, with spontaneous resolution of
ptosis.
35.3.6 Congenital Ptosis
hile the correction of congenital ptosis is not covered in this
chapter, the surgeon should be familiar with its diagnosis, since
it is not uncommon to encounter such patients in adulthood.
Although the vast majority of patients with congenital ptosis
will be appropriately diagnosed and managed in childhood,
the occasional patient may be unrecognized and then present
as an adult seeking repair in conjunction with blepharoplasty.
Since the repair is distinctly different, surgeons must be able to
distinguish it from the more common adult, aponeurotic ptosis.
If a congenital ptosis is treated as an acquired ptosis, the result
will almost always be a significant undercorrection.
Approximately 75 of congenital ptosis cases are unilateral
and will, of course, have a history that dates from infancy. About
30 of patients with congenital ptosis have an accompanying
amblyopia, strabismus, and/or anisometropia. Pathological exam
of the levator reveals replacement of muscle with fibrofatty tissue.
In general, the greater the degree of congenital ptosis, the more
severe the dystrophic changes and the lower is the measured
levator function.
hen severe and with the appropriate history, the identifica-
tion is obvious. The problem arises in those cases that are mild and
were never diagnosed. Patients may talk in terms of always having
had bedroom eyes or inaccurately describe their condition as
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 VI Eyelid Surgery
b function. As a rule, the greater the ptosis, the lower the levator
Fig. 35.15 (a) Patient referred for “ptosis” of the right upper eyelid
who actually has unrecognized retraction of the left upper eyelid
secondary to thyroid eye disease. (b) By pulling down on the retracted
left upper eyelid, the “ptotic” lid is now in normal position.
lazy eye. If unilateral or asymmetric, it is easy to distinguish
congenital ptosis from acquired ptosis. Simply have the patient
look from primary position to extreme downgaze while holding
the head straight. ith congenital ptosis, the involved lid will not
descend as low as the opposite lid on downgaze, while in acquired
ptosis the involved lid descends to a lower level than the opposite
lid (Fig. 35.17, Fig. 35.18). This occurs because the levator muscle
in congenital ptosis is best conceptualized as a tight muscle, so
it will hang up a bit on downgaze. Contrarily, the lid in acquired
ptosis can be thought of as being stretched out and thus drop
to a lower level on downgaze. This finding can be relied upon to
differentiate most congenital from acquired cases.
a
b b
Fig. 35.17 (a) A patient with congenital ptosis of the left upper eyelid
in primary position. (b) The same patient in downgaze. Note that
the ptotic left upper eyelid appears higher than the opposite lid in
downgaze. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New ork, N : Thieme; 2018.)
402
Fig. 35.16 Patient referred for ptosis of the left upper eyelid who
actually has enophthalmos due to an old orbital floor fracture.
If congenital ptosis is bilateral and symmetric, the only clue
other than the history may be a decrease in the measured levator
function. Any levator function of 10mm or less is strongly suspi-
cious for a congenital etiology.
The surgical repair of congenital ptosis is usually referred to
as levator resection and often involves the combined, en bloc
shortening of both the levator and M ller’s muscle. Unlike the
surgery of aponeurotic ptosis, which involves muscle shortening
on the order of 2 to 10 mm, levator resection typically involves
shortening of the muscles by 12 to 20 mm. Cases with poor levator
function (4 mm or less) will require a frontalis sling procedure
utilizing autogenous fascia lata, banked tissue, or alloplastic mate-
rials. hen performing surgery for acquired, adult ptosis, lagoph-
thalmos should be strictly avoided, whereas the full correction of
congenital ptosis usually results in some degree of lagophthalmos
given the relatively large resections that are required. If performed
before the age of 10 years, the corneal exposure that results is well
a
Fig. 35.18 (a) A patient with acquired ptosis of the left upper eyelid
in primary position. (b) The same patient in downgaze. Note that the
ptotic left upper eyelid descends lower than the right upper eyelid in
downgaze. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New ork, N : Thieme; 2018.)

tolerated for life. If the age of initial surgery for congenital ptosis
progresses beyond this point, corneal decompensation becomes
increasingly problematic.
When doing repair of congenital ptosis in adulthood, whether
combined with blepharoplasty or in isolation, some degree of pur-
poseful undercorrection is necessary to avoid exposure problems.
35.4 Preoperative Planning,
Including Markings
The addition of ptosis repair changes nothing in terms of
planning and marking from pure upper eyelid blepharoplasty.
The reader is therefore referred to the chapter on upper eyelid
blepharoplasty for a thorough discussion.
35.5 Operative Technique
Ptosis repair can be performed by either an anterior, skin
approach or a posterior approach through the conjunctiva.
Posterior approaches include the tarsoconjunctivom llerectomy
(Fasanella-Servat procedure) or Putterman’s m llerectomy
procedure. The addition of a second incision, which would be
required for a posterior approach, seems unnecessary if the sur-
geon is already performing a blepharoplasty, so the techniques
discussed here will focus on the anterior approach.
35.5.1 Surgery in the Awake Patient
ote the level of the eyelid(s) with the patient lying down and
prior to local anesthetic injection and any intravenous sedation.
This observation is important in the awake patient because the
resting lid level may be affected by epinephrine, local anesthesia,
patient anxiety, and level of consciousness. The eyelid level will
be reassessed prior to suture placement in the levator.
Skin, orbicularis, and fat management are first performed as
detailed in the chapter on upper eyelid blepharoplasty. At this
point, the levator muscle must be disinserted centrally from the
tarsal plate. This is accomplished by lifting up the lower edge of
Fig. 35.19 To disinsert the levator, cut straight down onto the tarsus in
the center of the upper eyelid.
35 Ptosis Surgery in the Blepharoplasty Patient
skin and orbicularis and cutting with a sharp scissors straight
down onto the superior border of the tarsal plate in the center
of the incision (Fig. 35.19). Extend this incision medially and
laterally for a 1-cm opening (Fig. 35.20). The superior tarsal
arcade is usually visible in the underlying M ller’s muscle (Fig.
35.21). Care should be taken to avoid cutting these vessels, since
they can bleed substantially and the application of cautery can be
painful in the awake patient. The surgeon can usually determine
the degree of natural adhesion between the levator and M ller’s
muscle by pulling up on the levator and inspecting under it. In
some cases the bond is quite minimal, and the muscles separate
easily from each other for several millimeters superiorly. If so, no
further dissection is needed. If the muscles are firmly attached,
then dissect superiorly between them for 5 to 6 mm (Fig. 35.22).
At this point, ask the patient to open the eyes; reassess the level
of the eyelid(s), comparing to what was observed before anesthetic
injection. Occasionally, the lid level will now be much higher due
to the effect of epinephrine on M ller’s muscle. If, for example,
the eyelid has artificially elevated by 3 mm compared to the start
of surgery, it will fall by that same amount after the epinephrine
wears off. Thus the surgeon should set the eyelid 3 mm higher
than the ideal level at this point, knowing that the epinephrine
effect is temporary.
Determine the exact location for suture placement by pulling
with a forceps on the superior border of the tarsal plate and
observing the contour of the lid margin to determine whether it
looks natural. This is usually between the pupil and the lateral
limbus of the eye. At this point, take a partial thickness bite with a
double-armed 5–0 or 6–0 polyester or polyglactin suture parallel
to and in the superior border of the tarsal plate (Fig. 35.23). Evert
the lid and inspect below to be certain that the needle did not
penetrate the conjunctival surface (Fig. 35.24). If the bite is secure,
pull the needle the rest of the way through the tarsus. ow pass
both arms of the suture through the levator from the posterior to
anterior surface about 2 to 3 mm apart (Fig. 35.25). There is no
accurate formula to determine how high in the levator to place
these bites, given the variability of the levator aponeurosis length
and muscle strength, but a good starting point is as follows:
Fig. 35.20 The levator disinsertion is carried medially and laterally for
a total of 1 cm. The arrow marks the superior border of the tarsal plate.
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 VI Eyelid Surgery

• For 1 to 2 mm of ptosis correction, place the sutures 4 to 5 mm needed to obtain a proper contour of the eyelid margin. This is
above the cut edge. required when an unnatural peak is observed that is not corrected
• For 4 to 5 mm of ptosis correction, place the suture 8 to 10 mm by moving the initial suture either medially or laterally in the
above the cut edge. tarsal plate. The reason for this occurrence is unclear but may be
related to the tarsal plate’s being more slack than normal. In this
circumstance, it will be necessary to disinsert the levator aponeu-
In general, it is only infrequently necessary to go significantly
rosis more medially and laterally, exposing the entire horizontal
higher than the musculoaponeurotic junction of the levator. Place
expanse of the tarsal plate. ow place one suture more medially
a slip knot in the suture (Fig. 35.26). Move the overhead lights off
and the second suture more laterally in the tarsal plate, or place
the field and ask the patient to open the eyes. Observe the height
three sutures evenly spaced across the tarsus centrally, medially
and contour of the eyelid to determine whether it is acceptable.
and laterally. Pass the sutures through the levator, tie slip knots,
It is sometimes helpful to sit the patient up to observe the eyes
and again observe the lid contour and height.
better (Fig. 35.27). If the height is wrong, untie the slip knot and
Ask the patient to close the eyes so as to check for lagophthal-
replace the suture arms either higher or lower in the levator as
mos. Depending on the amount of levator shortening and the
required. If the contour is wrong, untie the slip knot, remove both
degree of orbicularis paralysis imparted by the local anesthetic
arms of the suture from both levator and tarsus, and replace the
infiltration, 2 to 3 mm of lagophthalmos may be noted. Gently
tarsal bite more medially or laterally as needed. Observe the lid
push the upper lid closed to determine whether this can be done
height and contour again. These adjustments should ensure the
easily and without resistance. If the eyelid closes easily, there
desired ptosis correction (Fig. 35.28).
should be no permanent lagophthalmos as a result. If, however,
Although one suture will suffice under most circumstances,
the eyelid feels very tight or will not close, then the suture should
there are some cases in which two or three sutures will be

Fig. 35.21 The superior arcade is visible on the anterior surface of

Müller’s muscle just above the superior border of the tarsal plate.
Fig. 35.22 With the cut edge of the levator aponeurosis elevated with
a forceps, dissect between it and Müller’s muscle for 5 to 6 mm.

Fig. 35.23 Taking a bite of the superior border of the tarsal plate with Fig. 35.24 Everting the upper eyelid to be certain that the suture does
a 5–0 polyester suture. not penetrate the posterior surface of the tarsal plate.

404

a b
Fig. 35.25 (a) The first arm of the suture is passed from the underside of the levator through the muscle. (b) The second arm emerges 2 to 3 mm
from the first.
Fig. 35.26 A slip knot is placed into the suture to assess the eyelid
position.
be replaced lower in the levator. A slight undercorrection of ptosis
is preferable to lagophthalmos.
If reinforcement of the eyelid crease is desired, use the levator
suture(s) to create the crease as described in the chapter on upper
eyelid blepharoplasty and then close the skin (Fig. 35.29).
35.5.2 Surgery in a Patient under
General Anesthesia
It may be necessary to perform ptosis repair under general
anesthesia due to the need for more extensive concomitant pro-
cedures or as a matter of physician and patient preference. Under
these circumstances, it is not possible to utilize the assessments
outlined in the preceding section. The following describes two
techniques that can be utilized under these circumstances.
The Anatomic Method
Clinton McCord has developed what he referred to as an ana-
tomic method to be used in cases of bilateral ptosis requiring
heavy sedation or general anesthesia. In this technique, the
35 Ptosis Surgery in the Blepharoplasty Patient
Fig. 35.27 When this patient sits up and opens her eyes, it is obvious
that the lid is too high. The double-armed suture will be repositioned
slightly lower in the levator.
Fig. 35.28 After the sutures are repositioned lower in the levator
muscle, the level of the eyelid is now correct.
preaponeurotic fat is retracted to expose the musculoaponeu-
rotic junction. The levator itself is dissected centrally off the
underlying M ller’s muscle up to the level of the junction. As
with an awake patient, a double-armed suture is placed centrally
in the tarsal plate and then into the levator at the musculoapo-
neurotic junction in both eyes. It is important to place the sutures
in both eyes at precisely the same point in the tarsal plate and
levator. Place the first throw of a knot in each with exactly the
same tension and observe the gapping between the upper and
lower eyelids. Tighten or loosen the sutures until the gapping is
the same on both eyes.
For the last step in this technique, perform what McCord called
the spring back test. Grasp the center of both upper eyelid
margins with forceps, pull the lids closed, and then release them.
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 VI Eyelid Surgery
Observe the speed with which the lids spring back to the gapped
position. If uneven, adjust the tension on one or both lids until
the spring back is symmetric. Complete the knot and, if desired,
re-form the crease.
This technique is best suited to patients with bilateral ptosis.
For those with unilateral ptosis who undergo bilateral upper
blepharoplasty, the surgeon should employ the method previ-
ously outlined for awake patients or perform a m llerectomy as
described next.
Müllerectomy
Although the levator muscle is the main upper eyelid retractor,
a significant minority of surgeons prefer to treat acquired ptosis
with a m llerectomy utilizing a specially designed clamp as
originally described by Allen Putterman. In addition to its ability
to be used on a sedated patient, the appeal of the procedure is its
simplicity if one is comfortable working from the conjunctival
side of the eyelid. It is best utilized for relatively small degrees
of ptosis, 1 to 2 mm. There is some question as to exactly how
the procedure works, since there is evidence that it may actually
incorporate a resection or plication of the levator aponeurosis.
There are numerous variations described in the literature that
have attempted to fine-tune the results, but a discussion of these
many modifications well exceeds the scope of this chapter.
Most m llerectomy procedures are based on the response of
the eyelid to topically applied 2.5 ophthalmic phenylephrine
drops to determine the relative integrity of M ller’s muscle.
Originally, a 10 solution was used, but this may have significant
cardiovascular effects from systemic absorption and should be
avoided. Phenylephrine is an alpha-adrenergic agonist and will
stimulate the sympathetically innervated M ller’s muscle. A pos-
itive response, lid elevation, predicts the suitability of the muscle
for this procedure.
Fig. 35.29 The crease is reformed using the same suture to take a
bite of the orbicularis at the lower edge of the incision and tying.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New ork, N : Thieme; 2018.)
406
For the phenylephrine test, first note the position of the upper
eyelids. Place a drop of topical ophthalmic anesthetic into the
eye(s). ext, place a drop of the 2.5 phenylephrine into the ptotic
eye(s) every 15 seconds, for a total of four drops. ait 5 minutes
and observe again. Elevation of 2 to 3 mm predicts that the pro-
cedure will be effective. If evaluating a unilateral ptosis, recheck
the lid level of the opposite eye after observing elevation of the
involved eye. It may now be ptotic due to the effect of Hering’s
law, an indication that the problem is indeed bilateral and needs
bilateral repair. For repair of 1 mm of ptosis, plan to resect a total
of 4 mm of tissue. For 2 mm of ptosis, resect 8 mm. For 3 mm of
ptosis, resect a total of 10 mm of tissue.
For surgical repair of ptosis in combination with blepharoplasty,
perform skin, orbicularis, and fat removal in the standard fashion.
ext, place a traction suture through the central margin of the
upper eyelid and evert over a Desmarres retractor. If desired, mark
the superior border of the tarsus as visualized through the con-
junctiva with a marking pen or cautery. ext, mark one-half of the
planned resection amount on the conjunctiva centrally, medially,
and laterally as measured from the superior border of the tarsal
plate (Fig. 35.30). ext, place a running 6–0 silk suture through
these three marks. Exert traction with the suture by pulling it away
from the eyelid, tenting up the conjunctiva and M ller’s muscle
and thus (in theory) separating them from the overlying levator
fibers (Fig. 35.31). While maintaining traction, place a Putterman
clamp at the superior border of the tarsus, thus sandwiching the
elevated tissue in the center and securing the conjunctiva and
M ller’s muscle to be resected (Fig. 35.32). ow remove the
Desmarres retractor to aid visualization. Inspect to be certain that
no portion of the tarsal plate has been incorporated into the clamp.
Return the lid to its normal position and pull the lid skin and/or
lid margin superiorly while pulling the sutures inferiorly (Fig.
35.33). If the lid margin contour is peaked, tarsus may have been
incorporated into the clamp. If so, remove and replace the clamp.
Likewise, if the skin feels very tight, the levator may have been
incorporated. If so, remove and replace the clamp. ext, place a
6–0 plain gut suture through the anterior surface of the eyelid just
above the superior border of the tarsal plate in the lateral aspect of
the blepharoplasty incision to emerge on the conjunctival surface.
eave this suture back and forth under the clamp to its medial end
and then return in a similar fashion back to the lateral end. Pass
the suture back through the conjunctiva to the anterior surface of
the blepharoplasty incision and tie it to the other end in the open
wound. ext, use a blade or scissors to cut the conjunctiva and
M ller’s muscle tissue between the clamp and the running suture,
being certain not to cut the suture (Fig. 35.34). Inspect the edges
of the conjunctiva. If separated by more than 2 mm, consider an
interrupted, buried suture of 6–0 plain gut to approximate the
edges better. Close the skin to complete the procedure.
35.6 Ancillary Procedures
ith the exception of overcorrection and undercorrection of
ptosis, the ancillary procedures for ptosis repair performed in
conjunction with upper eyelid blepharoplasty are identical to
those outlined in the chapter on upper eyelid blepharoplasty, and
the reader is referred to that chapter. hen the postoperative
lid level differs from the desired level, a secondary procedure
 35 Ptosis Surgery in the Blepharoplasty Patient

Fig. 35.31 A 6–0 silk traction suture is placed through the three marks
Fig. 35.30 The superior border of the tarsal plate is denoted by the
that denote one-half of the proposed tissue resection.
downward arrows. One-half of the proposed resection of tissue is
marked centrally, medially, and laterally (upward arrows).

Fig. 35.33 After removal of the Desmarres retractor, the sutures are
pulled inferiorly while the lid margin is pulled superiorly to ascertain
Fig. 35.32 The Putterman clamp is placed on the tissue to be
whether any tarsus or levator has been incorporated into the tissue
resected.
clamped tissue.

may be warranted. In general, asymmetry equal to or greater

than 1 mm is easily noticed by patients. Likewise, a contour
difference between the two lid margins (which is essentially a
focal undercorrection or overcorrection) is also quite apparent to
most patients. Bilateral undercorrection or overcorrection that is
symmetrical is usually much less noticeable and better tolerated
if relatively small.

35.6.1 Overcorrection of Ptosis

Overcorrection is often easier to handle than undercorrection.
onsurgical treatment can begin as soon as 1 week after surgery
and can still be effective if begun in the month following the
procedure. Instruct the patient to massage the closed eyelid with
a finger over the underlying globe for 5 minutes, four times daily.
This can loosen the sutures attaching the levator aponeurosis to
the tarsus (or the sutures securing M ller’s muscle if a m llerec-
tomy was performed) and stretch the fibers of both the aponeuro- Fig. 35.34 Excision of the conjunctiva and Müller’s muscle between
sis and M ller’s muscle. Another technique is to have the patient the running suture and the clamp, performed with a scissors.
grasp the upper eyelid lashes and look repetitively upward. If

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 VI Eyelid Surgery

effective, improvement should be seen within a week and contin-
ued for up to 1 month until the desired lid level is obtained.
If conservative treatment is not effective, a surgical adjustment
is necessary and can usually be performed in the office. An ideal
time to do this is at least 1 month after the surgery, when edema
has subsided (Fig. 35.35a). Inject a small amount of local anesthetic
into the old incision and open it with a blade or scissors. Typically
it is necessary to open no more than 10 mm of the incision line
in the center of the lid (or the area of the focal overcorrection, as
the case may be). hile retracting the lower edge of the incision,
undermine beneath the orbicularis at the upper edge for a few
millimeters superiorly to identify the levator aponeurosis (Fig.
35.35b). ith scissors, disinsert the levator from the superior
border of the tarsal plate by cutting the suture(s) if still present,
and observe the lid level to see whether the desired lowering was
obtained. If not, dissect between the levator and on top of M ller’s
muscle to further divide adhesions that have formed since the
original surgery (Fig. 35.35c). If needed, extend the separation of
the levator medially and laterally until the lid is at the appropriate
level and the contour is satisfactory. It is not necessary to resuture
the levator, since the adhesions of the surrounding tissue will
be sufficient to hold the eyelid in place. Suture the skin closed
(Fig. 35.35d). This technique is applicable to both patients who
have had a prior levator shortening and those who have had a
m llerectomy.
35.6.2 Undercorrection of Ptosis
It is best to wait for 1 month before attempting to repair an under-
correction of ptosis. Eyelid edema and ecchymosis always cause
some degree of mechanical ptosis in the postoperative period, so
it can be difficult to assess the accuracy of an adjustment if per-
formed too early. The only way to remedy an undercorrection is
with additional surgery, which most often is easily accomplished
in the office. As in the technique just described for overcorrec-
tion, anesthetize and open approximately 10 mm of the incision
in the applicable area of the eyelid and disinsert the levator from
the tarsal plate. Place a new double-armed 5–0 or 6–0 polyester
or polyglactin suture in the superior border of the tarsus and then
into the levator more superiorly than the original suture. Place
a slip knot and observe the lid position to be certain that it is
satisfactory. If so, complete the knot and close the skin. For those
patients who have had a previous m llerectomy resulting in
undercorrection, a repeat m llerectomy is usually unsuccessful;
therefore, they too will require a shortening of the levator.

c d
Fig. 35.35 (a) A patient 2 months after bilateral upper eyelid blepharoplasty and ptosis repair. The patient desires that the left upper lid be lowered.
(b) The central incision is opened, exposing the levator on the anterior surface of the tarsal plate (arrow). (c) The levator was disinserted centrally,
exposing the superior border of the tarsal plate (arrow). (d) The patient immediately afterward, showing improved symmetry of the eyelid levels.

408

a
b
Fig. 35.36 (a) A patient before combined blepharoplasty and ptosis
repair. (b) The patient 2 months after combined blepharoplasty and
ptosis repair.
35.7 Postoperative Care
Postoperative care is identical to those steps described in the
chapter on upper eyelid blepharoplasty. If the patient has had a
m llerectomy procedure, it is helpful to apply a small amount of
the ophthalmic antibiotic ointment into the eye to lubricate the
posterior surface of the eyelid at the incision line. This is done
as needed for comfort. The patient should be cautioned that this
will blur the vision significantly for the 24-hour period after the
application.
35.8 Outcomes
The addition of ptosis repair to upper eyelid blepharoplasty will
certainly increase the frequency of postoperative adjustments
compared with that of blepharoplasty alone. The surgeon should
anticipate and plan for this. If the patient is appropriately coun-
seled during the preoperative evaluation, this should create little
difficulty for the physician and patient.
35.9 Results
Two patients are shown before and 2 months after combined
blepharoplasty and ptosis repair in Fig. 35.36 and Fig. 35.37.
35.10 Concluding Thoughts
The addition of ptosis repair to upper lid blepharoplasty is often
necessary and well within the area of expertise of surgeons
comfortable with upper eyelid surgery. The guidelines are
straightforward and if followed will lead to successful outcomes
in the vast majority of cases.
35 Ptosis Surgery in the Blepharoplasty Patient
a
b
Fig. 35.37 (a) A patient before combined blepharoplasty and ptosis
repair. (b) The patient 2 months after combined blepharoplasty and
ptosis repair.
Clinical Caveats
• Since ptosis repair involves shortening of the eyelid retractor
muscles, lagophthalmos can occur with greater frequency
than with upper eyelid blepharoplasty alone.
• Wait until eyelid edema has subsided to evaluate the postop-
erative eyelid position critically.
• Even a small amount of eyelid level asymmetry (1 mm) is
easily perceived by the patient and others.
• Although the vast majority of acquired ptosis is due to
age-related changes in the levator, be suspicious for signs and
symptoms that indicate an underlying cause representative
of systemic disorders or orbital pathology.
• Congenital ptosis is more difficult to correct than acquired,
age-related ptosis and will necessitate larger amounts of
muscle tightening, with an increased risk of lagophthalmos.
• Ptosis with less than 5 mm of levator function cannot be
adequately corrected with the techniques presented here
and will require a frontalis sling procedure.
Suggested Reading
1 Anderson RL. Age of aponeurotic awareness. Ophthal Plast Reconstr Surg
1985;1(1):77–79
2 Dresner SC. Further modifications of the M ller’s muscle-conjunctival resection
procedure for blepharoptosis. Ophthal Plast Reconstr Surg 1991;7(2):114–122
3 Perry D, adakia A, Foster A. A new algorithm for ptosis repair using conjunc-
tival M llerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg
2002;18(6):426–429
4 Putterman AM, Urist M . M ller muscle–conjunctiva resection. Technique for
treatment of blepharoptosis. Arch Ophthalmol 1975;93(8):619–623
409
 VI Eyelid Surgery

36 Lower Eyelid Blepharoplasty

Mark A. Codner and Juan Diego Mejia

to surgical improvement. Typical complaints include a tired look,

Abstract
puffy lower eyelids, malar bags, wrinkled skin, an accentuated
Lower eyelid blepharoplasty is one of the most complex and lid–cheek junction, and a deep nasojugal groove. Patients must
challenging procedures in aesthetic surgery. Achieving optimal understand the importance of treating the lower lid and midface
results requires careful preoperative planning and meticulous as an aesthetic unit. In most cases, treatment of one area without
intraoperative technique. In the preoperative evaluation, besides the other will produce unsatisfactory results (Fig. 36.1).
evaluating the eyelids, the midface must also be assessed. Both
of these areas have a profound effect on periorbital aging and
should be managed as one aesthetic unit. Emphasis on routine
lower lid support (lateral canthal anchoring), transpalpebral
elevation of the midface, and fat preservation and repositioning
are key to achieving good results and avoiding complications.

Keywords
lower blepharoplasty, canthal anchoring, canthopexy, canthop-
lasty, midface lift

36.1 Introduction
Despite the frequency with which lower blepharoplasty is
performed, the procedure remains a complex, challenging, and
technically demanding one that should not be considered rou-
tine. Minimizing complications and maximizing postoperative
results depend on careful preoperative planning and meticulous
intraoperative technique. In addition to evaluating the eyelids, Fig. 36.1 Aging changes.
the surgeon must carefully assess the periorbital anatomy,
including the midface, because midfacial aging can have a pro-
found effect on the appearance of the lower lid. The lower lid and
midface compose an aesthetic unit that is best treated together,
and the standard lower lid approach provides an easy entry for 36.3 Preoperative Assessment
midface rejuvenation. However, it is important to individualize
the operative plan to address individual patient needs. 36.3.1 Medical History and Evaluation
It is essential to identify risk factors and concomitant medical
The first step in a thorough evaluation includes taking a history
conditions that could contribute to postoperative complications.
to identify specific conditions, including inflammatory eyelid
Excellent blepharoplasty results can be achieved through the
disorders, Graves’ disease, benign essential blepharospasm, and
combination of careful preoperative assessment and meticulous
dry-eye syndrome. All of these increase the risk of complications
surgical technique using an anatomic approach to the aesthetic
after blepharoplasty and should be screened before surgery.
correction of aging changes of the eyelids and periorbital region.
Traditional blepharoplasty techniques placed little emphasis on
lower lid support or the correction of acquired anatomic changes Medical Conditions That Might Increase the
of the surrounding periorbital region. ewer techniques empha- Risk of Complications
size lower lid support, such as routine canthopexy or canthop-
lasty, as well as transpalpebral elevation of the midface and fat
• Blepharochalasis
preservation and repositioning. In our patients, routine canthal
• Rosacea
anchoring has been the key to achieving good, predictable results
• Pemphigus
and avoiding complications.
• Graves’ disease
• Benign essential blepharospasm
• Dry-eye syndrome
36.2 Indications • Sarcoidosis
• Menopause
Candidates for lower blepharoplasty are individuals with valid
complaints in conjunction with physical findings that are amenable

410

36.3.2 Physical Examination
To produce a result that will be aesthetically pleasing to the
patient, the surgeon must take time to understand the patient’s
complaints and concerns, and these should be confirmed by the
physical examination. For example, patients complaining of
lower eyelid bags may actually have midfacial aging or malar
bags, which would not be improved with standard lower bleph-
aroplasty techniques. Therefore the surgeon must be diligent
in evaluating both the patient’s complaints and the underlying
anatomic findings to improve the aesthetic appearance of the
periorbital region and provide the best possible outcome. The
physical examination should proceed sequentially to ensure
complete assessment of the periorbital anatomy. A Snellen
eye chart is used to document preoperative visual acuity in all
patients before blepharoplasty.
Eye Protection Mechanisms
Patients should be evaluated for the presence of Bell’s phenom-
enon, since the combination of dry eyes with a poor Bell’s phe-
nomenon may lead to significant postoperative corneal dryness
(Fig. 36.2).
These patients should be further evaluated with Schirmer’s
test. The conjunctiva is anesthetized in the inferior lateral fornix
with tetracaine eye drops. Then the excess tear film is blotted
a b
Fig. 36.2 (a) Test for Bell’s phenomenon and (b) Schirmer’s test.
Fig. 36.3 Evaluation of the position of the globe relative to the bony
orbit.
er ye id e r y
with a cotton-tipped applicator, and a Schirmer’s strip is placed
in the lateral fornix while the patient maintains a forward gaze.
Decreased tear production is present when less than 10 mm of the
Schirmer’s strip is wet after 5 minutes.
Eye Prominence
The globe should be examined to evaluate its position relative
to the bony orbit. Patients with prominent eyes have a negative
vector, which is visible on the lateral view of the orbit when the
anterior aspect of the globe is anterior to the underlying soft
tissue of the infraorbital rim. Patients with deep-set eyes have
a positive vector, where the globe is posterior to the infraorbital
rim and overlying soft tissues (Fig. 36.3).
A more detailed analysis can be performed with a Hertel
exophthalmometer, which measures the position of the globe
relative to the lateral orbital rim. ormal globe prominence is
in the range of 16 to 18 mm; patients with enophthalmos have
measurements less than 16 mm, and those with exophthalmos
have measurements greater than 18 mm. Patients with deep-set
eyes or prominent eyes are at increased risk for complications, and
the degree of prominence influences the level at which the lateral
canthus will be anchored during lateral canthoplasty (Fig. 36.4).
In patients with a standard eye position (16–18 mm), the lateral
canthal fixation should be in line with the inferior edge of the pupil
to produce a normal eye fissure. Patients with prominent eyes (19
Fig. 36.4 Analysis with a Hertel exophthalmometer.
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 VI Eyelid Surgery
mm or more) exhibit a tendency for downward migration of the
eyelid margin with lateral tightening, which will produce postop-
erative scleral show. Canthal anchoring in a standard position will
clothesline the lid margin underneath the eye. In patients with
mild prominence, supraplacement of the lateral canthal tendon is
needed at the level of the midpupil. However, canthal anchoring
in a higher position will impair upper lid closure. Therefore, with
increasingly prominent eyes (as in patients with Graves’ disease),
canthal anchoring should not surpass the midpupillary line; other
techniques are needed, such as recession of the inferior retractors,
insertion of primary spacers, or crisscross anchoring of the upper
and lower lids. Patients with deep-set eyes (15 mm or less) need
lower and deeper lateral canthal anchoring, because a standard
canthal position can cause upward clotheslining of the lower
lid, narrowing the eye fissure and reducing the size of the lateral
scleral triangle.
Lower Lid Evaluation
The lower eyelid should be evaluated for lateral canthal descent,
lower lid laxity, and the presence of scleral show as well as
excess skin and muscle, orbital fat, and malar bags. The presence
of scleral show should be a red flag to the surgeon; this is often
caused by a combination of a prominent eye, lower lid laxity,
and poor infraorbital support. Adjunctive procedures should be
considered, such as lateral canthal support, a possible midface
lift, or orbital rim augmentation.
Fig. 36.5 The eyelid should be evaluated for both shape and
function. Drawing an imaginary line from the medial to the lat-
eral canthus indicates the canthal tilt. The lateral canthal position
is normally 2 mm superior to the medial canthal position.
a b
Fig. 36.7 (a) Testing for lid laxity using the lid snapback test and (b) lid distraction.
412
The eyelid should be evaluated for both shape and function. The
lateral canthal position is normally 2 mm superior to the medial
canthal position; an imaginary line should be drawn from the
medial to the lateral canthus to indicate the canthal tilt (Fig. 36.5).
A positive lateral canthal tilt is present when the lateral canthus
is superior to the medial canthus; a negative lateral canthal tilt
is present when the lateral canthus is inferior to the horizontal
position of the medial canthus. A negative canthal tilt may indi-
cate descent of the lateral canthus from disinsertion, laxity, or the
presence of a prominent eye. These last patients are at increased
risk for lid malposition and require lateral canthal support during
blepharoplasty procedures (Fig. 36.6).
The lid snapback test may indicate the presence of lower lid
laxity; however, this is a fairly subjective test, and conclusions
drawn from it may be inaccurate (Fig. 36.7a). More precise eval-
uation can be obtained by lid distraction. Anterior lid distraction
should be less than 3 mm from the globe. Anything greater indi-
cates lid laxity and postoperative risk for scleral show, ectropion,
or corneal exposure. Appropriate lateral canthal anchoring can
help reduce the risk in these cases (Fig. 36.7b).
Herniated Fat Pads
Progressive weakening of the overlying septum as individuals age
has been an accepted theory for the protrusion of the fat pads.
Descent of the midface with aging also contributes to the unmask-
ing of the lower eyelid bags as the interface between the lid and
Fig. 36.6 Positive and negative lateral canthal tilt. A negative canthal tilt
may indicate descent of the lateral canthus from disinsertion, laxity, or the
presence of a prominent eye.
 er ye id e r y

cheek becomes more apparent, leading to a double-bubble its formation. Release of the orbitomalar ligament in the preperi-
appearance. The lower lid has medial, central, and lateral fat osteal plane and fat transpositioning or grafting are effective for
prominences. The volume of these fat pads varies among patients. adding volume and improving this concavity (Fig. 36.9).
The surgeon should mark and document the most prominent
fat pads preoperatively, because this can be difficult to do when
Skin Pigmentation
the patient is on the operating table. The lateral fat pad is the
Sometimes dark circles around the eyes are shadows produced
most commonly overlooked pad in lower lid blepharoplasty, yet
by the convexity of the herniated fat, and these can be improved
it generally contains the greatest volume and contributes most
with blepharoplasty. However, many patients have pigmentation
significantly to the lower lid bags. The options for managing the
of the skin that will remain even after surgery, and it is important
fat of the lower lid depend mostly on the amount of fat and on
that the patient be told this. Use of hydroquinone may be effec-
the characteristics of the lid–cheek junction. ith this in mind,
tive for lightening dark circles caused by hyperpigmentation.
the fat pads can be preserved, removed, redistributed, or even
augmented with autologous fat grafting (Fig. 36.8).
Midface
Tear Trough Deformity Aging changes in the midface are characterized by descent of
the tissues, exposing the inferior orbital rim and allowing the
The tear trough is a midfacial hollow that begins at the inner
postseptal fat to become more visible. Recognition of these
canthus and travels obliquely toward the lid–cheek junction. The
changes is essential as the surgeon chooses the proper proce-
orbitomalar ligament, along with the origin of the levator labii
dure. Transconjunctival fat removal alone without correction of
superioris and levator labii alaeque nasi muscles, contributes to

Fig. 36.8 Usual areas of fat herniation and protuberance.

Fig. 36.9 The tear trough is a midfacial hollow that begins at the inner canthus and travels obliquely toward the lid–cheek junction. The orbitomalar
ligament, along with the origin of the levator labii superioris and levator labii alaeque nasi muscles, contributes to its formation. Release of the
orbitomalar ligament in the preperiosteal plane and fat transpositioning or grafting are effective for adding volume and improving this concavity.

413
 VI Eyelid Surgery
vertical midface descent in these patients will lead to a skele-
tonized appearance of the lid–cheek junction. Patients with
mild midface descent can benefit from extended blepharoplasty
with release of the orbitomalar ligament with fat repositioning
to produce a smoother lid–cheek junction. Those with more
advanced aging changes and midface descent require a lower lid
blepharoplasty combined with a midface lift.
Malar Eminence
Fat should be removed conservatively in patients with prominent
cheekbones, because excessive resection will create a sunken
lower lid appearance, accentuate the malar eminence, and dis-
turb the balance of the lid–cheek junction. Patients with a lack
of projection of the malar eminence are at greater risk for lower
lid malposition after blepharoplasty. These patients can present
with preexisting scleral show and prominent eyes. Canthal
anchoring and lower lid release procedures are especially
important in these cases to decrease the risk of complications.
36.3.3 Patient Education
All of the potential risks of surgery should be discussed with
patients before blepharoplasty surgery. Common complications
may include swelling, ecchymosis, chemosis, and lagophthal-
mos. Other possible complications include infection, hematoma,
hypertrophic scarring, dry eye, epiphora, asymmetry, lid
malposition, ectropion, entropion, and the rare risk of vision
loss. Informed consent should include a detailed preoperative
discussion of these risks with the patient.
36.4 Preoperative Planning
36.4.1 i i n eri r i Aging
A classification system of periorbital aging may aid in selecting
the appropriate surgical procedure for correction. The classifi-
cation described in Table 36.1 is based on the anatomic findings
associated with aging of the eyelids as well as midface descent,
including the presence of tear trough deformity, nasolabial folds,
and bags under the lower lids. This classification system focuses
on the relationship between the lower lid and the midface using
an anatomic approach to develop a specific surgical plan.
Table 36.1 Classification of periorbital aging
Type Age-related changes Appropriate procedure
I Excess fat, no skin excess Transconjunctival
blepharoplasty
II Excess skin, muscle, and fat Transcutaneous blepharoplasty
Changes above intraorbital rim Preperiosteal cheek lift
Minimal lower lid laxity Lateral canthopexy
III Excess skin, muscle, and fat Transcutaneous blepharoplasty
Descent of malar fat pad Subperiosteal cheek lift
IV Malar bags Subperiosteal cheek lift
Significant lower lid laxity Lateral canthoplasty
414
Type I patients (Fig. 36.10) demonstrate the earliest changes of
periorbital aging, with findings confined to the lower eyelid. The
presence of dermatochalasis includes acquired age-related folds of
excess skin and muscle, along with apparent fat excess. However,
the volume of orbital fat remains relatively unchanged from youth
to middle age and is resistant to volume loss even in cachectic
patients. In contrast, facial fat, including the malar fat pad and
jowl, undergoes redistribution with age; that is, deflation and
descent. The perception of increased orbital fat volume is often
affected by the presence of edema. In type I patients, the focus is
to improve the appearance of the eyelids by means of upper and
lower blepharoplasty, including fat resection by a transconjunc-
tival or transcutaneous approach and possible skin resection or
resurfacing. Alternative procedures are also appropriate, including
resetting or tightening the orbital septum and repositioning and
retaining intraorbital fat.
Type II patients (Fig. 36.11) have a combination of lower lid
aging and early evidence of midfacial descent. As the malar fat pad
descends, the lid–cheek junction is more evident, with the infe-
rior orbital rim becoming visible through attenuated soft tissue.
Midfacial descent is often associated with loss of upper malar
fullness, which contributes significantly to the loss of lower lid
support. These patients require augmentation of the infraorbital
rim, either through arcus marginalis release and fat repositioning
or through elevation of the sub–orbicularis oculi fat (SOOF) to
camouflage the infraorbital rim. Modified superficial midface lift
techniques with dissection in the supraperiosteal plane may be
considered.
Type III patients (Fig. 36.12) display more advanced midfa-
cial aging, with further descent of the lid–cheek junction and
deepening of the nasolabial folds. Descent of the malar fat pad
contributes to the formation of the nasolabial fold and requires
elevation, either with a subperiosteal midface lift or combined
face lift procedures that elevate the malar fat pad.
Type IV patients (Fig. 36.13) have extensive midfacial aging
changes, including malar bags, and often demonstrate lower lid
malposition with lid laxity. Subperiosteal dissection is required,
with release of the orbitomalar ligament, orbital retaining liga-
ments, and the subzygomatic space to elevate the midface, along
with lateral canthal support to correct lower lid laxity.
36.4.2 Patient Preparation
Preoperatively the patient is instructed to stop taking all medi-
cations that increase the risk of bruising and swelling, including
aspirin, ibuprofen, and vitamin E. Homeopathic herbs such
as Arnica montana and bromelain may reduce postoperative
edema and ecchymosis and have been used routinely for sur-
gery patients for more than 15 years. Patients are instructed to
carefully remove all makeup, particularly mascara residue, and
to wash the face the morning of surgery. Lower blepharoplasty
can be performed with a general anesthetic or with intravenous
conscious sedation.
The patient should be placed in a reverse Trendelenburg posi-
tion to decrease venous pressure. Surgical preparation includes
application of a dilute povidone–iodine (Betadine) solution to the
eyelids and face, taking care to avoid exposure of the conjunctiva;
the eyes are irrigated with balanced saline solution before corneal
protectors are placed.

Fig. 36.10 Periorbital aging: type I.
Fig. 36.12 Periorbital aging: type III.
36.5 Operative Technique
36.5.1 Anesthesia
Adequate intravenous or general anesthesia is obtained; preop-
erative antibiotic administration is recommended. Local anes-
thetic, consisting of lidocaine 1 with epinephrine 1:100,000, is
injected with a 27-gauge needle into the lateral canthus, lower
eyelid, and inferior orbital rim, avoiding the marginal arcades
and the deep orbital structures to reduce the risk of eyelid or
retrobulbar hematoma.
36.5.2 Markings
The lower lid incision is initially marked with a single point at
the level of the lateral canthus. Markings should extend approxi-
mately 6 to 10 mm inferolaterally in a prominent crow’s-feet skin
line. Approximately 10 mm of skin should be preserved between
the lateral extension of the upper and lower blepharoplasty
er ye id e r y
Fig. 36.11 Periorbital aging: type II.
Fig. 36.13 Periorbital aging: type IV.
incisions. Postoperative webbing or distortion can occur if these
incisions are placed too close together. The remainder of the
marking parallels the lid margin approximately 1 mm below the
eyelashes (Fig. 36.14).
36.5.3 Lower Lid Blepharoplasty
The lower lid skin is incised with a scalpel lateral to the canthus,
exposing the underlying orbicularis oculi muscle, which is
then divided with electrocautery into the submuscular space
(Fig. 36.15).
With the lower lid on stretch, scissors are used to dissect a sub-
cutaneous tunnel over the pretarsal muscle just below the lashes,
and with the same instrument the skin is incised, stopping 4 mm
inferior to the punctum (Fig. 36.16).
Through the lateral incision, the scissors are used once again
to dissect a submuscular tunnel, and a second parallel incision
is made through the orbicularis, preserving a 5-mm strip of
pretarsal orbicularis muscle (Fig. 36.17). Electromyographic
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 VI Eyelid Surgery
analysis has revealed normal function to the pretarsal muscle
strip with minimal risk of denervation. The skin–muscle flap is
then dissected anterior to the septum with a Bovie cutting needle
to the level of the infraorbital rim. Dissection continues past the
infraorbital rim just superficial to the periosteum, releasing the
orbitomalar ligament to improve the appearance of the lid–cheek
junction.
Submuscular dissection continues over the septum down to
the orbital rim. The orbitomalar ligament is divided along the
entire infraorbital rim. A tear trough deformity requires release
of the medial origins of the orbicularis oculi, levator labii supe-
rioris, and levator labii superioris alaeque nasi muscles from the
Fig. 36.14 The lower lid incision is initially marked with a single point
at the level of the lateral canthus.
a b
Fig. 36.15 (a) The lower lid skin is incised with a scalpel lateral to the
canthus, exposing the underlying orbicularis oculi muscle, (b) which is
then divided with electrocautery into the submuscular space.
a b
Fig. 36.17 (a) Through the lateral incision, the scissors are used
once again to dissect a submuscular tunnel, and (b) a second parallel
incision is made through the orbicularis, preserving a 5-mm strip of
pretarsal orbicularis muscle.
416
inferior orbital rim. Once the orbitomalar ligament is released, the
sub–orbicularis oculi fat (SOOF) becomes visible, and dissection
superficial to the periosteum is continued approximately 10
mm below the orbital rim, preserving the zygomaticofacial and
zygomaticotemporal nerves (Fig. 36.18). Release of the orbitoma-
lar ligament allows elevation of the SOOF with the skin–muscle
flap. Elevation of the SOOF with orbicularis muscle redraping
camouflages the inferior orbital rim, giving the lid–cheek junction
a smoother appearance.
Fat can be removed conservatively with the Bovie from all three
lower lid compartments, and the orbital septum is resected along
with excess fat (Fig. 36.19). Removal of the septum may reduce
the risk of subsequent septal scar formation. If fat resection is
planned, the arcuate expansion of Lockwood’s ligament between
the central and lateral fat pad should be preserved for additional
support to prevent further herniation of periorbital fat. hen fat
transposition is the objective, Lockwood’s ligament should be
divided to allow adequate release and redraping of the fat pads.
Care should be taken to avoid injury to the inferior oblique
muscle between the nasal and central fat pads (Fig. 36.20).
The inferior oblique muscle is reportedly the most common
extraocular muscle injured during blepharoplasty, usually from
indiscriminate cauterization. The lateral fat pocket should be
a b
Fig. 36.16 (a) With the lower lid on stretch, scissors are used to dissect
a subcutaneous tunnel over the pretarsal muscle just below the lashes,
and (b) with the same instrument the skin is incised, stopping 4 mm
inferior to the punctum.
a b
Fig. 36.18 (a) Submuscular dissection continues over the septum
down to the orbital rim. (b) Once the orbitomalar ligament is released,
the sub–orbicularis oculi fat (SOOF) becomes visible, and dissection
superficial to the periosteum is continued approximately 10 mm below
the orbital rim, preserving the zygomaticofacial and zygomaticotem-
poral nerves.

a b
Fig. 36.19 (a) Conservative removal of fat with the Bovie from lower
lid compartment; (b) resection of orbital septum along with excess fat.
reevaluated after lateral canthopexy, because lateral tension will
cause additional herniation.
Alternative procedures might also be considered: arcus mar-
ginalis release, septal reset, or septal tightening. Septal reset, as
described by Hamra, involves suturing the septum orbitale over
the inferior orbital rim to produce a youthful convex contour to
the lower eyelid–cheek complex. Septal tightening, as described
by de la Plaza and Mendelson, encompasses suture tightening
of the septum after partial resection or septal plication with-
out resection. These procedures are designed to improve the
pseudoherniation of the orbital fat through the septum. As in
an upper blepharoplasty, the lower lid should be irrigated with
normal saline solution after resection of the orbital fat pads.
Lateral Canthal Support
The degree of lower lid laxity should be evaluated intraopera-
tively by placing anterior traction on the lower eyelid away from
the globe and measuring the amount of lid distraction with cal-
ipers (Fig. 36.21). Lid distraction of 1 to 2 mm indicates minimal
lid laxity; 3 to 6 mm indicates moderate laxity; more than 6 mm
indicates significant lid laxity.
Routine lateral canthal anchoring is performed as part of all of
our lower blepharoplasties. A lateral canthopexy is indicated in
patients with minimal or moderate lid laxity. hen lid distrac-
tion is more than 6 mm from the globe or when persistent intra-
operative lid laxity is seen after a routine canthopexy, horizontal
Fig. 36.21 The degree of lower lid laxity should be evaluated intraop-
eratively by placing anterior traction on the lower eyelid away from the
globe and measuring the amount of lid distraction with calipers.
er ye id e r y
Fig. 36.20 Care should be taken to avoid injury to the inferior oblique
muscle between the nasal and central fat pads.
shortening of the lid is performed with a lateral canthotomy and
canthoplasty. Regardless of the type of anchoring used (cantho-
pexy or canthoplasty), the internal vector of fixation is essential.
The canthus should be anchored inside the orbital rim to enable
the lid to conform to the globe (Fig. 36.22).
The vertical position at which the lateral canthal fixation
suture will be placed depends on the degree of eye prominence,
the amount of lower lid laxity, and the preoperative shape of the
lower eyelid. The preoperative shape of the lower eyelid must
be carefully maintained, avoiding overcorrection or alteration of
the preoperative canthal position. In patients who have normal
eye prominence, the position of the lateral canthal suture is most
commonly at the inferior edge of the pupil. However, patients with
prominent eyes require supraplacement of the canthal support
suture at the level of the midpupillary line, with overcorrection
and minimal tightening to avoid downward clotheslining of the
lower lid below the inferior limbus, which can cause scleral show.
The release of the inferior retinaculum and lower lid retractors
facilitates the supraplacement of the canthus. The downward
force of the prominent globe on the lower lid will cause descent
of the lid margin after lateral canthal anchoring. However, this
force does not exist in patients who have deep-set eyes. Patients
with deep-set eyes require more inferior and posterior placement
of the canthal suture to avoid upward clotheslining, with care to
avoid overcorrection (Fig. 36.23).
Fig. 36.22 Routine lateral canthal anchoring is performed as part of all
of our lower blepharoplasties. The internal vector of fixation is essential
to enable the lid to conform to the globe.
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 VI Eyelid Surgery
The objective of lateral canthopexy is to suture the tarsal plate
and lateral retinaculum to the periosteum of the lateral orbital
rim, thereby tightening the lower lid tarsoligamentous sling.
Through the blepharoplasty incision, a horizontal mattress suture
of 4–0 polyester fiber suture (Mersilene, ohnson ohnson, ew
Brunswick, ) is used to incorporate the tarsal plate and lateral
retinaculum. To prevent dehiscence of the Mersilene through the
tarsus, an interlocking 6–0 polyglactin (Vicryl, ohnson ohnson,
ew Brunswick, ) suture is placed around the 4–0 Mersilene.
The Mersilene suture is then placed inside the lateral orbital rim
periosteum from deep to superficial, which allows the lateral
canthus and lower lid to be tightened posteriorly and superiorly
to maintain the position of the lower lid margin against the globe
(Fig. 36.24).
A single tie is placed on the lateral canthal suture to set the cor-
rect tension as the lower lid assumes its desired position. Before
completing the knot, lower lid laxity is once again evaluated with
a pair of fine pickups. At this point, the lower lid should have a
normal distraction of 1 to 2 mm, and it should allow some upper
and lower displacement without restriction. If this is the case, the
canthopexy knot is completed. If the lid is too tight and does not
Fig. 36.23 Vertical position of lateral canthal fixation suture depends
in part on the degree of eye prominence.
a b
Fig. 36.25 (a) Placement of a single tie on the lateral canthal suture
to set the correct tension as the lower lid assumes its desired position.
(b) Before completing the knot, lower lid laxity is once again evaluated
with a pair of fine pickups.
418
permit displacement above the lower limbus with the pickups,
the knot should be loosened (Fig. 36.25).
Patients who have significant lid laxity with lid distraction
greater than 6 mm, or those with persistent intraoperative lid
laxity after canthopexy, require lateral canthotomy and can-
thoplasty. Lateral canthoplasty is performed after canthotomy
of the inferior limb of the lateral canthal tendon, followed by
cantholysis, which allows mobilization of the lower lid (Fig.
36.26). Before the lid is transposed over the lateral orbital rim, 2
to 3 mm of full-thickness horizontal lid shortening is performed
to correct significant lid laxity. A 4–0 Mersilene suture is used for
lateral canthoplasty and is placed through the edge of the tarsal
plate from inferior to superior, ensuring vertical alignment while
controlling lash rotation. The mattress suture is then placed along
the posterior aspect of the lateral orbital rim periosteum at the
appropriate level according to eye prominence and is tied in a
surgeon’s knot. The desired amount of tension created by the
lateral canthoplasty should allow 1 to 2 mm of lid distraction
away from the globe, and the lid should be easily mobilized over
the cornea. Overtightening of the lateral canthoplasty should be
avoided to minimize lid malposition. The lateral commissure is
then reconstructed with a 6–0 plain catgut suture placed in the
gray line to prevent postoperative lateral canthal webbing. To rec-
reate a normal-appearing lateral commissure, the suture is placed
Fig. 36.24 Objective of lateral canthopexy: to suture the tarsal plate
and lateral retinaculum to the periosteum of the lateral orbital rim,
thereby tightening the lower lid tarsoligamentous sling.
Fig. 36.26 Lateral canthotomy and canthoplasty.

in the posterior aspect of the upper lid gray line and the anterior
aspect of the lower lid gray line to allow the upper lid to overlap
the lower lid slightly in a normal anatomic relationship.
After lateral canthal support is achieved, the skin–muscle flap
is redraped in a superior lateral vector. A triangle of excess skin
and muscle is resected according to the amount that overlaps the
lateral extent of the lower blepharoplasty incision (Fig. 36.27).
The orbicularis muscle flap is then resuspended to the lateral
orbital rim at the level of the lateral canthus using a 4–0 Vicryl
suture, which is placed as a three-point quilting suture from the
incised edges of skin and muscle to the periosteum along the inner
aspect of the lateral orbital rim to recreate the normal concavity
associated with the lateral orbital raphe. Similarly, interrupted
absorbable sutures are placed in the lateral cut edge of the orbi-
cularis flap to the lateral orbital rim periosteum and temporalis
fascia to resuspend the orbicularis under appropriate tension.
Resuspension of the orbicularis provides additional lower lid
support as well as elevation of the SOOF over the inferior orbital
rim, anatomically blending the lid–cheek junction and giving it a
smoother look.
Minimal skin and muscle are resected parallel to the lower
lid margin to minimize the risk of lid malposition. A small strip
of orbicularis is removed from the skin–muscle flap to avoid a
redundant layer overlying the preserved pretarsal orbicularis.
Tension-free closure is then performed in the skin–muscle edges
with a 6–0 fast-absorbing catgut suture (Fig. 36.28).
36.5.4 Adjunctive Techniques
Treatment of the Tear Trough Deformity
The tear trough hollow can be corrected during a standard lower
blepharoplasty (Fig. 36.29). When releasing the orbitomalar
ligament along the infraorbital rim, the surgeon performs addi-
tional preperiosteal dissection and release of the tear trough.
This dissection is performed with low-power electrocautery and
should be limited to prevent injury to the buccal branch of the
facial nerve, which is located medial to the tear trough at the
level of the angular artery. If the levator labii superioris alaeque
nasi muscle twitches with the electrocautery, this may be a sign
of overdissection near the buccal branch. After release of the tear
trough, the nasal fat pad is transposed and secured with a 6–0
Vicryl suture into the periosteum. It is important to remember
that aggressive transposition of the nasal and central pads can
impair inferior oblique function and result in diplopia. Fat graft-
ing from excised orbital fat can also be used to fill this space.
36.6 Postoperative Care
At the end of the procedure, a 6–0 nylon suture can be placed as a
temporary tarsorrhaphy along the gray line lateral to the limbus.
Another option is to place a temporary Frost suture in the lower
lid margin lateral to the lateral limbus and either suturing to the
eyebrow or suspending to a Steri-Strip (3M, St. Paul, M ) above
the eyebrow. These techniques will reduce corneal exposure in
the immediate postoperative period and minimize chemosis.
These sutures are removed at the first postoperative visit 5 to 7
days after surgery (Fig. 36.30).
er ye id e r y
a b
Fig. 36.27 (a) After lateral canthal support is achieved, the skin-mus-
cle flap is redraped in a superior lateral vector. (b) A triangle of excess
skin and muscle is resected according to the amount that overlaps the
lateral extent of the lower blepharoplasty incision.
a b c
Fig. 36.28 (a) Minimal skin and muscle are resected parallel to the
lower lid margin to minimize the risk of lid malposition. (b) A small
strip of orbicularis is removed from the skin–muscle flap to avoid a
redundant layer overlying the preserved pretarsal orbicularis.
(c) Tension-free closure is then performed in the skin–muscle edges
with a 6–0 fast-absorbing catgut suture.
Postoperatively the patient’s head should remain elevated
to reduce edema and ophthalmic pressure. An ice pack or cold
compresses should be applied to the eyelids for 48 hours. The eyes
should remain lubricated at all times, using saline drops during
the day and lubricating ointment at night. Lagophthalmos can
be caused by periorbital edema; if this occurs, it resolves spon-
taneously in 1 to 2 weeks. In these cases eye drops and ointment
are essential to prevent corneal abrasions and exposure problems.
Before discharge the patient’s vision should be evaluated and
documented. Any signs of corneal irritation or decreased visual
acuity require careful ophthalmologic evaluation, including
slit-lamp examination with the use of fluorescein eye drops to
evaluate the cornea. Patients are asked to avoid the use of contact
lenses and any eyelid makeup on the suture lines for 2 weeks after
blepharoplasty.
Persistent postoperative chemosis can be treated with liberal
application of ophthalmic ointments and steroid eye drops. Use
of these eye drops should be limited to 2 weeks to avoid the
risks associated with prolonged treatment. Severe chemosis that
herniates through the palpebral fissure requires more aggressive
management with liberal use of ophthalmic ointment, topical ste-
roids, patching the eye closed for 24 to 48 hours, conjunctivotomy,
or tarsorrhaphy.
Mild lid malposition may contribute to lagophthalmos and
corneal exposure, which may require bandage contact lenses
to protect the cornea and conservative massage of the lower lid
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 VI Eyelid Surgery
Fig. 36.29 Treatment of the tear trough deformity.
margin until the patient has passed the critical 6-week postopera-
tive period, which corresponds with the peak inflammatory phase
of healing. Lower lid ectropion or persistent lid malposition after a
6-week period of conservative management may require surgical
intervention, including placement of a posterior lamella spacer
graft and lateral canthoplasty.
36.7 Outcomes
Lower blepharoplasty can no longer be considered a routine
operation. Surgical techniques have evolved and are today sig-
nificantly more sophisticated than in previous decades. Careful
preoperative evaluation is the initial step toward creating a spe-
cific and comprehensive treatment plan for each patient based
on individual findings and desired outcome. Patients who have
medical or anatomic characteristics known to be factors pre-
dictive of poor outcome should be considered high-risk patients
who require alternative procedures to minimize complications.
Once assessment and planning are complete, blepharoplasty
procedures should be performed with precision. Emphasis is
placed on maintaining the preoperative shape of the palpebral
fissure, with particular attention to maintaining lower eyelid
position. Lateral canthal support, most commonly with lateral
canthopexy, represents a very important step in the technique to
maintain lid shape and reduce the risk of lower lid malposition or
postoperative round-eye syndrome. The tradeoff, which should
be discussed with the patient before surgery, is that the lower lid
may appear tight, and this could last 2 to 3 weeks after surgery.
The natural S-shaped curve of the lower lid and the palpebral
aperture are preserved after healing is complete.
Complications associated with lateral canthoplasty have been
minor and primarily include canthal angle webbing or asymme-
try that requires surgical revision. The risk of frank ectropion is
significantly minimized with the use of lateral canthal support.
In addition to minimizing the risk of complications, maximizing
the aesthetic result is directly related to management of both
periorbital fat compartments, the orbicularis muscle, and SOOF.
Elevation of the skin muscle flap and release of the orbitomalar
ligament mobilize the SOOF, which is elevated with the orbicu-
laris muscle. Using the orbicularis muscle as a sling with secure
420
Fig. 36.30 A 6–0 nylon suture can be placed as a temporary tarsorrha-
phy along the gray line lateral to the limbus.
lateral orbital fixation is the key to maximizing the aesthetic
appearance of the infraorbital region. This can be performed
safely based on the anatomy of the lower eyelid. The posterior
lamella (tarsoligamentous sling) has a separate point of periosteal
fixation from the anterior lamella (skin–muscle flap). These basic
principles, founded on anatomy, are the two key points in max-
imizing surgical outcome after lower blepharoplasty. Adherence
to these basic principles significantly contributes to achieving the
overall goal.
36.8 Complications
36.8.1 Lower Lid Malposition
Lower lid malposition is the most common surgical compli-
cation after transcutaneous lower lid blepharoplasty and
includes lid retraction, scleral show, and ectropion (Fig. 36.31).
The incidence of this complication varies from 5 to 30 in the
literature. Lower lid malposition not only detracts from the
aesthetic results but can also lead to functional problems such
as exposure keratopathy. The most common etiologic factor
is vertical deficiency of the anterior or posterior lamella in
patients with preexisting tarsoligamentous laxity. Care should
be taken to avoid excessive skin and muscle resection. Patients
associated with increased risk include those with lower lid
laxity, prominent eyes, negative vector, negative canthal tilt,
and preoperative scleral show. To avoid this complication, some
have suggested less invasive approaches to the lower lid, such
as the transconjunctival lower blepharoplasty. Although more
conservative, this technique does not eliminate the risk of lower
lid malposition. In addition, most patients who consult for
lower lid rejuvenation need removal of excess skin and muscle,
which is a limitation of the transconjunctival approach. The
treatment of postoperative mild lower lid malposition is con-
servative, with postoperative massage, the use of tape to hold
the lower lid in position, and eye lubrication. If conservative
treatment fails to improve the position of the lower lid after 6
weeks, surgical revision with canthopexy or canthoplasty with
or without the use of spacers is recommended. Drill-hole can-
thal anchoring is often needed, because there might be a lack of

adequate periosteum for suture fixation. Severe postoperative
lower lid malposition, causing functional problems or corneal
exposure, requires immediate correction to avoid exposure
keratopathy.
The addition of routine lateral canthal anchoring provides an
anatomic solution for decreasing the risk of lower lid malposition
after transcutaneous blepharoplasty. In a review of our 10-year
experience with routine lateral canthal support in 264 primary
cosmetic transcutaneous lower lid blepharoplasties, we reported
ectropion in 0.8 , lower lid retraction requiring revision in 2.7 ,
and mild lower lid retraction (1 mm or less) that resolved with
massage in 6.1 . Patients who needed revision were treated with
secondary canthoplasty; three patients required posterior lamella
spacer grafts.
Causes of Postblepharoplasty Lower Lid
Malposition
• Lower lid laxity
• High-risk patients
• Excessive skin removal
• Excessive muscle removal
• Middle lamellar scarring
• Posterior lamellar scarring
• Damage to pretarsal orbicularis muscle
• Untreated hematoma
36.8.2 Chemosis
Chemosis is the most common nonsurgical complication after
lower blepharoplasty, occurring in up to 12 of patients under-
going the procedure. It is a transudative edema of the bulbar or
fornical conjunctiva and is characterized by visible swelling of
the conjunctiva (Fig. 36.32).
Patients may experience epiphora, irritation, foreign body
sensation, and mild visual alteration. In a lower blepharoplasty,
the causes include conjunctival desiccation from exposure,
regional edema, and lymphatic stasis resulting from local trauma.
Fig. 36.31 Lower lid malposition.
er ye id e r y
Chemosis usually presents in the first postoperative week. The
median duration is approximately 4 weeks and can range from 1
week to 3 months.
Prevention is the most important treatment in chemosis man-
agement, and it starts in the operating room. The use of lubricated
corneal protectors, preventing prolonged eye exposure and
dryness with frequent moisturizing of the eyes, and minimizing
trauma can all help reduce its incidence. If significant chemosis
is seen intraoperatively, it can be treated with an immediate
conjunctivotomy using a pair of small scissors. A temporary
tarsorrhaphy suture can be placed lateral to the lateral limbus to
reduce postoperative chemosis.
Postoperative treatment of chemosis starts by keeping the
eyes lubricated with wetting drops and ophthalmic lubricants.
Ophthalmic steroid drops (tobramycin/dexamethasone Tobradex;
Alcon, Fort orth, TX ) are also helpful. If the irritation does not
resolve, an eye patch to the affected eye with the use of an Ace
bandage at night can be used. In more severe cases (lasting more
than 2 weeks), especially if lagophthalmos is present, a conjunc-
tivotomy or tarsorrhaphy should be considered.
The patient in Fig. 36.33 presented with postoperative chemosis
that prolapsed through the eyelids during closure, causing lagoph-
thalmos. A conjunctivotomy of the prolapsed conjunctiva with the
patient under local anesthesia was performed in an office setting.
The patient in Fig. 36.34, seen before and immediately after a
conjunctivotomy with the use of a local anesthetic in the office,
shows an almost complete resolution of her chemosis.
36.8.3 Visual Changes
Visual changes such as diplopia are generally temporary and
can be attributed to edema. The most common extraocular
muscle damaged in lower blepharoplasty is the inferior oblique
muscle, which is located between the nasal and central fat
pads and can be inadvertently injured during fat manipulation.
Conservative treatment is recommended; normal vision is
usually regained when the muscle edema subsides. Vision loss
can also occur; it is discussed in the chapter on upper eyelid
blepharoplasty.
Fig. 36.32 Chemosis is a transudative edema of the bulbar or fornical
conjunctiva and is characterized by visible swelling of the conjunctiva.
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 VI Eyelid Surgery

Fig. 36.33 This patient presented with postoperative chemosis that Fig. 36.34 This patient, seen before and immediately after a
prolapsed through the eyelids during closure, causing lagophthalmos. conjunctivotomy with the use of a local anesthetic in the office, shows
A conjunctivotomy of the prolapsed conjunctiva with the patient under an almost complete resolution of her chemosis.
local anesthesia was performed in an office setting.

The patient shown in Fig. 36.37 similarly had herniated fat

36.8.4 Other Complications compartments, worse nasally, and a prominent tear trough defor-
mity. He also received a lower lid blepharoplasty and a lateral
Epiphora is usually a transient problem that can resolve sponta-
canthopexy.
neously in days; it is most commonly caused by edema distorting
The patient shown in Fig. 36.38 presented with herniated fat
the lacrimal canaliculi. If persistent, punctal eversion can be cor-
compartments and tear trough deformity and mild ptosis of his
rected by excising and closing an ellipse of conjunctiva below the
right upper lid. He desired only a lower blepharoplasty with
canaliculus, producing inversion. The same effect can be obtained
canthopexy, with the results shown.
by applying cautery below the lacrimal canaliculus on the conjunc-
The patient shown in Fig. 36.39 had dermatochalasis and malar
tival side to produce contraction and inversion of the punctum.
bags. Treatment involved preperiosteal dissection to the inferior
Corneal abrasions can be prevented by constant corneal lubrica-
extent of the malar bags.
tion, the use of ocular protectors, and avoiding prolonged exposure of
the cornea. Dry-eye syndrome, infection, and hematoma may occur;
these are discussed in the chapter on upper eyelid blepharoplasty. 36.10 Concluding Thoughts
As concepts of aging evolve and new techniques are developed,
36.9 Results operative approaches to blepharoplasty continue to be refined,
thereby producing a more natural, youthful eyelid appearance.
The following cases represent a variety and continuum of
The stigmata of surgery can be minimized, along with the
patients who demonstrate age-related changes of the eyelids and
risk of complications, by proper preoperative assessment and
periorbital region.
meticulous surgical technique. Appreciation of the underlying
Fig. 36.35 shows a patient preoperatively and after an extended
anatomy, along with the indications and limitations of tech-
lower blepharoplasty and correction of a tear trough deformity.
niques used to correct the anatomic changes that occur with
The patient shown in Fig. 36.36 had herniated fat compart-
aging, form the basis of a sound surgical approach that ensures
ments, worse nasally, and a prominent tear trough deformity. She
favorable results.
underwent a lower lid blepharoplasty and a lateral canthopexy.

a b a b
Fig. 36.35 This patient is shown (a) preoperatively and (b) after Fig. 36.36 (a) This patient had herniated fat compartments, worse
an extended lower blepharoplasty and correction of a tear trough nasally, and a prominent tear trough deformity. (b) She is shown after
deformity a lower lid blepharoplasty and a lateral canthopexy.

422

a b
Fig. 36.37 (a) This patient had herniated fat compartments, worse
nasally, and a prominent tear trough deformity. (b) He is shown after a
lower lid blepharoplasty and a lateral canthopexy.
a b
Fig. 36.39 (a) This patient had dermatochalasis and malar bags. (b)
Treatment involved preperiosteal dissection to the inferior extent of
the malar bags.
Clinical Caveats
• Preoperative evaluation should include the lower lids and
midface.
• This technique for lower blepharoplasty is an anatomically
based procedure that requires familiarity with periorbital
anatomy.
• Preoperative recognition of high-risk patients is essential; this
can be achieved with systematic clinical evaluation.
• Patients at high risk for lower lid malposition include those
with prominent and deep-set eyes, lower lid laxity, a negative
canthal tilt, and a negative vector.
• Modifications of the surgical technique are performed based
on the extent of the age-related changes present in the eye-
lids and periorbital region.
• Lower blepharoplasty using a skin–muscle flap can be safely
performed with minimal risk of denervation of the pretarsal
orbicularis muscle.
• Release of the orbitomalar ligament is an important part of
lower lid blepharoplasty to resuspend the orbicularis and
elevate the SOOF to achieve a smoother transition of the
lid–cheek junction.
er ye id e r y
a b
Fig. 36.38 (a) This patient presented with herniated fat compart-
ments, tear trough deformity, and mild ptosis of his right upper lid. He
desired only a lower blepharoplasty with canthopexy. (b) He is shown
postoperatively.
• Routine lateral canthal anchoring is required to minimize the
risk of postblepharoplasty lid malposition.
• Modest lower lid laxity with less than 6 mm of lid distraction
is managed with lateral canthopexy.
• Significant lower lid laxity of 6 mm or more of lid distraction is
managed with lateral canthoplasty.
• Lower lid malposition is the most common surgical com-
plication after lower lid blepharoplasty. Chemosis is the
most common nonsurgical complication after lower lid
blepharoplasty.
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 r n n un i e r y

37 Transconjunctival Blepharoplasty
Foad Nahai

Abstract
The transconjunctival approach to blepharoplasty has continued
to gain in popularity. The reasons include the minimal risk
of lid retraction, the ability to combine fat management with
skin pinch or resurfacing, and the addition of fat grafting. It has
evolved from simple fat excision to fat preservation, fat redrap-
ing, and gateway to the midface.
shown in Table 37.1, the overall complication rate was 5 for the
transconjunctival group but 13 for the transcutaneous group.
In the transconjunctival group there was no lid retraction, but
in the transcutaneous group 3.3 had lid retraction. The revi-
sion rate for the transcutaneous group was 2.2 , while for the
transconjunctival group it was 1.6 . The complication rates were
similar in primary and secondary blepharoplasties.

37.1.2 Disadvantages
Keywords
Although the addition of a skin pinch allows removal of skin
fat excision, fat redraping. fat grafts canthopexy, skin pinch excess, orbicularis muscle trimming and redraping is not possible
through this approach. Access for redraping and redistribution of
periorbital fat and access to the midface are possible through this
37.1 Evolution of Technique approach, but it is not as straightforward as the open approach.
In an effort to minimize the risks associated with the open or In the upper eyelid, only the nasal fat pocket can be approached
transcutaneous skin–muscle approach to blepharoplasty, there through the conjunctiva, which limits its role to removal of fat
has been renewed interest in the transconjunctival approach. from that pocket only.
Originally described by Bourguet in 1928, the transconjunctival
approach was reintroduced in 1973 by Tessier for removal of fat
from the lower eyelid and treatment of congenital deformities
37.2 Management of Fat in
and trauma. This approach was later popularized for the removal the Eyelids
of lower lid fat by Baylis et al and by McCord and Moses in the
oculoplastic literature in the 1980s, and by arem and Resnick in Over the years there has been considerable change in our man-
the plastic surgery literature in the early 1990s. These surgeons agement of periorbital fat. Gone are the days of the skin–muscle–
emphasized the safety of this technique and the significant fat excision blepharoplasty. It was through this evolution of fat
reduction in complications it offered, with almost complete management around the eye in the late 1990s that transcon-
elimination of lid retraction and its consequences. My personal junctival fat removal became less popular in general and I chose
experience, reported in 1995 and again in 2010, confirmed the
safety and efficacy of this approach for removal of fat from the
lower eyelid. Over time, interest in transconjunctival blepharo-
plasty waned as the focus shifted to amelioration of aging of the
Table 37.1 Series of 300 transconjunctival and transcutaneous
lid–cheek junction with an emphasis on fat redraping and the
blepharoplasties (March 1992–March 1996)
transpalpebral approach to midface elevation. Today, however,
r n n un i Transcutaneous
the transconjunctival approach is again attracting attention
(N = 120) (N = 180)
and gaining in popularity, not only for fat removal from the
Primary 101 (84%) 145 (80%)
lower eyelid but also for fat redraping, fat redistribution, and a blepharoplasty
transconjunctival gateway to the midface. In 1999 we described
Secondary 19 (16%) 35 (20%)
the transconjunctival approach to the medial or nasal fat pocket blepharoplasty
of the upper eyelid.
Mean follow-up 3 yr 3 yr

Range 2–4 yr 2–4 yr

37.1.1 Advantages Surgical revision 2 (1.6%) 4 (2.2%)
In addition to the obvious benefit of significantly decreasing Exposure 0 8 (4.4%)
complications, the other advantage to this technique is that there
Subconjunctival 2 (1.6%) 4 (2.2%)
is no visible scar. Lid retraction and its consequences exposure, hematoma
round eye, scleral show, and ectropion have all but been elimi-
Infection 0 2 (1.1%)
nated with this approach. Baylis et al reported no lid retraction,
as did arem and Resnick. A personal review of 300 consecutive Granuloma 2 (1.6%) 0
blepharoplasties between March 1992 and March 1996 (portions Scleral show/ 0 6 (3.3%)
of which were published in 1995) included 120 transconjunctival ectropion
blepharoplasties and 180 transcutaneous blepharoplasties. As Overall 6 (5%) 24 (13%)

425
 VI Eyelid Surgery
it with significantly less frequency in my practice. My current
management of lower lid fat includes the following:
• Redraping
• Preservation
• Excision
• Augmentation
In selected patients lower lid fat grafting with skin resurfacing
or skin pinch produces excellent results and obviates the need for
a skin–muscle flap.
Even in the upper eyelid, I am preserving fat rather than resect-
ing, especially in the lateral pocket.
37.3 Indications
Fat management, especially in the lower eyelid, is now custom-
ized to each individual. I base my options for fat management
on the amount of fat present and an evaluation of the lid–cheek
junction. If the patient has little if any aging of the lid–cheek
junction with true excess fat, I prefer resection of fat. If the
patient has no excess fat, the fat pocket is not opened. If the
patient has aging of the lid–cheek junction and sufficient fat
for redraping, then redraping or redistribution of that fat is the
procedure of choice. In patients who require improvement of
the lid–cheek junction and do not have an adequate volume of
lower lid fat, augmentation with autologous fat or a dermis graft
is necessary. Autologous fat grafting is far more popular, simpler,
and less invasive than dermis fat grafts (Fig. 37.1).
For individuals with excess lower lid fat and little or no lid–
cheek junction change, the postseptal transconjunctival approach
is an ideal operation with safe, easy fat removal from all com-
partments. It is also a good operation for patients with excess fat
and fine skin wrinkling and in those with apparent excess skin in
whom fat removal will result in redraping of the excess skin into
an acceptable contour with elimination of the skin laxity. Laser
resurfacing and peels have been advocated for skin tightening
Fig. 37.1 Lower lid fat management.
426
after transconjunctival fat removal to deal with the excess skin;
however, I have found that skin excision is best for handling the
excess skin. The combination of transconjunctival fat removal
and skin excision through skin-pinch blepharoplasty is a suitable
alternative to the transcutaneous skin-muscle flap blepharoplasty
in selected patients. For candidates for redraping or redistribution
or augmentation of the periorbital fat, the preseptal transconjunc-
tival approach allows access to the periorbital fat, sub–orbicularis
oculi fat (SOOF), and midface. This approach does not afford
the same easy access and visualization as the transcutaneous
approach.
37.4 Preoperative Assessment
A complete medical history is taken. e ask about hypertension
and medications that affect bleeding. A careful ophthalmologic
history is then obtained. The patient is asked about any history
of eye problems or operations, specifically inquiring about
glaucoma and laser in situ keratomileusis (LASI ) procedures,
symptoms of dry-eye syndrome or irritation, whether the
patient wears glasses or contact lenses, and any family history of
eye problems, especially glaucoma.
The examination includes an evaluation of the lower lid skin,
muscle, fat, and lid–cheek junction. Lid tone should be assessed
with the pinch and traction tests. Schirmer’s test is done on a
selective basis, as indicated. Although I routinely measure every
patient’s eyes with the Hertel ophthalmometer, it may not be as vital
to do so for patients undergoing transconjunctival procedures.
37.5 Upper Eyelid
37.5.1 Pertinent Anatomy
The only fat compartment to herniate in the upper eyelid is the
medial compartment. The other compartment is retained ana-
tomically, does not herniate, and cannot be exposed through the
conjunctiva (Fig. 37.2).
 r n n un i e r y

e consider the upper eyelid to be divided into tarsal and inaccessible through the transconjunctival approach. The medial
orbital portions at the level of the supratarsal fold, which is or nasal fat is usually pale yellow or white. It contains more sen-
located 3 to 5 mm above the upper border of the tarsal plate in sory filaments, branches of the supratrochlear nerve, and more
Caucasians and much lower in Asians. It is formed by the fusion blood vessels, branches of the superior ophthalmic artery. The
of the levator palpebrae superioris aponeurosis, orbital septum, fat of the lateral central or temple compartment is much more
and fascia on the deep surface of the orbicularis oculi muscle. yellow in color and has sensory fibers and vascular branches of
This fused layer acts as a sling and holds up the periorbital fat the supraorbital nerve and artery (Fig. 37.5).
so that the excess fat drapes over the fold rather than herniating
below it (Fig. 37.3).
This sling is lower laterally and much higher nasally, thus allow-
37.5.2 Transconjunctival Approaches
ing herniation of the nasal fat pocket below it. The other structure Only the nasal fat pocket can be approached through the medial
of importance here is the levator aponeurosis. The lateral horn of conjunctiva below the medial horn of the levator aponeurosis
the levator is much lower than its medial horn. These two factors through the so-called bare area described by Guerra et al.
combined allow transconjunctival access to the nasal or medial fat
pocket without risk of injuring or involving the levator aponeuro-
sis (Fig. 37.4).
The medial or nasal fat lies medial to the levator aponeurosis
and below its medial horn. The lateral temporal or central upper
eyelid fat pocket lies anterior to the levator aponeurosis and is

Fig. 37.2 Illustration that the only fat compartment to herniate in the Fig. 37.3 Anatomical relationships of the upper eyelid fat
upper eyelid is the medial compartment. compartments.

a b
Fig. 37.4 The levator muscle, (a) its aponeurosis, and (b) the sling allowing herniation of the medial or nasal pocket only.

427
 VI Eyelid Surgery
Fig. 37.5 The relationship of the sling with the fat pockets.
37.5.3 Preoperative Planning
Patient Protection
The transconjunctival approach is suitable for a primary or sec-
ondary procedure for removal of excess medial upper eyelid fat.
The best candidates for this procedure have excess fat limited to
the nasal pocket, with little or no true skin excess. In my experi-
ence, most of these patients have undergone previous blepharo-
plasties, with remaining excess fat in the medial or nasal pocket.
Markings
ith gentle pressure on the globe, I look for the maximum bulg-
ing of the medial fat pocket and place a small mark on the skin.
Fig. 37.6 Transconjunctival blepharoplasty: fat excision.
428
37.5.4 Operative Technique
Anesthesia
Local anesthesia is my choice if fat removal is the only procedure
to be performed. If it is combined with other facial rejuvenation
procedures, I prefer general anesthesia. Before injection of the
local anesthetic, 1 to 2 drops of topical tetracaine anesthetic are
placed on the eye. The local anesthetic, 0.5 lidocaine with epi-
nephrine 1:200,000, is infiltrated transcutaneously and through
the conjunctiva. If the patient is under general anesthesia, the
lidocaine–epinephrine mixture is injected for its vasoconstrictor
effect, but the tetracaine is not necessary.
Incision
A corneal protector is placed over the eye. The medialmost part of
the upper eyelid is retracted; I prefer to use a Blair retractor. The
bare area is immediately exposed and an incision made in the
conjunctiva with Colorado tip needle electrocautery. This incision
is kept in the medialmost part of the upper eyelid and should not
extend laterally beyond the bare area, where it may injure the
levator aponeurosis and risk postoperative ptosis. Once the inci-
sion is made, I take a pair of fine blunt-tipped scissors and spread
the blades. The nasal fat pocket immediately comes into view.
Fat Excision
The medial fat pocket is then easily teased and delivered through
the incision, where it is trimmed with the electrocautery. The
endpoint is reached when there is no bulging medially in the
upper eyelid with gentle pressure on the globe (Fig. 37.6).
Closure
The conjunctival incision is always left open.
 r n n un i e r y

Postoperative Care
The patient’s head is elevated, and ice packs are placed on the
eyelids.
37.5.5 Results
The transconjunctival approach for removal of fat in the upper
eyelid has been free of complications in our hands, specifically
free of eyelid ptosis. There have been no revisions, and patients
have been consistently pleased.
The middle-aged woman shown in Fig. 37.7 underwent an
endoscopic brow lift, transconjunctival removal of fat from the
upper eyelids, a lower lid blepharoplasty with transpalpebral
midface lift and neck lift, and laser resurfacing of the forehead.
She is seen 12 months postoperatively. o skin was removed
from the upper eyelids; the improvement seen in the upper lids
resulted from the endoscopic brow lift and excision of fat from
the medial fat pocket.
The 50-year-old woman shown in Fig. 37.8 underwent an
endoscopic brow lift, transconjunctival removal of fat from the
upper eyelids, lower lid blepharoplasty, and a face and neck lift.
She is shown 3 years after surgery. o skin was removed from the
upper eyelids. The medial upper lid improvement that resulted
from transconjunctival fat removal is most evident in the split-
face view.
The woman in her early fifties shown in Fig. 37.9 had had a
previous coronal brow lift. She underwent an endoscopic brow
lift with transconjunctival removal of fat from the nasal pocket of
the upper eyelids. The upper eyelids were improved as a result of
the transconjunctival removal of fat from the nasal pocket and the
endoscopic brow lift. There was no skin excision from the upper
eyelids.
37.6 Lower Eyelids
37.6.1 Pertinent Anatomy
An understanding of the anatomic relationships between the
fat pockets and other lid structures is the key to this approach.
It should be remembered that the outer lamella of the lower
eyelid is composed of the skin and orbicularis muscle. The
middle lamella is the orbital septum, and deep to it is the
periorbital fat; the posterior lamella behind the orbital fat is
made up of the lower lid retractors (capsulopalpebral fascia)
and conjunctiva.
Orbital Fat Pads
The orbital fat pads are bounded anteriorly by the orbital septum.
The septum is attached inferiorly to the arcus marginalis and
fuses superiorly with the lower lid retractors. The orbicularis

a b
Fig. 37.7 Middle-aged woman (a) pre- and (b) 12
months post an endoscopic brow lift, transconjunctival
removal of fat from the upper eyelids, a lower lid bleph-
aroplasty with transpalpebral midface lift and neck lift,
and laser resurfacing of the forehead.
a b c
Fig. 37.8 Woman aged 50 at presentation (a) pre- and (b) 3 years post an endoscopic
brow lift, transconjunctival removal of fat from the upper eyelids, lower lid blepha-
roplasty, and a face and neck lift. (c) The medial upper lid improvement that resulted
from transconjunctival fat removal is most evident in the split-face view.

Fig. 37.9 Woman in her early 50s who had had a previous coronal brow lift and underwent an endoscopic brow lift with transconjunctival removal of
fat from the nasal pocket of the upper eyelids.

429
 VI Eyelid Surgery
muscle and skin are anterior to the septum. The orbital fat pads
are bounded superiorly and posteriorly by the lower lid retrac-
tors. The lower lid retractors arise from the terminal muscle
fibers and tendons of the inferior rectus muscle. They fuse with
the orbital septum 5 mm below the inferior tarsus and insert on
the tarsal plate. The posterior lower lid retractors are applied
very close, in fact quite adherently, to the lower lid conjunctiva
(Fig. 37.10).
The inferior oblique muscle lies within the orbital fat and is the
only eye muscle at risk during blepharoplasty. The muscle origi-
nates along the anterior medial orbital floor, passing posteriorly
Fig. 37.10 Orbital fat pads.
Fig. 37.11 Anatomy of the lower lid fat compartments.
430
and laterally beneath the globe separating the medial and central
fat pockets (Fig. 37.11).
The Compartments
The central compartment is separated from the lateral com-
partment by the arcuate expansion of the inferior oblique
muscle, which inserts into the orbital rim anterolaterally. The
inferior oblique muscle separates the central and medial fat
compartments.
37.6.2 Transconjunctival Approaches
Transconjunctival approaches to the lower eyelid are either
preseptal or postseptal. Each approach has its own advantages
and limitations. The postseptal approach allows only fat
removal. The preseptal approach allows access for fat removal
and redistribution, along with access to the midface and orbital
rim (Fig. 37.12).
Transconjunctival Approaches
The preseptal approach allows the following:
• Fat removal
• Fat redistribution
• Access to midface
The postseptal approach allows the following:
• Fat removal only
The preseptal incision is placed in the following places:
• Below the tarsal border
• At the level of the upper arcade
The postseptal incision is placed in the following places:
• In the fornix 4 to 5 mm below the tarsal border
• At the level of the lower arcade

Postseptal Approach
Transconjunctival blepharoplasty by the postseptal approach
permits access to the orbital fat through an incision in the con-
junctiva and lid retractors/capsulopalpebral fascia without any
disruption or involvement of the skin, muscle, or orbital septum.
The incision is usually made in the conjunctiva of the inferior
fornix, 4 or 5 mm below the tarsal border at the level of the lower
conjunctival vascular arcade (Fig. 37.13).
Preseptal Approach
The preseptal approach permits access to the fat pads through
the orbital septum and allows access to the orbital rim, SOOF,
and the midface without any involvement of the orbicularis
muscle or skin. The incision is made along the lower tarsal
border, 1 or 2 mm below the lid margin. This incision extends
through the conjunctival lid retractors and capsulopalpebral
fascia. The space behind the orbicularis is then entered, and the
dissection is continued deep to the orbicularis but anterior to the
orbital septum. This dissection is continued down to the orbital
Fig. 37.12 Preseptal and postseptal transconjunctival approaches to the lower eyelid.
Fig. 37.13 Transconjunctival blepharoplasty by the postseptal approach.
r n n un i e r y
rim, and the arcus marginalis is easily released, affording access
to the midface. Access to the fat requires resection or incision of
the orbital septum (Fig. 37.14).
37.6.3 Preoperative Planning
Patient Selection
The best candidates for transconjunctival fat removal or redrap-
ing are those with excess fat and little if any real skin excess.
The combination of transconjunctival fat removal and skin-pinch
excision is a suitable procedure in some patients. Fat redraping
is appropriate for patients with aging of the lid–cheek junction
with little or no real skin excess.
Markings
ith gentle pressure on the globe, the skin is marked directly
over each bulging compartment. If fat redraping is planned, the
nasojugal groove and lid–cheek junction are marked.
Fig. 37.14 Transconjunctival blepharoplasty by the
preseptal approach.
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 VI Eyelid Surgery

Fig. 37.15 Transconjunctival blepharoplasty by the postseptal approach: incisions.

37.6.4 Operative Technique
The ideal candidate for the postseptal approach is a patient with
bulging lower lid fat compartments with no real excess skin. The
ideal candidate for the preseptal approach has aging of the lid-
cheek junction with no real skin excess.
Anesthesia
The choice of local versus general anesthetic is the same as
described previously for the upper eyelid.
Postseptal Approach
Incisions
The globe is protected with a corneal protector. Stay sutures
of 5–0 Prolene are placed medially and laterally through the
conjunctiva of the inferior fornix. These two sutures are then
pulled upward, facilitating the dissection and also affording
extra protection to the globe. A Blair retractor or traction sutures
are then placed in the lower lid margin (Fig. 37.15).
the central and lateral compartments. These two incisions leave
an intervening bridge of conjunctiva over the inferior oblique
muscle in an effort to minimize the risk of injury to the muscle
during fat removal (Fig. 37.17). A single continuous incision, by
contrast, affords better exposure without significantly increasing
the risk of muscle injury.
Once the conjunctiva and the adherent lower lid retractors and
capsulopalpebral fascia have been incised, the fat compartments
may not always be readily visible (Fig. 37.18).
If the fat is not readily visible, gentle spreading with fine, blunt-
tipped scissors will easily expose it. The central and lateral fat
compartments are more easily identified than the medial fat com-
partment. I have found that resection of the central fat facilitates
identification of the medial fat. It should be kept in mind that the
inferior oblique muscle separates the central and medial fat pock-
ets, whereas the arcuate expansion of the inferior oblique muscle

er Ar de
The incisions are made with the electrocautery, 4 to 5 mm below
the lid margin at the level of the lower arcade (Fig. 37.16).
I prefer to make two separate conjunctival incisions: one medi-
ally over the medial fat compartment and the second laterally over

Fig. 37.17 Use of two separate conjunctival incisions leaves an

intervening bridge of conjunctiva over the inferior oblique muscle in an
Fig. 37.16 Lower vascular arcade. effort to minimize the risk of injury to the muscle during fat removal.

432

separates the central and lateral compartments (Fig. 37.19). Once
the fat is exposed, I like to deliver the fat through the incisions to
assess the amount to be resected (Fig. 37.20).
The exposed fat is then removed in a careful, graded fashion
with the coagulator and Colorado tip needle. The endpoint is
reached when the remaining fat is flush with the infraorbital rim
when gentle pressure is applied on the globe (Fig. 37.21).
Closure
o closure is required if two separate incisions are made. If a single
continuous incision is made, the wound is sutured (Fig. 37.22).
Preseptal Approach
Incisions
One continuous, long incision is made just below the tarsal
border. This is facilitated by retracting the tarsal plate upward
Fig. 37.18 When the conjunctiva and the adherent lower lid retractors
and capsulopalpebral fascia have been incised, the fat compartments
may not always be readily visible.
Fig. 37.20 Once the fat is exposed, the fat is delivered through the
incisions to assess the amount to be resected.
Fig. 37.22 No closure is required if two separate incisions are made. If
a single, continuous incision is made, the wound is sutured.
r n n un i e r y
and inferiorly with Blair retractors or through the placement
of stay sutures in the lid margin. The incision is made with the
electrocautery and a Colorado tip needle (Fig. 37.23).
Once the incision has been made, stay sutures are placed along
the inferior margin to facilitate exposure. The dissection is con-
tinued through the conjunctiva and lower lid retractors, exposing
the orbital septum on the deep surface and the orbicularis on
the superficial side of the incision. A Desmarres retractor is then
placed deep to the orbicularis and pulled downward (Fig. 37.24).
ure nd edi ri u i n
Dissection is continued deep to the orbicularis but superficial to
the orbital septum, downward toward the orbital rim. The arcus
marginalis is released, and dissection may continue into the
midface as needed. The orbital septum is then opened, the fat
Fig. 37.19 If the fat is not readily visible, gentle spreading with fine,
blunt-tipped scissors will easily expose the fat. The central and lateral
fat compartments are more easily identified than the medial fat
compartment.
Fig. 37.21 The exposed fat is removed in a careful, graded fashion
with the coagulator and Colorado tip needle. The endpoint is reached
when the remaining fat is flush with the infraorbital rim when gentle
pressure is applied on the globe.
Fig. 37.23 Transconjunctival blepharoplasty by the preseptal
approach: incision.
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 VI Eyelid Surgery

compartments are exposed and trimmed if necessary, and then Postoperative Care
the fat is mobilized over the orbital rim (Fig. 37.25).
The patient’s head is elevated, and ice packs are placed on the
This fat is retained over the rim by transcutaneous sutures. My
eyelids.
preference is 6–0 catgut, tied over a small pledget of petrolatum
gauze if needed. The suture is introduced through the lower lid
skin at the lid–cheek junction according to the preoperative mark- 37.6.5 Results
ings (Fig. 37.26). The suture traverses the skin and orbicularis
The woman in her early 30s shown in Fig. 37.30 underwent
oculi muscle (Fig. 37.27). It is then placed through the mobilized
transconjunctival removal of fat from the lower eyelids. The dark
periorbital fat below and then back through the orbicularis and
circles were ameliorated by the application of hydroxyquinone
skin (Fig. 37.28).
skin bleach. Her postoperative result is shown several months
Several sutures are placed and tied over the pledgets if needed.
after the procedure.
Once the last such suture has been placed, the conjunctival incision
Transconjunctival fat removal with erbium laser resurfacing
is then closed with an intraconjunctival suture so that there will be
was performed on the lower eyelids of the woman in her forties
no exposed sutures that could irritate the cornea (Fig. 37.29).
shown in Fig. 37.31. One year and 3 years postoperatively, she

Fig. 37.24 Transconjunctival blepharoplasty by the preseptal approach: placement of stay sutures and Desmarres retractor.

Fig. 37.25 Exposure and redistribution of fat.

Fig. 37.26 Retention of fat over the rim by transcutaneous sutures. Fig. 37.27 Suture traverses the skin and orbicularis oculi muscle.

434

Fig. 37.28 The retaining suture is then placed through the mobilized periorbital fat below and then back through the orbicularis and skin.
demonstrated an average to below-average result because the
aging of the lid–cheek junction was not addressed through
the transconjunctival removal of fat from the lower eyelid. An
alternative approach would have been preseptal conjunctival fat
redraping over the lower lid–cheek junction.
The 70-year-old man shown in Fig. 37.32 requested improve-
ment of the fat bags in the lower eyelid. He wanted a simple
procedure with minimal recovery. Transconjunctival postseptal
removal of fat from the lower lid was done. The result shown
several months later demonstrates satisfactory reduction of the
fat bags, although the aging of the lower lid–cheek junction and
aging skin were not addressed.
Fig. 37.29 Once the last retaining suture has been placed, the
conjunctival incision is then closed with an intraconjunctival suture.
r n n un i e r y
37.7 Outcomes
The transconjunctival approach to upper and lower eyelid bleph-
aroplasty has been relatively trouble free. Complications involv-
ing exposure and lid retraction are extremely rare. Recovery
is rapid with little risk of chemosis. Postoperative swelling is
minimal compared to transcutaneous approaches.
Injuries to the levator aponeurosis in the upper eyelid resulting
in ptosis have not been reported. Although injury to the inferior
oblique muscle during transconjunctival lower lid blepharoplasty
has been reported, it is very rare, and I have not personally
encountered it. Although the muscle is always at risk when resect-
ing fat from the central and medial pockets, I do not think that this
risk increases with the transconjunctival approach.
37.8 Concluding Thoughts
The transconjunctival approach remains a safe and effective
method for eyelid recontouring, lid–cheek blending, and peri-
orbital rejuvenation. The approach offers little in the way of
orbicularis muscle reshaping, skin removal, or lid anchoring.
Modifications such as the skin pinch and approaching the orbicu-
laris and canthus through the upper eyelid have been described,
thus extending the indications for this approach.
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a b c
Fig. 37.30 (a,c) Woman in her early 30s pre and (b,c) several months post transconjunctival removal of fat from the lower eyelids and application of
hydroxyquinone skin bleach to the dark circles.

a b

c d

e
Fig. 37.31 (a,c) Woman in her 40s shown pre and (b,d) 1 year and (e) 3 years post transconjunctival fat removal with erbium laser resurfacing on her
lower eyelids. Procedure did not address the aging of the lid–cheek junction.

436
 r n n un i e r y

a b c

d e
Fig. 37.32 (a,c,d) Man aged 70 pre- and (b,c,e) several months post transconjunctival postseptal removal of fat from the lower lids.

Clinical Caveats
Suggested Reading
Upper lid:
Upper Lid
• Only the nasal fat pocket can be approached through the
conjunctiva.
• Lateral extension of the conjunctival incision should be
avoided, because it may damage the levator aponeurosis.
• Ideal candidates are individuals with fat herniation of the
nasal fat pocket with no real skin excess.
Lower lid:
• The preseptal approach allows fat excision, fat redistribution,
and access to the midface.
• A postseptal approach allows fat removal only.
• The inferior oblique muscle separates the medial and central
fat compartments.
• A preseptal approach with fat redistribution is technically
challenging.
• Ideal candidates have excess fat with no real excess skin.
1 Guerra AB, Berger A III, Black EB III, guyen AH, Metzinger RC, Metzinger SE. The
bare area of the upper conjunctiva: a closer look at the anatomy of transconjunc-
tival upper blepharoplasty. Plast Reconstr Surg 2003;111(5):1717–1722
2 Guerra AB, Metzinger SE, Black EB III. Transconjunctival upper blepharoplasty:
a safe and effective addition to facial rejuvenation techniques. Ann Plast Surg
2002;48(5):528–533
3 anuszkiewicz S, ahai F. Transconjunctival upper blepharoplasty. Plast Reconstr
Surg 1999;103(3):1015–1018, discussion 1019
4 amer FM, Mingrone MD. Experiences with transconjunctival upper blepharo-
plasty. Arch Facial Plast Surg 2000;2(3):213–216
5 ahai F. Transconjunctival upper blepharoplasty: a safe and effective addition to
facial rejuvenation techniques. Ann Plast Surg 2002;49(2):215
6 Pacella S , ahai FR, ahai F. Transconjunctival blepharoplasty for upper and
lower eyelids. Plast Reconstr Surg 2010;125(1):384–392

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Lower Lid
7 Baylis HI, Long A, Groth M . Transconjunctival lower eyelid blepharoplasty.
Technique and complications. Ophthalmology 1989;96(7):1027–1032
8 Bourguet . otre traitement chirurgical de poches sous le yeux sans cicatrice.
Arch Franco-Belges Chir 1928;31:133
9 de la Plaza R, Arroyo M. A new technique for the treatment of palpebral bags.
Plast Reconstr Surg 1988;81(5):677–687
10 Goldberg RA, uen VH. Restricted ocular movements following lower eyelid fat
repositioning. Plast Reconstr Surg 2002;110(1):302–305, discussion 306–308
11 Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital
fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000;105(2):743–
748, discussion 749–751
12 Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg
2011;127(1):386–395
13 ones GE, Trimble-Bried , ahai F. Transconjunctival blepharoplasty: a clinical
experience. Perspect Plast Surg 1995;9(2):72–82
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14 awamoto H , Bradley P. The tear TROUF procedure: transconjunctival repo-
sitioning of orbital unipedicled fat. Plast Reconstr Surg 2003;112(7):1903–1907,
discussion 1908–1909
15 McCord CD r, Moses L. Exposure of the inferior orbit with fornix incision and
lateral canthotomy. Ophthalmic Surg 1979;10(6):53–63
16 McCord CD r, Shore . Avoidance of complications in lower lid blepharoplasty.
Ophthalmology 1983;90(9):1039–1046
17 Pacella S , ahai FR, ahai F. Transconjunctival blepharoplasty for upper and
lower eyelids. Plast Reconstr Surg 2010;125(1):384–392
18 Sadove RC. Transconjunctival septal suture repair for lower lid blepharoplasty.
Plast Reconstr Surg 2007;120(2):521–529
19 Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital
malformation and trauma. J Maxillofac Surg 1973;1(1):3–8
20 Tonnard PL, Verpaele AM, eltzer AA. Augmentation blepharoplasty: a review of
500 consecutive patients. Aesthet Surg J 2013;33(3):341–352
21 arem HA, Resnick I. Expanded applications for transconjunctival lower lid
blepharoplasty. Plast Reconstr Surg 1991;88(2):215–220, discussion 221

38 The Lower Eyelid Pinch Blepharoplasty
Lorne King Rosen eld
Abstract
This chapter focuses on the surgical rejuvenation of the lower
eyelid by using an operative approach that at once delivers a more
aesthetic result with less complication compared with the tradi-
tional skin–muscle flap. Called the pinch lower blepharoplasty, it
can accomplish these better outcomes by enabling the surgeon to
take greater control of the lower eyelid. The pinch blepharoplasty
does so by offering three integral advantages: First, by preserv-
ing the eyelid’s structural middle lamella, it reduces the risk of
surgically induced dry eye or scleral show and promotes a faster
recovery. Second, the consistent integration of the stitch cantho-
pexy promises efficacious control of the tone and posture of the
eyelid and position of the canthus. Third, girded by this reliable
support, the crepiness, wrinkling, and even festooning can be
confidently recruited and treated and the orbital grooving effec-
tively effaced with a malleably robust, strategically positioned
pinch, without the need for release of the orbicularis retaining
ligament, adjuvant skin resurfacing, or grafting/filler treatments.
Effectively, this maneuver allows for a real-time, accurate assess-
ment and tailored adjustment of both the location and extent of
the pinch. And in doing so, the surgeon can remain confident that
this same pinch does not adversely impact but reliably preserves
the posture of the eyelid above. Ultimately, the pinch blepharo-
plasty abolishes the need for both early postoperative maneuvers
of taping and massage to address eyelid malposition and late
secondary interventions to clean up residual deformities.
Keywords
eyelid aging, eyelid rejuvenation, complications, scleral show,
dry eye, malposition, pinch blepharoplasty, stitch canthopexy,
eyelid posture, eyelid wrinkling, eyelid festooning, periorbital
grooving
a b
Fig. 38.1 This 48-year-old woman, (a) shown preoperatively and (b) 1 year after a traditional blepharoplasty, showing neglected redundancy of skin.
(Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)
e er ye id in e r y
38.1 Introduction
The lower eyelid blepharoplasty embodies a classic surgical para-
dox: the more one performs a complex surgery, the more respect
it ultimately commands. But that will happen only if the surgeon
critically assesses results. And when it comes to the skin–muscle
flap technique for the lower blepharoplasty, ignorance may be
bliss, but knowledge can be quite motivating
So, when I examined my own outcomes, I observed, not as
infrequently as I would have liked, two particular stigmata of a
less than perfect result at the lower eyelid. First, lingering crepey
skin was noted, most often in those with prodigious fat herniation
or skin wrinkling. And this scenario makes cogent sense when one
honestly considers how much skin is prudently not excised from
the truly bulky, relatively denervated, hard-fought skin–muscle
flap (Fig. 38.1).
Second, albeit mild but enduring scleral show was evident, often
preceded by weeks of overly optimistic eyelid taping and the like.
This outcome can equally be truthfully predicted if one concedes
all of the same unintended consequences of the skin–muscle flap
just described (Fig. 38.2).
I was compelled by these discomfiting observations to seek
an effective solution a modified procedure that would at once
ensure optimal correction of the eyelid deformities and yet secure
normal eyelid posture. And so was born the pinch blepharoplasty.
My personal experience, now approaching 1500 cases, began in
2001 and was originally reported in 2005, confirmed the sound
safety and efficacy of this approach.
Although the true incidence of eyelid malposition after a
traditional muscle flap blepharoplasty is not well defined, the
plethora of articles on the subject attests to its persistence.
Scleral show has been ascribed to multiple causes: excess skin
removal, untreated eyelid laxity, denervation of the orbicularis
oculi muscle, and scarring of the outer or middle lid lamellae.
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 VI Eyelid Surgery

a b
Fig. 38.2 This 55-year-old woman, (a) shown preoperatively and (b) 1 year after a traditional skin–muscle lower blepharoplasty, exhibits scleral
show, a telltale postoperative residuum. (Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr
Surg. 2005; 115:1405-1412.)

This postoperative problem may be considered subtle and indeed skin resection, unavoidable muscle denervation, and middle
is often not even acknowledged. But it is an undeniable, glaring lamellar scarring can conspire to explain this unpredictability. The
example of the operated look that we should all strive to avoid. deliberate placement of the skin–muscle incision more inferiorly
And there is an equally prevailing blind spot within our literature to preserve a wider remaining orbicularis strip of muscle may be
to the frequently incomplete removal of lower eyelid skin excess. salutary but has not proven to be a dependable tactic.
Like so many of our advances, the aforementioned panoply
of frustrations with our traditional techniques simply led me to
38.2 Birth of the Technique resurrect a better idea. The pinching of the excess skin from the
lower eyelid is not a new concept: Parkes et al were actually the
There have been many valiant efforts to reduce the incidence
first to suggest the technique, in 1973. However, their description,
of eyelid malposition following traditional blepharoplasty. As
which predated the transconjunctival approach, attenuated its
documented by arem and Resnick, one approach has been to
potential benefits with their division of the underlying orbicularis
forgo the skin incision entirely and approach the eyelid instead
muscle to retrieve the excess fat.
through the conjunctiva only, thus definitively preserving the
Then, in 1992, Dinner et al published a single case report on the
integrity of the outer and middle eyelid lamellae. Although the
ultimate combination of the skin pinch with the transconjunctival
incidence of scleral show with this technique may be less, except
approach in what they called a no flap technique. Ristow included
for the very young patient with nominal fat herniation and skin
a variation of the concept in Mimis Cohen’s 1994 textbook with a
wrinkling, even with natural shrinkage, redundant eyelid skin
direct, rather than pinched skin resection, guided by a measured
will otherwise be left untreated, if not worsened by the proce-
and marked technique akin to traditional upper eyelid.
dure’s inevitable eyelid deflation.
Ultimately, my actual impetus to revisit and refine the concept of
In an effort to mitigate this outcome, the addition of skin resur-
a pinch blepharoplasty did not arise from an exhaustive literature
facing with a chemical peel or laser has been suggested. However,
search. Instead, primed with the aforementioned concerns, it
unless the skin redundancy is quite modest, even this strategy may
began with the serendipitous observation of one single slide within
not adequately treat the skin redundancy. Also, should the entire
a comprehensive presentation by Glenn elks in 2000. The solution
face not be properly treated,, distracting lines of demarcation are
became even more lucid considering our decades-old standard
always possible. Additionally, if either of these therapies penetrates
approach to the upper eyelid blepharoplasty: we already measure
too deeply, undesirable changes in eyelid posture may still occur.
the extent of eyelid excess with a temporary skin pinch while
ith a skin–muscle flap, a relatively conservative resection
observing the effect on the eyelash and brow posture. hy not
of the skin has always been advocated, regardless of the extent
apply the same simple metric to the lower eyelid but with an actual
of redundancy. Indeed, it is often impressive how little skin is
skin pinch Thus was born the pinch blepharoplasty series.
actually removed despite such an aggressive flap dissection. And
of course, in a patient with more significant excess skin, this con-
servatism has surely led to inadequate treatment.
Another adjunctive technique, particularly in the patient with
38.3 Evolution of the Technique
a lax eyelid, is to enhance canthal support by an iteration of can- First, the most important evolution was that the pinch tech-
thoplasty or canthopexy. In principle, this strategy should ame- nique eventually fully displaced the skin–muscle flap approach
liorate the incidence of lid malposition, but the results have been in my practice. From there, three additional seminal technical
frustratingly inconsistent: we have all seen scleral show after a tweaks were made.
traditional blepharoplasty despite the addition of this attempted
1. Initially, as I reported, I did not invoke the stitch canthopexy in
canthal fortification. An inadequate canthopexy, overaggressive patients who did not demonstrate obvious laxity or show. How-

440

ever, before long I once again began to witness, even in these
patients, albeit not as severe or often, scleral show. Accordingly,
I have since integrated the canthopexy in all blepharoplasty pa-
tients with an incidence now of even mild show that approaches
zero. This strategy actually makes cogent sense when one con-
siders that any patient who presents with aging changes will per
force have laxity of their tarso-ligamentous sling.
2. Early in my experience, I found a subset of patients, particularly
the most wrinkled, who, despite the pinch excision, were still
left with some residual skin. Thus was born the planned, sec-
ond-stage re-pinch.
3. Despite its efficacy, this strategy did mandate a second inter-
vention, usually appended by a repeat stitch canthopexy. So, a
new tack was taken to endeavor to remove more if not all of the
redundant skin initially by gradually moving lower onto the eye-
lid and closer to the excess. This advance has indeed essentially
displaced the second-stage pinch while still delivering as incon-
spicuous a scar as before.
At this point in the evolution, I am now fully armed with a
maximally secured stitch canthopexy that in turn facilitates a
maximally confident pinch skin plasty, for not only the most
wrinkled but even the properly festooned.
38.4 Principles of the Technique
From its birth and evolution, this technique is girded by three
principles:
1. The first guiding premise is that one need not widely under-
mine tissue in order to recruit, excise, and otherwise treat its
Fig. 38.3 Demonstration of the principle that vertical skin excess
is most effectively removed by its vertical recruitment through a
horizontally oriented skin pinch.
e er ye id in e r y
excess. Instead, this excess is most efficiently removed by either
drawing the tissue in the same vector of its excess and/or ex-
cising it through an incision perpendicular to the excess. In the
case of lower eyelid wrinkling and the pinch skin plasty, both of
these maneuvers are employed: the vertical excess is effectively
captured by its naturally facile recruitment vertically and ex-
cised through a conveniently well-hidden incision horizontally
(Fig. 38.3).
This same principle is inherent in the powerful lateral
recruitment of neck skin in the pinch rhytidoplasty and in the
effective discontinuous dissection and advancement of skin in
the high tension abdominoplasty, as originally described by
Lockwood. In effect, the smoothing of lower eyelid wrinkling
may be analogized to the making of a rumpled bed (Fig. 38.4).
2. The second fundamental precept is that the inherent sup-
port within a structure must be strengthened before a load
should strain it. So, in the instance of the lower eyelid, before
the weight of any surgery should test this retinacular sling, it
should first be tightened: hence, the efficacy of the stitch can-
thopexy girding the eyelid prior to the pinch skin plasty. Effec-
tively, this maneuver is analogous to tightening a clothesline
before placing a load of wet garments on it (Fig. 38.5, Fig. 38.6).
b
Fig. 38.4 (a,b) Demonstration of the pinch skin plasty effectively
“making the bed” at the lower eyelid.
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 VI Eyelid Surgery

Fig. 38.5 Illustrating how the stitch canthopexy girds the eyelid before the pinch plasty, akin to the tightening of the “clothes line.”

3. The third motivating tenet is that to achieve maximal eyelid cor-

rection, the most efficacious tactic is to gravitate inferiorly and
pinch more of where the excess skin actually lives. This strategy
is akin to most effectively pulling a roll out of a living room car-
pet by doing so at the end nearest the excess.

38.5 Advantages
The true measure of success of any aesthetic surgical procedure
should be its ability to balance two goals at the same time: to
deliver better aesthetic results consistently whilst ensuring
maximal safety. My personal experience, now approaching 1500
pinch blepharoplasties, confirms that this approach is indeed
capable of simultaneously honoring those lofty goals as com-
pared with the traditional skin–muscle flap technique. This vari-
ation offers two distinctive advantages: more crepey skin can be
safely removed while an aesthetic eyelid posture is secured.
This rewarding marriage of these outcomes is primarily the
result of the inherent precision and power of the pinch technique.
The approach enables the surgeon to define more accurately and
execute, in real time, the maximal prospective skin resection
possible without affecting eyelid posture. The pinch technique
protects the eyelid and its posture on several fronts: it avoids the
creation of the bulky skin–muscle flap, which encourages both
excess swelling and attendant vertical traction, and it eschews the
violation of the orbicularis muscle and orbital septum, which can
lead to lid denervation and scarring.
Another reason for the improved aesthetic results is the often
seen amelioration of the eyelid–cheek groove with a more youth-
ful vertical shortening of the eyelid, secondary to the effacing
Fig. 38.6 Illustrating the third pinch principle.

442

effect of this deficiency by the overlying redraping with the more
complete skin resection.
These benefits translate into a more adaptable and consistent
blepharoplasty. And in so doing, the surgeon can forgo the need
for additional, more invasive procedures, such as fat grafting and/
or ORL release. This advantage is seen most gratifyingly in many
of our most both challenging and deserving patients: the morpho-
logically challenging with a negative vector and poor lid posture;
older patients with poor lid tone; those with extensive skin or fes-
toons; and younger patients with primary skin redundancy and
nominal excess fat. If there is asymmetric excess skin between
eyelids, or even within one eyelid itself, the pinch can be tailored
accordingly. Empowered with this versatile tool, the surgeon can
now treat, for example, the medial eyelid skin, a zone that was
traditionally neglected, for an even more complete result (often
including improvement of the nasojugal grooving). In addition,
because the skin excess is more thoroughly treated, the surgeon
can avoid the need for regional laser or other resurfacing of the
eyelid, with its added risks and period of healing and attendant,
often distracting lines of demarcation.
Moreover, in patients with an ample excess of skin and or even
proper festooning, the advantages of the pinch blepharoplasty
can be maximized with a more inferiorly placed eyelid pinch of
skin, to excise even more skin. This mid-eyelid pinch simply gets
closer to the excess, amplifying the pinch’s efficacy. Additionally, if
indicated, one can invoke a staged reapplication of the pinch. This
repinch can be accomplished quite simply, with a local anesthetic.
Thus, it is feasible to remove all crepey skin at the lower eyelid
safely.
38.6 Indications and
Contraindications
The pinch lower blepharoplasty can comfortably replace the
standard skin–muscle flap technique and be offered to the same
group of patients. In contrast to the standard technique, there
is a productive breadth of application, depending on the extent
of the patient’s problem. That is, all patients are candidates, but
Fig. 38.7 This 58-year-old woman demonstrates the “ideal” patient:
minimal fat, good morphology, and thin, crepey skin. (Reproduced
with permission from Rosenfield LK. The pinch blepharoplasty
revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)
e er ye id in e r y
some are better candidates than others. Although results will
be superior in all patients, defining the best and worst patient
candidates for the pinch most effectively illustrates the nuances
of the technique.
The ideal patient presents with abundant thin, crepey skin,
minimal excess fat, and morphologically advantageous anatomy
(such as high cheekbones and almond-shaped eyes). ith the
application of the pinch, the improvement achieved in these
patients can be dramatic, simply because the surgeon is able to
treat the eyelid more fully (Fig. 38.7).
At the opposing end of the spectrum, the imperfect patient is
one with thicker, sun-damaged skin, which clearly will not pinch
well (but is as equally a poor candidate for any surgical technique).
In these patients, it is best to plan the surgery so that the skin will
have the least distortion from local anesthetic so one may apply
the pinch most effectively (Fig. 38.8).
Because such a dramatic skin resection can be wielded with
this approach, the surgeon must be cautious when applying the
pinch to a patient with equally significant redundant fat, because
enough of this skin must remain to redrape the now less convex
lower eyelid.
38.7 Pertinent Anatomy
The essence of the pinch technique embodies a key anatomic
principle: to violate the eyelid anatomy as little as possible and,
if it is compromised by age and/or genetics, to rehabilitate it as
much as possible. Between the transconjunctival approach and
the pinch technique, this approach touches and takes only what
it needs to the skin leaving behind the critical neuromechan-
ical support: the orbital septum, the orbicularis muscle, and its
attendant nerves.
As for the canthopexy, the key anatomic principle is to keep
it simple. Because the lateral canthus truly comprises several
components and is not easily identified as a distinct structure,
the canthopexy has to become a kind of maneuver on faith : you
can only really feel its presence. That is, rather than trying to
painstakingly dissect and actually visualize the canthal tissues
themselves, the surgeon need only grasp and draw whatever
tissue is present in the area to know that the right stuff has been
Fig. 38.8 This 57-year-old woman exhibits the leathery, sun-damaged
skin that can resist the usual satisfying skin pinch.
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 VI Eyelid Surgery
captured. Then the strategy simply becomes a matter of manip-
ulating this anchor thoughtfully to perform an individualized
canthopexy.
38.8 Preoperative Assessment
38.8.1 History
The key to a better history in this and any aesthetic patient is to
glean all relevant information beyond the problem at hand, fi .
This becomes particularly pivotal since blepharoplasty patients,
by definition, are often more elderly and thus carry more his-
tory: such as other systemic diseases, skin cancers, smoking
or other drug addictions, or anesthetic and anesthesia issues.
Then there are several critical, site-specific historical points to
be gleaned, including a history of eye dryness, tearing, or the
need for drops; allergies; Graves disease; prior eyelid surgery;
and previous filler injections (hyaluronic acid HA , etc.) or
autologous fat grafts.
38.8.2 Physical Examination
The preoperative physical examination should include the same
component analysis as for any blepharoplasty. However, with
this approach the pinch allows one to modify the surgery to
match the patient’s problem, so the value of a detailed analysis is
even more rewarding.
The critical elements to evaluate are listed in the box.
Critical Factors to Assess in the Physical
Examination
• The extent of the redundant skin: If necessary, either a lower
pinch at the time and/or a staged second pinch procedure
is planned. This is particularly relevant in the patient with
significant “active” skin: exaggerated wrinkling on animation
or frank festooning.
• The extent of the redundant fat: Depending on the volume
of excess, more or less skin should be pinched to ensure that
enough skin is left behind.
• The degree of lid laxity and attendant scleral show (as eval-
uated by a snap/distraction test et al): This can be treated
efficiently with a stitch canthopexy.
• The level of the lateral canthus (canthal tilt): The canthal
position can be adjusted relatively precisely with the stitch
canthopexy.
• The vector angle of the globe to the malar (positive/neutral/
negative): This aids the surgeon in the design of the best
application of the pinch and canthopexy components of the
surgery.
444
38.8.3 Photography
There are several tenets to be followed for photographic evalua-
tion of the eyelids and documentation of the results.
Prevent Parallax Error
Parallax error refers to the distorting difference in the apparent
position of an object when viewed along two different lines of
sight. Thus, in order to avoid parallax error, photographs must
be taken with the patient and surgeon seeing eye to eye ; that
is, there should be no height discrepancy that could potentially
distort the appearance of the posture of the lower eyelid in
relation to the globe.
This problem can be manifested when either the patient is not
level or the camera is not level. These effects can either mask or
exaggerate the actual eyelid position (Fig. 38.9).
e re e r e e
hen a tighter photo of just the eyelids is taken, some patients,
responding to the flash’s effect, may widen their eyes dramati-
cally. If this is noted, pulling the camera back to include a full-
face picture should correct this distortion (Fig. 38.10).
Follow the Dermatologist’s Credo
To document the salutary effects of the pinch procedure accu-
rately, progressively closer pictures of the face should be taken,
from full face to true close-ups of the wrinkles at the lower eyelid
(Fig. 38.11).
Control the Patient’s Emotions
There is a place for both active and passive photographs of a
patient’s lower eyelid. Photos should be taken of the patient smil-
ing to define the extent of muscle–skin excess. Often orbicularis
wrinkling is the patient’s primary concern, and any correction
of this problem is a true measure of the technique’s efficacy.
However, a smile can camouflage an eyelid posture or scleral
show problem (Fig. 38.12).
Compare the Present with the Past
The patient should be asked to bring photographs from the
past (such as college or wedding photos or well-focused candid
photos). The insight gained from reviewing such historic images
is invaluable not only for observing changes in the characteris-
tics of the periorbital area but also in our attempt to recapture
the patient’s characteristic expression or persona.
38.8.4 Patient Education
A patient with significant wrinkling must be informed that
either a more inferior and/or a second pinch blepharoplasty may
be necessary. The goals and actions of a canthopexy should be
explained, because in some instances the palpebral fissure will
purposely become more almond-shaped.
 e er ye id in e r y

Fig. 38.9 Patient poses (above) and camera positions (below) that can affect the evaluation of eyelid posture, whether pre- or postoperatively.

Fig. 38.10 Photographs demonstrating the obvious influence of the camera flash on eyelid posture depending upon its distance from the subject.

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 VI Eyelid Surgery

a b
Fig. 38.11 Deliberately macro (a) pre and (b) post photo-documentation to more clearly demonstrate the effect of the pinch plasty on skin wrinkling,
with minimal scarring.

Fig. 38.12 Demonstration of how a smile can at once prove the significant improvement of orbicularis muscle effect with the pinch procedure and
deceive with the “correction” of a subtle scleral show.

38.9 The Procedure
38.9.1 Sequencing of Procedure
Following a proper sequence of steps in the pinch blepharoplasty
is critical if both predictable and maximal results are to be
realized:
1. Mark an eyelid pinch line, running horizontally from medial to
lateral, as close as possible to the preponderance of excess skin/
wrinkles.
2. Place no local anesthetic, if patient is under general or deep
anesthesia, or do so early (e.g., before the facial prep) to allow
the skin to return to a natural state in order to ensure maximal
control at the time of its pinch.
3. Conduct the upper eyelid blepharoplasty next, leaving the
wound open in anticipation of the canthopexy.
4. Complete the transconjunctival portion of the lower blepharo-
plasty, before the pexy, to ensure facile distraction of the eyelid.
5. Perform the stitch canthopexy through the upper eyelid wound
(or a 1-cm or so lateral upper eyelid counterincision), before the
pinch, since some measure of lower eyelid skin may be treated
with this maneuver.
6. Close the upper eyelid wound, before the pinch, as once again,
lower eyelid excess skin will be drawn by this step.
7. Perform the lower eyelid pinch procedure, as proximate to the
excess as possible and close the wound.
38.9.2 Details of Procedure
Protection
Corneal shields are placed at every facial case, whether or not an
eyelid surgery is conducted. It is prudent to utilize evaginated
shields, sporting an expanded cupula that promotes better
oxygenation of the cornea, particularly for more lengthy cases.

446

Markings
Mark a guiding pinch line along the lower eyelid, representing
the uppermost margin of the future excision. Medially, this line is
usually placed several millimeters from the ciliary margin, con-
tinuing in a straight line laterally, deliberately leaving a progres-
sively enlarging triangular island of intact skin reaching 5 mm in
minimum height below the lateral eyelid margin. This maneuver
further discourages scleral show by lessening the purse-string-
like scar contracture that may occur with a curvilinear incision
hugging the ciliary margin (Fig. 38.13).
However, the latitude of this line should be modified depending
on the location and quality of the excess skin. That is, the pinch
line could and should be moved progressively lower on the eyelid
when there is more excess skin, to chase the excess and facilitate
maximal skin removal. I go lower on the eyelid because that’s
where the excess skin is (to paraphrase illie Sutton). As long
as the final closure rests within the eyelid tissue proper, the scar
will remain as reliably imperceptible as all scars in this anatomic
zone (Fig. 38.14). In addition, by doing so, the nasojugal-orbital
grooves can often be simply and gratifyingly treated as well.
Local Anesthesia
After the markings, the surgeon applies local anesthetic every-
where but at the lower eyelid skin. Otherwise, it should be placed
early and judiciously to both minimize the amount of local
swelling and maximize its resolution.
Upper Blepharoplasty
If the upper eyelid is to be rejuvenated simultaneously, that pro-
cedure should be performed first. ormally just the premarked
excess skin is resected, preserving more or less of the underlying
muscle, depending upon the heaviness of the eyelid. Then
Fig. 38.13 A purposeful straight line of marking is designed to leave
a margin of intact skin that is wider (at least 5 mm) laterally than
medially as an added antidote to the inherent effects of scarring and
potential outcome of scleral show. (Reproduced with permission
from Rosenfield LK. The pinch blepharoplasty revisited. Plast
Reconstr Surg. 2005; 115:1405-1412.)
e er ye id in e r y
the underlying orbital fat is usually conservatively treated by
contraction with the electrocautery or, as indicated by direct
excision, most often just at the medial pocket. The upper eyelid
wound is purposely left open to allow access for the later can-
thopexy. If an upper blepharoplasty is not planned, then a lateral
1-cm counterincision is made within the outer portion of a
routine upper eyelid marking.
Transconjunctival Surgery
The transconjunctival portion of the procedure is best conducted
next, preceding the canthopexy, lest the surgeon have difficulty
distracting the tightened eyelid. ith two double hooks for expo-
sure, the conjunctiva is broadly incised, at least 5 mm superior to
the sulcus, with a needle-tipped electrocautery. Once identified,
the excess fat, just as in the upper eyelid, is conservatively either
trimmed or electrocauterized and the wound reapproximated at
its midsection with a 6–0 fast-absorbing catgut suture.
Stitch Canthopexy
The canthopexy should be performed next, before the lower
eyelid pinch procedure, because the potential lateral lift of the
pexy can treat a measure of the lower eyelid excess.
I distinguish two kinds of canthopexy to consider and execute:
prophylactic and therapeutic. The choice is primarily determined
by two factors: the position of the lateral canthus and the posture
and tone of the lateral lower eyelid. If the lateral canthus is at or
above the horizon and/or the lower eyelid tone is mildly weak
without scleral show, a prophylactic pexy is in order. If, instead, the
lateral canthus is at or below the horizon and/or the lower lateral
eyelid tone is measurably weak with scleral show, a therapeutic
lateral canthopexy should be performed. ithin the therapeutic
category, this repair can be functional, to correct a weaker eyelid,
and/or aesthetic, to create a more almond-shaped eye.
In either case, the procedure is conducted through the lateral
aspect of an upper blepharoplasty incision or, if an upper bleph-
aroplasty is not planned, through a counterincision: using the
Bovie, a segment of approximately 1 cm of the superolateral inner
orbital rim is exposed, with great care to preserve the integrity of
the periosteum, which will be relied upon for the ultimate pexy
stitch (Fig. 38.15).
a b
Fig. 38.14 (a) This patient has significantly more wrinkling than the
patient shown in Fig. 38.12. (b) The marking and resultant pinch are
intentionally set almost twice as far inferiorly to chase and treat the
excess skin on the eyelid more effectively, in one stage.
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 VI Eyelid Surgery
ext, a subfascial/submuscular tunnel is created between the
orbital rim and the lateral canthus using round-tipped iris scissors
(Fig. 38.16).
ith the index finger of the nondominant hand over the lateral
canthus, the lateral canthal tissue is then captured using a very
fine-tipped, curved mosquito clamp (Fig. 38.17).
Then, prior to committing the anchoring of the pexy, slight
traction is made on first the mosquito and then the suture to con-
firm the adequate, but not excessive, correction of eyelid posture
and canthal position as necessary (Fig. 38.18).
If a prophylactic canthopexy is planned, the mosquito clamp
tip is passed up to the orbital rim to determine the ideal pexy
location, which will at once effectively tighten the lower eyelid
and still maintain the canthal angle.
If a therapeutic pexy is desired, the mosquito clamp tip is
placed more superiorly on the orbital rim as needed to realize the
desired correction of the eyelid posture and/or canthal position. If
some resistance is felt when doing so, then the canthal tissues, still
within the grasp of the mosquito, can be gradually released with
a scissors or Bovie, essentially performing a gradated cantholysis.
This maneuver should be conducted with the mosquito on some
tension so that the surgeon can proprioceptively conduct a
controlled liberation of the canthus. At most, a partial release is
usually all that is necessary to treat the eyelid properly and still
thwart its overcorrection.
The canthopexy is sutured in place by taking a double bite of
the captured canthal tissue with a 5–0 clear nylon suture and
securing this tissue to the periosteum within the orbital rim. Of
technical note, if the surgeon is right-handed and standing fully at
the patient’s left side, the needle may erroneously be passed from
top down at the periosteum, resulting in the suture potentially
tearing out as it is tied. Thus, it is best, on this side, to deliberately
stand behind the head of the patient in order to pass the needle
Fig. 38.15 Through the lateral upper eyelid wound, careful dissection
to expose intact the lateral orbital periosteum, which will be crucial for
anchoring of the canthopexy.
Fig. 38.17 The micro-tipped mosquito clamp is seen capturing the
canthal tissues in preparation for the pexy.
448
more naturally from the bottom up along the orbital rim to ensure
a proper throw of the suture. Of course, this applies in reverse,
at the right eye, for a left-handed surgeon.
The canthopexy is shown here before and after it is secured.
Either opaque scleral protectors may be removed or transparent
scleral protectors employed to facilitate evaluation of the outcome
of the pexy stitch.
The surgeon can then evaluate the efficacy of the pexy on eyelid
tone by conducting an immediate distraction test. An intraoper-
ative distraction test is shown before and after the canthopexy
(Fig. 38.19). Based upon these assessments, the suture should be
reapplied if the desired lid tightening and/or canthal positioning
effect has either been unrealized or exaggerated.
38.9.3 Pinch Skin Plasty
If no local anesthesia was initially placed and the patient is not
under general anesthesia, a bolus of intravenous sedation medi-
cation is given in anticipation of the pinch procedure. Then, using
two fine Adson-Brown forceps, the eyelid skin is progressively
pinched along the strategically chosen premarked line to capture
the maximal amount of excess, creating a proportional standing
wall of skin (Fig. 38.20). The endpoint should be the maximal
recruitment of wrinkled skin resting primarily below while still
preserving a normal posture of the eyelid margin above. That
said, in the less common instance of significant wrinkled skin
above the pinch marking, this tissue can certainly be included
in the pinch (Fig. 38.21). An additional goal and outcome of
the pinch can be the simultaneous salutary effacement of any
orbital/nasojugal grooving that may be present.
Fig. 38.16 The path for the future capture of the canthal tissues is
made.
Fig. 38.18 Visual confirmation of the potential effect of the cantho-
pexy before it is permanently anchored to the orbital rim.
 e er ye id in e r y

Fig. 38.19 Additional confirmation, after the fixation of the cantho- Fig. 38.20 The two Adson-Brown forceps progressively and differen-
pexy, of an effective correction of lid laxity. tially gather the excess to the other, to ultimately create a “skin wall.”

a b

c d
Fig. 38.21 (a–d) Demonstration of progressively more inferiorly situated pinch walls depending upon the location and extent of the deformity to be
corrected. (Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)

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 VI Eyelid Surgery
Once the wall of skin is created, it is essential that its excision
take place in relatively rapid succession before it naturally recedes.
A fine forceps is used to deliver traction at an oblique angle and
then a straight pair of supercut type scissors is employed to
amputate the skin wall at its base, in the fashion of excising a skin
tag that is, not so superficial that excess tissue is left behind, but
not so deep that adjacent skin is inadvertently excised (Fig. 38.22).
The appropriate amount of skin has been removed if the wound
edges are properly kissing or at least proximate (Fig. 38.23).
Otherwise, in the very occasional instance that there is obvious
remaining excess, the surgeon can return with the same scissors
to trim any obviously still pinched skin judiciously. In what should
be truly a rare predicament, should too much skin have been
excised, the extracted skin would probably best be replaced as a
skin graft.
Prior to closure, the wound is purposely splayed open, both to
electrocoagulate any small bleeding vessels as well as to infuse
some local anesthesia with epinephrine if none had been initially
(Fig. 38.24, Fig. 38.25). The incision is closed with a 7–0 running
nylon suture. o taping or other support of the eyelids is neces-
sary postoperatively.
38.10 Ancillary Procedures
Except for those with truly advanced states of excess, in the
vast majority of patients, since the pinch blepharoplasty treats
the wrinkled excess skin at the lower eyelids so much more
comprehensively, the usual adjunct modalities, such as resur-
facing or peeling, are essentially never necessary at the primary
surgery and still only very rarely at a second stage treatment.
In addition, even though the aggressive removal of excess skin
from both the upper and lower eyelids does indirectly soften the
expression of the crow’s feet, a regular regimen of neuromodula-
tors is still usually necessary postoperatively. Finally, as has been
mentioned, with the now more inferiorly placed and ambitiously
conducted lower eyelid pinch, the naso-jugal-orbital grooving
is often effectively corrected by the effacement of the overlying
skin. Otherwise, if particularly recalcitrant, this grooving is
treated, sometimes intraoperatively but usually postoperatively,
with an injected dose of diluted HA.
38.11 Postoperative Care
Patients are started on iced cotton eye soaks during the surgery
itself. If the eyes are iced early and often, there will be reliably
less swelling and bruising. The patient performs this same icing
routine continually for the first 48 hours, with intermittent
breaks and then more on and off for an additional 3 days. Then,
by the fifth day, the sutures are usually removed and intermittent
warm compresses are started for the next 5 days. Of note, with
this technique, a taping and/or massage protocol is unnecessary.
In addition, herbal products (Arnica montana and bromelain) to
reduce bruising and swelling are given for the first 2 weeks post-
operatively. At 2 weeks after surgery, the patient may gradually
return to routine exercise over the subsequent 4 weeks.
The definitively greater efficacy of a lower on the eyelid pinch
has essentially replaced the need for my originally recommended
staged repinch. If a repinch is still deemed necessary, however,
450
it is best to wait at least 6 months for definitive healing. This stage
can be performed under local anesthetic with diazepam (Valium)
as necessary. If there is more than a minor amount of residual
redundant skin, then a repeat canthopexy is advisable to facilitate
a confident reapplication of the pinch.
38.12 Problems and Complications
The pinch blepharoplasty is a re-engineering of the traditional
blepharoplasty’s D A in order to prevent its equally traditional
complications and shortcomings. Thus, scleral show, eyelid
malposition, dry eye, and residual eyelid wrinkling are now very
rare occurrences. Accordingly, postoperative taping and massage
need no longer be a usual and customary step in the care of
the blepharoplasty patient. Concomitant resurfacing treatments
have also become unnecessary with this more complete treat-
ment of the eyelid redundancy.
However, some issues, albeit minor, are unique to the pinch
blepharoplasty and should be highlighted:
1. Visible knot: If a nonabsorbable nylon-type suture is used for
the canthopexy, care should be taken, particularly in the thinner
patient, to ensure that the knot rests on the inside of the orbital
rim and that the suture is cut close to the knot, to prevent its po-
tential visibility through the upper eyelid skin. If, despite these
efforts, the suture becomes visible, it has been clipped shorter
early in the postop course or even extracted with impunity after
3 months. I tried a braided fiber suture in an effort to avoid this
potential problem, but after two cases of stitch abscess mandat-
ing extraction, I returned to the clear nylon.
2. Reddened scar: hen the pinch is purposely performed lower
on the eyelid to maximize wrinkled skin removal, a reddened
scar will initially, per force, be more visible. The patient should
be duly informed of this and the fact that these same scars do
uniformly mature inconspicuously. In fact, as I tell my patients,
in contrast to the upper eyelid, I have never had to revise a lower
blepharoplasty pinch scar.
3. Lateral chemosis: Although it is not necessarily specific to the
pinch blepharoplasty, a lateral chemosis may result postsurgery.
Its exact etiology remains annoyingly unknown, but it is my and
others’ impression that canthal manipulation of any time may
be one of its contributing factors. This problem is always self-
limiting within a few weeks, but its resolution should be facili-
tated with a postoperative regimen of a combination antibiotic
and steroid drop and ophthalmologic guidance if it unduly per-
sists. If it is seen intraoperatively, phenylephrine drops can be
started right away for potentially immediate relief. To obviate
this nuisance problem, it is best to strive to capture the canthal
tissue with your first and only bite.
4. Fat necrosis: Like lateral chemosis, this problem is not directly
due to the pinch procedure, it may occur after fat manipulation
through the lower eyelid transconjunctival portion of the proce-
dure. That is, if the electrocautery either following or instead of
excision of the fat is too enthusiastic, one or more firm nodules
can, albeit very rarely, present themselves either early or, less
commonly, late postoperatively. atchful waiting over several
weeks has resulted in spontaneous resolution in the couple of
instances seen in my series.
5. Pexy variability: Finally, if performed too aggressively, the can-
thopexy can produce an overly corrected result. Usually this
effect will improve over the first few weeks postoperatively.
On the other hand, if the pexy is not harnessed adequately, the
patient may be left with a canthal or lid deformity mandating a

Fig. 38.22 Excision of the pinch wall with dedicated supercut scissors
angled slightly upwards to control the exact resection of only the skin
pinched and no more.
Fig. 38.24 Splaying the wound open, demonstrating both the minimal
bleeding post pinch and the primarily intact orbicularis muscle.
second repair. The best preventive maneuver is to deliberately
pause and critically assess the pexy result at surgery and redo
the repair as needed until it is right.
38.13 Outcomes
The foundation of this modification of the lower blepharoplasty
is built on a triad of maneuvers:
1. The deliberate preservation of the eyelid’s integrity, with inher-
ently less invasion, through the use of the transconjunctival ap-
proach
2. The mindful alignment of the canthus and the lower eyelid with
respect to the orbit and globe respectively, with the application
of the stitch canthopexy
e er ye id in e r y
Fig. 38.23 Ideally, if there is no visible or only a nominal wound cre-
ated immediately following the pinch, this finding definitively confirms
that the proper amount of excess skin has been excised.
Fig. 38.25 Illustrating the usual extent of the wound post pinch
(10–15 mm).
3. The proficient excision of the redundant skin, with a tailored
accuracy, by the robust harnessing of the pinch technique
These same strategies deliver three reliable outcomes:
1. Attenuation of postoperative swelling and bruising on account of
this technique’s inherently kinder, gentler approach
2. Both prevention and treatment of eyelid malposition and can-
thal displacement with a discerning application of the malleable
stitch canthopexy
3. Reduction in residual excess skin secondary to the flexibility
and horsepower of the skin pinch approach while maintaining
inconspicuous scarring
Together these efforts consistently deliver a salutary removal of
redundant skin of the eyelid while still safeguarding its posture.
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 VI Eyelid Surgery
In fact, with greater comfort performing the stitch canthopexy,
the surgeon can often go one step further and create a subtle,
more aesthetic shape to the otherwise normal lower eyelid. On
the other hand, particularly in a morphologically challenging
patient, the canthopexy may definitively correct the attendant
canthal deformity. If the pinch is deliberately placed more infe-
riorly, closer to the excess, most if not all of the redundant skin
can be captured without the need for my originally described
second-stage repinch.
These examples demonstrate the following:
1. Decidedly less bruising and swelling and, thus, faster healing
with the less invasive pinch blepharoplasty (Fig. 38.26, Fig.
38.27)
b
Fig. 38.26 The typical early appearance of a postoperative patient is
shown at (a) 5 days and (b) at 10 days.
452
2. The extent of skin excision possible with the pinch technique,
averaging from 5 to 20 mm, increasing in size when challenged
by greater degrees of excess skin and wrinkling, which in turn
navigates the pinch ever lower on the eyelid (Fig. 38.28)
3. The reliable production of nominal scarring even when the skin
pinch is conducted at a lower latitude on the eyelid to capture
the excess skin more productively (Fig. 38.29)
38.14 Results
The following cases were chosen to demonstrate the flexible
power of the pinch procedure given various patient presenta-
tions from the ideal candidate to the most challenging, from the
elderly to the youthful.
Fig. 38.27 Postoperative appearance at 2 weeks.
b c
Fig. 38.28 (a–c) Demonstrating typical pinch wounds resting higher
or lower on the eyelid depending upon the extent and location of the
excess skin.
 e er ye id in e r y

38.14.1 The Ideal Patient 38.14.4 The Aging Patient

The best patient to choose as an inaugural application of the
pinch blepharoplasty technique is an older patient who has thin,
fair skin, minimal fat herniation, moderate wrinkles, and good
eyelid tone and facial morphology.
38.14.2 The Festooned Patient
Patients with proper festooning, with cascading excess skin
encroaching the cheeks, have always represented a surgical
challenge. However, with the full-on application of the pinch
blepharoplasty, these cases can be corrected with both maximal
aesthetics and safety (Fig. 38.30).
38.14.3 The Elderly Patient
The key concern with the elderly patient is their inherent tarsoli-
gamentous laxity of the lower eyelid and its attendant risks when
strained by a lower blepharoplasty surgery: from distracting
scleral show to symptomatic ectropion. The goal, therefore, must
be to address this vulnerability proactively before attempting to
correct the aging changes. It is just this kind of scenario where
the pinch blepharoplasty shines.
The middle-aged patient who presents with the beginnings of
facial aging can be desirous of its complete correction but equally
fearful of its looking overdone. The pinch blepharoplasty, with its
protective but still comprehensive strategies, reliably addresses
both of these issues.
The 53-year-old woman shown in Fig. 38.31 with the classic
stigmata of aging would previously have undergone a routine
blepharoplasty with CO2 laser or chemical resurfacing. Instead, an
upper and lower pinch blepharoplasty was accomplished with a
conservative transconjunctival fat reduction, a therapeutic stitch
canthopexy to restore her albeit nascent senescent eyelid show,
and a confident pinch plasty to smooth out her lower eyelid. The
result hearkens back to her youthful aesthetics as seen in the
picture from her early 20s.
38.14.5 The Younger Patient
Patients between 35 and 45 years of age who present with nascent
but very real signs of aging and are often frustrated by the lack of
definitive results with nonsurgical treatments and still desirous
of both a proper correction and attenuated downtime can now

a b
Fig. 38.29 (a,b) Inconspicuous scar, resting practically in the middle of the lower eyelid, is the vestige of a more robust treatment of the excess
skin—a particularly powerful strategy in men.

a b
Fig. 38.30 (a) This 64-year-old patient underwent a comprehensive transconjunctival fat trimming and a notably robust pinch plasty (over 15 mm)
effectively performed with its placement at the mid-eyelid and confidently executed with the support of a secure stitch canthopexy. (b) The result
reveals a relatively “complete” repair not only of the skin but of the orbital groove as well. These lower pinch placements still consistently deliver, as
seen here, as an inconspicuous a scar as any other.

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 VI Eyelid Surgery

be offered a solution that efficaciously marries the extent of the satisfying reduction in this shadowing and dark circles (Fig. 38.32,
solution to the extent of the problem: the pinch blepharoplasty. Fig. 38.33).

38.14.6 The “ Orbitally-Grooved”/ 38.14.7 The Younger Congenital Scleral

“Dark-Circled” Patient Show Patient
Orbital-nasojugal grooving can be either an earlier or a later The younger patient can present with congenital scleral show
distracting sign of aging and fatigue. Again, there are as many that would otherwise be ascribed to eyelid laxity later in life.
contested solutions to the problem as there are many suspected These patients should thus be afforded a therapeutic stitch
causes. However, one can often avoid the direct treatment with canthopexy to restore the more natural, aesthetic almond-
fillers or fat, with the attendant risks and inconsistencies, by shaped eye with a pinch skin plasty as indicated (Fig. 38.34).
the effacing effect of the pinch skin plasty in combination with
the softening influence of a conservative excision of overhang-
ing fat.
38.14.8 The Morphologically
Often in tandem with the grooved patient is the common Compromised Patient
adjunct complaint of darkly colored lower eyelids, which falsely
Patients who present with all the attributes of poor design a
project the appearance of tiredness. There are again as many
lax eyelid with show, negative canthal cant, and a flat cheek with
suspect sources of this problem, including hypervascularity,
a larger globe are always at risk of suffering the full spectrum
thin skin, and true hyperpigmentation, as there are imperfect
of eyelid posture complications following the routine blepharo-
solutions, such as laser treatment, medicinal depigmentation, and
plasty, from detracting scleral show to debilitating ectropion.
camouflage makeup. A consistent additional factor, however, is
However, a reliable antidote to this scenario is the proper har-
the excess shadowing caused by the peaks and valleys of crepey
nessing of the pinch blepharoplasty with the stitch canthopexy
skin. ith the proper mobilization of the pinch technique, this
(Fig. 38.35).
offending crepey skin can be essentially effaced, delivering a

a b b
Fig. 38.31 (a) The patient is seen preoperatively at age 53, (b) in a historic photo at age 23, and (c) postoperatively at age 54, with an attractive,
youthful eyelid posture restored.

a b
Fig. 38.32 (a) Dark shadowing highlighted by the crepey skin and the grooving accentuated by the overhanging fat. (b) “Correction” of both by the
simulated pinch and pexy.

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 e er ye id in e r y

a b
Fig. 38.33 (a) Patient and (b) corroborative results at 1 year.

a b
Fig. 38.34 (a) This 32-year-old woman presented with the complaint of an overly large globe accentuated by excessive scleral show. (b) An isolated
therapeutic stitch canthopexy was successfully conducted along with an upper blepharoplasty.

38.14.9 The Male Patient with 38.14.11 The Aging Herniated Patient
Poor Morphology Patients who present primarily with herniated fat and little
excess skin must be treated with a more conservative pinch:
Men can often be more challenging for blepharoplasty by virtue
that is, most of this same skin must otherwise be preserved to
of their inherently thicker, heavier skin, which together both
repaper the future, more concave eyelid following the removal
resists facile excision, resulting in potential undertreatment,
of the prodigious volume of fat.
and attracts swelling, threatening eyelid posture deformities.
ith the application of the pinch blepharoplasty technique, it is
possible to prevent these kinds of complications and still deliver
a successful aesthetic result.

38.14.10 The Thick-Skinned Patient

The opposite end of the patient candidate scale from the ideal
a b
patient is the stiffer skinned patient. Such patients are inher-
ently harder to treat with any blepharoplasty technique. hen
performing the pinch technique on these kinds of patients, it
is doubly important that the eyelid be as virginal as possible
before pinching, so either no local anesthesia is placed or it is
placed long before the pinch to facilitate as much control as
possible. That said, the pinch approach still offers a safer tactic to
capture this excess skin and deliver an aesthetic result.
c d
Fig. 38.35 (a,c) This 65-year-old patient underwent an upper bleph-
aroplasty in tandem with a therapeutic canthopexy and pinch lower
blepharoplasty that corrected both the depressed canthus and the
eyelid problem itself, as shown 18 months postoperatively (b,d).

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 VI Eyelid Surgery

38.14.12 The “2-Day Prime” Patient 38.14.13 The “Repinch” Patient

Candidates, not unreasonably, often desire the delivery of the
quickest recovery as possible to allow for the earliest return to
work: the 2-day Prime. Although the pinch blepharoplasty
clearly cannot deliver a full recovery in 2 days, it does shorten
the healing significantly.
Although the planned second stage repinch has essentially been
replaced now by the more inferiorly positioned first pinch, this
approach remains a powerful cleanup tactic when implemented
(Fig. 38.36).

Fig. 38.36 (a,b) This 56-year-old patient presented with advanced sun-damaged skin for which a staged second pinch was planned at 6 months. (c) The
patient is seen in a historic photo at age 20 and 1 year after the repinch surgery, demonstrating reasonable success at recapturing her youthful look.

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38.15 Concluding Thoughts
The pinch blepharoplasty and stitch canthopexy modifications
together empower the surgeon to tame and command greater
control of the lower eyelid and ultimately deliver a better aes-
thetic result more safely. Personally, I have found the effects of
this technique quite gratifying: I have both a newfound serenity,
with its prevention of surgical stigmata, and a dependable satis-
faction with its promise of a more comprehensive correction. In
addition, because of its inherently kinder, gentler strategies, the
pinch lower blepharoplasty results in less bruising and swelling.
Thus, the patients enjoy a distinctly faster recovery. The pro-
verbial therapeutic postoperative taping and massage may be
abolished from routine practice.
The procedure’s advantages are particularly manifest whether
the surgeon is presented with the ideal, ber-wrinkled patient,
where one can offer a more complete correction, or the most mor-
phologically challenging patient. And now with the more inferi-
orly placed pinch, one can also realize improvements in patients
with proper festoons and orbital grooving. As an endorsement of
the efficacy of the pinch blepharoplasty, I have not performed a
skin–muscle flap for the lower blepharoplasty in over 20 years.
And the pinch blepharoplasty has eliminated the need for lower
eyelid resurfacing in most cases.
I now perform more canthopexies intelligently and excise more
skin confidently. The results of these efforts have included consis-
tently faster patient recovery, more accurate canthal and eyelid
positioning, and what is most important, significantly improved
aesthetic outcomes obtained more safely.
Clinical Caveats
• The surgeon should either infiltrate the local anesthetic after
the pinch or as early and minimally as possible.
• The less distortion of the tissues, the more accurate and facile
the pinch maneuver will be. This is particularly germane at
the start of a surgeon’s learning curve. To this end, it is often
helpful to sedate the patient more deeply just before the
pinch procedure.
• The stitch canthopexy should now be considered an integral
part of the surgery. Every patient presenting for a proper
blepharoplasty per force harbors laxity of the tarsoligamen-
tous sling. That said, the action of the canthopexy may be
classified as either prophylactic (elderly, prominent globe,
e er ye id in e r y
or malar hypoplasia) or therapeutic (measurable laxity, or
negative lateral canthal position scleral show). This stitch can-
thopexy, when judiciously harnessed, empowers the surgeon
to take full advantage of the pinch procedure and perform
the most complete removal of redundant skin.
• The pinch skin plasty should run horizontally and rest at least
5 mm from the ciliary margin to obviate cerclage-like and ver-
tical scarring, respectively. The pinch should be conducted as
low and close to the excess crepey skin as possible, taking
as much medially, if indicated, as one would traditionally
laterally. in order to recruit the skin maximally and correct
the orbital groove effectively. While creating the skin wall,
the surgeon endeavors to maximally “efface” the tissues
below the pinch while still preserving the posture of the ciliary
margin above. This same wall must be deliberately excised by
ensuring the ideal scissor angle while doing so.
• Both the pinch blepharoplasty and the stitch canthopexy
techniques have a notable learning curve. During this evo-
lution, the surgeon should be aware that it is deceivingly
easy to both “over- or underpinch” and “over or under pexy.”
So, when conducting either, the surgeon should have a low
threshold to both adjust the size of the pinch wall and replace
the pexy stitch if over- or undercorrection is perceived.
Suggested Reading
1 Dinner MI, Glassman H, Artz S. The no flap technique for lower-lid blepharo-
plasty. Aesthetic Plast Surg 1992;16(2):155–158
2 elks G , elks EB. o-touch lower blepharoplasty. In: Cardoso de Castro C,
Boehm A, eds. Techniques in Aesthetic Plastic Surgery, Vol. 5. Midface Surgery.
Philadelphia, PA: Elsevier/Saunders; 2009:59–76
3 Lambros VS. Hyaluronic acid injections for correction of the tear trough deformi-
ty. Plast Reconstr Surg 2007; 120(6, Suppl):74S–80S
4 im EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty. Ann Plast
Surg 2008;60(5):532–537
5 Rosenfield L . The pinch blepharoplasty revisited. Plast Reconstr Surg
2005;115(5):1405–1412; discussion 1413–1414
6 Parkes M, Fein , Brennan HG. Pinch technique for repair of cosmetic eyelid
deformities. Arch Ophthalmol 1973;89(4):324–328
7 Ristow B. Transconjunctival blepharoplasty. In: Cohen M, ed. Mastery of Plastic
and Reconstructive Surgery, Vol. 3. Boston, MA: Little, Brown; 1994
8 Rosenfield L . Pinch blepharoplasty: a safe technique with superior results.
Aesthet Surg J 2007;27(2):199–203
9 arem HA, Resnick I. Minimizing deformity in lower blepharoplasty. The
transconjunctival approach. Clin Plast Surg 1993;20(2):317–321
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 VI Eyelid Surgery

39 Avoidance and Treatment of Complications of Aesthetic

Eyelid Surgery
Ted Wojno

swelling should have the consistency of bread dough, which

Abstract
is greatest on the second or third postoperative day. Elevation
This chapter outlines the potential functional and aesthetic of the head and frequent application of cold compresses are
complications of eyelid surgery. Diagnosis and management are therapeutic.
discussed. Since most eyelid procedures involve opening the orbital
septum, infection, if it does occur, can spread into the orbit and
present as either a preseptal or orbital cellulitis or frank orbital
Keywords
abscess. Given the increasing prevalence of methicillin-resistant
canthotomy, cantholysis, lagophthalmos, retraction, ectropion, Staphylococcus aureus (MRSA) in the general population, any
epiphora, dry eye, chemosis, eyelid crease suspicion of bacterial infection should prompt a culture of
the wound to guide appropriate oral or intravenous antibiotic
therapy.
39.1 Introduction
Complications of aesthetic eyelid surgery range from tempo- 39.2.2 Orbital Hemorrhage
rary and mild to permanent and devastating (Table 39.1, Table
39.2). Although complications can never be completely avoided, and Hematoma
their frequency and severity can be minimized by a thorough Postoperative orbital hemorrhage is a true emergency, since
preoperative evaluation, judicious planning, and carefully it can lead to visual loss via compression of the central retinal
performed surgery. Listening to and understanding a patient’s artery or optic nerve. Hemorrhage usually develops quickly
postoperative complaints is extremely helpful in avoiding and often follows an episode of straining, coughing or Valsalva
unhappiness. maneuver. Patients complain of severe pain and firm swelling of
the eyelids and/or conjunctiva. Visual loss is often immediate but
may not be noticed by the patient if the upper eyelid is swollen
39.2 Functional Problems shut. Prompt treatment (ideally within the first hour) consists of
opening all the surgical incisions and, if necessary, canthotomy
39.2.1 Infection and cantholysis of the superior and inferior crura of the lateral
Given the robust blood supply to the periocular area, wound canthal tendon (Fig. 39.1). If possible, explore the wound to see
infection is fortuitously rare. Patients commonly complain of whether a clot can be expressed and to see whether there are
what they fear to be infection, but the vast majority of times, any sites of active bleeding that can be cauterized. If available,
their symptoms are simply the manifestations of the expected check the intraocular pressure and, if elevated or the globe is
postoperative edema and mucus discharge. The eyelid skin firm, administer topical ophthalmic timolol maleate 0.5 drops,
is thin compared with the rest of the body and swells quite oral acetazolamide 500 mg tablet (to decrease aqueous produc-
remarkably. The eye will typically respond to any insult with tion), and intravenous mannitol 20 , 2 g/kg as an osmotic agent
increased tear and mucus production, which patients fre- to shrink the vitreous humor. Ophthalmologic consultation is
quently mistake for bacterial infection, prompting a worried indicated.
phone call. I ask the patients to palpate the involved eyelid
and tell me whether it feels hot and firm to the touch, two
signs that would suggest infection. I tell them that the eyelid
39.2.3 Lagophthalmos and
Corneal Exposure
A small degree of lagophthalmos is normal immediately after
surgery due to the effects of local anesthesia. Eyelid edema can
Table 39.1 Functional problems that may be caused by eyelid surgery
also interfere with normal orbicularis oculi function, peaking on
Visual loss Trichiasis
Infection Ptosis
Orbital hemorrhage and Diplopia
hematoma Mydriasis
Lagophthalmos Paresthesias
Table 39.2 Aesthetic problems that may be caused by eyelid surgery
Corneal exposure Refractive change
Lid retraction Dry eye Eyelid shape Fat injection lumps
Lateral canthal rounding Epiphora Asymmetry Loss of lashes
Ectropion Chemosis Scar Underresection of fat
Entropion Skin texture differences Overresection of fat

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a b
Fig. 39.1 (a ) Canthotomy of the right lateral canthal tendon. (b) Another patient demonstrating cantholysis of the inferior crus of the right lateral
canthal tendon.

the second to third postoperative days. This is easily managed
by frequent application of bland ophthalmic ointment and cool
compresses. Exposure that persists beyond the first week is
usually due to overzealous skin excision or excessive tighten-
ing of the levator muscle in ptosis repair (Fig. 39.2). Massage
of the upper and/or lower eyelids may remedy mild cases, but
additional surgery is frequently needed. If due to ptosis repair,
the only solution is to release the levator muscle to the point
of closure of the eyelids. If due to excessive skin excision and
if the lagophthalmos is mild, it may be possible to open either
the upper or lower lid incisions and gently tease the wound
apart to alleviate the vertical skin shortage. The wound is then
allowed to heal by secondary intention and will usually provide
a surprisingly good cosmetic result. If severe, a skin graft will be
needed, much to the displeasure of the patient, since cosmesis
is rarely perfect.
For best cosmetic results in the upper eyelid, the skin graft
should be placed in the pretarsal portion of the eyelid immedi-
ately adjacent to the lid margin (Fig. 39.3). If, however, the upper
eyelid fold is still quite low, the lower edge of the skin graft can be
placed just superior to the eyelid crease, with the result that the
graft is nicely hidden in the fold (Fig. 39.4).
In the lower eyelid with overresection of skin, the graft
is generally best placed onto the surface of the tarsal plate
(Fig. 39.5). Lagophthalmos developing after several weeks is
uncommon but is usually due to scarring in the plane of the
lower eyelid retractors (so-called middle lamella scarring). This
can be remedied by cutting and recessing the capsulopalpebral
fascia and interposing a spacer graft (ear cartilage, hard palate,
or autologous or banked dermis) between the cut edge of the

b
Fig. 39.2 (a) A patient with lagophthalmos due to excessive resection Fig. 39.3 A patient 1 month after skin grafts to both upper eyelids
of upper eyelid skin. (b) The same patient demonstrating the retrac- placed onto the tarsal plates to treat lagophthalmos from previous
tion of the upper eyelids on downgaze. overresection of skin.

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 VI Eyelid Surgery
c (b) The same patient one month after skin grafts to the anterior
Fig. 39.4 (a) A patient with lagophthalmos of the left upper eyelid
due to excessive skin excision. (b) The patient after placement of a
skin graft in the left upper eyelid just above the eyelid crease (arrow).
(c) The patient in primary gaze, demonstrating that the skin graft is
covered by her upper eyelid fold.
retractors and the inferior border of the tarsal plate to lift the
lid vertically (Fig. 39.6).
Very rarely, lagophthalmos is due to damage to the branches of
the facial nerve innervating the eyelids. This may happen if there
has been extensive dissection in the periocular area for the eyelid
surgery or, more typically, from ancillary procedures such as rhyt-
idectomy or forehead lift. If permanent, procedures to improve
closure, such as placement of an upper eyelid weight or palpebral
spring, may be needed.
Also rare is presence of an adhesion between the levator muscle
and the superior orbital rim. This can occur if there has been
excessive resection of the preaponeurotic fat pockets (Fig. 39.7).
Release of the adhesion, accompanied by fat mobilization from
deeper in the orbit or fat grafting, may be necessary.
39.2.4 Lid Retraction and
Lateral Canthal Rounding
Upper eyelid retraction is due to excessive tightening of the
levator muscle in ptosis repair or excessive skin excision in upper
eyelid blepharoplasty. The treatment is as outlined in the pre-
ceding section on lagophthalmos and corneal exposure. Lower
lid retraction may be due to excessive skin excision or scar in
the plane of the lower eyelid retractors, as also discussed in the
preceding section. Lower lid retraction can also occur if an over-
zealous horizontal lid tightening procedure was performed on a
460
b
Fig. 39.5 (a) A patient with bilateral lower eyelid skin overresection.
surface of the tarsal plates.
globe with physiologic exophthalmos ( 18 mm). In such cases,
the lower eyelid bowstrings under the prominent globe. The
classic analogy is that of the man with the pot belly tightening
his belt. The more he tightens the belt, the greater the overhang
of his belly. This is more frequently seen in patients with a flat
malar eminence and heavy jowls. This may improve with time
and massage, but if it does not, it is best treated by recession of
the lower eyelid retractors with interposition of a spacer graft,
as discussed in the preceding section. If present, suspension of
a ptotic midface will also help. Lateral canthal rounding (round
eye deformity) is essentially a form of lower eyelid retraction
in which the retraction is more noticeable in the lateral eyelid
(Fig. 39.8).
39.2.5 Ectropion
Ectropion is present when the lower eyelid margin stands
away from the globe. It is differentiated from retraction,
wherein the lid margin is applied to the globe buts rests below
the inferior limbus. Lower eyelid retraction and ectropion may
coexist. A mild degree of ectropion may be noted in the hours
just after surgery. This is due to the effects of local anesthesia
on the orbicularis muscle and resolves when the anesthetic
wears off. This is more common when a horizontal shorten-
ing of the lid margin has not been performed at the time of
blepharoplasty. Persistent frank ectropion of the lower eyelid
generally has two causes. The first is overresection of the
anterior lamella, as is seen in lower eyelid retraction. In this
respect, ectropion is simply a more profound manifestation
of the same problem that causes lower eyelid retraction. The
second cause is failure to correct excess horizontal laxity of
 A id n e nd re men m i i n Ae ei ye id Surgery

a a

b
b
Fig. 39.7 (a) A patient who had adhesion of the upper eyelids to
the superior orbital rim after overresection of the preaponeurotic
fat (a prosthetic eye is present on the left). (b) The same patient in
downgaze.

Fig. 39.6 (a) A patient with middle lamellar scarring and retraction
of both lower eyelids. (b) The same patient 2 months after recession
of the lower eyelid retractors and interposition of ear cartilage grafts
between the retractors and the inferior border of the tarsal plates. (c)
Diagram of a spacer graft between the lower lid retractors and the
inferior border of the tarsal plate.

Fig. 39.8 Lateral canthal rounding is essentially a lower eyelid retrac-

tion more severe in the lateral part of the lower eyelid.
the tarsoligamentous sling at the time of lower eyelid bleph-
aroplasty. The two causes are intrinsically related, because as
vertical excision of the lower eyelid anterior lamella increases,
As with lower eyelid retraction, a mild case of ectropion can
so must the horizontal tension on the lid margin increase
be treated by opening the subciliary portion of the incision and
in order to support the entire lid. This may occur more fre-
teasing the edges apart to heal by secondary intention. If due to
quently if the lower eyelid blepharoplasty has incorporated fat
uncorrected horizontal laxity, a lid shortening procedure will
repositioning into the cheek, which is done to soften the naso-
usually suffice (Fig. 39.9). Severe cases will require the addition
jugal fold. Fat repositioning involves cutting the orbitomalar
of a skin graft and/or recruitment of skin from the midface
ligament to access the sub–orbicularis oculi fat (SOOF). Since
(Fig. 39.10).
the orbitomalar ligament is one of the supporting ligaments of
It is often difficult to determine what steps are necessary to
the midface, lysing it essentially converts the cheek and lower
correct lower lid malposition after blepharoplasty. If uncertain,
eyelid into a single unit, which can pull down the lower eyelid
one can perform a two-finger test as outlined by Patipa to
margin.
determine the etiology of the problem. In the first step of this

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test, the examiner places the index finger against the lateral
lower eyelid and pushes it toward the lateral orbital rim (effec-
tively performing a horizontal tightening of the lower lid). If the
ectropion/retraction is corrected with this maneuver, horizontal
shortening of the lower eyelid is indicated (Fig. 39.11). It is
important to push the eyelid only laterally and not superiorly.
If the ectropion remains, the examiner then pushes superiorly
with the middle finger in the middle third of the eyelid. If the
ectropion/retraction is eliminated by this additional step, a
middle lamellar graft may be needed (Fig. 39.12). Some have
added an additional step with a three-finger test in which a
third finger is used to push skin up from the midface. Here, if the
ectropion/retraction is now reduced, a skin graft or midface lift
may additionally be required, indicating a relative skin shortage
in the eyelid.
39.2.6 Trichiasis and Entropion
Entropion is an inward deviation of the eyelid margin, result-
ing in the normally positioned eyelashes abrading the globe.
Trichiasis is a true misdirection of the lashes in a normally posi-
tioned lid margin. In fact, most of what is called trichiasis is

a
a

b b
Fig. 39.9 (a) A patient who developed ectropion after lower eyelid Fig. 39.10 (a) A patient with severe ectropion of the left lower eyelid
blepharoplasty due to failure to correct horizontal lid laxity. (b) The after lower eyelid blepharoplasty. (b) The same patient after horizontal
same patient after horizontal lower eyelid shortening. eyelid shortening and skin graft to the left lower eyelid.

a b
Fig. 39.11 (a) A patient with retraction of the right lower eyelid. (b) In the first step of the “two-finger test,” the lateral lower eyelid is pushed against
the lateral orbital rim. In this case, the retraction is corrected by this maneuver, indicating the need for horizontal shortening of the lower eyelid.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New ork, N : Thieme; 2018.)

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 A id n e nd re men m i i n Ae ei ye id Surgery

a b c
Fig. 39.12 (a) A patient with retraction of the right lower eyelid. (b) In the first step of the two-finger test, the lateral lower eyelid is pushed against
the lateral orbital rim. In this case, the retraction is not improved. (c) In the second step of the two-finger test, the examiner pushes up on the
middle of the lid margin with the middle finger. Now the retraction is improved, indicating the need for middle lamella support in the form of a graft.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New ork, N : Thieme; 2018.)

actually a focal cicatricial entropion of the lid margin. Entropion
and trichiasis may be present in the same eyelid. Cicatricial
entropion is due to contraction of the posterior lamella of the
upper or lower eyelid. It can occur after any surgery utilizing a
conjunctival approach including lower eyelid blepharoplasty.
Treatment consists of any of a number of procedures to rotate
the lid margin outward or expand the posterior lamella of the
eyelid with a graft, usually mucous membrane. In general, trichi-
asis and entropion are exceptionally uncommon problems after
blepharoplasty surgery.
True trichiasis or a very focal entropion can be treated with
electrolysis, cryotherapy, or surgical excision of the involved lid
margin.
39.2.7 Ptosis of the Upper Eyelid
Many cases of ptosis after blepharoplasty are undoubtedly due to
lack of recognition in the preoperative period. This may be seen
in cases where the patient is exerting significant frontalis muscle
action to compensate for the loss of field induced by the redun-
dant skin and eyelid position. Careful preoperative evaluation and
nullifying the action of the frontalis muscle with the examiner’s
finger are needed to detect this. Extreme postoperative swelling
of the upper eyelids can also lead to ptosis due to stretching of
the levator aponeurosis. hen noted postoperatively, the only
solution is to perform a ptosis repair.
It is common for patients to note some diplopia in the hours
following eyelid surgery due to the effects of local anesthetic on
the extraocular muscles. This is quite frequent when hyaluro-
nidase has been added to the local anesthetic mixture, which
functions to spread the solution into the anterior orbit. This
will resolve within a few hours as the effect of the local wears
off. Orbital hemorrhage and edema also cause diplopia and are
accompanied by obvious signs of proptosis, eyelid swelling, and
ecchymosis. This will resolve after several days and is helped
by frequent cool compresses. Persistent diplopia is usually due
to damage to the inferior oblique muscle, which separates the
medial and middle fat pockets in the lower eyelid. The muscle
is relatively anterior in this location and can be easily harmed
by direct trauma from the surgical instrumentation (Fig. 39.13).
Given the primary and secondary action of this muscle, patients
may complain of a vertical deviation with a torsional component.
Ophthalmologic consultation is indicated. Strabismus surgery
may be needed and, if so, is usually only partially successful in
alleviating symptoms.
A less frequent cause of diplopia in the postoperative period
is decompensation of a previously existing phoria to a tropia. A
phoria is a latent deviation of the globe held in check by normal
fusional abilities and can become a manifest tropia after surgery
due to edema or sedation. This, too, usually resolves in a few
days.

39.2.8 Diplopia
By far and away, the most common cause of this complaint
after surgery is the natural tendency of patients to use the term
double vision for any disturbance in visual function. Swelling
from the surgery, blurred vision from lubricating ointments, and
tearing are the usual causes. The physician should ask patients
whether they frankly see two distinct objects side by side or one
on top of the other. Also inquire whether the problem is tempo-
rarily resolved by wiping the eyes or blinking. If so, the patient
can be reassured that this symptom is normal and temporary.
39.2.9 Mydriasis
Pupillary dilation may be observed for a few hours after
lower eyelid surgery. This occurs if local anesthetic is used,
especially when combined with hyaluronidase. The local dif-
fuses into the anterior orbit and affects the inferior division
of the oculomotor nerve, which supplies the parasympathetic
fibers to the pupil. Since this nerve also supplies the inferior
rectus and inferior oblique muscles, a vertical deviation of
the globe may be observed and the patient complain of diplo-
pia. This resolves quickly as the effect of the local anesthetic
dissipates.

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 VI Eyelid Surgery

a b
Fig. 39.13 (a) The inferior oblique muscle visible between the medial and middle fat pockets of the lower eyelid (forceps retracting the medial fat
pocket). (b) Diagrammatic representation of the inferior oblique muscle of the right lower eyelid separating the medial and middle fat pockets.
(Reproduced from Codner MA, McCord CD. Eyelid and Periorbital Surgery. New ork, N : Thieme; 2016.)

39.2.10 Paresthesias of the Eyelid
Cutaneous incision performed in upper or lower eyelid blepharo-
plasty severs many of the fine sensory nerves to the lid margin
(Fig. 39.14). This results in numbness and paresthesias of the
lash line, most noticeable to women when applying eye makeup.
Some will complain that it makes application of makeup difficult
due to loss of tactile feedback from the makeup brush. This
resolves in 6 to 12 months.
39.2.11 Refractive Changes
The refractive state of the eye (myopia, hyperopia, and astig-
matism) is in part determined by the level and pressure of the
eyelids on the globe, which in turn determine corneal shape and
curvature. Any eyelid procedure leads to swelling and often a
difference in the lid level, which may cause significant changes
in the refractive error. Patients may quite suddenly notice that
vision is compromised, although the occasional patient may
actually report acuity improvement. Such changes are almost
universally temporary, with the refractive state of the eye
returning to baseline in 2 to 4 months. Patients should be advised
against changing their eyeglass or contact lens prescriptions
during this time.
39.2.12 Dry Eye and Epiphora
It is important to realize that any procedure on the eyelids
temporarily changes the mechanics of blinking, thus altering the
complex nature of the precorneal tear film (Fig. 39.15), leading
to a variety of symptoms. Fortunately, this is usually temporary
and patients return to baseline when edema resolves and normal
eyelid mechanics resume.
Dry eye and tearing are two of the commonest problems in
the ophthalmologist’s office and probably the most common
complaints after periocular surgery. Symptoms of ocular surface
problems are very bothersome to patients and cause significant
visual complaints. The etiology of such problems often confounds
those whose sole practice is ophthalmology. Adding to this prob-
lem is the unfortunate tendency of some providers of eye care to
label any complaint as dry eye, thus telling the patient to use
frequent artificial tears. Even worse is the almost reflex prescrip-
tion of an antibiotic–steroid combination eye drop or ointment
in the complete absence of infection or inflammation. umerous
ophthalmic disorders that present with symptoms of foreign body
sensation, ocular irritation, and inflammation are often misdiag-
nosed, leading patients to subsequently report that they have dry
eyes or blocked tear ducts. So what is a nonophthalmologist to do
when confronted with these complaints
Most true dry eye disorders are due to a decreased production
of the aqueous component of the tear film (keratoconjunctivitis
sicca), which occurs with age and certain ocular disorders.
Symptoms of aqueous deficiency dry eye can be exacerbated by
any ocular or periocular surgery. The documentation of aqueous
tear deficiency is made by the Schirmer tear test (Fig. 39.16) per-
formed with application of a topical ophthalmic anesthetic (often
called the basic secretion tear test). Unfortunately, the test is not
completely reliable, having frequent false positives and negatives.

464
 A id n e nd re men
Fig. 39.14 One of the many vertically oriented sensory nerves that are
usually cut as part of an upper eyelid blepharoplasty.
Examination of the corneal surface is easily done by instilling a
drop of fluorescein from a premoistened, sterile ophthalmic strip
(Fig. 39.17) into the eye and observing the ocular surface with a
cobalt blue light (Fig. 39.18).
Initial treatment of aqueous-deficiency dry eye consists of
supplementing the tear film with over-the-counter lubricating
drops or ointments. Lacrimal gland secretion may actually be
increased by using cyclosporine or lifitegrast drops. Regrettably,
these medicines take 2 to 3 months to be effective, and they work
on only a minority of patients. Dry eye can also be treated by
decreasing lacrimal outflow, thus keeping the naturally produced
tears in contact with the ocular surface for a longer period of time.
This is achieved by occluding the lacrimal puncta with dissolvable
plugs, silicone plugs, or even thermal cautery. In general, it is
legitimate to suggest to patients who complain of ocular irritation
after surgery to use liberal amounts of over-the-counter artificial
tears and/or ointments. Various preservative-free preparations
are less likely to cause long-term hypersensitivity issues, but for
Fig. 39.16 Schirmer tear test (basic secretion tear test) for dry eye.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New ork, N : Thieme; 2018.)
m i i n Ae ei ye id Surgery
Fig. 39.15 Diagram of the precorneal tear film. (Reproduced from
Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New
ork, N : Thieme; 2018.)
short-term treatment there is no real reason to prefer one brand
over another.
Evaporative dry eye occurs when despite normal aqueous tear
production, there is excessive exposure of the ocular surface. This
form of dry eye can also be seen in certain ocular surface disorders
that affect the outer, lipid-containing layer of the tear film, which
is responsible for preventing evaporation of the aqueous layer of
the precorneal tear film. Since the mechanics of normal blinking
constantly spread the lipid layer of tears over the aqueous layer,
surgically induced lid edema will temporarily interfere with this
process. Evaporative dry eye secondary to surgery will usually
Fig. 39.17 Moistening a fluorescein-impregnated ophthalmic strip
with tap water. (Reproduced from Nahai F, Wojno T. Problems in
Periorbital Surgery: A Repair Manual. New ork, N : Thieme; 2018.)
465
 VI Eyelid Surgery
Fig. 39.18 Illumination of the cornea with a cobalt blue pen light,
demonstrating keratitis of the inferior cornea, which is stained with
fluorescein. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New ork, N : Thieme; 2018.)
normalize in few weeks as swelling diminishes and lid function
normalizes. This, too, is treated with liberal amounts of artificial
tears and ointments.
True epiphora is caused by increased tear production or
decreased lacrimal outflow. Increased tear production occurs
in any situation that causes ocular irritation, which, of course,
includes periocular surgery. Lacrimal outflow obstruction,
common with age and periocular injury, is also seen when con-
junctival edema (chemosis) from eyelid surgery blocks the egress
of tears from the eyes. Patients can be reassured that epiphora
secondary to eyelid surgery will resolve when edema subsides.
Epiphora can also result from a subciliary lower eyelid incision.
This incision may cut the fibers of the buccal branch of the facial
nerve that innervate the medial orbicularis, and thus weaken the
lacrimal pump function of this part of the muscle (Fig. 39.19).
This, too, usually resolves with time as reinnervation takes place.
39.2.13 Chemosis
This can be one of the more annoying complications of eyelid
surgery and is most commonly seen after lower eyelid blepha-
roplasty, especially if inferior crus cantholysis was performed.
The frequency is also increased in the presence of concomitant
upper lid surgery. It likely represents accumulation of lymphatic
fluid in the sub-Tenon’s space, exacerbated by inflammation (Fig.
39.20). Lymphatic drainage of the upper lid is to the preauricular
nodes, while the lower lid drains to the submandibular nodes.
Ancillary procedures performed in these areas can also increase
its incidence.
Patients may complain of seeing a bubble, blister, or tear
in the lateral part of the eye and comment that they feel a foreign
body sensation when blinking. hile most chemosis resolves
spontaneously, there certainly are cases that can last up to a year.
The bothersome nature of the problem and its unpleasant appear-
ance prompt the patient to ask for treatment. umerous therapies
have been proposed, often with little evidence of effectiveness.
466
Fig. 39.19 Diagram of the innervation of the lower eyelid by the buccal
branch of the facial nerve. A subciliary incision can cut the branches
to the medial lower eyelid orbicularis, weakening the lacrimal pump
mechanism.
This perhaps leads to the conviction that the last intervention
tried was the right treatment, when what actually occurred was
spontaneous resolution.
Chemosis is sometimes seen developing even while lower
eyelid surgery is being performed. In this situation it may be
helpful to make a small 2-mm incision through the conjunctiva
and anterior Tenon’s capsule. This often results in a gratifying
immediate drainage of the fluid. The surgeon may also add a
temporary lateral tarsorrhaphy, which functions as a localized
pressure patch in the involved area.
Most of the time, the problem becomes apparent in the first
few weeks after surgery. If mild, it can be ignored and the patient
reassured. If symptomatic and unilateral, a pressure patch may
be placed for 24 to 48 hours. Topical ophthalmic steroid drops
(1 prednisolone) four times daily may help by decreasing
inflammation and edema. Topical ophthalmic nonsteroidal
anti-inflammatory drugs ( SAIDs), antihistamines, and decon-
gestants may also help. Severe chemosis may result in conjunc-
tival drying, and thus a bland ophthalmic ointment may provide
symptomatic relief.
Massage of the lower eyelid from medial to lateral (in the direc-
tion of the lymphatic drainage) may assist in resolution. A small
injection of hyaluronidase in the lateral conjunctiva may make
massage more effective. Conjunctival incision may also work for
chemosis that develops in the postoperative period. This is easily
done with only a topical ophthalmic anesthetic drop followed by
topical 1 to 4 lidocaine (Fig. 39.21).
39.3 Aesthetic Problems
39.3.1 Change in Eyelid Shape
Patients may complain about changes in the shape of the eyelids.
Some have the mistaken notion that surgery will restore their
youthful contours, which, of course, is rarely the case. This needs
 A id n e nd re men m i i n Ae ei ye id Surgery

to be pointed out in the preoperative evaluation. Actual changes levator aponeurosis and/or tarsus. ith a 5–0 or 6–0 polyester or
in shape of the eyelids are common with upper eyelid ptosis polyglactin suture, take a bite of the levator aponeurosis or tarsal
repair and lower eyelid horizontal shortening, both of which plate just deep to the lower edge of the incision (Fig. 39.23c). Then
affect the position of the eyelid margin. If objectionable, these take a bite of the orbicularis at the lower edge of the incision (Fig.
problems may require small surgical touchups in the months 39.23d), and tie (Fig. 39.23e). Repeat in two other spots evenly
following the original procedure. As with any other surgery, a placed across the incision (Fig. 39.23f).
very small group of patients seem to be exceptionally dissatisfied Upper eyelid asymmetry is also seen when pre-existing, unilat-
with their appearance despite what is in fact an excellent tech- eral brow ptosis is not corrected at the initial surgery. Sometimes
nical result. Such problems rarely have a satisfactory conclusion. however, brow asymmetry is not apparent until well after the
surgery, when frontalis relaxation occurs. A unilateral brow sus-
pension may be needed, while additional skin excision from the
39.3.2 Eyelid Asymmetry upper eyelid may suffice in mild cases.
Even a 1-mm difference in eyelid or crease levels is easily noticed
by most patients. Eyelid asymmetry may be due to uneven skin
or orbicularis muscle excision in lids that were evenly matched
39.3.3 Unacceptable Scar
prior to surgery. This is most easily remedied by additional skin Scars in the upper and lower eyelid generally heal nicely by 6
or muscle excision on the side with excess. Eyelid asymmetry months after surgery. Encouraging patients to avoid sun expo-
also due to failure to sculpt the fat pockets evenly. Again, addi- sure will be very helpful. Patients may, however, object to scars
tional fat removal on the side with excess will be effective. that do not match on the left and right eyes in terms of length and
Crease and fold asymmetry will result if the inferior edge of the angulation. Careful marking at the time of the original surgery is
upper eyelid incision was placed at different levels on each side. most important.
Careful preoperative measurement and marking will prevent this
problem. Most often, patients will complain that the eyelid with
the lower crease needs additional skin removal, when in fact, the
39.3.4 Complications of Fat Injection
surgical removal of skin was symmetric. Correction is best accom- Fat injections are increasingly incorporated into facial aes-
plished by raising the lower crease, a procedure that is generally thetic surgery. Injection of fat into the subcutaneous plane
more successful than attempting to lower a high lid crease (Fig.
39.22).
Crease elevation is accomplished by the following technique.
First, draw the proposed new crease on the upper eyelid above
the old, low crease. The new crease should be placed at the same
level as the crease on the opposite upper eyelid (Fig. 39.23a).
ith a blade, incise through skin and muscle at the proposed
new crease. ext, undermine with scissors the skin and muscle
below the incision line across the eyelid and on the surface of
the tarsus (Fig. 39.23b). This will remove the old, lower crease
by severing the attachments of the old crease to the underlying

b
Fig. 39.21 (a) Chemosis of the conjunctiva 2 months after a four-lid
Fig. 39.20 Chemosis of the conjunctiva 2 months after a four-lid blepharoplasty. (b) Chemosis is improved immediately after lateral
blepharoplasty. incision of the conjunctiva.

467
 VI Eyelid Surgery

a b c
Fig. 39.22 (a) A patient who complained of excess skin of the left upper eyelid after upper blepharoplasty. (b) The patient in downgaze, demonstrat-
ing that the real problem is asymmetric placement of the upper eyelid incisions, with the left being lower than the right (arrows). (c) The patient after
elevation of the crease on the left upper eyelid, demonstrating improved symmetry of the lid folds. No skin was removed on the left upper eyelid.

a b c

d e f
Fig. 39.23 (a) For crease elevation, draw the proposed new crease (down arrow) above the old crease (up arrow) to match the crease level on the
opposite upper eyelid. (b) With scissors, remove the old crease by undermining it across its length on the anterior surface of the levator aponeurosis
and/or tarsus. (c) Take a bite of the levator aponeurosis or tarsal plate with a 5–0 or 6–0 polyester or polyglactin suture just deep to the lower edge
of the incision. (d) Next, take a bite of the orbicularis at the lower edge of the incision. (e) Diagrammatic parasagittal section of the crease suture. (f)
Diagram of the three sutures forming the new crease. (Parts b,c,d,f reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual.
New ork, N : Thieme; 2018.)

of the eyelids can lead to a bumpy appearance in the skin.
This is a particularly difficult problem to cure and consists of
meticulous dissection and removal of the offending fat. hen
this problem occurs, treatment is rarely completely successful
(Fig. 39.24).
39.3.5 Skin Texture Problems
Patients with very thin skin who have a large resection of tissue
from the upper eyelid may complain that the skin above and
below the scar line does not match. This occurs when very
thin preseptal skin is sutured to thicker subbrow skin, creating
a sudden transition in the texture of skin at the scar line. o
treatment is possible, and fortunately, most patients seem to
adjust to this.
Some patients complain that the upper eyelid pretarsal skin,
especially just above the lash line, looks thicker than normal
after surgery. In some cases this is caused by persistent edema
and does normalize with time. In other cases, it seems that the
increased pretarsal show is simply perceived as thicker when in
fact it is normal. Again, patients seem to adjust eventually to the
appearance.

468
 A id n e nd re men m i i n Ae ei ye id Surgery

a b
Fig. 39.24 (a) A patient after upper eyelid blepharoplasty with fat grafting. She wanted the multiple eyelid folds corrected and some of the grafted
fat removed. (b) The patient 2 months after crease reformation and removal of some of the grafted fat.

39.3.6 Loss of Eyelashes Suggested Reading

1 Bernardino CR. Evaluating epiphora: nothing to cry about. Rev Ophthalmol
Patients may comment that their eyelashes are thinner after
2011: une 13. https://www.reviewofophthalmology.com/article/evaluat-
eyelid surgery. It is unclear whether this really occurs or is ing-epiphora-nothing-to-cry-about
simply a matter of perception. Lower eyelid lashes may have 2 Hirmand H, Codner MA, McCord CD, Hester TR r, ahai F. Prominent eye: oper-
indeed been cut with a subciliary incision, leading to the false ative management in lower lid and midfacial rejuvenation and the morphologic
appearance of lash loss. As the lashes grow back out, this will classification system. Plast Reconstr Surg 2002;110(2):620–628, discussion
629–634
normalize. Alternatively, the density of the lower eyelid lashes
3 Lelli G r, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg
may have decreased if a large horizontal lower eyelid shortening 2010;125(3):1007–1017
was incorporated into the repair. In this case, the overall number 4 McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg
of lashes per unit area will be decreased due to the stretching out 2003;112(1):222–237, discussion 238–239
of the lid margin. 5 McCord CD, reymerman P, ahai F, alrath D. Management of postblepharo-
plasty chemosis. Aesthet Surg J 2013;33(5):654–661
either of the mechanisms just described explains the per-
6 McCord CD, alrath D, ahai F. Concepts in eyelid biomechanics with clinical
ception of thinning of the lashes on the upper eyelid, however. implications. Aesthet Surg J 2013;33(2):209–221
It is possible that blepharoplasty sometimes induces a degree of 7 Mejia D, Egro FM, ahai F. Visual loss after blepharoplasty: incidence, manage-
ischemia of the lid margin, with subsequent loss of some of the ment, and preventive measures. Aesthet Surg J 2011;31(1):21–29
eyelashes. Be it real or imagined, there are a number of products 8 ahai F, ojno T. Problems in Periorbital Surgery: A Repair Manual. ew ork, :
Thieme Publishers; 2018
available for topical application that will improve lash growth.
9 Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface
These preparations can, however, cause contact dermatitis and suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite
permanently change the color of a lightly pigmented iris to dark approach. Plast Reconstr Surg 2005;115(7):2105–2114, discussion 2115–2117
brown. 10 Putterman AM. Regarding comprehensive management of chemosis following
cosmetic lower blepharoplasty. Plast Reconstr Surg 2009;124(1):313–314
11 Symbas , McCord C, ahai F. Acellular dermal matrix in eyelid surgery. Aesthet
Clinical Caveats Surg J 2011; 31(7, Suppl):101S–107S
12 einfeld AB, Burke R, Codner MA. The comprehensive management of chemosis
• Although most complications of periocular surgery are mild following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122(2):579–
and self-limited, visual loss and double vision can be severely 586
debilitating.
• Orbital hemorrhage is best treated within the first hour of
occurrence. Knowledge of canthotomy and cantholysis is
essential.
• Lid retraction, canthal rounding, ectropion, and lagophthal-
mos share common etiologies and may coexist in the same
eyelid. When severe, spacer grafts into the middle lamella
may be needed for adequate treatment.
• Dry eye and tearing are the most commonly reported com-
plaints after eyelid surgery. These symptoms can be easily
managed by the surgeon in the vast majority of cases.
• Chemosis is common after lower eyelid surgery, especially
when canthotomy and cantholysis have been performed.
Although it is usually self-limited, some cases can be very
resistant to treatment.
• Even a 1-mm asymmetry of eyelid levels between left and
right is easily noticed by most patients and is a common
source of dissatisfaction.

469
 Part VII
Midfacial Rejuvenation

VII

40 Clinical Decision Making in the Midface
Foad Nahai
Abstract
Rejuvenation of the midface is intricately related to periorbital
and lower eyelid rejuvenation. Options include volume enhance-
ment with fillers and fat as well as surgical approaches through
a temporal incision, the eyelid, or a facelift approach.
Keywords
transpalpebral mid facelift, endoscopic mid facelift, high SMAS,
MACS lift, fillers, fat grafts
40.1 Introduction
For most individuals, aging of the lower lid and midface is
intrinsically interrelated; therefore the best treatment options
rejuvenate both areas. There are many surgical and nonsurgical
options for rejuvenation of the midface. Facial rejuvenation in
Fig. 40.1 Temporal, transpalpebral (eyelid), and facelift approaches to malar fat pad elevation with their vectors of elevation. The transpalpebral
approach is the only one that offers a vertical vector of elevation.
40 Clinical Decision Making in the Midface
general, and periorbital and cheek rejuvenation in particular,
is no longer solely in the surgical domain. The role of inject-
able fillers has evolved and offers another option for mid face,
periorbital, and lower lids. Despite the popularity of injectables
for most patients surgical procedures are the best option, with
longer-lasting results and cost effectiveness in the long run.
Restoration of volume and repositioning of the malar fat pad is
the foundation of midface rejuvenation. Approaches for surgical
elevation of the malar fat pad include the following:
• Temporal approach
• Transpalpebral approach
• Standard or modified facelift approach
Although all of these approaches elevate the midface, with the
exception of the transpalpebral approach, the vector is usually
diagonal. A true vertical vector of elevation is achieved only
through the lower lid (Fig. 40.1).
473
 VII Midfacial Rejuvenation
40.2 Temporal Approach
The temporal approach entails an incision in the temporal area
and endoscopic dissection into the midface. Elevation and fixation
of the midface are accomplished through long suspension sutures
or fixation devices, such as the Endotine devices (MicroAire
Surgical Instruments, LLC, Charlottesville, VA).
The advantage of the temporal approach is that the scar is well
hidden within the hair. It is effective for elevating the midface
(malar fat pad) and affords some blending of the lid–cheek junc-
tion. However, it produces only a diagonal vector for elevation of
the midface and does not address aging of the lower lid or of the
lower face. The temporal approach is best for individuals with
isolated midface aging. It can be combined with blepharoplasty
and a lower facelift in individuals with panfacial aging.
40.3 Transpalpebral Approach
This approach affords not only a diagonal vector but also the only
true vertical vector for elevation of the midface, combined with
lower lid rejuvenation. The major concern about this approach
involves lower lid retraction. The approach can be modified to
minimize the risk.
If manipulation of the lower eyelid fat is planned, a full-length
skin–muscle incision is made and the skin–muscle flap elevated for
access to the periorbital fat. The risk of lid retraction is minimized
through the routine application of lid-anchoring techniques and a
diagonal vector on the orbicularis oculi muscle to add extra support
to the lower lid in addition to the aesthetic improvement (Fig. 40.2).
If fat manipulation is not planned, a very limited incision is
made laterally in the orbicularis, and midface mobilization is
accomplished with an endoscope, a headlight, or a small lighted
Aufricht retractor. This alternative approach, in which the orbi-
cularis is not divided along the entire length of the lid, carries a
lower risk of lid retraction while offering the same vertical and
diagonal vectors as the full open approach (Fig. 40.3).
Fig. 40.2 Elevation of the mid face through upward traction and
fixation of the orbicularis flap.
474
40.3.1 Clinical Cases
Two cases of this approach are shown in Fig. 40.4 and Fig. 40.5.
40.4 Facelift Incisions
Through the standard facelift incision or the modified prehair-
line incision, the superficial musculoaponeurotic system (SMAS)
is easily accessed and can be manipulated to elevate the midface.
Surgical Options
• The high-SMAS technique
• The extended minimal-access cranial suspension (MACS) lift
• SMASectomy and SMAS plication
40.4.1 The High-SMAS Technique
The incision in the SMAS at or above the level of the zygomatic
arch, combined with adequate mobilization of the SMAS, facili-
tates effective elevation of the midface and malar fat pad with
blending of the lid–cheek junction in a diagonal direction. hen
performed in isolation, it is not effective in dealing with the
aging lower lid; it does, however, reliably rejuvenate the midface,
lower face, and jaw line (Fig. 40.6).
40.4.2 The Extended MACS Lift
The third and highest of the purse-string sutures described with
the extended MACS lift effectively and diagonally elevates the
midface with some blending of the lid-cheek junction (Fig. 40.7).
Tonnard and Verpaele combine this procedure with a skin–pinch
blepharoplasty to rejuvenate the aging lower lid.
Fig. 40.3 Vertical and diagonal vectors of midface elevation through
the transpalpebral approach.
 40 Clinical Decision Making in the Midface

Fig. 40.4 (a) This 51-year-old woman underwent an endoscopically assisted brow lift, upper lid blepharoplasty, and lower lid blepharoplasty, together
with transpalpebral midface lift with orbicularis redraping and canthopexy. She also had a short-scar facelift. (b) The postoperative view at 1 year
shows blending of the lid–cheek junction and elevation of her midface as a result of the transpalpebral procedure. The lower face improvement is the
result of the short-scar facelift.

Fig. 40.5 (a) This 59-year-old woman underwent a secondary short-scar facelift and secondary upper- and lower-lid blepharoplasty, with transpalpe-
bral endoscopic midface lift and orbicularis redraping with canthopexy. (b) Her result is shown 1 year postoperatively with elevation of the midface
and blending of the lid–cheek junction.

475
 VII Midfacial Rejuvenation

a b
Fig. 40.6 (a) Superficial musculoaponeurotic system (SMAS) mobilization for complete cheek and eyelid rejuvenation. (b) SMAS mobilization for
jowls and neck only.

Fig. 40.7 Malar fat pad suspension using the extended minimal-access cranial suspension (MACS) lift.

40.4.3 SMASectomy
The upper part of the diagonal SMAS, when excised and sutured
or plicated, does effectively elevate the midface with some
blending of the lid–cheek junction. To rejuvenate the lower
eyelid fully, the surgeon must perform a blepharoplasty to deal
with the eyelid, skin, and orbicularis muscle (Fig. 40.8).

40.5 Choosing the Best Option

For patients who require a blepharoplasty to address the skin,
orbicularis muscle, and fat pads, the transpalpebral route offers
midface lifting and full rejuvenation of the lower lid. If the lower
lid rejuvenation requires only lid–cheek blending without exten-
sive skin, muscle, or fat manipulation, the temporal and facelift
approaches are suitable options. Fat grafts or fillers offer a less
invasive option for these patients. Fig. 40.8: Midface elevation by superficial aponeurotic system (SMAS)
excision and closure or plication.

476
 40 Clinical Decision Making in the Midface

Although the transpalpebral approach affords a more direct Table 40.1 Choosing the best option for midface rejuvenation
midface lift with unlimited opportunities for eyelid rejuvenation,
Vectors Rejuvenation/lift
it is also the only approach that poses a risk of eyelid retraction and
Vertical Diagonal Eyelids Midface Lower Jawline
its consequences. Some surgeons think that this risk is not ade- face
quately offset by the advantages. The eyelid approach also involves Transpalpebral + + + + ++++ ++++ ++++ — —
longer recovery, as does any complex procedure in this area.
Transtemporal + ++++ ++ +++ + —
Alternative approaches involving the percutaneous insertion of
barbed sutures have been advocated, but their efficacy and long- Facelift + ++++ ++ ++++ +++ +++
approach
term outcomes remain in question (Table 40.1).

[9] Hester TR, Codner MA, McCord CD, Nahai F. Transorbital lower-lid and midface
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[1] Codner MA, McCord CD, Hester TR. The lateral canthoplasty. Oper Tech Plast
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[11] Hirmand H, Codner MA, McCord CD, Hester TR r, ahai F. Prominent eye: operative
2 Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg
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1997;24(2):347–367
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3 Finger ER. A 5-year study of the transmalar subperiosteal midface lift with
12 elks G , Glat PM, elks EB, Longaker MT. The inferior retinacular lateral cantho-
minimal skin and superficial musculoaponeurotic system dissection: a durable,
plasty: a new technique. Plast Reconstr Surg 1997;100(5):1262–1270, discussion
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13 Lambros V. Fat injection for the aging midface. Oper Tech Plast Reconstr Surg
4 Hamra ST. Periorbital rejuvenation in composite rhytidectomy. Oper Tech Plast
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5 Hester TR Jr. Evolution of lower lid support following lower lid/midface
Reconstr Surg 1998;102(7):2471–2479
rejuvenation: the pretarsal orbicularis lateral canthopexy. Clin Plast Surg
15 Psillakis M, Rumley TO, Camargos A. Subperiosteal approach as an improved
2001;28(4):639–652
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6 Hester TR. Subperiosteal malar cheek lift with lower lid blepharoplasty. In Mc-
16 Ramirez OM. The subperiosteal approach for the correction of the deep nasolabi-
Cord CD, ed. Eyelid Surgery. Philadelphia, PA: Lippincott-Raven; 1995
al fold and the central third of the face. Clin Plast Surg 1995;22(2):341–356
[7] Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of
[17] Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift.
facial aging using the transblepharoplasty subperiosteal cheek lift. Aesthetic Surg
Aesthet Surg J 2012;32(8):927–936
Q 1996;16(1):51–58
[18] Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift: surgical technique
[8] Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. Evolution of
with indications and outcomes. Ophthal Plast Reconstr Surg 2002;18(5):319–330,
technique of the direct transblepharoplasty approach for the correction of lower
discussion 329–330
lid and midfacial aging: maximizing results and minimizing complications
[19] Tessier P. Subperiosteal face-lift in French . Ann Chir Plast Esthet
in a 5-year experience. Plast Reconstr Surg 2000;105(1):393–406, discussion
1989;34(3):193–197
407–408

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41 Midface Recontouring
Patrick Tonnard, Alexis Verpaele, and Adriana Cely

Abstract Keywords
Midface recontouring can be seen as the correction of centrofa- facial aging, midface rejuvenation, facial contouring, centrofacial
cial deflation as part of the facial aging process or as a minimally rejuvenation, augmentation blepharoplasty, fat grafting, lip lift,
invasive method to correct facial deformities in facial bone nanofat, lipofilling, prophyloplast
hypoplasias. A better understanding of the aging process of the
face shows that a combination of processes occurs rather than
just sagginess of the skin. There are changes in skin texture and 41.1 Introduction
pigmentation, and volume is lost in certain areas of the face.
The different mechanisms involved in facial aging are expressed to
The deflation process is most important in the centrofacial area,
varying degrees and in different combinations in each individual.
which consists of the periorbital and perioral areas.
Furthermore, because the distinct fat compartments in the face can
Fat grafting has become an integral and indispensable part of
change at different rates with age, the whole face does not age as a
the modern facial rejuvenation process. If the treatment goal is a
compound mass. Skin texture and pigmentation also change with
total and natural facial rejuvenation, the therapeutic plan must be
aging. Aging skin loses elasticity, resulting in sagging of certain facial
a combination of different modalities individually adapted to each
features, especially around the mouth and the neck. Contraction of
patient’s needs. In this chapter, main techniques for centrofacial
certain muscles will produce permanent wrinkles for example,
rejuvenation are reviewed as augmentation blepharoplasty, correc-
in the frontal area and the glabella, or the muscular bands of the
tion of nasolabial fold, lip enhancement, lip lift, perioral sharp-nee-
anterior neck. Finally, volume loss or deflation results in an implo-
dle intradermal fat injection (S IF), lip resurfacing, and nanofat
sion-like appearance with aging (Fig. 41.1). Sagging of facial skin can
treatment, showing results and outcomes with different cases.
be corrected with a surgical facelift procedure. Surgeons can treat
The main purpose of microfat grafting in facial contouring is
the eyelids, the eyebrows, the lips, and the neck; perform subman-
aesthetic correction of the facial proportions while avoiding inva-
dibular gland resection; or remove the adipose corpus of Bichat.
sive orthognathic surgery in patients with mild maxillary or man-
The difficulty is not in mastering all the surgical techniques but
dibular hypoplasia where occlusion problems of the teeth occur
rather in choosing the right combination of procedures and in
infrequently and can usually be corrected through orthodontic
understanding the correct indications for the different techniques.
treatment. This technique has become a valuable alternative
The texture and quality of the skin can be altered by skin care
to performing more complicated advancement osteotomies in
products with alpha-hydroxy acids or retinoic acid, light therapy
patients solely for aesthetic reasons. The low morbidity and rapid
such as intense pulsed light (IPL), or, more drastically, with resur-
recovery associated with facial microfat grafting make it a power-
facing techniques such as dermabrasion, a chemical peel, or carbon
ful tool in the armamentarium of the modern aesthetic surgeon.

Fig. 41.1 Aging is a combination of different mechanisms: sagging, wrinkling, contraction, volume loss, and loss of animation. Understanding the
importance of each of these factors will influence the therapeutic plan. IPL, intense pulsed light; SMASectomy, resection of the superficial musculoapo-
neurotic system. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

478

dioxide (CO2) or erbium laser resurfacing. Muscle hypertrophy
or hypertonia can be treated with surgical myotomies, selective
neurotomies, or less invasive temporary chemical denervation with
botulinum toxin. Volume depletion can be corrected with volumet-
ric surgical techniques or by adding volume with a heterologous
filler or autologous fat.
Every patient must be carefully analyzed, and a personal treat-
ment plan must be developed in consultation with the patient. The
surgeon is personally responsible for choosing and combining the
different treatment modalities according to the patient’s wishes,
the surgeon’s personal experience, and technical training. For the
past 20 years, we have always tried to use a combination of mini-
mally invasive surgical techniques. The magic word in this context
is synergy. The combination of fat grafting and surgical facelift
is an example of synergy. Performing facial fat grafting alone can
produce certain results, whereas surgical facelift procedures have
certain other effects. However, the combination of these two can
achieve results that cannot be obtained by either option alone.
41.2 Facial Aging
Loss of fat tissue is an important cause of physical aging in the
face. On the basis of analyzing more youthful pictures of patients
Fig. 41.2 Deep facial grooves are mainly present in areas of repeated facial animation, such as occurs with crow’s feet, orbitomalar grooves, nasola-
bial folds, or a marionette groove. With time these folds become permanent as a consequence of atrophy of the underlying fat tissue. (Reproduced
from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)
41 Midface Recontouring
seeking consultation for facial rejuvenation surgery, we have
found that most volume loss appears to take place in the centro-
facial and temporal regions, areas where the most muscle and
hence motion activity is present. This observation led us to
propose the hinge hypothesis of fat disappearance with age,
which rests on the fact that fat cells are known to atrophy under
higher pressure (Fig. 41.2). This can be seen clinically in skin
overlying tissue expanders, where subcutaneous fat atrophy
is observed in the expanded flap, as well as in the skin under
an abdominal belt. In regions where repetitive motions occur
over an extended period of time, such as in the periorbital and
perioral areas, it seems plausible that fat cells will get atrophic
with time. This might provide a purely mechanical explanation
for the fat atrophy seen in the centrofacial and temporal regions,
even in patients who have gained weight while aging. The only
peripheral facial area where significant volume atrophy can be
observed is the temporal area, overlying the temporal muscle.
Understanding the importance of facial fat grafting in facial reju-
venation depends on understanding the difference between facial
sagging and facial deflation. Facial sagging occurs at the periphery of
the face (for example, lateral to the lateral canthus and oral commis-
sure) and continues into the neck (Fig. 41.3a). Facial deflation takes
place in the central part of the face, such as the periorbital region,
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including the glabella and the eyelids, the malar area, and the perioral
region (Fig. 41.3b). This is exactly the region where most mimic mus-
culature is present and most movement occurs in the face. Superficial
changes in skin surface quality are independent from both sagging
and deflation and take place on the whole facial skin (Fig. 41.3c).
For facial rejuvenation, volume distribution in the face plays
a very important role in this process. The typical changes in the
transition from a younger to an older face make up the evolution
from an inverted triangle with high cheekbones, a full midface, and
a well-defined sharp jawline to an upright triangular shape with
flat cheekbones, an empty midface, and an undefined heavy jaw-
line. Little made this analysis previously in his description of the
inverted cone of youth.”
The 62-year-old-woman shown in Fig. 41.4a requested facial reju-
venation and correction of a secondary nasal deformity. Compared
with the photograph taken of her at age 26 (Fig. 41.4b), the malar area
and the lips are deflated. The treatment plan consisted of an extended
minimal-access cranial suspension (MACS) lift, short-scar temporal
lift, secondary rhinoplasty, and microfat grafting of the upper eyelids,
malar area, and lips. The result 18 months after surgery is seen in Fig.
41.4c. Except for correcting the sagging of the neck, jowls, and tail
of the eyebrow, the reconstruction of the facial architecture can be
compared with the photograph showing the patient at 26 years of
age; the facial ogee curve and periorbital and perioral volume have
been restored. This natural rejuvenation result could not have been
obtained without restoration of centrofacial volume.
41.2.1 Centrofacial Rejuvenation
The current perspective is that centrofacial aging is more the result
of deflation than of sagging. Lambros showed in his tridimensional,
long-term facial aging study that centrofacial landmarks such
as nevi and folds are not displaced downward during aging. This
means that lifting the soft tissues in the central part of the face, as

Fig. 41.3 Different modalities of aging. (a) Sagging, especially in the lower third of the face and neck. (b) Deflation problem. (c) Structural changes in
skin quality. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

Fig. 41.4 (a) Patient aged 62 with lifting and volume repletion. (b) Patient at age 26, showing facial architecture of youth. (c) Restoration by microfat
grafting of the periorbital area, the midface, and the lips. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New York,
N : Thieme Medical Publishers; 2018.)

480
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is done in traditional facelift, may not be logical. He concluded that
facial deflation, which is present in almost every aging face, mimics
descent. Our experience is similar, especially regarding the midface
and eyelids. Difficult and invasive midfacelift techniques have
been replaced by filling techniques with far better results, without
the risks of disastrous complications and with less morbidity and
a shorter recovery. In our MACS lift experience, placement of the
third suture loop to lift the midface has been almost completely
replaced by lipofilling of the malar area. The logic behind this is that
an empty space does not need to be lifted but rather to be filled.
That facial deflation mimics descent and most facial landmarks
stay exactly in the same position is particularly true for the
midface. The only facial feature that lengthens (descends) is the
vertical height of the upper lip (Fig. 41.5). The concept of cen-
trofacial rejuvenation is based on the premise that deflation is a
major causal factor. The center of the face involves three zones:
the periorbital area, the midface, and the perioral area.
Traditionally, periorbital aging was treated with a combination
of resection and lifting procedures. Current concepts reveal that
periorbital aging is more the result of deflation than of sagging.

Fig. 41.5 Visual illusion of sagging in aging faces while all the anatomic landmarks (eyebrows, orbitomalar groove, nasal tip, and mental crease)
remain in the same position. The only feature that truly lengthens is the upper lip. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

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Fig. 41.6 The principle on which microfat grafting relies: Reducing the diameter of a sphere proportionally increases its contact surface. (Reproduced
from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

Fagien described volume-preserving blepharoplasty as the first are known as grater-type cannulas (Fig. 41.7). ith this method of
step toward a more natural eyelid rejuvenation. Several surgeons harvesting, which results in smaller fat particles, we have begun to
(Benslimane, Little, Marten, Roberts, and Trepsat) have taken a use smaller-diameter injection cannulas. Today we exclusively inject
further step by adding volume around the orbit. This has led to microfat through 0.7- to 0.9-mm-diameter blunt-tipped cannulas.
the concept of augmentation blepharoplasty. e usually select the infraumbilical region, the inner thighs, or
Perioral aging involves different aging mechanisms such as volume the knee areas as donor sites, because these areas are easily acces-
loss, sagging of the upper lip, and textural changes in the skin. The sible with the patient in the supine position. The donor areas are
logical treatment involves a combination of different techniques that infiltrated with a tumescent lein solution containing 0.8 lidocaine
will work synergistically toward a comprehensive rejuvenation. and 1:1,000,000 epinephrine. In the acceptor areas the anesthetic
solution is the same as that used for MACS lift procedures: a diluted
0.3 lidocaine solution is used along with 1:650,000 epinephrine,
41.3 Microfat Grafting 2 mL of 8.4 sodium bicarbonate (when under local), and 0.15
Microfat grafting is now used in 95 of all facial rejuvenation
treatments. e realized that a reduction in grafted particle size
may resolve many of the problems that arise with conventional
fat grafting techniques. According to oshimura, any fat particle
exceeding 2 mm in diameter will have a central necrosis zone.
Geometry teaches that the ratio of the surface area of a spherical
particle to its volume is inversely proportional to its radius (Fig.
41.6). Thus, given a certain volume of fat particles, reducing the
particles to half their size will double the total contact surface
area. Because a fat particle is dependent on the diffusion of nutri-
ents during its initial embedding phase before revascularization,
the likelihood of particle survival is increased.
Benefits of smaller fat graft particles are better survival, less need
for overcorrection, reduced downtime, and less risk of visible and
palpable lumps, especially under the thin lower eyelid skin. At present
we harvest all fat with small (2- to 3-mm-diameter) cannulas with Fig. 41.7 Sharp “grater” or “Tonnard” cannula. The harvesting cannula
multiple sharpened 1-mm-diameter holes. ith the sharp holes, the consists of a sharp, multiport cannula that is 2.4 mm in diameter, with
fat is literally grated out of the subcutaneous tissue. These cannulas holes 1 mm in diameter. (Courtesy Tulip Medical Products, San Diego, CA.)

482

ropivacaine (a long-acting local anesthetic with very low cardiotox-
icity). After harvesting, the fat is rinsed with either normal saline or
lactated Ringer’s solution through a nylon tissue cloth with a pore
size of 400 pm, which is mounted on a sterile canister. hen the oil
and debris are washed away, the fat is transferred to 10-mL Luer lock
syringes with a spatula or by direct aspiration. Then 1-mL syringes
are filled from the 10-mL syringes with the help of a female-to-
female Luer lock adapter. e prefer the filtering and rinsing method
rather than centrifugation, because this produces a very liquid graft,
which can easily be injected through 0.7-mm cannulas with min-
imal plunger pressure. For microfat injection a skin puncture hole
is created with an 18-gauge intravenous needle. The multistroke
delivery of the fat graft is key. On average, 30 to 50 passes are made
to inject a volume of 1 mL of fat. A meticulous injection technique is
very important. By moving the injection cannula swiftly backward
and forward, only minute amounts of graft are deposited with each
pass. For facial microfat grafting, midface recontouring is achieved
by putting the fat in the main areas hit by deflation or with bone
hypoplasia (Fig. 41.8), considering the correct plane and the advised
quantities (Table 41.1), which are discussed later in this chapter.
41.4 Periorbital Rejuvenation
For the upper eyelid, analysis of photographs of people aged
80 years or older reveals that almost all of them have hollow
Fig. 41.8 Areas where a fat grafting procedure in the face is usually
indicated.
Table 41.1 Usual and advised quantities of fat for each face region and
level of injection
Grafted area Level of injection Volume (mL)
Infra brow Deep 0.8–2.0
Malar Deep 3.0–15.0
Nasolabial fold Deep and superficial 1.0–3.0
and intradermal
Perioral Superficial and 1.0–4.0
intradermal
Marionette grooves Deep and superficial 1.5–3.0
41 Midface Recontouring
eyelids (Fig. 41.9). Even in the presence of a bulging medial fat
pad, a hollowing in the apex of the eyelid can be observed, often
referred to as the A-frame deformity. As aging continues, the
eyelids continue to deflate and an apparent skin excess develops.
Because skin growth likely is not occurring in that region, the
skin excess can be seen as an optical illusion provoked by both
the deflation phenomenon and the descent of the tail of the eye-
brow. The descent of the tail of the eyebrow is known as temporal
hooding and is explained by the lack of muscular suspension from
the frontal muscle in its lateral part. e believe that periorbital
aging is essentially a deflation phenomenon; this concept has led
to a paradigm shift from resection toward filling in periorbital
rejuvenation. The logical way to rejuvenate the upper periorbital
region is thus to suspend the tail of the eyebrow by a temporal
lift, together with filling the hollowness below the supraorbital
rim and conservative resection of skin excess if necessary.
In the lower eyelid, the aging eyelid deformity is accentuated by
the deflation of the midface or malar area below the orbit. Most
of this deflation takes place in the anterior malar area medial to
the lateral canthus. This is logical in view of the hinge hypothesis
(Fig. 41.2), which states that most deflation takes place in a region
overlying a gap between mimic muscles. A logical correction of the
Fig. 41.9 (a-d) Hollow eyelids in older adults. (Reproduced from
Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New
ork, N : Thieme Medical Publishers; 2018.)
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lower eyelid aging deformity is to add volume to the deflated malar
area, especially in its anterior part medial to the lateral canthus. This
can be combined with a resection or transposition of the bulging fat
from the lower eyelid compartments over the inferior orbital rim.
In 2003, on the basis of studies by Trepsat, Lambros, Little,
Roberts, and Benslimane, we began using fat grafts to address
periorbital aging, gradually incorporating the correction of volume
loss into standard orbital rejuvenation procedures. Since 2008 we
have been using this revised approach, which now incorporates
fine-particle fat grafting (microfat grafting) in 95 of cases, and we
call it augmentation blepharoplasty. The term augmentation bleph-
aroplasty refers to the two components of the surgical procedure:
the addition of volume and the resection of skin. Unlike classic
resection blepharoplasty techniques, our approach is based on
maximal preservation of all existing volume, along with correction
of volume loss in the eyelids and the periorbital region by means of
microfat grafting and conservative trimming of excess skin.
Deflation is an integral part of the aging process. Consequently,
volume restoration is necessary in almost every aged eyelid situa-
tion. This is the true expression of a paradigm shift. Once one learns
to analyze the aging eyelid properly, a deflation can be discovered
in nearly all situations. An isolated skin redundancy can be found
in a small subpopulation of young people who have a familial eyelid
laxity. In those cases, a pure skin resection may still be indicated
(Fig. 41.10). hen deflation has not yet occurred as a consequence
of the aging process, such as in very young patients (younger than 35
years), a conservative skin excision may be sufficient. Once deflation
begins, a classic resection blepharoplasty will result in more tarsal
show, but an aged, deflated eyelid will remain (Fig. 41.11).
Because of the different mechanisms that influence facial aging
(such as sagging, deflation, wrinkling, contraction, and loss of ani-
mation) and because facial aging is not the same in every patient,
we routinely ask all facial rejuvenation patients to bring pictures
taken at a younger age (20–30 years), and these are analyzed
during the preoperative consultation to determinate the main
areas to be treated so as to restore a youthful appearance.
41.4.1 Upper Eyelid Rejuvenation
Critical analysis of pictures of patients at a younger age reveals
that there is nearly always a certain degree of volume loss in
the upper eyelid, especially in the medial part. This was earlier
described as the A-frame deformity. Classic resection blepha-
roplasty removes the apparent excess of upper eyelid skin and
orbicularis muscle with or without emptying of the medial and
lateral fat compartments. This approach will rarely restore the
features of youth if volume loss is not addressed.
Surgical Technique
The area to be augmented is marked in green preoperatively with
the patient in the upright position (Fig. 41.12). This area typically
comprises the medial one-half to two-thirds of the infrabrow
region and often incorporates the lower third of the medial part

Fig. 41.10 Traditional resection blepharoplasty will suffice for patients whose upper eyelids are still full. In this case only a conservative excision of skin
has been performed. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

Fig. 41.11 Classic resection blepharoplasty performed in the presence of deflation will fail to rejuvenate the eyelids. It results in increased tarsal
show, but it does not correct the hollowing of the infrabrow region. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New ork, N : Thieme Medical Publishers; 2018.)

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 41 Midface Recontouring

be done before or after eyelid fat grafting. Orbicularis muscle is

not resected, so as to preserve as much volume as possible.

41.4.2 Lower Eyelid and Malar

Rejuvenation
Most patients experience a loss of volume in the malar area,
especially in the anterior part, even those who have gained some
weight in recent decades. The malar area typically supports the
lower eyelid; therefore, volume loss in this area will accentuate
the appearance of the bags in the lower eyelid. In traditional
lower eyelid blepharoplasty, fat is removed from the medial,
median, and lateral compartments, with or without suspension
of the orbicularis muscle and trimming of the lower eyelid skin.
Although the bulging of the lower eyelid is temporarily corrected,
the blending of the eyelid–cheek junction is seldom improved,
especially as further deflation of the malar area takes place with
aging. These shortcomings thus decrease the rejuvenative value
of standard resection blepharoplasty techniques.
The decision to combine fat grafting of the malar area with
fat manipulation through lower eyelid surgery is based on the
extent of fat herniation in the lower eyelids. In patients who
do not have fat herniation and whose eyelid–cheek junction is
slightly marked (mostly in the medial part, nasojugal groove, or
tear trough), isolated fat grafting of the tear trough together with
the malar area is proposed. hen obvious fat herniation exists,
transconjunctival trimming of excess orbital fat is performed. Fat
transposition over the inferior orbital rim through a subciliary
lower eyelid incision combined with fat grafting of the malar area
can also be used for augmentation of the malar area. However,
Fig. 41.12 Areas of microfat grafting of the infrabrow area and the tear
trough and malar area are marked in green. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.)

of the eyebrow. Eyelid fat grafting is a confusing and anatomically

incorrect term; the fat is injected not into the eyelid proper but
rather into the infrabrow region extending under the upper orbital
rim. The extent of this area depends on the hollowness of the upper
eyelid in comparison with how it appeared when the patient was
younger.
The area marked is infiltrated in a deep layer beneath the muscle
with a lidocaine and epinephrine solution (0.3 lidocaine and
1:600,000 epinephrine) together with subdermal infiltration of
the marked upper eyelid skin excess. Starting with the micro fat
grafting, an 18-gauge needle is used to make a puncture hole in the
lateral part of the eyebrow. The 0.7-mm microcannula is inserted,
and the fat is deposited with the typical multistroke Coleman
technique in a layer deep to the orbicularis muscle in contact with
the superior orbital rim (Fig. 41.13). An important factor is that
the fat is deposited not into the eyelid but rather directly onto the
periosteum of the inferior and anterior surface of the supraorbital
rim (Fig. 41.14). This is actually more under the eyebrow skin than
under the eyelid skin. Grafting the upper eyelid skin could lead to
undesirable fullness and even ptosis of the upper eyelid.
An amount of 0.5 to 2.5 mL is injected depending on the
Fig. 41.13 Infrabrow fat grafting with approach from the lateral part of
patient’s needs. Most frequently the fat injection is accompanied
the eyebrow.
by a resection of apparent skin excess in the upper eyelid. This can

485
 VII Midfacial Rejuvenation

Fig. 41.14 Fat grafting to fill the hollowness below the supraorbital rim of the upper eyelid. The area that is augmented comprises the medial one
half to two thirds of the upper eyelid and the lower third of the medial part of the eyebrow. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

this increases the risk for temporary scleral show by denervating
the orbicularis oculi muscle and lower eyelid retraction by mid-
lamellar cicatrization. Incision in the muscle is avoided whenever
possible.
Surgical Technique
The malar recipient area is marked preoperatively with the
patient standing or sitting. The marked areas are infiltrated with
the previously mentioned solutions in the deep layer on top of
the zygomatic bone. For patients who will have lower eyelid
surgery, infiltration is performed in the classic way.
Malar area fat grafting is performed through two 18-gauge needle
punctures (lateral and inferior; Fig. 41.15). A perpendicular approach
is made to the tear trough and malar area from the inferior puncture
to crisscross the grafted area and to prevent a sausagelike deposit of
the grafted fat. The index finger of the surgeon’s nondominant hand
is used for tactile control over the position of the cannula tip. This is
especially important when grafting from the inferior puncture over
the inferior orbital rim. If necessary, the malar augmentation can

Fig. 41.15 Malar fat grafting. (a) Inferior access to perpendicular approach to fat grafting of the tear trough and malar area. (b) Lateral access to
address malar body.

486

Fig. 41.16 Marking and guideline for volume distribution of malar
augmentation. Because most of the deflation is anterior, two-thirds
of the volume will go to the area medial to the lateral canthus.
The area lateral to the lateral canthus will take approximately
one-third of the volume. (Reproduced from Tonnard P, Verpaele A,
Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical
Publishers; 2018.)
Fig. 41.17 Placement of microfat grafts in the malar area of the lower eyelid, extending over the infraorbital rim. Most of the grafted volume is in the
malar area, blending into the lower eyelid. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme
Medical Publishers; 2018.)
41 Midface Recontouring
blend out into the lower eyelid up to the level of the inferior border
of the lower tarsus. However, the level of injection is always beneath
the orbicularis muscle. The lateral part of the malar area must not
be overfilled. Most of the volume will go in the anterior part of the
malar area, medial to the level of the lateral canthus, where most
volume loss has taken place (Fig. 41.16, Fig. 41.17).
The amount of fat injected varies depending on the volume
loss in the midface and the desired amount of anterior projection.
This amount is determined during the preoperative assessment
and marked in the patient notes. On average 4 to 10 mL of fat per
side is injected, but some cases may require as much as 25 mL per
side. However, we do not overcorrect the periorbital fat grafting,
because very little or no fat resorption occurs in this immobile
area. hen skin excess exists, a conservative skin excision is
performed (pinch blepharoplasty). After transconjunctival fat
resection, good alternatives to skin trimming are croton oil peel-
ing or erbium-doped yttrium aluminum garnet (Er: AG) laser to
improve the eyelid skin quality and tighten the skin.
41.4.3 Nanofat Treatment for Dark Circles
ith the nanofat grafting technique, we inject regenerative cells
and elements by processing adipose tissue with a very simple
mechanical manipulation. The mechanical emulsification destroys
the mature adipocytes but leaves the complex mixture of peri-
vascular smaller cellular components intact and in their native
paracrine environment. e could perceive changes in quality,
pigmentation, and texture of the facial skin of many patients
months after they had nanofat transferred into certain regions of
the face. Dark circles under the eyes are caused by a combination
of translucency of the skin because of thin dermis and a degree of
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 VII Midfacial Rejuvenation

Fig. 41.18 This 33-year-old woman presented with baggy eyelids with dark pigmented circles. Nanofat grafting of the lower eyelids was performed.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.) (a) Preoperative.
(b) At 4 months postoperative. (c) At 7 months postoperative. (d) At 5 years postoperative.

melanin pigment deposits. Both components appear to improve
after nanofat grafting. anofat is injected in a superficial intra-
dermal plane in the area to be treated. The 33-year-old woman
in Fig. 41.18 presented with baggy eyelids with dark pigmented
circles since childhood. Treatment involved a lower fat redraping
blepharoplasty through a subciliary incision and nanofat injection
(1.6 mL per side) of the lower eyelid and the pigmented nasojugal
groove. She had inflammation in the nanofat-treated skin in the
early postoperative follow-up, complete disappearance of the dark
skin pigmentation by 7 months postoperative, and stable results at
5 years postoperative.
The appearance of the lower eyelids immediately after nanofat
injection can be quite concerning and has the aspect of a giant
xanthelasma (Fig. 41.19a). However, because nanofat contains no
viable adipocytes, this appearance is simply the result of the oily
fraction of the disrupted cells and disappears within a few hours
after injection. By postoperative day 7 it appears as a slightly
erythematous inflammation (Fig. 41.19b); this inflammation can
persist for several weeks.
41.4.4 Postoperative Care
o obvious increase of bruising or swelling is seen compared
with a classic blepharoplasty. Oral antibiotics are prescribed for
3 days (amoxicillin 500 mg three times daily). Smoking is strictly
prohibited from 3 weeks before until 3 weeks after surgery. The
patient must avoid losing body weight during the first 4 months
after microfat grafting, because any catabolic state will counter-
act the take of the fat graft. Patients are seen for follow-up after
6 days for suture removal and then after 6 weeks, 3 months, 6
months, and 1 year. At the 3-month follow-up, the take of the fat
graft is assessed. Approximately 15 of patients need a touchup
microfat grafting refill, depending on the surgeon’s clinical judg-
ment and the patient’s desires. All touchup procedures are done
on an outpatient basis with a local anesthetic.
41.4.5 Results and Outcomes
The 40-year-old woman in Fig. 41.20 presented with bulging of
the lower eyelid orbital fat and a marked tear trough and orbi-
tomalar groove. Treatment consisted of a transconjunctival fat
resection in three compartments and microfat grafting with 2.5
mL in the tear trough and 3 mL in the malar area. The result is
shown at 7 months postoperatively. The eyelid–cheek junction
is blended, the malar contour is improved, and correction of the
negative vector is evident in the lateral view.
The 55-year-old woman in Fig. 41.21 presented for upper and
lower blepharoplasty. She had low-lying eyebrows, deflated upper
eyelids (especially in the medial portion), and a descent of the tail
of the eyebrow resulting in temporal hooding. Her lower eyelids
showed marked bulging of retroseptal fat, resulting in a very marked
eyelid–cheek junction and atrophy of the anterior malar area.
An augmentation blepharoplasty was performed under local
anesthesia. Simple skin excision (no muscle or fat resection) was
performed in the upper eyelid, with 1.5 mL of microfat grafted
in the medial part of the upper eyelid. Internal browpexy was
performed to lift the tail of the eyebrow. In the lower eyelid, a fat
Fig. 41.19 Nanofat injection: (a) intraoperative view; (b) 7 days
postoperative. (Reproduced with permission from Tonnard P, Verpaele
A, Peeters G, et al. Nanofat grafting: basic research and clinical
applications. Plast Reconstr Surg. 2013; 132:1017-1026.)

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 41 Midface Recontouring

Fig. 41.20 Transconjunctival fat resection and nanofat injection in a 40-year-old woman. (Left) Preoperative. (Right) 7 months postoperative.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

Fig. 41.21 Augmentation blepharoplasty, simple skin excision, internal browpexy, and fat redraping in a 55-year-old woman. (Left) Preoperative.
(Center) 2 months postoperative. (Right) 9 months postoperative. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New ork, N : Thieme Medical Publishers; 2018.)

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redraping procedure was performed without resection of fat, and 41.5.1 Perioral Rejuvenation Techniques
4 mL of microfat was grafted into the anterior malar area. Skin
was excised conservatively after orbicularis muscle suspension.
An elevated position of the eyebrow tail and a smooth eyelid– Correction of the Nasolabial Folds
cheek junction were obvious after 2 months preoperatively. ine The nasolabial fold has historically been corrected with a multi-
months after the augmentation blepharoplasty, the stability of tude of techniques, which is most often a sign that none of them
the result was evident. is perfect. In particular, the lifting techniques, for which the
nasolabial fold was seen as a component of the descent of the
midface, were prone to relapse. Some techniques even described
41.5 Perioral Rejuvenation very extensive undermining from the facelift incision progressing
under the nasolabial fold or even more medially, but they could
The mouth and the perioral area are, like the periocular area, a
not guarantee long-lasting results. If the nasolabial fold is con-
source of the emotional expression and sensuality of the face.
sidered as an atrophying area, because of repetitive movements
evertheless, this area’s aging is often overlooked, resulting in
over the years, the logical treatment is filling. In theory, another
a disappointing result of a comprehensive facial rejuvenation.
option would be to stop the movement in this area with toxins.
Nearly every facial rejuvenation treatment should involve some
This can be observed in the case of facial paralysis, in which the
modality of perioral rejuvenation.
affected hemiface nasolabial groove is completely eradicated.
Aging changes around the mouth are multifactorial, and
However, clinically this is impossible, because all mimic activity
contrary to common belief, they are not limited to deflation
of the face would be disturbed. Therefore, correction of the naso-
alone. Therefore, only revolumizing the vermilion may result
labial fold is better achieved by microfat grafting.
in disappointing or even unnatural results. Redefining the lip
The deep filling of the crease is accomplished with classic 0.7-
contours should also be a consideration rather than blowing up
to 0.9-mm fine blunt cannulas via a puncture with an 18-gauge
the vermilion with volume. This, combined with resurfacing or
intravenous needle. A crisscrossing approach is used, starting
lip lift, delivers a more comprehensive restoration of the youthful
perpendicularly to the crease in the deep plane, to build up a
appearance of the lips and perioral area.
foundation. This is important to prevent a sausagelike deformity,
Aging of the perioral region involves the accentuation of the
as seen in parallel lipofilling techniques. Most volume goes into
nasolabial crease and fold; changes in skin texture with the appear-
the canine fossa, with a triangular blending extension toward the
ance of perioral rhytids ( barcode ); atrophy of the vermilion
corner of the mouth (Fig. 41.24). ext, a second, more superfi-
volume; loss of definition of the vermilion border, white roll, and
cial layer is deposited parallel into the fold. Finally, a subdermal
philtrum; and increase in vertical height of the upper lip between
subcision maneuver is executed with an 18-gauge needle, used
alar base and vermiliocutaneous border (Fig. 41.22, Fig. 41.23).
as an internal knife. This procedure cuts all the ligament attach-
Remarkably, this lengthening of the upper lip is the only region in
ments from the skin to the deeper structures (Fig. 41.25). A small
the central part of the face where sagging is obvious, observed in
volume of microfat (0.3–0.5 mL) is then injected into the created
long-term photographic studies of facial aging. The treatment plan
cavity, not so much as a filler but rather as a spacer to prevent
is multimodal by combining fat grafting, resurfacing techniques,
reattachment of the skin to the deep tissues.
and surgical lip lift. The combination of these techniques is another
The average injected volumes are 1 to 3 mL of microfat per
example of synergy in the rejuvenation of the perioral area.
side. Undercorrection is preferable to overcorrection in this area.
Effective, natural, and long-term correction is expected with
this technique. Marionette grooves can be addressed with this
technique from the same access or from a chin approach in an
intermedium plane (Fig. 41.26).

Fig. 41.22 Mouth and perioral area in the same woman between
(a) age 24 years and (b) age 54 years. With aging, a deflation of the
vermilion, decreased turgor and an inversion of the vermilion mucosa,
a lengthening of the vertical skin segment between the alar base and
vermiliocutaneous border, and vertical rhytids appear gradually in the
upper lip skin and later in the lower lip skin. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.)
Fig. 41.23 Mouth and perioral area of the same woman between
(a) age 50 years and (b) age 65 years. The most obvious change is in
the perioral skin surface with the appearance of vertical rhytids and
an accentuation of the nasolabial folds. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.)

490
 41 Midface Recontouring

Fig. 41.24 Correction of nasolabial folds. Deep microfat grafting filling of the crease with 0.7-mm fine blunt cannula.

Fig. 41.25 Nasolabial fold fat grafting with the anatomic location of the associated fat grafting planes: (a) deep plane perpendicular to the fold
(SMAS: superficial musculoaponeurotic system); (b) the superficial plane parallel to the fold; (c) surgical subcision and subsequent placement of a
small amount of fat graft in the cavity created. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N : Thieme
Medical Publishers; 2018.)

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 VII Midfacial Rejuvenation

Lip Rejuvenation and Enhancement lip decreases and becomes level with or even posterior to the lower
lip. The contour from the nasal base to the vermilion border becomes
Adding volume to the lips and vermilion can be very rejuvenating
straight to convex because of lengthening of the lip and subsequent
and feminizing. Lip augmentation is not only restricted to rejuvena-
inversion of the vermilion. The philtral columns lose prominence and
tion procedures but also is used for younger patients who wish to
definition. The oral commissures tend to turn downward. The ver-
enhance the shape and volume of their native thin lips. Volumizing
milion mucosal surface becomes dryer and atrophic and loses turgor.
the lips can certainly enhance the sensuality of the mouth. However,
The skin surface becomes rough, pigmentary irregularities occur, and
when this is exaggerated, it likely will result in a sausagelike or
vertical rhytids appear (the barcode appearance).
ducklike deformity of the upper and/or lower lip. Eversion of the
vermilion border is better achieved by adding a lip lift.
Ideal lip aesthetic proportions may cause some confusion, in most
people the lower lip is somewhat larger than the upper lip in the
frontal view. The proportions of upper to lower lip dimensions must
be respected (Fig. 41.27; Table 41.2). In the frontal view the lower lip
should be approximately 60 higher than the upper lip (approximat-
ing the golden proportion of 1:1.618). In the profile view, in contrast,
the upper lip should project slightly (1–2 mm) further anterior than
the lower lip. Often patients ask for an isolated upper lip augmenta-
tion. In most cases this disturbs the natural proportions of the upper
to lower lips. Failure to respect these observations may result in an
unnatural appearance. The surgeon should explain to these patients
that the lower lip needs to be enhanced in proportion to the upper lip.
In the young lip, the vermiliocutaneous border, or white roll, is
well defined and pouted, with a distinct Cupid’s bow in the frontal
view. The contour from the nasal base to the vermilion border
should be slightly concave. The philtral columns are prominent
and well-defined. The oral commissures should be horizontal or
curve slightly upward. The mucosa is soft with a distinct turgor.
The skin surface is smooth, equally toned, and without rhytids.
Aging disturbs these parameters to a certain degree. The vermilio-
cutaneous border loses its definition and flattens out. The definition of
the Cupid’s bow fades in the frontal view. The projection of the upper

Fig. 41.27 Comparison of female youthful (left) and aged (right) lips.
In the frontal view, deflation of lip volume, change in skin texture, and
diminished definition of the white roll and philtrum occur. In profile
view, loss of projection of both the upper and lower lips, a change
in upper lip shape from concave to convex, and a lengthening of the
vertical height of the upper lip skin segment is apparent with aging.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

Table 41.2 Comparison of lip characteristics in the youthful and aged

female lip
Youthful Female Lip Aged Female Lip
Upper to lower lip 1:1.618 Mostly unaltered
height ratio
Projection of upper lip Upper lip 1–2 mm Upper lip equally
anterior to lower lip projected or posterior
to lower lip
Vermiliocutaneous Well defined, pouted Ill-defined, loss of
border pouting
Cupid’s bow Distinct Faded
Nasal base to vermilion Concave Straight or convex
Philtral columns Distinct Faded
Mucosa Soft, good turgor Dry, loss of turgor
Skin surface Smooth, equal tone Rough, pigmented:
rhytids
Fig. 41.26 Marionette grooves can be corrected by fat grafting with Oral commissures Horizontal or curved Curved downward
the same access of the nasolabial folds or from a chin approach. upward

492

Ideally, harmonic lip enhancement treats all of these aesthetic
features. A combination of several treatment modalities will work
synergistically toward a natural enhanced appearance. The tools
are volume enhancement, lip lift, and resurfacing.
Lip Microfat Grafting
Because of the high mobility of both lips, this is the area with
the highest fat graft resorption of the whole face. e estimate
the average resorption of lip microfat grafting to be 40–50 . The
patient must be counseled about this likelihood and allowed
to choose between overcorrection with a prolonged downtime
(months) or else one or two touchup procedures under local
anesthesia 4 to 6 months apart. e believe that the latter option
is better, and most of our patients make this choice.
All patients are prescribed acyclovir 800 mg daily for 5 days for
herpes simplex prophylaxis.
Lip enhancement indications can be divided into two catego-
ries: lip volume and lip definition. For lip volume enhancement,
most of the fat will be delivered into the orbicularis oris muscle.
For enhancing the lip definition and shape, the injection should
be made more superficially into the white roll with S IF. This
technique is explained in more detail in Chapter 46 of this book.
The perioral area can easily be numbed by a double nerve block
of both infraorbital and mental nerves. The microfat is injected with
a 0.7- or 0.9-mm blunt microfat cannula via two punctures made
Fig. 41.28 Parasagittal section of the lips, before and after enhancement with microfat, illustrating the location of sharp-needle intradermal fat
grafting (SNIF) and deep intramuscular lipofilling. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.)
41 Midface Recontouring
with an 18-gauge needle in both oral commissures. The fat is deliv-
ered in all layers, with most of the volume in the orbicularis muscle
(Fig. 41.28). Bidigital palpation is used to check the homogeneous
distribution of the injected fat. Minor irregularities can be corrected
by gentle bidigital massage. The punctures are not closed. Average
volumes are 0.5 to 2.0 mL per hemilip. Thus, the total volume for
a complete mouth rarely exceeds 8 mL. The average volume for a
standard vermilion lip augmentation is between 5 and 6 mL.
The white roll can be enhanced with a 21-gauge sharp-needle
injection or a blunt 0.7-mm cannula inserted immediately sub-
dermally, threading the roll and injecting upon withdrawal. On
the average a volume of 1 mL is injected in the white roll of both
the upper and lower lip. The philtral columns can be enhanced
by S IF with the same needle. An average volume of 0.25 mL per
column is used (Fig. 41.29).
Lip Lift
The upper lip is the only feature in the central part of the face
that actually descends with age, resulting in an increase of the
vertical height of the lip (nasal base–vermilion border). This is
very commonly overlooked, but careful analysis of the aging face
reveals that most of these patients demonstrate a ptosis of the
upper lip (Fig. 41.30). This is another good reason for comparing
the patient’s present face with pictures taken at a more youthful
age. A lip lift is a very simple and rewarding surgical procedure
493
 VII Midfacial Rejuvenation
with a very feminizing and rejuvenating effect. It effectively
everts the vermilion border and restores the concave shape of
the lip segment between the nasal base and vermilion border.
Because of its simplicity and its very limited morbidity and com-
plication rate, this is one of the few procedures that we suggest
to our patients even if they do not request it. Most people are
aware of this aged feature of their mouth.
The combination of lip lift with microfat grafting of the vermil-
ion works synergistically: the fat grafting results in an increased
anterior projection, whereas the lip lift creates an eversion of the
vermilion (Fig. 41.31). Any attempt to evert the lip by filling alone
will result in an unnatural sausagelike or fish-mouth deformity.
A lip lift consists of resecting a segment of subnasal skin at the
base of the nose. Many pattern shapes have been described, the most
b including resection of 3 mm of skin at the nostril base. The anterior lip
Fig. 41.29 Superficial sharp-needle intradermal fat grafting (SNIF)
with a 21-gauge needle for definition of (a) the vermilion border (white
roll) and (b) philtral columns. The superior and inferior labial arteries
are a safe distance from the location of the SNIF.
494
popular ones being gullwing or bullhorn shapes. e find the most
effective pattern more approaches the shape of a mustache. This
pattern extends well laterally into the alar crease, with the purpose
of creating a concentric lift of the lateral portions of the upper lip.
The upper excision line follows the alar base, and then turns inside
the nostril sill to hide the scar effectively inside the nostril. It crosses
the midline exactly at the columellar base (Fig. 41.32). The lower
excision line is then tailored to the desired lip shape. Most commonly
the lower line is almost straight. This causes a maximal lifting effect at
both apices of the Cupid’s bow. If more lifting is desired in the lateral
aspect of the lip, the lower excision can be curved slightly downward,
or in some cases the excision can be extended into the nasolabial fold.
On the average a 3- to 6-mm-wide segment is excised. Only skin is
excised, and only 1 to 2 mm of undermining is performed at the caudal
Fig. 41.30 Patient is shown (a) at age 20 years and (b) at 48 years. Nearly
all anatomic landmarks (eyebrow, pupil, orbitomalar groove, nasal tip,
nasal base, labiomental crease) stay exactly in the same position. The only
feature that truly lengthens in the central part of the face is the upper
lip. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)
Fig. 41.31 Patient consulted for a secondary rhinoplasty and perioral
rejuvenation. She presented with a long, masculine, unattractive
upper lip. The secondary open rhinoplasty was combined with a lip lift,
projection was enhanced by 3 mL of intramuscular microfat grafting.
Shortening of the vertical height of the upper lip and attractive ever-
sion of the vermilion border are evident. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.)
 41 Midface Recontouring

skin edge to promote skin edge eversion. After thorough hemostasis

the skin is closed in two layers with 5–0 polydioxanone subcutaneous
sutures and an intradermal 4–0 monofilament polyglactin suture. The
knots of the skin suture are hidden in the nostril base. If the lengths of
the skin segments exhibit a significant incongruence, the skin closure
can better be performed with a running 5–0 monofilament nylon
horizontal mattress suture for more effective adjustment (Fig. 41.33).
These sutures are removed at postoperative day 6.
Because the excision is at the interface of two adjacent aesthetic
units, the final scar is inconspicuous even in younger patients.
However, the surgeon must respect the inward curving of the
excision line into the nostril sill to prevent a disturbing scar at the
nostril base.
The different excision patterns are demonstrated in Fig. 41.34.
e believe that only pattern A delivers a satisfactory result.

Perioral Sharp-Needle Intradermal Fat Injection

The sharp-needle intradermal fat injection method was pub-
lished by eltzer, Tonnard, and Verpaele under the acronym SNIF.
This procedure involves the injection of microfat intradermally
through a sharp needle into facial rhytids with the intent of
achieving a permanent correction without the perils of a syn-
thetic permanent filler. It can be used liberally in combination
with any facial cosmetic procedure and is used for static perioral
wrinkles (nasolabial and barcode) and enhancing the lip definition
and shape of the white roll and philtral columns. Injection needs
to be performed meticulously, and the receptor area should be
infiltrated with a local solution containing epinephrine. Before
injection the facial rhytids are marked with a fine permanent
marker while the patient stands and makes exaggerated facial
expressions. Injection is done with a 23-gauge needle and should Fig. 41.32 Lip lift markings. The upper incision starts along the alar
be made in a superficial dermal plane, never in the subcutaneous groove, curves along the alar base into the nostril sill, and crosses the
columellar base. The lower incision curves out in the lateral portion
plane (Fig. 41.35). The S IF endpoint is slight overcorrection around the alar groove; the medial section is straight.
with blanching of the skin that will disappear in few minutes.

Fig. 41.33 Lip lift technique. (a) Skin resection. On average a 3- to 6-mm-wide segment is excised, preserving perioral muscle fibers intact. (b) Skin is
closed in two layers with 5–0 polydioxanone subcutaneous sutures and running 5–0 monofilament nylon horizontal mattress suture. (c) After white
roll and upper lip microfat grafting.

495
 VII Midfacial Rejuvenation

Fig. 41.34 Correct and incorrect excision patterns for lip lift. (a) Correct pattern of lip lift. This creates an adequate lift of the lateral lip and an accen-
tuation of the Cupid’s bow. (b) Gullwing or bullhorn excision pattern. This creates insufficient lifting of the Cupid’s bow. (c) Straight incision crossing
the nostril sill. This pattern results in a visible scar. (d) Correct pattern shape, but made too narrow with no effect on the lateral lip. This may result in
an unnatural “puppetlike” pouting of the central lip and overaccentuation of the Cupid’s bow. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

The 56-year-old woman in Fig. 41.36 had a MACS lift combined

with pure S IF on her fine perioral rhytids (nasolabial and barcode).
A total volume of 4.6 mL was used. The result was powerful and
stable. As in any microfat grafting procedure, after S IF a variable
resorption of the injected fat occurs, which stabilizes after 4 months.

Perioral Nanofat Treatment

Fig. 41.35 Sharp-needle intradermal fat (SNIF) injection of the
nasolabial fold in a superficial dermal plane with a slight overcorrection
with blanching of the skin.
Nanofat is applied as an adjunct to perioral rejuvenation for
enhancing the quality of the lip skin and vermilion. anofat has
no filling capacity and must be considered an in vivo tissue regen-
eration cellular therapy. Therefore it can be applied in conjunction
with other modes of perioral rejuvenation such as S IF, microfat,
resurfacing, and lip lifting. anofat is applied in the skin by fan-
shaped superficial injection with a 27-gauge needle or with the
needling device that reaches the dermis with 20 needles 1.5-mm
long. The 60-year-old woman in Fig. 41.37 sought correction of
upper lip aging. Treatment consisted of S IF injection into indi-
vidual vertical rhytids (red circles) and the vermilion border and
nanofat injection of the whole upper lip skin. The improvement of
skin quality can be observed on the left side of the image (green
circles). A volume of 4 mL of nanofat was used for the whole upper
lip. The result is shown 6 months postoperatively.
The 71-year-old woman in Fig. 41.38 sought correction of aging
in the perioral area and lip vermilion. Treatment included a com-
bination of fat injection techniques: S IF with a 23-gauge needle
into the individual rhytids of the upper lip and nasolabial fold (1.5
mL), S IF with a 21-gauge needle into the philtral columns and
the white roll (2.7 mL), and nanofat injection of the whole upper
lip surface and dry lip vermilion. A total of 4.5 mL of nanofat was

496

Fig. 41.36 Minimal-access cranial suspension (MACS) lift combined with perioral sharp-needle intradermal fat (SNIF) injection in a 56-year-old
woman. (a) Preoperative. (b) At 1 year postoperatively. (c) At 24 months postoperatively. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)
a b
Fig. 41.37 Correction of upper lip aging in a 60-year-old woman,
(a) preoperatively and (b) 6 months postoperatively. Red circles show
the effect of the sharp-needle intradermal fat grafting (SNIF) injection
directly into the rhytids. Green circles show the effect of nanofat injec-
tion on the skin quality. (Reproduced with permission from Tonnard
P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and
clinical applications. Plast Reconstr Surg. 2013; 132:1017-1026.)
injected into the skin, and 2 mL was injected into the vermilion.
The result is shown 2 years postoperatively.
Lip Resurfacing
An effective resurfacing technique is necessary to correct the
surface changes of the aging lip. Historically we started with
mechanical dermabrasion and later introduced the CO2 laser.
Because of prolonged erythema and a high incidence of depig-
mentation, we replaced the CO2 laser with the purely ablative
cold Er: AG laser, which we still use. Recently we also adopted
croton oil peeling, which is a very inexpensive but very effective
method for deep peeling.
Preoperatively, the patient is prescribed a 0.1 tretinoin
ointment for 4 to 6 weeks. This renders the stratum corneum
more compact, thickens the stratum granulosum, and decreases
melanin density. In the dermis, it stimulates the formation of
new collagen. If the patient has a high risk for postinflammatory
hyperpigmentation, a 4 hydroquinone ointment can be added.
For herpes simplex prevention, a minimum of 800 mg of acyclovir
41 Midface Recontouring
a b
Fig. 41.38 Correction of lip perioral aging in a 71-year-old woman,
(a) preoperatively and (b) 2 years postoperatively. (Reproduced from
Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New
ork, N : Thieme Medical Publishers; 2018.)
is administered daily starting 2 days preoperatively and continu-
ing until complete reepithelialization occurs.
Routine safety precautions are necessary for Er: AG laser resur-
facing: metal eye shields and dental protection with a moist gauze
for the patient, safety goggles for the surgeon and assistant, and
smoke evacuation.
For resurfacing of the whole lip, a spot size of 5 mm is used at
1000 m , which results in a fluence of 6.25 /cm2, at a frequency of
10 to 12 Hz. The surface is painted in three to four layers with a
50 overlap between the patterns, crisscrossed to each other until
an even surface is obtained. The endpoint is the visual elimination
of rhytids, before the appearance of the typical pattern of the
reticular dermis. In most cases bleeding of the papillary dermis
doesn’t occur because of vasoconstriction. If bleeding does occur,
the laser energy is absorbed by the blood and efficient wrinkle
reduction is no longer possible.
If a patient has only a few isolated rhytids and the skin quality
between them is good, a spot painting or microlaser resurfac-
ing of the rhytid can be considered (Fig. 41.39). e then use a
2-mm spot at 200 m . This significantly shortens the recovery
time and reduces the morbidity of the procedure.
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 VII Midfacial Rejuvenation

Fig. 41.39 Upper lip rhytids, (a) before and (b) 6 months after microlaser resurfacing. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

e use an open dressing technique with a nonantibiotic oint-
ment, consisting of equal parts of petroleum jelly and paraffin.
The addition of liquid paraffin to the petroleum jelly makes it
less viscous and easier to apply over the wound. The patient is
instructed to continuously keep the wound moist and well cov-
ered with ointment.
41.5.2 Results and Outcomes
The patients shown in Fig. 41.40 and Fig. 41.41 give a good over-
view of all of the perioral aesthetic features that were discussed
in this chapter. The selected rejuvenation technique is based on
analysis of images of the patient in a more youthful stage of their

Fig. 41.40 This 73-year-old woman had a minimal access cranial suspension (MACS) lift with perioral rejuvenation that included microfat grafting
of the nasolabial folds and marionette grooves, sharp needle intradermal fat grafting (SNIF) of the vertical lip rhytids, and erbium-doped yttrium
aluminum garnet (Er: AG) resurfacing and liplift. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers; 2018.) (a) Preoperative view. (b) One year after her procedure, she has notable shortening of the vertical height of the
upper lip and eversion of the vermilion, together with complete eradication of the vertical upper lip rhytids.

Fig. 41.41 This 54-year-old woman had facial and perioral aging. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New ork, N : Thieme Medical Publishers; 2018.) (a) Vertical lengthening of the upper lip, loss of definition of the vermilion border and philtrum,
deflation of the upper and lower lips, and an accentuation of the nasolabial and marionette grooves are evident in comparison with (b) her image
from 30 years earlier. (c) The result 7 months after a combination of minimal access cranial suspension (MACS) lift and liplift with sharp-needle
intradermal fat grafting (SNIF) in the white roll and philtral columns and microfat grafting in the nasolabial folds and marionette groove.

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 41 Midface Recontouring

lives (between age 20 and 30 years). The treatment is always per- hypoplasia with pronounced malocclusions, especially Type 3,
sonalized to the individual morphology and needs. The endpoint requires orthognathic correction. Dental malocclusion can be
should be a natural perioral area that approximates the aspect of treated through orthodontic splinting.
the individual’s youthful mouth. The procedure is performed most of the time under local anes-
thesia, and the microfat grafting is done as previously explained in
this chapter. For maxillary hypoplasia, the malar region and the lip
41.6 Facial Contouring are treated. For malar augmentation, fat deposition is carried out
as deep as possible on the malar bone. To augment the anterior
The appearance of the face is mainly based on two structures:
projection of the upper lip, the whole thickness of the upper lip
the bony framework of the skull and the soft-tissue cover. Some
is injected 3-dimensionally from one nasolabial fold to the other,
patients have congenital hypoplasia by either osseous underde-
from the nasal base to the vermilion border, and from the oral
velopment (for example, maxillary and mandibular hypoplasia,
mucosa to the lip skin. In patients with mandibular hypoplasia,
cranial clefts, and syndromes such as Treacher Collins syndrome)
the treatment areas include the mandibular ramus and the chin as
or atrophies of the soft tissues as seen in Parry–Romberg
well as the lower part of the lower lip. Chin augmentation is made
syndrome), and some have a combination of osseous atrophy
with 0.7-mm canulae approaching lateral in a deep plane with
with deflation in the midface that cause a visible facial volume
multistroke technique (Fig. 41.42). In mandibular augmentation,
deficit. Hypoplasia of bony structures has been treated through
the microfat grafts are deposited along the mandibular bone in
orthognathic surgery. However, the rate of complications is high
the chin area, blending into the lower lip (Fig. 41.43, Fig. 41.44).
due to the invasiveness of the procedure, and patients inevitably
Injected volumes of microfat range from 8 to 25 mL (mean,
face a long recovery period. In patients with mild maxillary or
13 mL) per side for the malar areas, from 8 to 17 mL (mean, 12
mandibular hypoplasia, occlusion problems of the teeth occur
mL) for the upper lip, and from 12 to 27 mL (mean, 15 mL) for
infrequently and can usually be corrected in childhood or later,
the chin area. hen we start, the only complication is visible fat
during adult life, through orthodontic treatment. Therefore, the
lobules under the lower eyelid skin, which is resolved by using
main purpose of this patients is a purely aesthetic correction
1-mm multiholed cannulae and avoiding excessively superficial
of the facial proportions. In this group of patients we consider
fat deposition under the lower eyelid skin. Fat resorption is seen
the use of facial fat grafting to address volume deficiency. Facial
in all patients and ranges clinically from 15 in the immobile
microfat grafting is a safe and effective alternative to more com-
malar area and chin region to 50 in the mobile lip area. The
plicated and potentially dangerous advancement osteotomies
low morbidity and swift recovery associated with facial microfat
performed in patients for purely aesthetic reasons in the absence
grafting make it a valuable new tool in the armamentarium of the
of any functional problems.
facial aesthetic surgeon.
The impression of facial beauty relies largely on symmetry
and balanced proportions. Although the eyes and the lips are
typically the most striking facial elements, the appearance of the
middle and lower thirds of the face and their relationship to each
other play a pivotal role in creating harmony. This is particularly
true when the face is viewed laterally; that is, in profile, when
disproportions in the relationship between the maxilla and the
mandible become more evident. The most common procedures
to address facial hypoplasia are the Le Fort I osteotomy for
maxillary hypoplasia and the bilateral sagittal split osteotomy
(BSSO) with or without genioplasty for mandibular hypoplasia.
The most commonly performed genioplastic procedure is chin
augmentation, which can be achieved through sliding genio-
plasty or implant placement, and the risk for mental nerve
injury in genioplasty alone has been described to be as high as
10 and up to 29 in genioplasty combined with BSSO. In case
of insertion of a chin implant to augment soft tissue volume
without having to perform an osteotomy, complication rates are
lower because of a decreased chance for nerve injury, but one
major issue related to silicone chin implants is bony resorption.
This loss of bone tissue may lead to exposure of the roots of the
incisors with an overall tooth complication rate of 3 , including
infection and extrusion.
ith these complications in mind, most patients are requesting
aesthetic corrections that carry a lower risk of potentially per-
manent damage. Soft tissue augmentation by microfat grafting
to address bony hypoplasia has become an effective method to
achieve good aesthetic facial correction, leading to high patient Fig. 41.42 Chin augmentation. Lateral approach to fat grafting in a
satisfaction. It is obvious that severe maxillary or mandibular deep plane of the chin.

499
 VII Midfacial Rejuvenation

Fig. 41.43 This 41-year-old woman presented with moderate midfacial retrusion. An upper and lower blepharoplasty combined with lipofilling
of the midface were proposed. 8 mL of microfat was grafted into each malar region, 2.5 mL in the nasolabial folds, and the 10 mL in the upper lip
region. In the upper lip, fat was distributed in the whole thickness of the lip to augment the anterior projection of the lip region. (Reproduced with
permission from Lindenblatt N, et al. The role of microfat grafting in facial contouring. Aesthet Surg J. 2015; 35(7): 763-771.) (a–c) Preoperative. (d–f)
Photographs 3 years after the procedure demonstrate the improvement of the anterior projection of the midface and the change of the proportion
of the upper to lower lip projection because of the microfat grafting and show durable results.

41.6.1 Problems and Complications
Periorbital Fat Grafting
Fat grafting in the upper and lower orbital region has not been
without complications, especially in the earlier phase, when the
procedure was introduced. Between 2003 and 2008 we gradually
started introducing fat grafting in our blepharoplasty practice.
After 2008 we applied microfat grafting as a routine addition to
virtually all blepharoplasties. Most complications were seen in
the early phase of our use of the technique and can be attributed
to technical errors or misconceptions.
Typical beginner mistakes are grafting too much volume, graft-
ing too close to the skin and too close to the eyelid margin, and,
most significant, grafting with too large fat particles, producing
visible or palpable lumps under the skin (Fig. 41.45).
The classic 2-mm Coleman injection cannulas are too big to
be used under the delicate, fine eyelid skin. e adapted the style
of harvesting and injection cannulas to the specific needs of the
periorbital region. For harvesting the fat, we started using the typ-
ical grater multihole sharpened cannulas with 1-mm-diameter
holes on the tip.
Another mistake is failure to blend the fat into the shape of
the surrounding structures. Depositing the fat as a lump into the

500
 41 Midface Recontouring

Fig. 41.44 18-year-old woman consulted for facial contouring. (Reproduced with permission from Lindenblatt N, et al. The role of microfat grafting in
facial contouring. Aesthet Surg J. 2015; 35(7): 763-771.) (a,d,g) She presented with rhinokyphosis and hypoplasia of the chin with stable occlusion after
orthodontic treatment. Chin augmentation was done with microfat grafting. Nine months later the patient underwent for a second procedure in which 5
mL of microfat were placed. (b,e,h) The posttreatment result 11 months after the second infiltration shows the rhinoplasty result, which is a significant
improvement in chin projection. (c,f,i) The photographs taken 5 years posttreatment prove the stability of the microfat grafting.

501
 VII Midfacial Rejuvenation

Fig. 41.45 Beginners’ mistakes include overgrafting and malpositioning. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.) (a,b) Six months after an attempt to correct her hollow lower eyelids with microfat.
Assuming an important resorption would take place, 3 mL of fat was administered, resulting in a permanent overcorrection, for which revision
surgery was needed. (c,d) Two months later, 2 mL of fat graft was excised. (e) The living adipose tissue under the orbicularis muscle.

infrabrow sulcus without fading it out into the lateral eyebrow Lip Lift
region can lead to unsatisfactory show of the fat graft (Fig. 41.46).
The main problems are caused by an incorrectly designed
Secondary blending can be performed in touchup procedures.
excision pattern and sloppy suturing technique (Fig. 41.47).
e have had no major complications. Complications in the early
The scar should not visibly cross the nostril sill. Inadequate
premicrofat phase (before 2008, n 138) included underfilling
lateral excision results in an unnatural pouting of the central
(21 ), overfilling (9 ), graft visibility and lumps (8 ), asymmetry (4 ),
scleral show (2 ), and hematoma (1 ). In the late microfat series
(after 2008, n 362) we have not had any expanding hematomas, but
bruising was seen in varying degrees in all patients. Prolonged edema
(more than 1 month postoperatively) of the malar area occurred in
7 of patients. Postoperative scleral show occurred in 1 , associated
with orbital fat redraping (skin–muscle flap). There were no reports
of sensory or motor nerve lesions, infections, asymmetries, or over-
filling. One patient in this series who gained 12 kg of weight over the
course of a year after smoking cessation for her facelift surgery ended
up with an overprojection of both malar areas. This was solved by
performing a microliposuction under local anesthesia.

Perioral Fat Grafting

The main problems can be categorized as follows:

• Underfilling (easy to correct)

• Overfilling (very difficult to correct and less acceptable to the
patients)
• Malpositioning of fat (prevented by meticulous preoperative
planning, marking, and technique)
Fig. 41.46 Micro fat grafting of the infrabrow sulcus failed to blend into
the lateral brow. This is most visible in a forced eyebrow elevation. It can
be prevented by blending the fat graft laterally into the eyebrow region.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)

502

Fig. 41.47 Incorrect design of lip lift excision pattern in a transwoman.
The scar crosses the nostril sill, and inadequate lateral extension of
the incision results in an unnatural pouting of the central lip portion.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New ork, N : Thieme Medical Publishers; 2018.)
lip. Overresection of lip skin can lead to impossibility of mouth
closure and is virtually irreparable.
Lip Resurfacing
The main problems are undercorrection, scarring, hypopigmen-
tation, and hyperpigmentation.
• Undercorrection results from resurfacing too superficially and
is easily solved by a cautious touchup procedure. e never
promise our patients complete wrinkle removal but rather a
significant wrinkle reduction.
• Overcorrection may lead to scarring and can be caused by
resurfacing too deeply or by concomitant bacterial or viral
infection. Herpes simplex prophylaxis is routinely adminis-
tered, and meticulous wound care and close follow-up for 3
months postoperatively are important for infection preven-
tion. Any induration may lead to a hypertrophic scar and is
immediately treated with an intralesional injection of 50/50
triamcinolone and 5-fluorouracil.
41.7 Concluding Thoughts
Around the turn of the millennium, the awareness that physical
aging of the face is a multifactorial process was growing. Aging
is now understood to consist of facial sagging and skin laxity,
changes in skin texture and pigmentation, changes in volume in
certain areas of the face, and contraction of certain facial mus-
cles producing permanent folds and rhytids. This understanding
has caused a true paradigm shift in how surgeons analyze and
treat the aging face. The deflation process is most important
in the centrofacial area, which consists of the periorbital and
perioral areas and can be addressed very well by combining dif-
ferent kinds of fat applications such as lipofilling with microfat
grafting technique, explained in this chapter, to add volume in
the infrabrow and malar area, and fill folds in nasolabial and
marionette grooves; S IF for superficial rhytids; and nanofat
grafting to improve skin quality. All these procedures become an
41 Midface Recontouring
essential tool for rejuvenation of the face additional to surgical
techniques such as lip lift and MACS lift. Furthermore, lipofilling
is being used as a valid procedure to correct facial proportions,
avoiding invasive orthognathic surgery in patients with mild
maxillary or mandibular hypoplasia, becoming a valuable alter-
native to more complicated surgeries. The low morbidity and
rapid recovery make facial microfat grafting a welcome tool in
the armamentarium of the modern aesthetic surgeon.
Clinical Caveats
• The surgeon should think in terms of definition and shape and
not so much in terms of volume.
• Patients must be educated; most patients need to be
informed of the different components of aging, and pictures
of their youthful appearance are a great tool to help them
understand the mechanisms of deflation and lengthening of
the upper lip.
• There is a relationship between graft particle diameter and
the diameter of the holes in the harvesting cannula. “Fine-
particle fat” can be obtained by harvesting fat with small-hole
cannulas.
• Small fat particles can be grafted with small-diameter can-
nulas (0.7–0.9 mm). This is indicated if grafting will be done
underneath thin fine skin, such as grafting eyelids, preventing
complications such as visible and palpable fat grafts under
the skin.
• Small fat particle grafting will also reduce postoperative
morbidity and downtime as a result of the reduced resorption
of the fat particles.
• Augmentation blepharoplasty combines the restoration
of lost periorbital volume with judicious and conservative
excision of lax skin, with or without a lifting of the tail of the
eyebrow.
• Periorbital microfat grafting is a valuable and safe alternative
to complicated, difficult, and potentially dangerous midface
and eyelid rejuvenation techniques.
• In particular when grafting the lips, less overcorrection is
needed if small fat particles are used because of diminished
resorption and thus better take of the fat.
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42 Endoscopic Rejuvenation of the Midface
Renato Saltz, Gabriele Miotto, and Carlos Casagrande
Abstract
Over the years, many different approaches have been described
for the treatment of the aging midface, including access through
the lower eyelid, face lift, open temporal, endoscopic temporal,
and intraoral. The use of endoscopic surgical techniques for
midface lift rejuvenation has advantages. It allows for smaller
and hidden incision placement and precise dissection under
magnification. Critical anatomy can be clearly identified and
preserved. It provides a safe plane of dissection along the deep
temporal fascia in the upper lateral face, along the orbital rim
periosteum in the periocular area, and along the periosteum in
the midface and lid–cheek junction. The extend of the dissection
can be tailored to specific patient needs, and the type of fixation
can be modified accordingly. Creating an optical cavity in the
midface allows for excellent visualization and easy fixation.
Endoscopic midface lifts can be easily combined with brow lifts
or associated with neck lifts for a global facial rejuvenation. In
our hands, endoscopic midface suspension has been a safe and
reproducible technique with stable long-term results.
Keywords
facial rejuvenation, midface lift, endoscopic midface lift, endo-
scopic facial rejuvenation, cheek lift
42.1 Indications and
Contraindications
The most common clinical indications for endoscopic midface
lifting are the following:
• Ptosis of the malar fat pad
• Loss of the projection of the malar area
• Accentuation of the nasolabial fold
• Ptosis of the corner of the mouth
• Ptosis of the lateral corner of the eyelid
• Deep orbitomalar groove
• Accentuated nasojugal groove
Contraindications for endoscopic treatment of the midface:
• Lack of soft tissue volume in the midface
• Prominent malar bones or adequate midface volume
• Medical contraindications
42 Endoscopic Rejuvenation of the Midface
42.2 Pertinent Anatomy
Success with facial rejuvenation surgery requires a basic under-
standing of the aesthetic subunits and anatomic structures of
the face and how they are affected by the aging process. These
should be studied and respected to obtain a harmonious result.
It is important to know which structures need to be altered and
then to match the deformity with the most appropriate tech-
nique for correction of it.
Midface aging is characterized by four anatomic changes:
1. Descent of the malar fat pad
2. Increase in markedness of the lid–cheek junction
3. Increase in prominence of the nasolabial folds
4. Loss of cheek projection
The changes associated with midface aging occur due to defla-
tion and descent, with an inferior medial sliding of tissues due
to cutaneous and ligamentous laxity. Malar bags or festoon may
also develop in the malar area. Other changes include maxillary
reabsorption, ptosis of the corners of the mouth, and descent
of the perioral tissues (Fig. 42.1). The aging process also creates
an increase in the vertical length of the lower eyelid and a more
demarcated lid–cheek junction. The arcus marginalis of the lower
eyelid divides the orbital region from the midface. Aging makes
this transition more demarcated: the orbitomalar groove. It is
formed by the orbital septum and a thin fascia of the deep portion
of the orbicularis oculi inserted at the inferior orbital rim. Release
of this ligament improves the lid–cheek junction grooving and
makes the midface blend better into the lower lid.
The muscles of the orbitofrontal area have a fundamental
importance in determining brow position. The frontal muscle is
the anterior belly of the occipitofrontal muscle, a paired muscle
that covers the forehead and actively lifts the brows. It begins at
the level of the hairline extending through the supraorbital skin.
Its function is to elevate the brows. It extends laterally toward
the superior temporal line (temporal crest) and varies in width;
it is an extension of the galea aponeurotica in the midline of the
scalp. The brow is strongly suspended by the frontal muscle in
its medial two-thirds. Because the lateral third is usually thinner
and weaker, the descent of the tail of the brow is usually more
evident than in the head and body. Clinically, the descent of the
brow in the temporal region contributes to the hooded and tired
facial appearance often associated with aging. e consider the
temporal area and lateral periorbital area a continuation of the
middle third of the face, and these areas are routinely addressed
during endoscopic midface rejuvenation, since it is unlikely that
there will be no upper face aging when there is midface aging.
505
 VII Midfacial Rejuvenation
b
Fig. 42.1 Anatomic aging changes in the midface and periocular area. (a) Malar fat pad compartment descent and deflation; (b) ligament, muscle,
and skin laxity.
42.3 Preoperative Assessment
Preoperative evaluation includes a complete evaluation of the
face, skin quality, history of previous procedures and current
skin care routine, complete medical history, and medications
especially the ones that change platelet adhesion, such as
aspirin, ginkgo biloba, and anti-inflammatory drugs. Patients are
scheduled for a formal preoperative visit with the surgeon, the
nursing team, and the anesthesiologist 1 to 2 weeks before the
procedure to review all the details of the surgical procedure, pro-
vide prescriptions, plan for medication discontinuation, perform
the venous thromboembolism (VTE) risk assessment, evaluate
the need for preoperative testing, and address special equipment
needs and any other preoperative requirements. If needed by
history and physical exam, the requested preoperative exams
include the following:
• Complete blood cell count
• Coagulation function assay
• Glycemia testing
• Electrocardiogram
• Chest radiographs
506
42.4 Preoperative Planning
and Markings
42.4.1 Zones of the Brow and Midface
Facial aging is a clinical manifestation of the changes in volume
and position of the facial anatomy. The midface has a direct
anatomic relationship with the temporal and periorbital areas,
and we divided the upper face and midface into three surgical
zones to facilitate understanding of the endoscopic anatomy and
surgical technique (Fig. 42.2).
Zone 1
one 1 comprises the temporal region, starting 2 cm behind the
hairline, extending medially to the temporal crest, inferiorly to
the supraorbital and lateral orbital rim, laterally to the inferior
temporal septum, and inferolaterally to the superiomedial
zygoma. The floor of zone 1 is the deep temporal fascia, and the
roof is the superficial temporal fascia above the temporal muscle
and the periosteum at the level of the orbital rim and zygoma.
 42 Endoscopic Rejuvenation of the Midface

Zone 2 The deep branch of the supraorbital nerve is an important

landmark. Its trajectory should be outlined to avoid incisions and
one 2 extends laterally to the temporal crest, inferiorly to the
fixation points in its trajectory, which can cause pain and pares-
supraorbital rim and radix, and superiorly to the level of the
thesias. Fig. 42.3 shows the following landmarks:
incisions. Dissection in zone 2 is subperiosteal, keeping the galea
and the skin above intact. During a midface surgery, the surgeon • The inferior orbital rim and zygomatic arch
must connect zones 1 and 2 by releasing the temporal crest and
• The nasolabial folds
the lateral orbital adhesions.
• Point A at 3 cm lateral to the lateral orbital rim at the level of
the superior border of the zygomatic arch
Zone 3 • A line between the distal end of the nasolabial fold and point
one 3 starts at the lateral and inferior orbital rim, zygoma, and A, to define the area of subperiosteal dissection and elevation
premaxilla. Dissection is subperiosteal, under the malar fat pad. of the midface
The infraorbital rim is often visualized in its lateral half. one 3 • The anterior temporal line
also incorporates the inferior eyelid, but we do not consider it to
• A line outlining the trajectory of the temporal branch of the
be part of the midface approach.
facial nerve
Understanding the transition between zones 1 and 3 and their
anatomic structures is critical for safe and precise dissection in • A line that outlines the orbital rim
the midface. The transition between zones 1 and 3 is outlined by
the sentinel vein, the zygomaticotemporal nerve, and the zygoma-
ticotemporal vein and artery. The preservation of these cutaneous
42.5 Operative Technique
nerves avoids numbness over this area of dissection.
The midface is limited superiorly by the lid–cheek junction,
medially by the nasofacial angle, laterally by the pretragal area
42.5.1 Pertinent Instruments
and sideburn, and inferiorly by the nasolabial groove. The three The following instruments are of particular importance for
zones of dissection are routinely marked on the skin before the endoscopic midfacial rejuvenation (Fig. 42.4):
procedure starts. The scalp and temporal areas are marked, and
the hair can be styled to accommodate the incision sites, either by • Subperiosteal hockey-stick elevators
combing or by using hair bands. • Fixation devices

Fig. 42.2 Anatomic zones of the upper and midface that are addressed Fig. 42.3 Preoperative markings of the upper and midface used as
during a midface lift. landmarks for dissection during the endoscopic midface lift.

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 VII Midfacial Rejuvenation
Casagrande’s needle and 3–0 nylon or polydioxanone
sutures (PDS)
Endotine Midface (MicroAire Surgical Instruments, LLC,
Charlottesville, VA)
42.5.2 Operating Room Setup and
Patient Positioning
The surgical suite must be well organized to perform an endo-
scopic procedure, including correct patient positioning. The
imaging equipment should be at the foot of the surgical table to
permit better visualization; the surgeon and the assistant should
be at the head of the table (Fig. 42.5). The endotracheal tube
should be tied to a tooth using dental floss or wire and wrapped
with sterile drapes. The patient’s head should be placed on a
soft head support that facilitates bilateral head mobilization.
The patient’s hair is prepped and tied back without shaving. The
eyes should be protected with ointment and corneal shields.
The endoscope cord should be long enough to permit adequate
movement and should be covered with a sterile plastic sleeve.
Fig. 42.4 Instruments and fixation tools used for endoscopic midface lift. (a) Complete set. (b) Hockey stick elevators. (c) Casagrande’s needle.
Fig. 42.5 (a) Operating room setup and (b) surgical instrumentation for the endoscopic midface lift.
508
42.5.3 n r i n
The endoscopic midface lift can be done under local anesthesia
and sedation or general anesthesia. Tumescent infiltration with
a local anesthetic to the temporal, forehead, and midface areas
creates an excellent field for dissection.
e perform nerve blocks with lidocaine 2 with epinephrine
(supraorbital, supratrochlear, zygomaticofacial, and infraorbital).
An anesthetic solution containing 20 mL of 2 lidocaine, 20 mL of
0.5 bupivacaine, 1 mL epinephrine, and 160 mL of normal saline
is used to inject the dissection areas.
42.5.4 Incisions
A temporal incision gives access to the temporal area, the lateral
frontal area, and the midface. It is positioned 2 cm posterior
to the hairline in a coronal direction, corresponding to a line
from the alar base of the nose, passing through the lateral tail
of the brow, and reaching the scalp. Three other access points
can be created with incisions placed just behind the hairline in
a longitudinal fashion when the complete forehead needs to be
undermined for a complete endobrow lift (Fig. 42.6).
 42 Endoscopic Rejuvenation of the Midface

42.5.5 Dissection
Dissection through the temporal incision is carried down on top
of the deep temporal fascia. Identifying the temporal muscle
under the deep temporal fascia is useful to secure the right plane
of dissection (Fig. 42.7). Blunt dissection continues inferiorly
down to a point of resistance at the level of the supraorbital rim.
At this point, the endoscope is introduced into the cavity to allow
better visualization, safer dissection, and adequate hemostasis.
Medially the dissection continues through the areolar tissue up
to the fusion line (temporal crest), where the deep temporal fascia
fuses with the subperiosteal plane (zones 1 and 2). The fusion line
is released, and dissection continues in the subperiosteal plane
with the release of the lateral supraorbital rim periosteum for
temporal elevation. This dissection extends to the frontal area in
case of a combined endobrow.
In zone 1, the temporal branch of the facial nerve is superficial
to the plane of dissection. It is above the intermediate fat pad
and superficial temporal fascia. The nerve is in the roof of the
dissection. The temporal dissection continues on top of the deep
temporal fascia until it reaches the supraorbital rim and superio-
medial border of the zygoma, where zone 3 begins.
The sentinel vein is identified at this point, preserved when
possible or cauterized under direct vision (Fig. 42.8). The assistant
should aspirate or irrigate the dissection site when necessary to
optimize the quality of the optical field.
Creation of a limited area of dissection in the transition between
zones 1 and 3 will prevent harm to the frontal branch of the facial Fig. 42.6 Access incisions for the endoscopic midface lift. For access
nerve by avoiding the two lateral thirds of the zygomatic arch, to zones 1 and 3, the temporal incision is usually the only one needed.
where the nerve transits from deep to superficial (Fig. 42.9). For complete access to the forehead such as for a complete endoscopic
browlift, three other frontal incisions are also needed. (Adapted
If the brow is also being elevated (zone 2), the supraorbital dis- with permission from Saltz R. Endoscopic temporal-incision only
section continues medially until the corrugator muscle is seen. The midface lift is enhanced by Endotine technique. Aesthet Surg J.
corrugators are completely avulsed with an endoscopic grasper; 2005; 25:80-83.)
the branches of the supraorbital and supratrochlear nerves are
preserved (Fig. 42.10). The assistant keeps finger pressure over
the glabella to assist in the removal of the corrugator fibers and to If the brow is not being treated, only zones 1 and 3 are dissected.
minimize trauma to the underlying skin and the development of After the fusion line is released, the subperiosteal dissection is
possible future indentations in this area. carried down into the lateral orbital rim. Careful attention to this
narrow and delicate area is needed to maximize endoscopic vision
and minimize trauma to the neurovascular structures present in
this transition zone.
The endoscopic temporal subperiosteal approach for release of
the orbitomalar ligament does not interfere with the lower eyelid

a b

Fig. 42.7 Temporal incision and exposure of the temporal muscle

below the deep temporal fascia, confirming the correct dissection Fig. 42.8 (a) Intraoperative endoscopic view of the sentinel vein
plane. piercing through the deep temporal fascia and (b) being cauterized.

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 VII Midfacial Rejuvenation

Fig. 42.10 Intraoperative endoscopic view of the transition between

zones 1 and 2.

Direct Needle Fixation

Fig. 42.9 Dissection of zone 1 and partial dissection of zone 2 for
release of the lateral orbital adhesions and elevation of the lateral brow.
This technique uses a straight, thin needle with an eye in its
sharp tip, based on a modified Reverdin needle that has been
developed by one of the authors (Casagrande’s needle; Fig. 42.12).
Under endoscopic visualization, the needle is introduced
through the skin at premarked points of traction for optimal tissue

structures and thereby avoids the risk of ectropion and scleral

show that can sometimes be seen with the subperiosteal approach
through the inferior eyelid. Once the lateral orbit rim periosteum is
elevated, the endoscope is advanced and subperiosteal undermining
of the inferior orbital rim is performed with a hockey-stick elevator
to allow improvement of the orbitomalar groove. The subperiosteal
dissection of zone 3 continues inferiorly. It is sometimes necessary
to release some of the attachment fibers of the masseter muscle
from the zygomatic bone for midface access. These fibers should
be carefully avulsed or transected with the endoscopic scissors.
Dissection in this very narrow tunnel allows better visualization
of the midface cavity, more secure fixations, and decreased inci-
dence of relapse after midface lifting with the potential for better
long-term results (Fig. 42.11). However, a wide midface dissection
can also cause pronounced and prolonged edema. The buccal fat
pad can also be suspended during the endoscopic midface lift. It
is located inferiorly and deeper to the malar fat pad, medial to the
masseter muscle and superficial to the buccinator muscle.
hen needed, the inferior eyelid fat pads are treated separately
through a transconjunctival approach. If there is skin excess, it is
usually treated by very conservative skin-only removal or by laser
therapy.

42.5.6 Fixation
Long-lasting results of an endoscopic midface lift depend on
adequate dissection, periosteal release, and appropriate fixation.
Two different techniques of fixation are used by the authors: the Fig. 42.11 The extent of dissection of zones 1 and 3 for midface
direct needle fixation technique with Casagrande’s needle and elevation, and pertinent anatomy. DTF: deep temporal fascia; TPF :
the fixation with Endotine. temporoparietal fascia.

510

elevation. The endoscopic visualization allows direct observation
of the needle penetrating the optical cavity. The needle is brought
out through the temporal incision, and a braided nonabsorbable
suture is introduced through the needle tip. The needle tip suture
grasps the soft tissues as a loop and is brought out again through
the temporal incision. Both sutures are removed from the needle’s
eye. Traction is confirmed by pulling the suture and noticing ele-
vation of the tissues before suture fixation to the deep temporal
fascia. The midface loops are placed first, and two or three or
more points of fixation can be used. Usually the first point is at
the level of the malar fat pad, the second to the sub–orbicularis
oculi fat (SOOF) pad, and a third one at the infraorbital area when
necessary.
In the frontal region, the lateral fixation points are placed in
a line of traction that elevates the lateral corner of the eye, the
lateral brow, and the temporal skin below the hairline. The fixa-
tion should be placed as close as possible to the hairline to avoid
visible indentation on the temporal skin. This fixation technique
permits precise repositioning and fixation of soft tissues. Care is
taken to achieve maximum symmetry between sides at the end
of the fixation.
The subperiosteal dissection provides an adequate blood
supply to the skin flaps and allows the simultaneous use of skin
resurfacing modalities, such as lasers and chemical peels. The lim-
itations of this technique are that it (1) relies on suture suspension
only and appropriate healing, (2) may result in minor asymmetry
because of different vectors for fixation and different traction
forces between sides, and (3) involves a long learning curve and
dexterity with the use of the endoscope (Fig. 42.13).
Fixation Using Endotine
The Endotine Midface device (Fig. 42.4c) is the senior author’s
preferred method of suspension and fixation for midface lifts.
The Endotine Midface device is an absorbable device with five
prongs or tines that will engage the soft tissues and suspend them
in position. A sleeve protects the device during insertion, and
deployment is achieved with a simple trigger release to attach
a b c
Fig. 42.12 (a) Casagrande’s needle and (b,c) the Endotine Ribbon
device. (Reproduced with permission from Casagrande C, Pintarelli
G, Barazetti DO. Tratamento cir rgico total da face. In: Casagrande C.
ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Convencional e Procedimentos Não Invasivos. S o Paulo, Brazil: Dilivros;
2018:223–238.)
42 Endoscopic Rejuvenation of the Midface
tines to soft tissue. Digital pressure engages the tines. Once the
soft tissue is engaged, the insertion sleeve is removed through
the temporal incision. Tension is applied to the anchoring end of
the device to achieve the desired elevation. The end of the device
is then sutured to the temporal fascia and the excess is trimmed
(Fig. 42.14).
This is an easy step-by-step midface suspension–fixation that
provides adjustability for elevation and projection, and maintains
mechanical fixation until healing is completed. The five tines pro-
vide multiple points of contact for secure soft tissue fixation. The
elevation forces are evenly distributed over a wide area, prevent-
ing potential skin irregularities. Insertion and deployment are
accomplished through the temporal incision. Implant palpability
is minimal, and reabsorption starts at 6 months. The Endotine
Midface fixation technique offers the following advantages:
• No intraoral incision
• No sutures
• Simple deployment with multipoint fixation
• Absorbable device
• Fast and simple adjustability for control of the elevation and
volume of the midface
Fig. 42.13 Fixation with Casagrande’s needle. (Reproduced
with permission from Casagrande C, Pintarelli G, Barazetti DO.
Tratamento cir rgico total da face. In: Casagrande C. ed. Plástica
da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Convencional e Procedimentos Não Invasivos. S o Paulo, Brazil: Dilivros;
2018:223–238.)
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 VII Midfacial Rejuvenation

Fig. 42.14 Endotine Midface device fixation. (a) Deployment system protects the device during insertion. Trigger release to attach tines to soft
tissue. Digital pressure engages the tines. (b) Insertion sleeve is removed. (c) Tension is applied to the device for elevation. Device is sutured to the
temporal fascia. (Adapted with permission from Saltz R. Endoscopic temporal-incision only midface lift is enhanced by Endotine technique. Aesthet
Surg J. 2005; 25:80-83.)

42.5.7 Closure monitored to avoid bleeding and hematomas, usually maintaining

The scalp is closed in the temporal area with several sutures
between the scalp and the deep temporal fascia to seal the dead
space. The incision is closed with interrupted nylon sutures,
the hair and scalp are shampooed and rinsed, and the patient is
extubated and taken to the recovery room.
it below 120/80 mm Hg. Crushed ice bags can be used over the
eyes, forehead, and midface. The patient is allowed to shower on
the first postoperative day. Oral analgesia is given, and antibiotics
are used for up to 24 hours. Lymphatic drainage massage, starting
at 48 to 72 hours postoperatively, can help with initial swelling
improvement in the initial postop period, improve discomfort,
and improve appearance in the early postoperative period.

42.6 Postoperative Care

In the recovery room the position of the patient’s head is main-
42.7 Outcomes
tained elevated to 30 to avoid airway obstruction and excessive Endoscopic midface lifts are safe procedures but require specific
facial edema. The patient’s blood pressure must be carefully equipment and training and have a long learning curve. They are

512
 42 Endoscopic Rejuvenation of the Midface

routinely combined with brow lifts and neck lifts in our clinical
practice for global facial rejuvenation with reproducible results.
42.8 Results
Swelling may be present for 3 to 4 weeks and numbness for 6 to Three case studies are shown in Fig. 42.15, Fig. 42.16, and Fig.
8 weeks. 42.17.
Temporary supraorbital and supratrochlear nerve paresthesias
are caused by pocket dissection and stretching of the nerves. They
are common for 2 to 3 weeks, are manifested frequently as numb- 42.9 Concluding Thoughts
ness or forehead and scalp itching, and recover spontaneously,
Endoscopic midface suspension has been a safe and reproducible
usually at 8 weeks.
technique with stable long-term results. Proper elevation of
Temporary paralyses of the frontal branches of the facial nerve
the flaps and precise dissection in the subperiosteal plane at
can also happen but are rare.
the level of the lateral orbital rim are the key to facilitating safe
undermining and fixation of the midface.

Fig. 42.15 (a,c,e) Preoperative images of a patient in her 40s with brow ptosis, midface descent, upper and lower lid skin excess, and neck
laxity. (b,d,f) Postoperative images after endoscopic brow and midface lift (treatment of zones 1, 2, and 3) associated with upper and lower lid
blepharoplasty and limited neck lift with superficial musculoaponeurotic system (SMAS) plication. (Reproduced with permission from Casagrande C,
Pintarelli G, Barazetti DO. Tratamento cir rgico total da face. In: Casagrande C. ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Covencional e Procediments Não Invasivos. S o Paulo – SP: Dilivros; 2018: 223-238.)

513
 VII Midfacial Rejuvenation

Fig. 42.16 (a,c,e) Preoperative images of a patient in her 50s with brow ptosis, midface descent, upper and lower lid skin excess, and neck laxity.
(b,d,f) Postoperative images after endoscopic brow and midface lift (treatment of zones 1, 2, and 3) associated with upper and lower lid blepha-
roplasty and neck lift with superficial musculoaponeurotic system (SMAS) plication. (Reproduced with permission from Casagrande C, Pintarelli G,
Barazetti DO. Tratamento cir rgico total da face. In: Casagrande C. ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica, Covencional
e Procediments Não Invasivos. S o Paulo – SP: Dilivros; 2018: 223-238.)

• Fixation with needle is safe and inexpensive and can be

Clinical Caveats
• The endoscopic midface lift should be precise to preserve
the neurovascular structures of the face to avoid permanent
facial paresthesias.
• The sentinel veins can be preserved or cauterized for better
dissection exposure and easier instrument manipulation in the
transition zone between the temporal region and the midface.
• Subperiosteal elevation of the lateral orbital rim is a key to
facilitating safe undermining and fixation of the midface.
• Proper visualization and dissection of the midface may require
release of masseter attachments from the malar bone.
tailored for different elevation needs. Fixation with Endotine
Midface is quick, safe, reliable, and less likely to produce
asymmetry than suture fixation.
• It is important to preserve the integrity of the inferior orbital
nerve so as to prevent midface paresthesias.
• Patients should be informed that swelling may be present for
3 to 4 weeks and numbness for 6 to 8 weeks.
• Endoscopic midface lifting does not treat jowling and aging
of the neck—it does not replace a face lift.

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 42 Endoscopic Rejuvenation of the Midface

Fig. 42.17 (a,c,e) Preoperative images of a patient in her 60s with brow ptosis, midface descent, upper and lower lid skin excess, and neck laxity.
(b,d,f) Postoperative images after endoscopic brow and midface lift (treatment of zones 1, 2, and 3) associated with upper and lower lid blepha-
roplasty and necklift with superficial musculoaponeurotic system (SMAS) plication. (Reproduced with permission from Casagrande C, Pintarelli G,
Barazetti DO. Tratamento cir rgico total da face. In: Casagrande C. ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica, Covencional
e Procediments Não Invasivos. S o Paulo – SP: Dilivros; 2018: 223-238.)

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 Part VIII
Surgical Rejuvenation
of the Face and Neck

VIII

43 Clinical Anatomy of the Face and Neck:
Visualizing the Face
Joel E. Pessa and Foad Nahai
Abstract
e present a fresh approach to facial anatomy for the aesthetic
surgeon. Aesthetic surgery challenges the clinician to under-
stand basic anatomy: how it is arranged during youth and how
it changes with age. The ability to visualize the face as a logical,
three-dimensional construct enables the aesthetic surgeon to
meet these challenges. The authors include some novel ana-
tomic findings gleaned from thousands of hours of anatomic
work performed during the past 5 years, many of which are as
yet unreported. By improving the clinician’s understanding of
facial anatomy, this chapter will help in avoiding some common
iatrogenic injuries and achieving safe, effective, and predictable
surgical results.
Keywords
facial anatomy, face, fascia, anatomic spaces, lymphatic supply,
wrinkles, rhytides, fat, fat compartments
43.1 How the Face Is Designed
Although facial anatomy exhibits tremendous variability between
individuals, we see a common pattern or design, much like a
building or a mall. The ground floor (the deep fascia) rests atop
a foundation (the facial skeleton). Escalators (retaining ligaments)
travel from the ground floor to the roof (skin and dermis). The
escalators act like walls and form rooms on the ground floor
(the deep fat compartments) and on the first floor ( fi f
compartments). On the way up, the visitor may get off on the first
floor (motor nerves) or travel directly from the ground floor (deep
fascia) to the roof (skin) (perforating blood vessels, sensory nerves).
Traffic (lymphatic vessels, veins) usually descends directly from
the roof (skin) to the ground floor (deep fascia). Only on the floor
does one encounter special rooms (anatomic spaces). One likewise
encounters some business-use-only escalators (facial muscles; lip
elevators) traveling from the foundation (bone) to the roof (skin),
or traveling along the first floor ( fi f
platysma). The roof may develop cracks (wrinkles, creases) over
exposed pipe (lymphatic vessels). Although tremendous variabil-
ity exists, it does so within this common design (Fig. 43.1).
43.2 Learning Anatomy:
An Approach
One can learn facial anatomy in a variety of ways. The great
atlases such as Grant’s, Gray’s, and Sabotta’s provide a wealth
of information and detail. Earlier textbooks, notably those
of McClellan and Bell, supplemented their dissections with
43 Clinical Anatomy of the Face and Neck: Visualizing the Face
exquisite drawings and lithography. A determined study of these
texts more than satisfies the needs of the basic anatomist. The
aesthetic surgeon, however, faces several unique challenges that
suggest a slightly different approach.
The aesthetic surgeon not only needs to understand basic
structure but must know how structures are arranged in youth
and how they change with age. o two faces are exactly alike:
therefore, variability in size, shape, and structural relationships
to one another is the rule. Anatomic variability further extends
to discrete structures: for example, a bifid zygomaticus major
muscle. The surgeon must also be able to anticipate the location
of structures to avoid injury, even when intraoperative edema
distorts the basic framework of the face.
e therefore propose a slightly different approach to learning
facial anatomy. Our approach is not the only way, maybe not even
the best way, but it does address the distinct challenges faced by
the aesthetic surgeon while simultaneously providing flexibility
to incorporate new observations and findings. e simply build
a mental image a three-dimensional construct of how facial
anatomy is arranged and why. Each section begins with a rep-
resentative dissection or illustration. The sections are brief and
follow one another, so that by the end the reader has assembled
a working roadmap of the human face. Supplemental images are
included to provide greater detail for the interested reader.
43.3 Wrinkles, Crow’s Feet,
and Laugh Lines
Terminology
Crease: indentation that occurs at the boundary between
some superficial fat compartments, perpendicular to muscular
action. Defined lymphatics travel beneath creases.
Rhytid (wrinkle): an indentation into dermis that may occur
(1) related to muscular activity or (2) in a more random fashion
with age. Large wrinkles (crow’s feet) are related to lymphatic
vessels.
Facial communication involves interpreting expression, much
of which is dictated by dynamic creases and wrinkles. Facial
animation, such as contraction of the zygomaticus major muscle,
accentuates the nasolabial crease. Although current literature
tends to draw a distinction between static (e.g., nasojugal or
lid/crease junction) and dynamic (nasolabial) creases, anatomic
dissection suggests a remarkable similarity in their constant
relationship to a major underlying lymphatic vessel.
The nasojugal crease defines the lid–cheek junction (Fig.
43.2a). A plexus of lymphatic vessels travels from medial to
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 VIII Surgical Rejuvenation of the Face and Neck

lateral, parallel to the so-called V-deformity (both superficial
and deep!). This lymphatic plexus lies directly deep to the
crease. One can always identify this structure in vitro and in vivo.
Recurrent lower lid edema has been problematic for the plastic
surgeon. Furnas used the term malar festoons to describe what he
thought were redundant furrows of skin and muscle. In the mid-
1800s, Sichel, an ophthalmologist, used the term blepharochalasis
to describe a phenomenon he thought to be related to recurrent
lower lid edema. Over 150 years later, our dissections substantiate
Sichel’s hypothesis: lower lid edema always occurs superior to the
lid–cheek crease defined by a subdermal lymphatic plexus.
ork over the past 5 years suggests that the cutaneous
boundaries between some fat compartments are determined by
underlying lymphatic plexuses. This is true for the nasolabial
crease (Fig. 43.2b). In vitro one can inject just deep to the dermis
with filler to show the course of the nasolabial crease lymphatic.
To date, a growing number of cutaneous creases and rhytides are
known to be associated with a major subdermal lymphatic plexus.

Fig. 43.1 The design of (a) the face is similar to that of (b) a building or mall. The ground floor (deep fascia) lies atop the foundation (facial skeleton).
Escalators travel from the ground floor (deep fascia) to the first floor (superficial fascia or SMAS) and then to the roof (skin). Escalators (retaining
ligaments) divide the ground floor rooms (deep fat compartments) and the first floor rooms (superficial fat compartments). Special rooms (anatomic
spaces) occur only on the ground floor. Traffic may travel from ground floor to first floor (nerves), from ground floor to roof (blood vessels), and from
roof to ground floor (lymphatic vessels).

Fig. 43.2 (a) Static rhytides such as the nasojugal crease occur directly over major lymphatic vessels. Direct cannulation of the nasojugal lymphatic
system and injection with fluorescent tracers identifies continuity from medial to lateral across the entire crease. Crow’s feet overlie smaller
lymphatic vessels that join nasojugal crease lymphatics at the lateral canthus. Nasojugal lymphatics drain the periorbital contents and some of the
sclera, especially medially. No artery lies directly beneath the nasojugal crease: this cutaneous boundary is determined solely by lymphatic pathways.
(b) Dynamic rhytides and the cutaneous boundaries between some adjacent fat compartments lie directly over major lymphatic vessels. Dynamic
wrinkles form perpendicular to the direction of muscular activity (e.g., the nasolabial crease forms perpendicular to contraction of the zygomaticus
major muscle) and directly over a major lymphatic vessel and/or plexus. Repetitive muscular contraction over a relatively fixed site (i.e., the lymphatic
vessels and perilymphatic fat) is a possible etiological factor in dynamic rhytid formation. Other dynamic creases, including corrugator creases and
the transverse nasal crease (perpendicular to the procerus muscle), likewise occur over definite, identifiable superficial lymphatic systems. When
we perceive expression displayed by rhytides—crow’s feet and corrugator and nasolabial creases—we are observing lymphatic territories and their
distribution on the human face.

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 43 Clinical Anatomy of the Face and Neck: Visualizing the Face

43.4 Anatomical Correlation of imaging technique is tremendously more precise than mapping
with visible dyes and carries a profound message for the aesthetic
the Boundaries between surgeon. What we observe with our vision (under ambient light)

Topographic Planes . Suami discusses the

Terminology
Facet: A landmark created where two planes of tissue, not bound-
aries between fat compartments, meet each other. Examples:
vermilion cutaneous junction, lower lid rim between conjunctiva
and skin. De ned by: lymphatic vessels traveling beneath dermis.
Transitions in facial planes, or facets, may occur at the boundar-
ies between adjacent superficial fat compartments. Transitions
between facets also occur at the vermilion–cutaneous junction
of the upper lip and along the philtral columns (Fig. 43.3).
Histologic evaluation and even electron microscopy have pre-
viously failed to identify any distinct anatomy associated with
these particular areas. However, as Fig. 43.3a illustrates, a major
lymphatic vessel with accompanying perilymphatic fat is always
situated directly beneath the vermilion–cutaneous junction. This
particular lymphatic vessel had a lumen that could be cannu-
lated with a 25-gauge needle. The lymphatic vessel travels in
the superficial fat, enabling it to be easily differentiated from the
labial artery traveling in the muscular layer.
Lymphatic mapping with near-infrared imaging ( IR) docu-
ments proximity of a lymphatic vessel to the vermilion cutaneous
junction (Fig. 43.3b). Subcutaneously injected fluorescent tracer
does not invade the lumen of the lymphatic vessel. However, wide-
spread diffusion of dye is noted within the perilymphatic fat. This
role of indocyanine green lymphography, a technique of unques-
tionable value for future work.
This anatomy suggests a possible explanation for long-term
distortion of the upper lip that is occasionally associated with
aggressive lip augmentation techniques. The nasolabial crease,
vermilion cutaneous junction, and philtral columns are defined
by underlying lymphatic vessels that drain the upper lip. Probably
nothing untoward occurs if one inadvertently occludes one
lymphatic. However, if one obstructs the philtral column and
the vermilion cutaneous junction and the nasolabial lymphatics
(by direct intraluminal injection or by increased pressure within
the perilymphatic fat), the redundancy in this design is over-
come. Lymphatic obstruction leads to cytokine production and
inflammation, which in turn leads to scarring and adipose depo-
sition. The end result is distorted anatomy and loss of definition.
Lymphatic obstruction is the major cause of chronic lip distortion
seen after upper lip augmentation.
43.5 Building a Roadmap:
Types of Adipose Tissue
Terminology
Su er i above superficial musculoaponeurotic system
(SMAS).

Fig. 43.3 (a) Topographical planes change acutely between some anatomic tissues and/or structures, examples being Cupid’s bow and the vermilion
cutaneous junction. The philtral column is another boundary between anatomic facets or planes. Previously these were thought to be regions with
no anatomic distinction. Recent work has provided overwhelming support that the vermilion–cutaneous junction lies directly over, and is defined by,
a large underlying lymphatic vessel with its accompanying perilymphatic fat. This anatomy applies equally to the philtral columns, thought previously
to be related solely to interblending of the orbicularis oris muscle. With modern-day cadaver preparation, the major lymphatic of the white roll can
be identified without magnification. Note that the dissected lymphatic is super cial to the orbicularis oris muscle. The superior labial artery has an
intramuscular location. (b) Dynamic near infrared imaging (NIR) identifies the lymphatic anatomy of Cupid’s bow. Random subcutaneous injection of
infrared fluorochrome travels around the lymphatic vessel beneath the white roll. Dye does not flow into the lymphatic unless injected directly into
the lumen. However, NIR imaging shows that dye diffuses widely along the entire upper lip throughout the perilymphatic fat. This occurs clinically when
the clinician injects the vermilion cutaneous junction and notes flow along the entire course of the upper lip. This imaging technique is tremendously
more precise than mapping with visible dyes and carries a profound message for the aesthetic surgeon. What we observe with our vision (under
ambient light) during routine facial injections significantly underestimates the extent of diffusion that actually occurs.

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 VIII Surgical Rejuvenation of the Face and Neck

Deep fat: beneath SMAS.

Fat compartments: discrete regions determined by the system
of retaining ligaments.
Sub–orbicularis oculi fat (SOOF): fat between the orbicularis
retaining ligament (ORL) and zygomaticocutaneous ligament
below the lower eyelid.
Retro–orbicularis oculi fat (ROOF): fat deep to the upper lid
ORL.

Our first impression of the human face is largely determined by

adipose tissue draped about the skeletal framework. Anatomists
such as Hunter and Bell referred to this as subcutaneous fat.
Bichat identified and named the buccal fat pad, a type of fat
thought to facilitate muscular gliding. Later anatomists more
precisely defined the subcutaneous layer as consisting of superfi-
cial and deep layers (Fig. 43.4a). Adipose tissue plays a variety of
a
roles, including metabolic and structural support. To date, types
of adipose tissue are classified based on location and/or morpho-
logical appearance. Metabolic studies are in their infancy.
Fig. 43.4b shows adipose tissue within the orbit as well as the
cerebrospinal fluid (CSF) circulation of the optic nerve’s dural
sheath. CSF channels are not lymphatic vessels (they do not dis-
play lymphatic biomarkers). This system is the extracranial analog
of the intracranial glymphatic system (CSF circulation) identified
by Iliff in murine cortex. It is critical for the aesthetic surgeon to
recognize that these novel CSF transport vessels on nerves com-
municate with and drain directly into the intraorbital lymphatic
system.
Intraorbital lymphatics drain to the lower lid along the orbi-
cularis retaining ligament (ORL) via perforating vessels and along
veins and ligamentous support (e.g., the canthi). The nasojugal
b
crease lymphatic is in communication with the intraorbital system,
suggesting a potential retrograde path by which extraorbital Fig. 43.4 (a) There are several types of adipose tissue based on
injections may travel retrograde into the orbit. morphology and location, including superficial and deep layers.
Anatomists have historically characterized adipose tissue based on
The aesthetic surgeon is most familiar with manipulation of the
either its location or its gross structural appearance. The two layers
superficial and deep layers of fat. The morphological differenti- of fat are well known: superficial and deep. More recent work on the
ation between these two layers has been recognized at least as molecular basis suggests several additional layers may exist. Fat always
surrounds muscles, thereby reducing friction and enhancing glide.
early as Bell and Hunter. The divisionary structure is, of course,
The levator anguli oris muscle shown here literally pierces several
the superficial fascia. fat compartments on its way to insert at the modiolus. Fat within
anatomic spaces, such as the buccal fat shown here, provides archi-
tectural support (here, for the inner cheek) and facilitates muscular
43.6 The Many Faces of movement (here, gliding of the underlying buccinator muscle). The
clinician knows from experience that the thickness of the superficial
Su er i i layer varies, the most demonstrable variations occurring near muscular
insertions and around the oral and orbital apertures. This observation
suggests adipose tissue provides “stiffness” and structural support:
regions with the greatest mobility usually have the thinnest layer of
superficial adipose tissue. Abbreviations: ROOF, retro–orbicularis oculi
Terminology fat; SOOF, sub–orbicularis oculi fat. (b) While the aesthetic surgeon
Su er i i Synonym: superficial musculoaponeurotic focuses on structural support offered by adipose tissue, it is important
to remember that it also plays a metabolic role. Here it surrounds the
system (SMAS). Name based on location: cervical fascia, tempo- intraorbital optic nerve. Cerebrospinal fluid (CSF) transport channels
roparietal fascia, SMAS, Scarpa’s fascia. in the dura, like the (true) lymphatics into which they drain (to
decompress the nerve), are always invested by a delicate layer of fat.
The association of adipose tissue with the lymphatic vascular system is
The superficial fascia is the dividing boundary between super- poorly understood: lymphatic damage leads to adipose hypertrophy,
ficial and deep facial adipose tissue. Recognized throughout as seen in several disease and posttraumatic conditions.
history in a variety of forms, it was probably first noted by Sir
Charles Bell, in the late 1790s. Bell was aware that the cervical
fascia continues onto the face. Antonio Scarpa identified the his work in 1974. However, the definitive work was performed by
superficial fascia of the trunk and thorax. Skoog mentioned this Mitz and Peyronie, two of Tessier’s trainees, who coined the term
layer in the description of his face lift technique; Tessier presented fi (SMAS; Fig. 43.5).

522

It is important to recognize the SMAS as a dynamic structure. Not
only does SMAS invest the facial muscles, but it has also been shown
to respond to stress in a dynamic fashion. Manipulation/tightening
of this layer may eventually lead to the nonsurgical facelift.
The dissection shown in Fig. 43.6 was performed to convey one
of the single most important anatomic concepts relevant to facial
surgery: the SMAS always covers the facial nerve, the branches of
which travel deep until they near their target muscle. At that point,
nerve branches ascend along retaining ligaments. Seckel’s “danger
zones,” where facial nerves are prone to injury during rhytidec-
tomy, are always located directly adjacent to a facial muscle where
the facial nerve ascends from deep to superficial along a defined
retaining ligament. McGregor’s patch is the prototypical description
of an anatomic region where division of the retaining ligament risks
inadvertent injury to a nerve and artery (bleeding as a sign of possible
nerve transection). e will discuss this concept in greater depth later.
43.7 Deep Fascia of the Face
Terminology
Deep fascia of the face: fascia deep to the superficial fascia
that invests the muscles of mastication. Examples: paroti-
domasseteric fascia, masseteric fascia, buccal fascia.
The deep facial fasciae are named based on their proximity to
anatomic structures. The parotid fascia, covering the parotid
gland, continues over the masseter muscle, forming the
Fig. 43.5 The layers of the face defined by fasciae. The superficial
fascia is also referred to as superficial musculoaponeurotic system
(SMAS) and is continuous from the thorax and neck (cervical fascia)
to the forehead (temporoparietal fascia). The SMAS invests certain
facial muscles that travel strictly within its plane: the orbicularis and
platysma muscles. Windows illustrate the different planes of the face.
43 Clinical Anatomy of the Face and Neck: Visualizing the Face
parotidomasseteric fascia. The parotidomasseteric fascia contin-
ues inferiorly into the neck, where it merges with the superficial
layer of the deep cervical fascia. The superficial layer of the deep
temporal fascia, covering the temporalis muscle, splits prior to
inserting onto the lateral zygomatic arch.
The critical point for the aesthetic surgeon is that superficial to
the parotidomasseteric fascia represents a safe zone in the cheek:
the facial nerve lies beneath the deep fascia in the lateral cheek.
The dissection in Fig. 43.7 is a nonwashout/non-latex-injected
dissection that emphasizes a particular point: the frontal branch
of the facial nerve (Fig. 43.7, top left) ascends along a retaining
ligament accompanying a well-defined artery.
43.8 Highways of the Face:
Retaining Ligaments,
Vascularized Membranes, and
SMAS Fusion Zones
Terminology
Retaining ligament: fascial membranes that travel from bone or
from deep fascia and that insert into skin. Examples: masseteric
cutaneous ligament, mandibular ligament, ORL. Synonyms: retain-
ing ligaments, SMAS fusion zones, vascularized membranes.
Fig. 43.6 Superficial fascia is the dividing boundary between super-
ficial and deep layers of facial adipose tissue. The superficial fascia
was probably first recognized by Sir Charles Bell in the late 1790s.
Bell understood that the cervical fascia covering muscles such as the
sternocleidomastoid (SCM) continued into the face as the superficial
fascia. The superficial fascia of the face is in continuity with the cervical
fascia of the neck and with the temporoparietal fascia of the forehead.
It invests the facial muscles and as such was termed the superficial
musculoaponeurotic system (SMAS) by Mitz and Peyronie. In this
dissection the SMAS has been elevated away from the zygomaticus
major muscle, such that the buccal space has been opened. This dis-
section was performed not only to show continuity of the SMAS from
the neck to the scalp but to emphasize a most critical point for the
operating surgeon: that the facial nerve always travels deep, beneath
the SMAS, until it nears its target muscle. At this point the facial nerve
(and vessels) ascends along a retaining ligament.
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 VIII Surgical Rejuvenation of the Face and Neck

The retaining ligaments were first described independently by This characterization addresses a number of contemporary
Furnas and by Stuzin. These authors identified fascial systems problems in aesthetic surgery. Facelift techniques that require
that travel from deep fascia to SMAS or from deep fascia to
skin. Stuzin suggested the additional category of osteocuta-
neous ligaments, which traveled directly from bone to skin.
These authors ascribed the function of structural support
to these tissues, hence the name retaining. A tremendous
body of work involving the fasciae emerged from the work
of dedicated researchers during the 1950s. Holyoke and
Grodinsky noted the close apposition of superficial and deep
fascia at specific regions of the face and named these fusion
zones. Later work related to the fat compartments identified
vascularized membranes as the partitioning membranes (Fig.
43.8, Fig. 43.9).
The terms retaining ligaments, vascularized membranes, and
fusion zones are therefore redundant. It is perhaps best to adopt
the term retaining ligament to avoid un-necessary confusion. The
retaining ligaments may arise either from deep fascia or from
bone and travel to dermis, where they partition fat into discrete
compartments. The zygomaticocutaneous ligament, previously
described as McGregor’s patch, is a type of osteocutaneous retain-
ing ligament.
Retaining ligaments play a role in structural support. Baker
differentiated regions of SMAS based on its ease of mobility,
applying the terms fixed and mobile. The mobile SMAS occurs
where no retaining ligaments travel from deep to superficial
fascia. This anatomic description of fixed SMAS applies to the
observation that retaining ligaments represent highways for
facial anatomy.

Fig. 43.7 The deep facial fasciae are named according to their
proximity to anatomic structures. The parotid fascia covers and
invests the parotid gland and merges anteroinferiorly with the
masseteric fascia. Superiorly, a thin layer of fat separates the superficial
musculoaponeurotic system (SMAS) from the superficial layer of the
deep temporal fascia, which descends to insert on the outer or lateral
surface of the zygomatic arch. Inferiorly, the parotidomasseteric fascia
merges with the superficial layer of the deep cervical fascia. The buccal
and marginal mandibular branches of the facial nerve travel deep to
the parotidomasseteric fascia. The frontal branch of the facial nerve
travels between the temporoparietal fascia and the superficial layer of
deep temporal fascia.
Fig. 43.8 (a) Retaining ligaments are the highways of the face. The
facial nerve travels deep to the parotidomasseteric fascia in the lateral
cheek. As it nears its target muscle, in this case the zygomaticus major
muscle, it ascends along the retaining ligament between deep fascia
and superficial musculoaponeurotic system (SMAS) at the edge of the
buccal space. A major lymphatic plexus descends from SMAS to deep
fascia along this same retaining ligament. The retaining ligaments
perform several functions, including offering protection from shear
to delicate structures as they transition from deep to superficial (and
superficial to deep). These retaining ligaments are analogous to the
septocutaneous membranes described in reconstructive microsurgery.
(b) Specialized techniques identify lymphatic vessels that travel along
retaining ligaments. The masseteric cutaneous ligament is shown. This
retaining ligament shown in this dissection was described by Stuzin in
his original paper and exists between the deep lateral cheek fat and
the buccal space. This fascial structure must be divided to mobilize
the SMAS. Stuzin described a “picket fence-like arrangement” of fascia
in his description of this retaining ligament. Some of these picketlike,
vertically oriented fibers (not all) are lymphatic vessels (fluorescent
vessels, right). Left shows the dissection viewed under ambient light.
The right dissection was performed after whole mount, in situ (ex vivo)
immunohistochemistry with the lymphatic biomarkers L VE-1 and
human D2-40 (which recognizes the human transmembranous lym-
phatic marker podoplanin). Secondary antibody with an FITC-tagged
fluorochrome is imaged using ultraviolet light and identifies the prolific
lymphatic system that travels along this retaining ligament. Such
techniques have the ability to discriminate anatomy at an unparalleled
level of precision. This anatomic description holds true for all retaining
ligaments studied, including the orbicularis retaining ligament (ORL).

524

widespread SMAS undermining and division of multiple retain-
ing ligaments lead to prolonged edema. Hamra first described
the retaining ligament between platysma and mandible, later
characterized as an osteocutaneous by Reece. Transection of this
ligament, a major lymphatic pathway for the lower face, may
result in prolonged edema.
hile the authors provide a reading list, they suggest Stuzin’s
description of the relationship between superficial and deep fas-
cias is a classic and an absolute must-read. The retaining ligament
system of the scalp and forehead is considered analogous to the
facial system and has been well documented by investigators such
as nize, Mendelson, and ahai.
43.9 Danger Zones
Terminology
Danger zones: locations where facial nerve branches are prone
to injury. Anatomic correlation: regions where nerves ascend
along retaining ligaments.
nowledge of the location and orientation of retaining ligaments
is some of the most important information for the aesthetic
surgeon. Retaining ligaments determine the fat compartments;
the location of perforator blood supply; and the potential sites
of nerve injury during a facelift, referred to as danger zones.
Seckel introduced this concept. Its relationship to the anatomy is
captured by the following illustration and dissection (Fig. 43.10,
Fig. 43.11).
Facial nerve injury is a disastrous complication for the aesthetic
surgeon. Fortunately communication occurs between most buccal
Fig. 43.9 The appearance of ligaments varies with where we encoun-
ter them on the face. Usually they are broad, thin fascial membranes
like the masseteric cutaneous ligament. However, when two or more
ligaments meet each other, they appear more like what we imagine
ligaments to look like: firm, dense, and cylindrical in nature. The
mandibular ligament was described where the platysmal retaining
ligament (along the mandible) merges with the lateral chin retaining
ligament (boundary between deep cheek and chin fat).
43 Clinical Anatomy of the Face and Neck: Visualizing the Face
and zygomatic branches. However, even reinnervation may distort
dynamic facial anatomy; the smile-blink reflex (healing between
buccal and zygomatic branches) leads to a dynamic form of tic.
Three concepts help the aesthetic surgeon to avoid iatrogenic
nerve injury. Most important is knowledge of the ligamentous
support of the face, where nerves transition from deep to super-
ficial (Fig. 43.12).
43.10 The Compartmentalization of
Facial Adipose Tissue
Terminology
Fat compartments, anatomic fat compartments: General
location: superficial above SMAS, deep fat compartments
between SMAS and deep fascia. De ned by: retaining ligaments.
The characterization of the fat compartments has improved
surgical results by enabling site-specific augmentation. Like any
Fig. 43.10 Seckel described specific points where the facial nerve is at
risk during facelift surgery. These are referred to as danger zones. Danger
zones exist where a facial nerve branch ascends from deep to superficial
fascia along a retaining ligament just proximal to its target muscle.
Fig. 43.11 (a) The mandibular ligament occurs where the platysma
cutaneous ligament merges with the lateral chin retaining ligament
(traveling from deep fascia to superficial musculoaponeurotic system).
(b) The marginal mandibular nerve ascends along this retaining
ligament and is prone to injury during rhytidectomy. Another example
of this anatomy is the zygomatic ligament, where a buccal branch
ascends along with a prominent blood vessel. Understanding the
ligamentous structure of the face yields unparalleled knowledge of
soft tissue anatomy.
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 VIII Surgical Rejuvenation of the Face and Neck
other concept, this has evolved from the individual observations
of numerous investigators. Hand surgeons were the first to iden-
tify superficial fat compartments. Aiache and Ramirez described
the retro–orbicularis oculi fat (ROOF), a deep compartment of
the upper lid. Pessa described the superficial malar fat pad in
his work on the etiology of periorbital ecchymosis. However, not
until Rohrich and Pessa was this concept applied to the entire
face, forehead, and neck. Like many advances in surgery, this
breakthrough resulted from an out-and-out mistake in the anat-
omy lab a good story, perhaps, for another time and another
place (Fig. 43.13, Fig. 43.14).
43.11 The Facial Muscles
Terminology
Facial muscles: Characterized by action: elevator vs. depressor
(e.g., frontalis as brow elevator; procerus as brow depressor).
Characterized in relationship to other muscles: agonist vs. antago-
nist (e.g., depressor anguli oris depresses corner of the mouth;
antagonist is levator anguli oris). Relationship to SMAS: SMAS
invests muscles traveling within the same plane (orbicularis,
platysma).
Selective chemodenervation of facial muscles is a powerful tool
for the aesthetic surgeon. The reaction to chemodenervation is
best thought of as increasing the result of resting tone in the target
muscle’s paired antagonist. For example, chemodenervation of
Fig. 43.12 Three concepts help the surgeon avoid iatrogenic nerve
injury. (1) Most, if not all, of the “danger zones” noted by Seckel occur
directly over retaining ligaments, where the facial nerve transitions
from deep to superficial. Transition occurs near each nerve’s anatomic
target, so knowledge of ligamentous and muscular anatomy enables
one to predict these locations. (2) Nerves accompany blood vessels
and lymphatics as they travel along retaining ligaments. As has been
understood since the description of McGregor’s patch, brisk bleeding
encountered during ligamentous release is a warning sign of possible
inadvertent nerve injury. (3) The facial nerve lies deep to the superficial
musculoaponeurotic system (SMAS) and the parotidomasseteric fascia.
Even when a facial nerve branch with a minimal diameter is encoun-
tered, knowledge of anatomic planes ensures safe dissection.
526
the orbicularis oculi muscle, a brow depressor, results in fore-
head elevation. Chemodenervation of the depressor anguli oris
muscle increases the effectiveness of lip elevation by the levator
anguli oris (Fig. 43.15).
The facial muscles have been described in four layers, with the
buccinator being the deepest layer. Most facial muscles, however,
have a defined bony origin and insert into dermis or into a conflu-
ence of other muscles. There are a few brief points we can make
relate to all facial muscles in general (Fig. 43.16).
1. Facial muscles are innervated on their deep surface. Technically
speaking, even the buccinator muscle is innervated on its deep
surface, which happens to be anterior when viewed from the
frontal position (it would be like saying the trapezius or rhom-
boids are innervated on their superficial surface if one views
them from anteriorly).
2. Facial muscles are innervated proximally. ygomaticus major
included always reveal two or three facial nerve branches located
just proximal to its origin. This is where nerve injuries occur.
3. Facial muscles insert into either the dermis or a confluence of
other muscles. The corner of the mouth is an excellent example.
4. The SMAS invests muscles traveling within its plane; for exam-
ple, the orbicularis oculi and the platysma.
A cursory review of any anatomic atlas affords ample knowl-
edge to the clinician. However, experience in the cadaver lab lends
an intuitive understanding for the location of specific muscles and
significantly reduces the chance of iatrogenic nerve injury during
submuscular and/or subfascial dissection.
Fig. 43.13 The retaining ligaments determine the presence and
location of the anatomic fat compartments. Just as the presence of
superficial fascia determines a superficial and a deep layer, the course
of retaining ligaments from deep fascia (or from bone) to skin defines
both deep and superficial fat compartments. Initially dye was used to
identify discrete regions of fat, a technique that has been supplanted
by far more precise technologies. Elevation of both zygomaticus major
muscle and superficial musculoaponeurotic system (SMAS) exposes
the sub–orbicularis oculi fat (SOOF). With proper anatomic prepa-
ration, the retaining ligaments can be easily identified. The superior
retaining ligament is the orbicularis retaining ligament (ORL); the
inferior retaining ligament travels horizontally but has not been named
formally. This is a nonwashout/non-latex-injected prep that preserves
lymphatic filling so that the lymphatic plexuses traveling along the
retaining ligaments can be visualized.

Fig. 43.14 Loss of deep fat may lead to pseudoptosis. Note: the
boundaries of the nasolabial fat compartment, shown above (b)
within the black and red arrows, if defined by cutaneous lymphatic
vessels.(a) Superficial fat compartments are shown. The nasolabial fat
compartment is shown, followed by the cheek compartments: medial,
middle, and lateral temporo-cheek. The periorbital fat compartments
include the superior, inferior, and lateral compartments. (Adapted
with permission from Schaverien MV, Rohrich RJ, Pessa JE. Vascularized
membranes determine the anatomical boundaries of the subcutaneous
fat compartments. Plast Reconstr Surg. 2009; 123:695-700.) (b) Deep
fat compartments may lose volume with aging, which may result in a
form of pseudoptosis. (Note: the boundaries of the nasolabial fat com-
partment, shown above, are within the black and red arrows, if defined
by cutaneous lymphatic vessels.) (Adapted with permission from Rohrich
RJ, Pessa JE. The fat compartments of the face: anatomy and clinical impli-
cations for cosmetic surgery. Plast Reconstr Surg. 2007; 119:2219-2227.)
a
b
Fig. 43.16 (a,b) The facial muscles represent targets for potential
chemodenervation. The facial muscles are usually described as four
layers from superficial to deep. Most facial muscles are innervated
from their deep surface.
43 Clinical Anatomy of the Face and Neck: Visualizing the Face
Fig. 43.15 The facial muscles represent a potential target for facial
rejuvenation through selective chemodenervation. The reaction to
chemodenervation is best understood in terms of enhancing the
resting tone of selected muscles through weakening of their paired
antagonists. For example, the levator anguli oris muscle, which travels
from maxilla to insert into the modiolus, is the antagonist to the
depressor anguli oris. Chemodenervation of the depressor anguli oris
thus increases the effect from the resting tone of the levator anguli
oris muscle. This results in elevation of the corner of the mouth.
Understanding of the paired agonists/antagonists is easily gained by
even a cursory review of any anatomic atlas. Direct experience in the
cadaver lab provides an intuitive understanding of the location of
specific muscles and adds safety to any subfascial dissection.
43.12 Anatomic Spaces
Terminology
Anatomic spaces: Spaces are always located beneath the super-
cial fascia and contain gliding fat and/or glandular tissue. They
lie between retaining ligaments but in addition are contained
within their own discrete fascia (e.g., capsule of the buccal fat).
Examples: buccal or masticatory space, submandibular space,
premasseteric space.
Mendelson has furthered much of our knowledge of anatomic
spaces and their importance to the aesthetic surgeon. He
described the premasseteric space as the area beneath a line
drawn from the tragus to the corner of the mouth (Fig. 43.17).
The premasseteric space represents a zone of safe dissection
during SMAS elevation. The buccal or masticatory space is located
medial to the premasseteric space and contains the buccal fat
pad of Bichat. Both Stuzin and ahai suggest that division of the
lateral fascial border of the buccal space is necessary to reduce the
prominence of jowls. Transection of this fascia with SMAS repair
basically decreases the volume of the buccal space and relocates a
ptotic buccal fat pad (Fig. 43.18).
The submandibular space is shown for illustrative purposes in
Fig. 43.17. Its medial border is represented by the four structures
of the carotid sheath: the carotid artery, the internal jugular vein,
the vagus nerve, and the terminal cerebrospinal drainage of the
entire human brain.
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 43.17 Anatomic spaces are defined as having a circumferential

fascial boundary, within which either fat or glandular tissue is further
Fig. 43.18 The floor of the premasseter space is made up of the mas-
enclosed by a well-defined capsule. The submandibular space is
seter fascia. This space is devoid of facial nerve branches, enabling safe
shown in this dissection. The surrounding fascia has been freed to
dissection during rhytidectomy. The roof consists of the superficial
show the submandibular gland within its capsule. The overlying
musculoaponeurotic system (SMAS) as it invests platysma muscle. At
sternocleidomastoid muscle has been transected to show the medial
the medial (toward the midline) aspect, this space is bordered by the
boundary of this space, the carotid sheath with its four structures:
masseteric cutaneous ligament. There are no nerves within the roof of
the carotid artery, the internal jugular vein, the vagus nerve, and the
this space.
terminal drainage of the entire cerebrospinal fluid (CSF) circulation of
the human brain.

Suggested Reading
43.13 Concluding Thoughts
by Foad Nahai
My fascination with anatomy first began in medical school, when
I recognized the beauty and complexity of the body’s anatomic
structures. I well remember one of my professors telling me that
I would learn anatomy three times and forget it four times. Little
did I know how true that statement was. Over the span of my
career I have not only learned and relearned my anatomy, but
also have grown to recognize that this is a topic that requires
frequent revisiting if one is to gain familiarity with anatomic
structures, their relationships, and the intricacies of their vas-
culature and innervation. Perhaps it was this fascination with
anatomy that led me into a career as a surgeon. Regardless, it is
knowledge of anatomy that is the foundation of all of the surgical
procedures that I perform today.
[1] Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: an anatomic and
clinical study. Plast Reconstr Surg 1995;95(1):37–42
2 Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and
clinical applications. Aesthet Surg J 2013;33(6):769–782
3 acono AA, Malone MH. Characterization of the cervical retaining ligaments
during subplatysmal facelift dissection and its implications. Aesthet Surg J
2017;37(5):495–501
4 Huettner F, Rueda S, Ozturk C , et al. The relationship of the marginal mandibu-
lar nerve to the mandibular osseocutaneous ligament and lesser ligaments of the
lower face. Aesthet Surg J 2015;35(2):111–120
5 Ozturk C , Ozturk C, Huettner F, Drake RL, ins E. A failsafe method to avoid
injury to the great auricular nerve. Aesthet Surg J 2014;34(1):16–21
6 Owsley . Rejuvenation of the midface. Plast Reconstr Surg 2001;108(1):262–
264
[7] Pessa E. SMAS fusion zones determine the subfascial and subcutaneous anat-
omy of the human face: fascial spaces, fat compartments, and models of facial
aging. Aesthet Surg J 2016;36(5):515–526
[8] Pessa E, Garza R. The malar septum: the anatomic basis of malar mounds and
malar edema. Aesthet Surg J 1997;17(1):11–17
[9] Pessa E, guyen H, ohn GB, Scherer PE. The anatomical basis for wrinkles.
Aesthet Surg J 2014;34(2):227–234
10 Rohrich R , Pessa E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
[11] Rohrich R , Pessa E. The retaining system of the face: histologic evaluation of the
septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg
2008;121(5):1804–1809

528

44 Clinical Decision Making in Facelift and Neck Lift
Foad Nahai
Abstract
ith a variety of surgical and nonsurgical options for facial
rejuvenation, evaluation of the aging face and patients’ wishes
should guide the surgeon in making the appropriate recom-
mendations to each individual. Location and length of scars, flap
elevation, and superficial musculoponeurotic system (SMAS)
and volume management are customized to address specific
changes.
Keywords
short-scar facelift, pretragal and intratragal incisions, high
SMAS, low SMAS, platysma, fat grafts
44.1 Introduction
As noninvasive treatments, especially injectables such as
toxins and fillers, have been proven safe and effective and have
gained in popularity, facial rejuvenation has ceased to be only
in the surgical domain. Aesthetic surgeons are familiar and
experienced with surgical and nonsurgical options. The choice
between the two is based on assessment of the aging face and
the patient’s desires. Generally noninvasive options are better
suited to those with only early signs of aging. For all others, I
believe the results of surgery are better, last longer, and in the
long run are far more cost-effective.
Fig. 44.1 Evaluation of the face is organized by thirds.
44 Clinical Decision Making in Facelift and Neck Lift
44.2 Evaluation
ot all faces age in the same way, nor do they require the same
procedures for rejuvenation. The degree of volume loss, tissue
descent, and skin changes will vary. Each face ages individually,
with some areas remaining more youthful than others. I evaluate
the entire face, assessing skin quality, volume, and descent. I do
not believe in a facelift for all seasons ; rather, I feel we should
customize or tailor the procedure to each individual patient a
freestyle facelift where the length and location of the incisions,
extent of undermining, superficial musculoaponeurotic system
(SMAS) management, volume management, and ancillary proce-
dures are all individualized based on the patient’s aging changes,
facial morphology, and desires. During the initial evaluation of a
patient for facial rejuvenation I specifically ask, hat concerns
you most or what would you most like improved Answers vary
from my neck, my jowls, or my eyes to I want to see improve-
ment of all of it. Occasionally a patient responds, I am here for
your recommendations.” The patient’s wish and my assessment
will then guide me in selecting the appropriate procedure.
For descriptive purposes, I think of the face in terms of three
zones: periorbital, perioral, and neck.
The forehead, brow, and upper midface make up the periorbital
zone; the lower part of the face nasolabial folds, lips, jowls, and
chin is called the perioral area; and the jawline, submental area,
and neck are referred to as the neck zone. I also think of these three
zones as dividing the face and neck into upper, middle, and lower
thirds (Fig. 44.1).
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 VIII Surgical Rejuvenation of the Face and Neck

Ideally, I prefer to rejuvenate all three zones simultaneously so
as to restore a youthful appearance with a harmonious transition
from zone to zone. Most of the time, however, patients request
improvement in one zone or only one component of a given zone.
Many patients who would be excellent candidates for full facial
rejuvenation say, I just want my eyes or my neck done. Another
typical request is, I know I could use a facelift, but I just want to
get rid of my baggy eyelids. These patients require an explanation
of the aging process so that they will understand that it is best to
address an entire zone rather than individual components of a
zone. It is even better to address all three face and neck zones rather
than only one. Nevertheless, some patients truly need rejuvenation
of only one zone rather than of the full face. In these patients, the
aging process has advanced more rapidly in one zone than in the
others.
In the 56-year-old patient shown in Fig. 44.2, aging affected
all three of the facial zones. She underwent an endoscopic brow
lift, upper and lower blepharoplasty, and face- and neck lift. Her
postoperative result demonstrates harmonious rejuvenation of all
three facial zones.
The signs of aging are not as far-reaching in the 48-year-old patient
shown in Fig. 44.3. Her facial aging was confined mostly to the upper
third, or periorbital zone. She underwent an endoscopic brow lift and
upper lid blepharoplasty with transpalpebral midfacial rejuvenation.
Her postoperative result also demonstrates harmonious facial reju-
venation, even though the surgical correction was far more limited.
hen a patient expresses interest in a procedure involving only
one zone, I advise her or him about how the overall result could be
enhanced by adding procedures involving adjacent zones. Doing so
avoids a patchwork effect in which a rejuvenated periorbital area
leads into an aging lower face and neck. The patient’s motivation for

a b

c d
Fig. 44.2 (a,c) Preop and (b,d) postop photos of patient who underwent endoscopic brow lift, upper and lower blepharoplasty, and face and neck
lift. An optimal result required rejuvenation of all three facial zones.

530
 44 Clinical Decision Making in Facelift and Neck Lift

The 51-year-old patient shown in Fig. 44.5 also demonstrates

facial aging in all three zones but has better skin quality. Her
full, heavy face has more apparent than real excess skin, normal
elasticity, and minimal photoaging. o rhytids are visible at rest.

44.2.2 Upper Third of the Face:

a b
Fig. 44.3 (a) Preop and (b) postop photos of patient who underwent
endoscopic brow lift and upper lid blepharoplasty with transpalpebral
midfacial rejuvenation. As her facial aging was confined mostly to
the periorbital zone, a more limited surgical correction achieved a
harmonious result.
The Periorbital Zone
Evaluation of the periorbital zone begins with an analysis of
the medial and lateral brow position and the relationship of the
brow to the upper eyelid. I look at the glabella for lines as well
as active and passive rhytids. The temporal–brow junction, with
the upper cheek-zygomatic area, is evaluated for the presence of
deep rhytids (crow’s–feet) and excess skin. I evaluate the upper
and lower lids, assessing the skin, muscle, and fat in the lids.
After noting the relationship of the upper lid to the brow, I move
to the lower lid, noting the relationship of the lower lid to the
cheek and the transition from the periorbital to the perioral zone
and the nasolabial fold. Lower lid tone is assessed. The volume of
the cheek and midface area is also noted.

seeking less rather than more may be financial or could be related to

Checklist for Evaluating the Upper Third of the
a fear of surgery and anesthesia, or the patient may have a genuine
lack of concern about the rest of the face compared with the area Face/Periorbital Zone
in question. The surgeon should initiate an open discussion of the
Brow position
patient’s wishes, concerns, and fears so that the patient will be
pleased rather than disappointed with the results. hen examining
• Lateral
a candidate for facelift surgery, I first determine which zones require
• Medial
intervention and whether the aging process has affected the face Glabella
equally. For example, is the most striking feature of this aging face • Depth of rhytids
the neck, the midface, or the brow Or are they all equally involved • Muscle activity
Facial aging involves more than sagging, wrinkling skin with
Upper eyelid
shifting soft tissue; most of these patients have also lost volume. An
aging face in a thin patient looks much older than an equally aged • Skin
full face in an overweight patient. This is obviously related to loss of • Muscle
volume. After my initial impression, I evaluate the skin, each zone, • Fat
and the components of each zone according to my mental checklist. • Relationship to brow
Lower eyelid

44.2.1 Facial Skin • Skin

• Muscle
The evaluation includes an assessment of skin quality and skin • Fat
excess, along with the presence of rhytids at rest and on animation. I • Lid–cheek junction
look for signs of photoaging and sun-related dyschromia. I assess the • Lid tone
skin’s thickness and elasticity and make a mental note of where the
Nasolabial folds
excess skin is and whether the excess is real or apparent (Table 44.1).
Transition to perioral zone
The 50-year-old woman shown in Fig. 44.4 has facial aging in
Soft tissue volume
all three zones. Her skin quality is rather poor, showing real and
apparent excess skin, significant photoaging, and deep rhytids at
rest and on animation.
44.2.3 Middle Third of the Face:
The Perioral Zone
Table 44.1 Checklist for evaluating the aging face—facial skin
The perioral area, or middle third, is evaluated next. The naso-
Quantity Quality Rhytids labial folds and marionette grooves are categorized by noting
Visible skin excess Thickness At rest their depth at rest and when smiling. The angle of the mouth is
Elasticity On animation noted. The lips are evaluated for volume and length of the upper
lip. ith aging, the lips lose a significant amount of volume, and
Photoaging
Texture the distance from the nose to the upper lip vermilion lengthens,

531
 VIII Surgical Rejuvenation of the Face and Neck

leading to a loss of definition of the philtral columns. Lip lines

sternocleidomastoid muscle. I look also for transverse neck
are noted. I specifically look at the depth of the chin crease for
lines or creases, noting how many and how deep they are. A
chin ptosis and evaluate the jowls. I also evaluate the role of the
judgment is made as to whether the submental skin excess is
mandibular ligament in the aging appearance in this area. The
real or apparent. I then look at the jawline, submental area,
nose, especially the tip, often becomes ptotic with aging.
and neck–jaw angle and their relationship to each other.
Assessment of the submental and neck fat includes the subcu-
Checklist for Evaluating the Middle Third of taneous fat and the subplatysmal fat. I differentiate between
the Face/Perioral Zone subcutaneous and subplatysmal fat by pinching the submental
area at rest and then after contraction of the platysma muscles.
• Nasolabial folds and marionette grooves
• Angle of the mouth Checklist for Evaluating the Lower Third of the
Downward
Neutral Face/Neck Zone
Upward
Skin
• Upper lip • Quality
Volume Elasticity
Length Transverse creases or lines
Philtral columns
Lip lines • Quantity
Real excess
• Lower lip Apparent excess
Volume
Fat
Lip lines
• Subcutaneous/preplatysmal
• Chin • Subplatysmal
Chin crease • Platysma bands
Chin ptosis • Jawline
• Neck/jaw angle
• Jowls • Digastric muscles
• Nose • Submandibular gland
Tip ptosis

The platysma bands are evaluated. I like to note not only

44.2.4 Lower Third of the Face:
The Neck Zone
In assessing the quality and quantity of the neck skin, I look
for excess skin below the thyroid cartilage and over the
central platysma bands but also lateral bands usually seen only
on animation. The submandibular gland and digastric muscles
are assessed by looking for a bulge below the mandibular rim
within the submandibular triangle, especially on neck flexion
(Fig. 44.6).

a b a b
Fig. 44.4 Assessment of this patient’s skin quality reveals real and Fig. 44.5 (a) This patient has a full, heavy face with more apparent
apparent excess skin, significant photoaging, and deep rhytids (a) at than real excess skin, normal elasticity, minimal photoaging, and (b) no
rest and (b) on animation. rhytids visible at rest.

532
 44 Clinical Decision Making in Facelift and Neck Lift

c d

Fig. 44.6 Evaluation of the neck. (a) Evaluation of excess skin of the neck and platysma bands with the patient at rest. (b) Evaluation of platysma
bands on animation. (c) Evaluation of the location of submental fat by pinching the submental area at rest. (d) Subcutaneous versus platysma fat is
assessed by pinching the submental area during contraction.

44.2.5 Facial Adhesions and Retaining
Ligaments
Determining whether the facial ligaments and adhesions should
be released is an important step in planning surgical rejuvena-
tion of the face.
Proper elevation and rejuvenation of the periorbital area
depends on the appropriate release of a number of temporal
adhesions and attachments, regardless of the degree of brow
ptosis or facial aging. In contrast to the face, these temporal
adhesions and attachments are not visible and cannot be assessed
clinically.
Retaining ligaments of the midlateral face can be assessed
clinically. These ligaments maintain the facial skin in its
normal anatomic position. Stuzin et al described two types of
retaining ligaments: a true osteocutaneous ligament, running

533
 VIII Surgical Rejuvenation of the Face and Neck

from a fixed bony origin to the dermis (such as zygomatic and always necessary to divide them in younger individuals and in
mandibular), and a second system made up of a coalescence those who are undergoing limited rejuvenation procedures.
of superficial and deep facial fascia fixing the fascial layers to
the underlying structures, such as the parotid and masseter,
and then attaching superficially to the skin (the parotid cuta- 44.3 Treatment Options
neous and masseteric cutaneous ligaments). These ligaments
are essentially fixed structures, so facial tissue, especially fat 44.3.1 The Face
pads, can pivot around them, producing creases such as the I have already mentioned that I do not believe that there is a
marionette lines of the lower face. ith age, the ligaments facelift for all seasons. However, all described facelift techniques
attenuate and relax. This relaxation, along with loss of skin have five things in common:
elasticity and soft tissue, causes some of the stigmata of aging.
The zygomatic ligaments suspend the malar soft tissues and 1. An incision
fat pad over the zygomatic prominence. As this support weak- 2. Flap elevation
ens, the malar soft tissues gradually migrate downward, and 3. SMAS management
redundant skin hangs over the fixed nasolabial sulcus. Rather 4. Volume management
than deepening with age, it is the downward migration of the 5. Ancillary procedures
soft tissues against the fixed nasolabial sulcus and volume
Evaluation of the face leads to selection of the procedure,
depletion that accounts for the observed changes. Similarly,
including length and location of scars; level and extent of dis-
attenuation and weakness of the masseteric cutaneous liga-
section or flap elevation; management of the SMAS, including
ments allow a downward shift of the cheek tissues below the
vectors; volume management; and ancillary procedures. These
mandibular margin. Tethering by the mandibular ligament
decisions are based on analysis of the patient’s degree of aging,
forms the jowls (Fig. 44.7).
morphology, skin quality and quantity, and, most important, the
Clinical evaluation of the face should take note of these
patient’s expectations and my understanding of the result antici-
ligaments and the role they play in the aging face. Ligaments
pated. Video imaging has proven a be a useful tool in this regard.
extending from bone to dermis must be released during a facelift
The options include a variety of incisions, different levels of dis-
to achieve the desired results. Leaving the masseteric ligaments
section, varying extent of skin and SMAS undermining, different
intact limits lateral mobility. An evaluation of the relevance of
vectors, and repositioning of the subcutaneous tissues through a
these ligaments to the observed aging changes enables the sur-
number of suspension or plication techniques.
geon to plan appropriately for ligament release. Although release
of these ligaments is required in most older individuals, it is not

a b

Fig. 44.7 (a) Facial adhesions and (b) retaining ligaments.

534

Treatment Options for the Face
Incisions
• Length
• Location
Levels of dissection and extent of undermining
• Subcutaneous
• Subfascial sub-SMAS
• Subperiosteal
• Combination
SMAS management
• Plication
• Mobilization and plication
• Resection and plication
• Mobilization, resection, and plication
Sub-SMAS work
• Buccal fat pad
• Parotid
Vectors
• Vertical
• Diagonal
Suspension sutures
Incisions
The length of the incisions varies from minimal incisions for
liposuction and endoscopic to the classic full-length facelift
incision. The purpose of skin incisions is to gain access to deeper
tissues or to resect excess or inelastic skin or both.
If the purpose of the skin incision is to allow access to the
deeper tissues and the deep tissue rearrangement renders the
desired result without skin excision, these access incisions
can be kept to a minimum, as in liposuction and endoscopic
procedures. If the desired result cannot be attained through the
rearrangement of the deeper tissue without skin excision, a
longer skin incision is necessary, and the length of that skin inci-
sion will reflect the location of the excess skin to be removed. For
example, endoscopic facelifting is achieved without removing
any facial skin, whereas short-scar facelift techniques eliminate
the postauricular scar in patients who have no excess skin below
the level of the cricoid and posterior to the sternocleidomastoid.
However, the success of endoscopic and short-scar procedures
depends not only on the location of excess skin but also on
the quality and elasticity of the skin. These procedures rely on
redraping and redistribution of the skin, especially in the neck.
Stretched, inelastic skin, regardless of location face, breast, or
abdomen will not redrape, redistribute, or retract and must be
excised.
The short-scar techniques have increased in popularity as
patients demand minimally invasive procedures, with less
downtime and reduced morbidity. Patient selection is the key,
because unless a less invasive procedure with a shorter scar
produces a result comparable to that of standard procedures, it
44 Clinical Decision Making in Facelift and Neck Lift
is not in the best interest of the patient and may result in loss of
the surgeon’s credibility. I believe the quality of the result and
not the length of the incision should be foremost. In selecting
patients for the short-scar technique, I assess the quality of the
neck skin and then evaluate the patient with what I call the
vertical simulation test. I place my hand on the side of the
patient’s face in front of the tragus and pull vertically upward,
simulating the vertical vectors of the short-scar facelift. hile
my hand is elevating this tissue, I observe the junction of the
earlobe and neck skin. If there are no folds of excess skin extend-
ing posteriorly beyond that area, the patient is an excellent
candidate for a short-scar facelift. If there is excess skin or if a
fold develops there, the patient is best suited for a full-scar pro-
cedure. Additionally, this one of the tests that also enables me to
evaluate the neck and submental area and determine whether
I will make a submental incision or not by observing the neck
during the vertical simulation test.
For example, the images in Fig. 44.8 depict an ideal candidate
for a short-scar facelift. The vertical vector, as demonstrated by
the examiner’s hand, does not result in any folds of excess skin
behind the earlobe, and the improvement seen in the submental
area obviates the need for a submental incision.
In contrast, the images in Fig. 44.9 show an individual who
would not be a candidate for a short-scar facelift, because the
vertical vector demonstrated by the examining hand results
in folding of excess skin beyond the earlobe, and the lack of
improvement in the submental area and jawline indicates the
need for a submental incision and a central approach to neck
recontouring.
Location
The scar location depends on the patient’s facial structure,
including the hairline, sideburns, skin color, and ear topography.
Temple Incision
The options include placement of the incision 2 to 3 cm behind
the temporal hairline or right at the temporal hairline. This
decision is based on the distance between the lateral canthus
and the anterior part of the temporal hairline, which ideally
should be 3 to 5 cm. To maintain this ideal distance, the excess
skin over the upper cheek is assessed. This excess skin will be
recruited and rotated upward when the facelift flap is elevated.
If resection of excess cheek skin through the incision behind
the temporal hairline would widen the distance between the
hairline and lateral canthus, I prefer a prehairline incision to
maintain a natural 3- to 5-cm distance. idening beyond 5
cm results in an unnatural or operated-on appearance. hen
resection of the excess cheek skin would not shift the temporal
hairline posteriorly or widen the distance between the hairline
and lateral canthus, the incision can safely be placed behind the
hairline. This placement is of more significance in men than in
women (Fig. 44.10).
In patients with short sideburns, I prefer the prehairline inci-
sion to avoid elevation or elimination of the sideburns through
the vertical shift of facial skin. In secondary facelifts I make a
prehairline incision, because most of these patients already have
shortened sideburns (Fig. 44.11).
535
 VIII Surgical Rejuvenation of the Face and Neck

b
Fig. 44.8 (a) The “vertical simulation” maneuever facilitates selection of patients for the short-scar facelift technique. Observe the junction of the
earlobe and neck skin. (b) If there are no folds posterior to this area, as in this case, the patient is an excellent candidate for a short-scar approach.

536
 44 Clinical Decision Making in Facelift and Neck Lift

Fig. 44.9 (a) In this patient, a vertical simulation test demonstrates folding of excess skin beyond the earlobe. (b) The submental area and jawline do
not improve with a vertical lift alone, so a central approach to recontour the neck is necessary as in a full scar approach.

537
 VIII Surgical Rejuvenation of the Face and Neck

a
Incision behind the temporal hairline

b
Prehairline incision

Fig. 44.10 The temple incision can be placed to 2 to 3 cm behind the temporal hairline (top) or right at the hairline (bottom).

a
Incision behind the temporal hairline

b
Prehairline incision

Fig. 44.11 (a) As the incision approaches the ear, it can be continued behind the hairline or (b) anterior to the hairline, as is preferred in patients with
short sideburns.

538
 44 Clinical Decision Making in Facelift and Neck Lift

men whose facial skin may be ruddier than the ear skin. In these
patients a pretragal incision is preferred (Fig. 44.16, Fig. 44.17,
Fig. 44.18). These factors are summarized in Table 44.2.

The Earlobe
Distortions of the tragus and earlobe are clearly visible signs of
a facelift, a poorly executed facelift I do not suture the earlobe
down but instead anchor the facial flap to the deep tissues at the
level of the lower conchal border, with the earlobe hanging free
over the flap. This avoids the pixie earlobe.
The two main procedures I undertake to rejuvenate and
enhance the appearance of the earlobe are fat grafting to replace
lost volume and reduction of the elongated earlobe to remove the
deflated excess skin.

Fig. 44.12 The preauricular incision is made in the anatomic margin Retroauricular Incision
between the ear and the face, and it may be intra or pre-tragal.
I used to make retroauricular incisions only in patients with inelas-
tic or stretched neck skin with excess skin below the cricoid and
posterior to the sternocleidomastoid, but now I rely on the vertical
Preauricular Incision simulation test to determine the need for a retroauricular incision.
This incision is best placed just above the retroauricular sulcus so
The incision in the preauricular area is made in the anatomic
that once it has healed, the resultant scar will be in the sulcus.
margin between the ear and the face rather than in front of
it. ot only the color but also the texture and thickness of the
ear skin, including the tragus, vary from that of facial skin (Fig.
44.12). To mask this difference, a curved incision along the curve
of the anterior border of the helix is made to the upper border of
the tragus. At this juncture, the incision may be curved in front
of the tragus or along the posterior border of the tragus; then it
follows the sulcus between the earlobe and the cheek. My pref-
erence is for the intratragal incision along its posterior border
but not behind the tragus. A well-executed intratragal incision
is imperceptible compared with a pretragal incision. In the rare
patient who has little color difference between the facial and
tragal skin, the pretragal incision may serve as well. For a tragal
incision to be imperceptible, the tragus has to have a beginning
and an end (Fig. 44.13, Fig. 44.14, Fig. 44.15) and not blend into
the cheek at the lower border. The inferior tragal border must
be preserved. The entire closure must be without tension. The
prominence of the tragus plays a role in selecting the intratragal
incision. The more prominent the tragus, the better the result will
be. A flat tragus may retract forward and lead to enlargement of
the external auditory meatus. Special attention must be paid in Fig. 44.13 The tragus must have a beginning and an end.

Fig. 44.14 (a–c) Tragus. Beginning but no end. Incision closed under no tension with 6.0 suture.

539
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 44.15 (a, b, c) Tragus. Pre , early (middle), and late post op demonstrating a normal tragus and earlobe following an intra tragal incision.

Fig. 44.16 Pretragal or intratragal. Avoid undesirable scars and tragal

distortion such as this when planning incisions. The tragus must be Fig. 44.17 Pretragal or intratragal. Avoid tension such as this with
distinct and must have a beginning and an end. There is a beginning the closure where there is a beginning and no end with distortion
and no end with distortion secondary to tension. secondary to tension.

Fig. 44.18 Result of intratragal incision resulting n a natural tragus and

earlobe. Tragus has a beginning and end but no color or texture match.

540
 44 Clinical Decision Making in Facelift and Neck Lift

Table 44.2 Selecting a pretragal or intratragal incision the risk of vascular compromise and hematoma and may not be
necessary for all faces (Fig. 44.20).
Pretragal Intratragal
Color No match Match
Subfascial
Thickness Thicker Match
Most modern facelifts include some form of subfascial or sub-
Texture Textured Smooth
SMAS dissection. The extent of this dissection varies from
Tragal prominence Flat Prominent technique to technique. The vectors and methods of plication
Primary/secondary Secondary Primary also vary from surgeon to surgeon. I rely heavily on SMAS mobi-
lization and a vertical vector for improvement of the perioral
area, jowls, and jawline.
Low dissections of the SMAS have a limited effect on the upper
The upward length is not only a matter of personal preference but
midface and periorbital area. High SMAS dissections dramatically
of practical importance. I vary it according to my estimate of the
improve the upper midface and periorbital area.
amount of skin to be removed. The less skin that is being removed,
In thin faces, I try to preserve the SMAS; in heavy faces, I resect
the longer I make this retroauricular incision before taking it
it. I plicate the SMAS or undermine and plicate as necessary. My
transversely across into the occipital hairline. In patients with an
preference is to incise the SMAS not immediately preauricularly,
excessive amount of redundant skin, I take this incision across to
as in some described techniques, but rather at the junction of the
the occipital hairline and then follow it downward. I discuss these
mobile and fixed SMAS. This avoids dissecting the very thin SMAS
options with patients so that they understand that the incisions
in the preauricular area. My decision to plicate or to mobilize and
are being altered to achieve a better result (Fig. 44.19; Table 44.3).
plicate the SMAS depends on its mobility. I pick the SMAS up at
the junction of the fixed and mobile SMAS and pull it superiorly
Levels of Dissection while observing the effect on the jawline and perioral area. If the
pull provides the desired effect, I simply plicate (in thin faces) or
Subcutaneous resect and plicate (in heavy faces). However, if pulling without
I do not perform a subcutaneous facelift, and I believe that few mobilization does not produce the desired effect, I incise and
surgeons do. The subcutaneous dissection serves two purposes: mobilize the SMAS until the desired effect is observed; in thin
access to deeper tissues (SMAS) and skin resection. All modern faces I plicate with no resection, but in heavier faces I resect then
facelift techniques include various degrees of skin undermining. plicate. If I plan sub-SMAS procedures such as buccal fat pad
Extensive skin undermining to release the nasolabial fold and management or parotid gland reduction, then SMAS elevation and
mandibular retaining ligaments, although effective, can increase mobilization are mandatory (Fig. 44.21, Fig. 44.22).

a b c

Fig. 44.19 The retroauricular incision. (a) High retroauricular incision. (b) Lower retroauricular incision. (c) Occipital hairline incision.

541
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 44.21 Superficial musculoaponeurotic system is elevated and

buccal fat pad is delivered into the field.

Fig. 44.20 Subcutaneous dissection plane in facelift.

Table 44.3 Choosing the incision in a facelift

Facelift: Incision options
Features Prehairline Prehairline Temporal
with continuous
discontinuous with
temporal preauricular
incision incision
Sideburns
High or short
Low or long
Hairline
Anterior: Lateral
canthus to hairline
distance 3 to 5 cm
Posterior: Lateral
canthus to hairline
distance > 5 cm Fig. 44.22 Sub SMAS dissection following elevation of the skin.
Secondary facelift Plication suture is shown.

Subperiosteal
The advantage of the subperiosteal approach to the midface is
its relative ease, speed, and safety. The facial nerve branches are
less at risk with this approach; however, it is limited in its effects
on the lower face, jawline, and jowls. The subperiosteal approach
depends on suspension sutures to maintain the result (Fig. 44.23).
Combinations
The subperiosteal and subfascial or subperiosteal and subcuta-
neous levels of dissection can be combined in a variety of ways.
Examples include a subperiosteal approach to the periorbital
area and midface and a sub-SMAS approach to the perioral area
and jawline.

542

Fig. 44.23 Endoscopic subperiosteal dissection of the mid face.
Vectors
Most modern facelifts include separate vectors for the skin and
deeper tissues. The deeper tissues are elevated in a more vertical
or diagonally vertical vector and the skin in a more posterior and
vertical direction. The vertical vector on the SMAS improves the
jawline, the perioral area, and, with the high SMAS technique,
the midface. The more diagonal vector on the platysma improves
Fig. 44.24 The skin and superficial musculoaponeurotic system (SMAS) are fixed with different vectors.
44 Clinical Decision Making in Facelift and Neck Lift
on the neck and submental area. ith a short-scar facelift, the
skin vector is vertical, but the vector on the SMAS and platysma
can be varied (Fig. 44.24; Table 44.4).
Suspension Sutures
Most endoscopic and subperiosteal midface techniques require
suspension sutures or other devices to elevate and hold the soft
tissues in the desired position. Although usually effective, these
sutures are not risk-free; a disadvantage is that the fixation point
is far removed from the tissue being fixed (Fig. 44.25).
Volume Management
ith the clear understanding that deflation as an important and
integral part of facial aging, adding volume, usually in the form
of fat, has become an integral part of facial rejuvenation with and
without facelifts (Fig. 44.26). I do not routinely fat-graft every
facelift. The patients and areas of grafting are selected based on the
degree of deflation, most commonly the cheeks, temple, and peri-
oral areas followed by lips, earlobes, and submalar areas. The areas
to graft and the amount of fat are individualized for each patient.
Although volume management usually includes augmentation
of tissues, in selected patients I also remove excess volume, espe-
cially in the neck and jowls. Alloplastic implants, autologous fat,
and fillers are available for volume enhancement. By far the most
popular material of choice for volume enhancement is autologous
fat. In some patients, volume enhancement with fat transfer has
become routine. Alloplastic materials such as chin and cheek and
submalar implants may be preferable to fillers or autologous fat
in selected patients. Fillers are also an acceptable alternative to
autologous fat for volume enhancement.
The buccal fat pad is very prominent in some heavy faces and
must be addressed to recontour the perioral area and jawline.
The buccal fat pad can be approached either through the facelift
543
 VIII Surgical Rejuvenation of the Face and Neck

Table 44.4 Choosing the dissection level and vector in a facelift

Facelift: levels of dissection
Subcutaneous Subfascial Subperiosteal Suspension
egi n e e Low or standard High SMAS Extended SMAS SMASectomy sutures and
SMAS devices

Periorbital + + ++++ ++ ++ ++++ ++++

Cheek and ++ ++ ++++ ++++ ++++ ++++ ++++
nasolabial folds
Jowls and jawline ++ ++++ ++++ ++++ ++++ + +
Neck ++ +++ +++ +++ +++
Vectors Diagonal Vertical Vertical Vertical Vertical Vertical Diagonal
Diagonal Diagonal Diagonal Diagonal Diagonal
Risks
Skin flap viability ++++ ++ + + +
Facial nerve + ++ ++++ ++++ ++

Fig. 44.25 Endoscopic and subperiosteal midface techniques require suture suspension to a usually distant fixation point, typically the temporal fascia.

incision deep to the platysma or through an intraoral incision. I Ancillary Procedures

have resected the buccal fat pad as an isolated procedure in heavy,
Ancillary procedures include may include resurfacing, earlobe
youthful faces (those that present a cherubic appearance) and in
reductions, or augmentation and lip lifts. One or more of these are
primary as well as secondary facelifts for recontouring. Despite
performed almost routinely in all of my facial rejuvenation proce-
the intimate relationship of the superficial portions of the buccal
dures to enhance the overall result. Although in the past the actual
fat pad with the facial nerve, I have found this procedure to be both
facelift was the end result, today many of us feel that the facelift
safe and effective. Although I do not routinely modify the buccal
lays the foundation while volume management and the ancillary
fat pad, in the right patient it has a dramatic effect in recontouring
procedures that are performed concomitantly represent the finish-
the lower face and managing volume.
ing touches that result in true rejuvenation rather than simply the
It is rarely and only in a heavy face that I resect fatty tissue.
rearrangement of soft tissues and removal of excess skin.
hen I do so, it is limited to the jowls. However, in all but the
thinnest of necks I resect some fat below the skin, between the
platysma muscles, or deep to the platysma, depending on the Resurfacing
volume of the neck and distribution of the fat in these three layers, Rearranging the deep tissues and resecting excess skin does
as described in the section on the neck. not always result in improvement of the quality of the skin.

544
 44 Clinical Decision Making in Facelift and Neck Lift

a b
Fig. 44.26 Woman aged 64 (a) before and (b) after face- and neck lift, fat grafting of cheeks, upper and lower eyelids.

Sun-damaged, inelastic, wrinkled skin is usually dealt with Incisions

through resurfacing, concomitant with the facelift. This
includes dermabrasion, peels (croton oil or trichloroacetic acid Length
TCA ), and lasers. These procedures, when combined with a
Incisions for rejuvenation and recontouring of the neck range
facelift, are not only effective but also safe if limited to the
from liposuction access incisions to submental incisions and
areas where there has been no skin undermining. The under-
preauricular and retroauricular incisions. Incision length is
mined skin may also be treated with dermabrasion, peel, or
dictated by the anatomic and morphologic findings as well as the
laser, but cautiously and very superficially. udgment must be
planned procedure. The submental incision allows access to the
exercised on an individual basis when resurfacing over facelift
medial platysma and subplatysmal structures. The retroauricu-
flaps (Fig. 44.26).
lar incision allows access to the lateral platysma and affords the
opportunity for skin resection.
44.3.2 The Neck
Location
My preference for the submental incision, varying in length
Treatment Options for the Neck
from 3 to 5 cm, is to place it just caudal to the submental crease.
Incisions Others prefer to place the incision within the crease. I believe
• Length placement within the crease further deepens the crease and
• Location attracts attention to the scar. Caudal placement affords better
access to the submental area and allows dissection cranially
Levels of dissection to eliminate or render the submental crease less shallow. This
• Subcutaneous incision also allows access to the chin for correction of the ptotic
• Subplatysmal or witch’s chin (Fig. 44.27).
In the isolated neck lift without a facelift, it is sometimes
Extent of skin undermining
necessary to start the incision at or below the level of the tragus,
Vectors
continuing around the earlobe and into the retroauricular area
• Vertical
to prevent earlobe distortions and improve access to the jawline
• Diagonal
and neck. In the past I typically reserved retroauricular incisions
Suspension sutures for patients with inelastic or stretched neck skin with excess
Plication sutures skin below the cricoid and posterior to the sternocleidomastoid,
but now I rely much more on the vertical simulation test. The

545
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 44.27 The submental incision in neck lift is placed just posterior
to the submental crease.
best placement is just above the retroauricular sulcus. Upward
length should be varied according to the amount of skin removal
required. The less skin to be removed, the longer I make this
vertical component before crossing to the hairline. If neck skin
is excessive, I place the incision along the occipital hairline in a
downward and backward direction rather than extending it into
the hair. These incisions are all planned preoperatively, and their
location and alternatives are fully discussed with the patient. I
emphasize the benefits of a lower incision in terms of tightening
the lower neck skin (Fig. 44.28; Table 44.5).
Fig. 44.28 Options for the retroauricular incision in neck lift.
546
Levels of Dissection
Planes of the Neck
• Superficial plane
• Intermediate plane
• Deep plane
I think of the neck as having three planes: superficial (skin and
subcutaneous fat), intermediate (platysma and interplatysmal
fat), and deep (subplatysmal structures).
Su er i ne
The superficial plane includes the skin and subcutaneous fat;
each neck and submental lift includes varying degrees of dissec-
tion and undermining in this plane. It is important to leave at
least a 3- to 5-mm thickness of fat on the deep surface of the skin,
whether the defatting is performed directly or through liposuc-
tion. Leaving this layer of fat with a suitable thickness renders a
smooth contour to the neck and eliminates the skin irregulari-
ties that are seen with aggressive removal of subcutaneous fat.
Aggressive removal of fat leads to adherence of the skin onto the
platysma. Intervention in this plane is usually combined with
interventions in the other two planes, except in individuals who
are candidates for liposuction only (Fig. 44.29).
Intermediate Plane
The platysma and the small amount of fat between the medial
border of each platysma muscle make up this plane. Plication of
 44 Clinical Decision Making in Facelift and Neck Lift

Table 44.5 Choosing the incision in a neck lift

Features Neck lift: incision options
Preauricular Submental Short in Longer above level Long to level of Long to just below
retroauricular of tragus, crossing tragus, crossing level of tragus,
sulcus only into hair into hair then crossing down
along occipital
hairline
Skin quality
Normal
elasticity
Inelastic,
stretched,
sun-damaged
Skin quantity
No skin excess
Apparent skin
excess
Real skin excess
Planes of
intervention
Superficial
Deep to
platysma

the platysma in the midline is the most common procedure at Deep Plane
this level. In a patient with a heavy submental area, the interven-
The subplatysmal fat, digastric muscles, and submandibular
ing fat between these medial borders is resected as necessary.
gland make up the structures of the deep plane. Resection of the
If fat is resected from between the platysma muscles and deep
subplatysmal fat, the anterior belly of the digastric muscle, and
to the platysma, it is important that sufficient fat be left deep
the superficial lobe of the submandibular gland are the proce-
to the skin. Removing fat aggressively below the skin, between
dures performed in this plane. If needed, a suprahyoid fascial
the platysma muscles, and deep to them, leads to an unnatural
release is also performed in the deep plane (Fig. 44.31).
hollowing of the submental area. Very rarely do I remove fat from
To distinguish between excessive preplatysmal (subcutaneous)
all three layers. The more deep fat I remove, the more superficial
fat and subplatysmal fat, a useful maneuver is to grasp the sub-
fat I leave behind (Fig. 44.30).
mental fold between the thumb and index finger and then ask the
patient to grimace, thus contracting the platysma muscles. If the

Fig. 44.29 Superficial plane in neck lift. Fig. 44.30 Intermediate plane in neck lift.

547
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 44.31 The deep plane, including the subplatysmal structures.

fold between the examiner’s thumb and index finger is unchanged, Extent of Skin Undermining
the bulk of the fat is subcutaneous; if it diminishes, then the bulk
ith the exception of liposuction only, extensive neck undermin-
of the fat is deep to the platysma and must be removed in that
ing is the rule to facilitate the redraping of the apparent excess
plane to recontour the submental area (Fig. 44.32).
skin of the neck, especially in the submental area. The under-
Once the subplatysmal fat has been dissected, the anterior belly
mining usually extends from the sternocleidomastoid muscle on
of the digastric muscle is easily viewed. If it appears as a bulge when
each side, across the midline, and down to the level of the thyroid
the patient’s neck is flexed, a tangential excision of the anterior
cartilage. More extensive lateral and inferior dissection and
belly would further improve the submental contour (Fig. 44.33).
undermining may be necessary in some individuals who have an
A large submandibular gland is often visible preoperatively.
excessive amount of neck skin or inelastic skin. Undermining of
Once the digastric muscle has been identified, the superficial lobe
the neck deep to the transverse creases will significantly improve
of an enlarged submandibular gland is readily visible. If it bulges
the appearance of the neck and the creases. Direct excision of the
further on neck flexion, the superficial lobe can be resected to
deep creases has also been described (Table 44.6).
further enhance neck contour and improve on the visible bulge.

Fig. 44.32 Maneuver to distinguish subcutaneous from subplatysmal fat. The submental fold is grasped and the patient asked to grimace. If the fold
is unchanged, the excess is likely subcutaneous. If it diminishes, it is mostly deep to the platysma.

548
 44 Clinical Decision Making in Facelift and Neck Lift

Fig. 44.33 The anterior belly of the digastric muscle is encountered after dissection of the subplatysmal fat.

Table 44.6 Choosing the incision in a neck lift

Neck lift: incisions and anatomic features
Incisions Fat distribution Structures
Planes or layers Liposuction Submental Subcutaneous Interplatysmal Deep or Platysma Digastric Submandibular Hyoid fascia
of the neck access subplatysmal muscles gland
Superficial
Intermediate
Deep

Vectors
The vectors that influence the appearance of the neck and jaw-
line include the vertical vector applied to the jawline through the
platysma plication of a facelift. A more diagonal and posterior
vector involving the lateral border of the platysma combined
with a medial plication of the two platysma muscles defines the
submental area and the neck–jaw angle (Fig. 44.34).
Sutures
Suspension Sutures
Suspension sutures running over the platysma and below the
mandibular border, designed to define the neck–jaw angle, were
described by Guerrerosantos and later popularized by Giampapa.
In carefully selected patients, suspension sutures can be effec-
tive, but I have found them to be of limited value in individuals
with large submandibular glands. In my experience, a more
direct approach in the deep plane produces longer-lasting results
(Fig. 44.35).

Fig. 44.35 Suspension sutures from the platysma to below the

Fig. 44.34 Platysma vectors. mandibular border

549
 VIII Surgical Rejuvenation of the Face and Neck
Plication Sutures
Plication of the platysma in the midline, as advocated by Feldman
(the corset platysmaplasty), is highly effective in recontouring
the submental area. hen combined with a lateral plication,
platysmal plication defines the jawline and neck–jaw angle. This
step is an integral part of almost all the neck lifts I perform.
Ancillary Procedures
Although volume management in the neck almost always means
removal of fat or partial resection of the digastric or subman-
dibular gland, volume addition in the form of autologous fat or
acellular dermal matrix has been advocated for correction of the
contour irregularities associated with aggressive oversuction
superficial to the platysma. Resurfacing either with laser or (my
preference) TCA peels is an acceptable adjunct to neck lift. The
energy levels on the laser are set below those for a facelift. I apply
20 , 30 , or even 50 TCA to the face, but I limit neck peeling to
550
20 TCA, and even then the endpoint is a mottled frosting rather
than the uniform frosting that I look for on the face. For the very
deep transverse creases, fillers or fat are effective.
Suggested Reading
[1] Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and
clinical applications. Aesthet Surg J 2013;33(6):769–782
2 Baker DC, Nahai F, Massiha H, Tonnard P. Short scar face lift. Aesthet Surg J
2005;25(6):607–617
3 Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMA-
Sectomy: evolution and application. Aesthet Surg J 2001;21(1):14–26
4 Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMA-
Sectomy. Aesthet Surg J 2001;21(1):68–79
5 Barton FE Jr. Aesthetic surgery of the face and neck. Aesthet Surg J
2009;29(6):449–463, quiz 464–466
6 Hashem AM, Couto RA, Duraes EFR, et al. Facelift part I: history, anatomy, and
clinical assessment. Aesthet Surg J 2019;sjy326; Epub ahead of print doi:
10.1093/asj/sjy326
[7] Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J
2007;27(2):188–198
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
45 Structural Fat Grafting: Basics and Clinical Applications in
the Hand and Face
Michael J. Cammarata and Sydney R. Coleman
Abstract
This chapter reviews the essential steps of harvesting, refining,
and placing autologous fat using the Coleman technique and
applies these methods in the hand, lips, nasolabial folds, and
marionette grooves. The Coleman technique was introduced in
the 1990s and has proven to be a reliable method of achieving
hand and facial rejuvenation, hence its adoption by plastic sur-
geons throughout the world. Meanwhile, the clinical applications
of fat grafting continue to expand, owing to the unique properties
of autologous fat, which provides a safe, predictable, and long-
lasting soft tissue filler that not only restores youth and subcuta-
neous fullness but also improves skin quality by way of growth
factors and adipose-derived stem cells within the harvested
lipoaspirate. This chapter takes the reader step by step through
the basics of the Coleman technique and applies them across
several clinical regions, specifying appropriate sites of incision
and correct levels of infiltration to achieve the ideal postoperative
result. After each technical explanation of proper fat placement,
the chapter also features postoperative images and cases with
extended long-term follow-up, highlighting the stability of struc-
tural fat grafting performed with the Coleman technique.
Keywords
fat grafting, structural fat grafting, Coleman technique, lipo-
structure, facial augmentation, autologous fat, fat, lipoaspirate,
soft tissue augmentation
45.1 Structural Fat Grafting Basics:
The Coleman Technique
45.1.1 Evolution of the Technique
For over 100 years, surgeons have been in search of the ideal soft
tissue filler. From paraffin, a hydrocarbon injected into the face
and body beginning in the late 19th century, to the modern-day
dermal filler hyaluronic acid, each has its respective drawbacks,
such as risk of foreign body reaction and gradual resorption.
Adipose tissue has long offered a natural and readily accessible
solution to soft tissue augmentation, but the techniques and
clinical applications of autologous fat grafting have undergone
considerable evolution since first reported by Gustav euber
in 1893. In 1910, Eugene Hollander described the transfer of
autologous fat into the face, and by 1919, Erich Lexer published
on the harvesting and transplantation of fat en bloc to perform
reconstructions of the breast, face, and hand. The first account
in U.S. literature, however, was by Charles C. Miller in 1926, who
described subcutaneous fat injections using injection cannulas
for aesthetic restoration of the face. Despite the achievements of
these pioneers, the process of fat resorption was poorly under-
stood, and the technique failed to be widely adopted.
It was not until the advent of liposuction in the 1980s that inter-
est revived in the harvest and transfer of fat, now in a semiliquid
form amenable to reinjection through cannulas and needles;
however, attempts at fat grafting continued to yield mixed results
owing to graft resorption over time. High negative pressure during
tissue harvesting subjected fat cells to considerable stress, not
unlike the harmful manipulations such as straining, whisking, and
filtering utilized during the processing of fat in years past. Seeing
promise in the potential applications of fat grafting, particularly in
restoring iatrogenic liposuction deformities, one of us (Coleman)
applied the principles of tissue transplantation to fat harvest
and transfer. In 1994, he refined his technique and established
Lipostructure for hand and facial rejuvenation, which emphasized
low-trauma harvest via syringe liposuction combined with the
delicate and meticulous layering of autologous tissue. His impres-
sive results and reproducible technique helped repopularize fat
grafting and made it one of the techniques most widely adopted
by practicing surgeons.
45.1.2 Overview of Harvesting,
e nemen nd r n er
and Placement
The three cardinal steps of structural fat grafting via the Coleman
technique are the following:
1. Harvesting of autologous fat with
a low-suction syringe
a blunt cannula attached to
2. with brief centrifugation
to facilitate removal of nonliving components, with refined
lipoaspirate then transferred to low-volume syringes for
placement
3. C into recipient tissues in
small aliquots
hile progressing through the aforementioned steps, consider
the following corresponding principles:
A. Fat is a delicate structure with its own supporting architecture,
and it is susceptible to mechanical, chemical, temperature, and
barometric insults and thus requires careful handling.
B. Accurate estimation of the volume of harvested fat is facilitated
by centrifugation to separate viable fat from blood, lidocaine,
and the oil expelled from lysed adipocytes. Failure to isolate and
discard nonfatty components will yield unpredictable results.
C. Fatty parcels are composed of adipocytes, which require oxygen
and nutrients from the surrounding host tissue for aerobic res-
piration and survival. Overzealous placement of large volumes
can compromise access to nutrients, leading to cell death and
poor graft retention.
551
 VIII Surgical Rejuvenation of the Face and Neck

45.1.3 Harvesting
Incisions and Donor Site Access
The choice of donor site for fat harvesting is largely dependent on
patient preference and the quantity of fat needed. Harvest sites
typically include the abdomen; the flank; the love handles ; the
medial, lateral, and anterior thighs; the suprapubic region; and
above the knees (Fig. 45.1). hen accessing these areas, an effort
should be made to hide incisions in previous scars, natural creases,
stretch marks, or hirsute regions. The pubic region is often used
as an incision site given the ease of access to the inner thighs,
flank, and abdomen. This is especially convenient during facial
rejuvenation, when the patient is already in the supine position.
In thin patients or men with limited abdominal or medial thigh
fat, consider harvesting from the suprapubic region, anterior
thighs, or above the knees. Additional incision sites include the
midback and lateral sacrum to access the love handles and flanks,
as well as the umbilicus and upper abdomen to access fat from the
flanks and upper abdomen. Occasionally, an incision at the lateral Fig. 45.1 Common incisions for donor site access when fat harvesting
hip can be used to access the thigh or lower love handle. from (a) anterior and (b) posterior. (Reproduced with permission
Previous research has found no significant difference in the from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
volume or weight of fat harvested from various donor sites;
however, a higher concentration of adipose-derived stem cells
(ADSCs) has been found in the fat of the lower abdomen and inner
thighs. The author preferentially utilizes the densest fat from Basic Harvesting Instruments
these regions to infiltrate recipient sites that require functional
Harvesting instruments should be efficient and minimally trau-
rejuvenation of the overlying skin. hen harvesting, be mindful
matic to the grafted tissue, which must be harvested in intact
of the volume removed from a donor site, as large-quantity har-
parcels small enough to pass through the lumen of a narrow
vests may leave the patient with a liposuction deformity and thus
cannula but large enough to maintain tissue architecture.
a new cosmetic concern; in fact, the harvesting process should
Smaller-bore cannulas paired with 10-mL syringes have been
offer an opportunity to simultaneously improve contour.
previously shown to result in greater fat viability and facilitate
the eventual passage of fat through the much smaller placement
Sterile Technique cannulas without clogging (Fig. 45.2). For small harvests when
Although postoperative infections are uncommon after struc- fat grafting to the face, use a 14-gauge nine-hole cannula. For
tural fat grafting, they can compromise aesthetic outcomes and larger-volume harvests, the author recommends either a 15- or a
patient satisfaction by leading to resorption. Hence, strict adher- 26-cm 12-gauge nine-hole cannula. Each cannula should be con-
ence to sterile technique is essential during harvesting, refining, nected to a 10-mL Luer lock syringe, with the plunger held at 1 to
and placement. 2 mm of negative pressure to encourage a gentle, nontraumatic
harvest. It is recommended, however, that surgeons with little
exposure to fat grafting use shorter cannulas given the greater
Anesthesia torque placed on the Luer lock aperture by longer cannulas. This
To begin harvesting, infiltrate lidocaine solution with a 25-gauge torque may break the syringe tip, and the surgeon should prog-
needle into the planned incision site. Proceed with a 2-mm ress to using 26-cm cannulas only after becoming familiar with
incision using a no. 11 blade. Anesthetic solution should be the instruments and comfortable with the harvesting process.
infiltrated into the projected sites of fatty removal using a nine- Similarly, a curved cannula may be a useful tool to harvest from
hole Coleman harvesting cannula attached to a 10-mL Luer lock regions such as the flanks, thorax, or thighs once the surgeon
syringe. For smaller procedures, a purely local approach can be is more confident in his or her handling of the harvesting
used. In this case, 0.5 lidocaine with 1:200,000 epinephrine instruments.
buffered with sodium bicarbonate can be infiltrated into the Proper instrumentation during the Coleman technique ensures
donor site. For larger procedures, IV sedation using propofol and greater adipocyte viability and long-term graft retention as
local infiltration is the preferred method. The author uses lac- compared with suction-assisted lipectomy. Previous studies have
tated Ringer’s solution with lidocaine and 1:400,000 epinephrine shown that the high negative pressure generated during conven-
to ensure hemostasis. Avoid excessive tumescent techniques, as tional liposuction may be more traumatic to adipocytes and that
these may disrupt adipocyte structure. Note that exposure to cells harvested via the Coleman technique have a statistically sig-
epinephrine and lidocaine during harvest has not been shown nificant increase in viability and cellular functioning as measured
to result in functional or histological damage to adipocytes once by glyceraldehyde 3-phosphate dehydrogenase (G3PD) levels.
grafted, nor has it been shown to interrupt the process of micro- The gentle, constant pressure offered by syringe liposuctioning
angiogenesis at the recipient site.

552
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face

Fig. 45.2 (a) Nine-hole harvesting cannulas. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (b) This configuration promotes efficient fat harvest. The right oblique view, (c) left oblique view,
and (d) back view are shown.

preserves the architectural integrity of the grafted fat and fosters
long-term graft retention.
Harvesting may result in frictional trauma due to the repetitive
motion of the cannula against the incision sites. To prevent irrita-
tion and friction burn, use oil acquired from centrifugation and
separation to lubricate the harvest incisions. Incisions are then
closed with simple interrupted nylon sutures.
in the oil or aqueous components; hence, the top and bottom
layers can safely be removed from the central layer without jeop-
ardizing successful results. After decanting the excess oil from
the top (which should be saved for use in lubricating the incision
sites), wick away the remaining oil using Codman neuropads or

45.1.4 e nemen nd r n er
Centrifugation
Once the fat has been harvested into the 10-mL Luer lock syringe,
remove the cannula and replace it with a dual-function Luer lock
plug to cap the syringe. Do not use the caps that come with the
syringes, as these are less reliable and may leak aqueous fluid
during centrifugation (Fig. 45.3). After removing the plunger, the
author then performs centrifugation at 1,286g for 2 minutes. Be
sure to sterilize the rotor and syringe sleeves after each proce-
dure. Sterilization should be performed with steam instead of
liquid solutions to prevent rusting and corrosion of the centrifuge
parts. The author also recommends that the central rotor be held
in place by gravity, given that bolted rotors can rust over time.

Separation of Components
Centrifugation separates the lipoaspirate into three layers: the
uppermost layer (least dense), consisting of oil released from
lysed adipocytes; a middle layer of potentially viable fatty par-
cels; and a lower layer (most dense), consisting of blood, water,
and lidocaine (Fig. 45.4). Isolated growth factors will not be lost
Fig. 45.3 Demonstration of proper syringe plugging. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration. 2nd ed. New ork, N : Thieme; 2018.) (a)
Do not use the plugs that accompany the syringes. These may allow
spillage of aqueous contents. (b) Use a dual-function Luer lock plug for
capping.

553
 VIII Surgical Rejuvenation of the Face and Neck
Telfa strips (Medtronic, Minneapolis, M ) for 4 minutes. Repeat
this process at least once, but avoid prolonged exposure to air
to prevent damage to adipocytes. Discard any fat that has likely
been damaged by exposure to barometric or mechanical trauma.
Dispose of the lowermost aqueous layer by removing the Luer
lock cap and draining by gravity into a collecting receptacle.
Replace the plunger and remove the remaining dead space. ote
that 10 mL of harvested fat will yield approximately 4 to 6 mL of
refined fat suitable for placement once centrifugation and dis-
posal of the oil and aqueous components have been completed.
At this point, the syringes can be safely stored temporarily before
transfer to smaller syringes.
Transfer to Syringes
ithin the middle layer of potentially viable fatty parcels,
higher-density fat will be found toward the bottom of the
syringe. This layer has been shown to survive with less fibrosis
and to contain more ADSCs and growth factors. Higher-density
fat will yield more predictable postoperative results, and the
author therefore separates the harvested fat into 1-mL syringes
based on density. This enables a more strategic placement of the
highest-quality fat into prioritized recipient sites.
Fig. 45.4 Three layers produced by centrifugation during
refining. Viable fat for placement is retained within the middle level.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
Thieme; 2018.)
554
In preparation for placement, transfer the isolated fat in the
processed 10-mL syringe into either a 1-mL or 3-mL Luer lock
syringe. Use 1-mL syringes for fat grafting in the face and hands
and 3-mL syringes for larger-volume fat grafting in the body.
Maintain both syringes in a relatively vertical orientation to
prevent the introduction of air bubbles during transfer (Fig. 45.5).
The use of larger placement syringes is discouraged, as those
syringes do not facilitate the placement of small fatty aliquots and
thus pose greater risk of clumping, fat necrosis, and fat emboli.
i u i n e nemen
Alternative processing techniques such as washing and straining,
and harvesting by conventional liposuction, disrupt tissue archi-
tecture and may make fatty parcels more susceptible to damage
by centrifugation. Syringe liposuction used in the Coleman tech-
nique facilitates removal of tissue debris and preserves tissue
architecture, allowing it to withstand greater centrifugal forces.
This is supported by findings that centrifuge speed does not
impact graft survival when harvested with syringe liposuction,
suggesting that this method is less traumatic to grafted tissue.
Studies have also shown, however, that excessively long or vig-
orous centrifugation has been shown to damage adipocytes and
ADSCs, leading urita et al to recommend 1,200g centrifugation.
Hoareu et al recommended a gentler centrifuge speed of 400g for
1 minute after washings; however, washing may break important
Fig. 45.5 Transfer of fat to smaller placement syringes. Maintain the
syringes in a vertical orientation to prevent the introduction of air
bubbles. (Reproduced with permission from Coleman SR, Mazzola RF,
Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork,
N : Thieme; 2018.)
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
connective tissue and reticular fibers that provide architectural
support to fatty parcels. ashing can also remove fibrin, which
plays an important role in promoting fat engraftment. In a recent
review of the literature, Strong et al concluded that results
among animal and human studies on processing methods have
been inconclusive and that no single technique is superior; but
the discrepancies between study protocols make it difficult to
compare published results. hile further research is warranted,
it has been the author’s experience that centrifugation alone at
1,286g for 2 minutes is the optimal processing method and pro-
motes successful fat grafting without damage to the lipoaspirate.
45.1.5 Placement
Anesthesia
Infiltrate a solution of 0.5 lidocaine with 1:200,000 epinephrine
via a 27-gauge needle into planned incision sites and make an
incision with a no. 11 blade. Regional blocks with 1 lidocaine
and 1:100,000 epinephrine through a 25-gauge needle may be
used when appropriate. If general anesthesia is administered,
small amounts of dilute epinephrine solutions should be infil-
trated into the recipient site to induce vasoconstriction. If the
procedure is performed under local anesthesia or IV sedation
with propofol, the graft sites should be infiltrated with 0.5
lidocaine with epinephrine 1;200,000 using an appropriate can-
nula. This will help prevent intravascular injection and reduce
intra- and postoperative hematomas.
a b
Fig. 45.6 (a) Placement of fat into the recipient site. Introduce the cannula, (b) pushing down gently on the plunger as the cannula is withdrawn to
(c) create layers of fat with maximal contact with the host tissue. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
Placement Technique
Proper fat placement will ensure long-term graft viability and
yield more predictable postoperative results. Placement requires
the meticulous deposition of small aliquots of fat such that each
parcel is within a minimum of 1.5 mm of vascularized host tissue
and thereby has access to essential nutrients and integrates
into the recipient site (Fig. 45.6). Large fat injections prevent
the diffusion of host nutrients to adipocytes, resulting in cell
death, manifesting as large areas of resorption, calcification,
necrosis, and sometimes oil cysts (Fig. 45.7). Postoperatively,
this will yield poor aesthetic outcomes, with regions of either no
notable cosmetic improvement or, worse, palpable irregularities.
Maximizing the surface area of contact between fat parcels and
host tissue will promote continued respiration of grafted adipo-
cytes and will lead to a smooth and predictable postoperative
result.
To begin placing fat, insert the infiltration cannula through
the same incision used for injection of local anesthetic. Once the
cannula is within the desired plane, stabilize the skin and protect
vulnerable structures (e.g., the eyeballs) with the opposite hand.
Press down on the plunger of the syringe while simultaneously
withdrawing the cannula, allowing the deposited fatty parcels to
fall into natural tissue planes as the tissue drapes around them
(Fig. 45.8). This will prevent clumping, promote engraftment, and
increase the chance of graft survival. Fat should be placed in very
small quantities 0.1 mL at most and often as little as 0.02–0.033
mL in areas that require finer contouring, such as the periorbital
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 45.7 Placement principle. (a) Placement of large quantities of fat may compromise access to nutrients and (b) lead to fat necrosis and resorp-
tion. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme;
2018.)

Fig. 45.8 Placement technique. (a) During placement, the cannula is inserted to the appropriate plane, and (b) withdrawn slowly as fatty parcels fall
into natural tissue planes. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed.
New ork, N : Thieme; 2018.)

region. The injected material will likely contain remnants of blood,
lidocaine, or oil even postrefinement; therefore, it is best to start
with small quantities of infiltrate and progress to larger volumes
gradually with experience. Although small-quantity grafting
may not have the desired aesthetic affect with one operation, it
is preferable to perform an undercorrection and return to the
operating room at a later time for further augmentation than risk
tissue necrosis due to an overzealous augmentation.
Fat grafting requires the ability to visualize the desired 3D con-
tour and achieve it with multiple passes through specific tissue
planes, a process known as structural manipulation. During this
process, the Coleman technique promotes integration of the fat
into the host tissue such that the recipient site retains its original
structural quality. This may make it difficult to manipulate a graft
once it has been placed, and postoperatively, patients may believe
that the fat disappeared given that there is no palpable change
(hence the importance of pre- and postoperative photographs to
document clinical differences). Placement of fat deep against the
periosteum is used to modify projection; intermediate-level grafts
are used to restore volume and improve proportions; and super-
ficial intradermal or subdermal grafts enhance skin quality and
eliminate wrinkles. Although the Coleman technique promotes
fat integration, areas of greater mobility (e.g., nasolabial folds,
corrugators) may still be susceptible to fat migration as patients
inevitably resume normal facial expressions postoperatively.
Once fat has been placed, it is important to avoid manipulating
the tissue by hand. Hence, the surgeon should never place fat with
plans to manipulate it into shape by digital pressure. If a large-
volume graft has been mistakenly placed, it can be digitally
molded to restore the desired contour, but otherwise, tissue
should be placed in small linear aliquots as just described.
Instrumentation for Placement
To perform fat grafting, the author uses three basic cannulas
as well as V- and -dissectors, each with its own purpose (Fig.
45.9). In contrast to harvesting cannulas, placement cannulas
have only one distal opening:
• Coleman Style I has a capped lip that extends 180 over the
distal aperture. This is the workhouse of structural fat grafting.
The rounded lip minimizes traumatic injury to surrounding
tissues during placement.
• Coleman Style II is similar to a Style I but has a capped lip that
extends only 130 to 150 over the distal aperture.
• Coleman Style III has a flat tip instead of a capped lip and is
therefore a reliable tool for dissection through fibrotic tissue
or for placement in tougher, immediately subdermal tissue.
• The Coleman V-dissector is used for release of adhesions.
Placement cannulas can range from 14- to 21-gauge, depending
on the clinical application.
Larger-gauge cannulas are used for corporeal fat grafting, while
shorter, smaller-gauge cannulas are used in the more delicate
structures of the face, such as the eyelids.

556
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face

Fig. 45.9 Available instruments. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd
ed. New ork, N : Thieme; 2018.) Coleman placement cannulas (a,d,g,j,m,p,s) Style I; (b,e,h,k,n,q,t) Style II; (c,f,i,l,o,r,u) Style III; (v–x) V-dissector
for release of adhesions.

Use of Blunt Cannulas for intradermal placement of fat grafts. Carraway and Mellow
previously recommended tissue undermining prior to intradermal
The author switched from sharp to blunt placement cannulas in
placement, which the author does not routinely perform, except
1992 to prevent underlying tissue damage, lower the risk of intra-
in cases of acne or other scarring. Deep dermal placement has
vascular injection, and allow placement into more natural tissue
demonstrated remarkable improvement of acne scars and enables
planes. Sharp needles were seen to create unnatural spaces and
a more significant softening of deep facial wrinkles. Be sure to
cut swaths through the tissue, leading to less stable grafts, while
master the basic cannula techniques of fat grafting before proceed-
blunt cannulas separated tissue in a more physiologic manner.
ing with intradermal placement (Fig. 45.10).
Despite previously discouraging the use of sharp needles out-
right, the author has more recently begun utilizing sharp needles

557
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 45.10 Intradermal placement. Deep dermal placement may be accomplished with sharp needles. (Reproduced with permission from Coleman
SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)

45.1.6 Conclusions
The Coleman technique is rooted in the principles of tissue trans-
plantation and provides a reliable foundation for fat grafting.
Long-lasting results in the hand and face are achievable with
proper harvesting, refinement, and placement techniques that
emphasize careful tissue handling and small volume placements.
45.2 Structural Fat Grafting: Clinical
Applications
f ,
is important to weigh the patient at the time of consultation, right
before surgery, and at each postoperative visit to evaluate distant
postoperative changes properly.
The appropriate plane of placement is immediately subder-
mal, between the skin and the veins. Use of only the bluntest of
cannulas will prevent damage to any exposed structures. In the
author’s experience, significant bruising is rare when this plane
is respected. The key to successful fat grafting in the hand is the
placement of a smooth, consistent layer just deep to the dermis,
with additional placement in the web spaces and intermetacarpal
regions.

45.2.1 Hand Rejuvenation Indications and Patient Selection

Much like the head and neck, the hands are often unclothed and Patients who may benefit from structural fat grafting in the hand
exposed. They are also one of the first areas to display signs of display signs of aging at the hands that do not correspond with
aging and may become a cosmetic concern if their appearance is their facial appearance or age. The best candidates have a loss of
incongruous with a more youthful face. In a healthy, attractive subcutaneous fullness, leading to prominent veins and tendons.
dorsum of the hand, the extensor tendons are visible and become Patients with enlarged joints and arthritic changes are also can-
more pronounced during metacarpophalangeal (MCP) joint didates. Their hands will appear much healthier by decreasing
extension. Extensor tendons remain the color of the overlying the relative size of the joints and filling the intermetacarpal
skin, while superficial veins are visible but not conspicuous and spaces.
display only a mild blue hue. Although fat will be placed in the
dorsum during rejuvenation, this region is not a repository of fat
in younger hands. The goal of adding fat into the dorsum is to
increase the subcutaneous tissue thickness over time, restoring
a subtle fullness over the hand and fingers that obscures dispro-
portionately prominent features. hen the Coleman technique
is used, the grafted fat will feel like thicker skin upon palpation,
not like additional subcutaneous fat.

Aesthetic and Anatomic Considerations

In an aging dorsum of the hand, the skin is thin and crepelike
and clings to the surface. The contours of the superficial veins are
significantly more prominent, and the hand appears bony with
clearly defined MCP joints and deepened intermetacarpal spaces
(Fig. 45.11). Appropriately conservative placement of fat in the
dorsum of the hand and fingers restores a fullness reminiscent
of youth, softens the skin color, and masks the extensor tendons Fig. 45.11 Age-related changes visible at the hands. Note the tortuous
and tortuous veins. However, an overzealous augmentation that superficial veins, visible extensor tendons, and crepiness of the skin.
completely obscures the superficial structures of the dorsum (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
will appear unnatural and overfilled. Remember that in fat Thieme; 2018.)

558
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
Technical Approach
Markings
Orange lines delineate the limits of placement along the perimeter
of the hand and extend to the proximal forearm. Green markings
represent areas of greater fat placement, while blue dots chart
the courses of large, superficial veins (Fig. 45.12). These lines
may be obscured during fat placement; therefore, they should
be photographed before the patient enters the operating room
so that the photograph can serve as an intraoperative reference.
Incisions
Six to nine incision sites should be placed throughout the dorsum
of the hand. The following sites are recommended: ulnar and
radial wrist, central dorsum of the hand, ulnar and radial thumb,
radial index, web space between the third and fourth fingers,
and the fifth finger (ulnar) MCP joint (Fig. 45.13, see blue dots).
Incisions should be made with a no. 11 blade and should be
slightly longer than 1 mm. Obscure incisions by placing them in
the direction of wrinkle lines.
Cannulas
Be sure to use only Style I cannulas to avoid damage to the
underlying structures, especially the veins. Trauma to the veins
may produce a hematoma and complicate visualization of fat
Fig. 45.12 Skin markings for fat grafting to the hand. Red lines delin-
eate the borders of placement, blue dots trace the course of superficial
veins, and green markings indicate areas of placement. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
placement. The author prefers 17-gauge cannulas that are either
7 or 9 cm long.
e e In r i n
In addition to use of the blunt cannula, staying in the appropriate
plane immediately deep to the dermis, but superficial to the
veins, will help prevent tissue damage (Fig. 45.14). Filling in this
plane will provide support, thicken the skin, and obscure the
protuberant veins.
Volumes
Placement volumes of at least 20 to 30 mL in each hand is
recommended. Patients with more significant skin atrophy or
who require feathering into the proximal forearm may require
additional volume, but be very cautious about overcorrecting. Do
not place more fat than necessary in anticipation of resorption.
Placement Pattern
The key to placement is the use of a very superficial plane with
very little layering. Fat will be placed over the proximal fingers
and the entire dorsum of the hand and extend to the wrist and
occasionally the forearm. At the intermetacarpal spaces, fat can
be placed in a deeper plane for additional support.
Begin placement through the central dorsum incision, extend-
ing along the phalanges, past the MCP joints, and into the web
spaces. The most common technical error during placement is
undercorrection of the proximal digits, so be sure that each digit
receives about 1 mL of fat.
Fig. 45.13 Incision sites for placement at the hand. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
Fig. 45.14 Proper level of infiltration for placement at the hand. Note
that the cannula tip remains in the immediately subdermal plane
superficial to the veins. (Reproduced with permission from Coleman
SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd
ed. New ork, N : Thieme; 2018.)
559
 VIII Surgical Rejuvenation of the Face and Neck

Fat can be placed as distally as the proximal interphalangeal

(PIP) joints and across the MCP joints for continuity, but be cau-
tious about placing fat over already enlarged joints, as this may
accentuate their size, particularly if placement is not adequate
in the intermetacarpal spaces. Infiltrate up to 7 mL of fat in the
phalanges and web spaces (Fig. 45.15a,b). Place about 1 mL or
more at the first web space from the ulnar thumb and radial
index incisions. Placement can extend from the dorsal hand to
the palmar aspect (Fig. 45.15c,d). Proceed to the radial thumb
incision, placing another 3 mL or more in a radiating pattern (Fig.
45.15e). Using the middle MCP joint incision, pass over the entire
dorsum toward the distal forearm (Fig. 45.15f). The radial and
ulnar MCP joint incisions, along with the central dorsum incision,
can be used similarly to spread across the dorsum to the wrist
(Fig. 45.15g–i). Place an additional 5 to 10 mL across the wrist
from the dorsal and radial wrist incisions (Fig. 45.15j). This area
requires larger quantities of fat, given that it is the primary site of
wrinkling of the dorsal upper extremity. Incisions can be closed
with Steri-Strips (3M, St. Paul, M ) or nylon sutures.

Postoperative Care
Incisions are generally closed with Steri-Strips only. The author
formerly dressed the hands, wrist, and phalanges in Microfoam
(3M, St. Paul, M ) tape for 3 to 4 days postoperatively to help
combat edema. However, the tape rarely remained more than
24 hours. More recently, he uses fingerless gloves made from
sterile stockinette to cover the hands. An extra pair of two can be
given to the patient, who is advised to wear them until the first
postoperative visit. Elevation of the hands will certainly help
with swelling; cold compresses are contraindicated. Patients Fig. 45.15 Placement pattern at the hands. (Reproduced with permis-
sion from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling
should refrain from putting pressure on the dorsum of the hands to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a,b) Begin
for at least 1 week, especially during sleep. However, movement at the central dorsum extending toward the wrist and past the MCP
of the fingers, as in typing, is encouraged after the first few days joints. (c–e) Proceed to the first web space. (f–i) The middle, radial,
and ulnar MCP joint incisions, along with the central dorsum incision,
to help reduce swelling. Most swelling will resolve by 6 to 8 can be used to spread across the dorsum. (j) An additional 5 to 10 mL
weeks, although some edema may be present for up to 20 weeks can be placed across the wrist.
or more.

Results patient was enthusiastic about the results, shown at 39 months

A 55-year-old woman was concerned that her hands appeared postoperatively (Fig. 45.17).
much older than her face. Her veins were prominent, and the
whites of her extensor tendons were visible. She elected to
Complications
undergo structural fat grafting to the dorsum of both hands,
Prior to 1992, the author primarily used sharp needles for
and fat was harvested under epidural anesthesia. Forty mL of fat
placement, which led to occasional lumps and irregularities,
were removed from the abdomen, 30 mL from each medial thigh,
presumably due to fat migration. This complication resolved
and another 15 mL from each medial knee, totaling 130 mL. After
once the author began using only blunt instruments in the hand.
refinement, 60 mL were left for equal distribution between both
Blunt instruments also protect against damage to underlying
hands. Fat grafting was performed from the proximal phalanges
structures, contributing to the safety profile of this procedure. o
to the distal third of the forearms. Only one procedure was
postoperative infections have been seen. The author had one case
required, and at 7 years’ follow-up, the patient remained pleased
of scarring of the dorsal skin secondary to a concomitant chemical
with the continued elegant definition of her hands as well as
peel and thus no longer combines these two procedures.
the decreased prominence of her veins and tendons (Fig. 45.16).
A 62-year-old woman presented with prominent veins and ten-
dons, as well as crepiness of the skin. Twenty-nine mL of refined Conclusions
fat was placed into her left hand, and 28 mL were placed into Fat grafting to the aging dorsum of the hand can restore a subtle
her right hand. Fat placement extended to the middle phalanges fullness and thicken the skin over time. Attention to the appro-
and almost to the distal interphalangeal (DIP) joint, given her priate tissue planes combined with the use of blunt cannulas
concern that her PIP and MCP joints were excessively bony. The makes this a safe and predictable procedure.

560
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
Fig. 45.16 (a–f) Results of fat grafting to the hands in a 55-year-old
woman. Seven-year postoperative results demonstrate longevity
and continued fullness of the dorsum. No revision procedures were
necessary. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
ork, N : Thieme; 2018.)
45.2.2 Lips
Aesthetic and Anatomic Considerations
Comparative studies have shown that fuller lips are deemed
more youthful and attractive. Although some surgeons prefer
synthetic fillers for lip augmentation, fat provides durability, has
excellent consistency, is easily accessible, and is well tolerated.
Given that the lips are a central aesthetic feature of the face and
also play functional roles in speech and eating and drinking, it
is important that they remain soft, flexible, and mobile after
enhancement with fat.
Another important consideration during fat grafting to the lips
is discussion about lip shape. Before proceeding with augmenta-
tion, it is important to have a clear idea of what constitutes attrac-
tive lips in the mind of the patient and to reach an agreement
on the aesthetic goals of augmentation. Attractive lips generally
have a well-defined and protuberant white roll that tapers from
the peaks of Cupid’s bow and fades laterally. The upper cutaneous
lip has two distinct philtral columns, which become less concave
as they curve up toward the columella. Moving from medial to
lateral, the body of the upper lip has a central tubercle, then a
slight depression, and a fullness adjacent to the lateral commis-
sures. The lower lip has a central depression bordered by right
and left tubercles, which are larger than the central tubercle of
the upper lip. These lower lip tubercles contribute to the char-
acteristic everted pout of the lower lip. Overall, the lower lip has
significantly more vermilion show than the upper lip (Fig. 45.18).
Fig. 45.17 (a–f) Results of fat grafting to the hands of a 62-year-old
woman. Results at 39 months postoperative continue to provide
a subtle fullness, obscuring once-prominent superficial veins and
extensor tendons. (Reproduced with permission from Coleman SR,
Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed.
New ork, N : Thieme; 2018.)
Most surgeons agree that the upper lip should be approximately
two-thirds the size of the lower lip, but many patients want larger
upper lips.
The goal of lip augmentation is to increase fullness and restore a
youthful, sensual appearance with an everted vermilion. This can
be achieved by layering fat immediately under the mucosa and
vermilion to increase the exposed surface area of the lip. If the
patient’s lips do not yet have an aesthetically pleasing form prior
to the procedure, fat grafting without consideration of their shape
may worsen their appearance.
Indications and Patient Selection
The primary indication for fat grafting to the lips is aging, which
results in volume loss, thinning and drooping of the lips, and
perioral rhytids. Both younger and older patients may desire
fuller, more sensual lips to restore facial proportions. These two
indications may also be present in the same patient. The best
candidates are often older patients who had full lips when they
were younger and are seeking a restoration of youth. Fat grafting
to the lips of male patients is becoming increasingly common.
Technical Approach
Incisions and Markings
Markings are made along the vermilion of the upper lip, caudal to
the white roll. Placement along the vermilion should terminate
561
 VIII Surgical Rejuvenation of the Face and Neck

about 4 mm medial to the lateral commissures. ote the green augment the base of the philtral columns, orient the cannula tip
circles of the upper lip highlighting areas of concentrated fat up toward the columns from the same lateral incisions, but be
placement to emphasize the medial and lateral tubercles (Fig. sure to remain superficial and avoid placement into the deeper
45.19). Between these areas will be purposefully placed concav- orbicularis oris. To assist in placement at the philtrum, an addi-
ities. Markings also extend to the base of the philtral columns to tional incision can be made centrally in the vermilion, about 0.5
create a slight turgor. On the lower lip, green markings indicate cm inferior to the Cupid’s bow.
the right and left tubercles. Markings may occasionally extend to Placement into the white roll of the lower lip is nearly identical
the cutaneous portion of the lip, as in this patient, where added to that of the upper lip (Fig. 45.22a–c). Focus on placing into
fullness was desired at the lateral cutaneous portion of the com- the central two-thirds of the white roll. hen placing into the
missures. Otherwise, placement should be focused only at the vermilion of the lower lip, be sure to accentuate the right and
vermilion to promote the characteristic everted pout. Placement left protuberances (Fig. 45.22d–f). Some feathering should be
in the cutaneous portion will lead to lip projection, but not the performed between the two tubercles to contribute to the cen-
desired eversion. tral pout, but a slight cleft should be left centrally. At the upper
Incisions can be made at the lateral commissures, though occa- lip, begin by augmenting the central tubercle. Then proceed to
sionally a midmalar or lateral chin incision is used for additional
access.
Given that incisions are being made near the oral mucosa, the
author prefers to use intraoperative antibiotics (most commonly
an intravenous cephalosporin). Patients are also instructed to
gargle with chlorhexidine gluconate solution preoperatively and
will receive prophylaxis with valacyclovir if they report a history
of cold sores. hen multiple areas of the face are being grafted,
the lips should be completed last to prevent contamination of
other areas with oral flora.
Fig. 45.18 Ideal shape of attractive lips. (Reproduced with permission
Cannulas from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
The author prefers to use a Coleman Style III cannula, the sharpest
of the blunt cannulas. This cannula offers the greatest accuracy
in grafting into the plane just deep to the mucosa or vermilion.
The mini–Style III cannula may also be used.

e e In r i n
Fat should be placed at the most superficial plane possible, just
deep to the vermilion and mucosa (Fig. 45.20). Placement into
the muscle will only increase the distance from the cutaneous lip
to the teeth and lead to forward projection.

Volumes
Fig. 45.19 Markings and incision sites for placement at the lips. Red
Small volumes can make a significant difference in the lips. Use lines indicate incisions, while green circles indicate areas of intended
the following volumes as guidance: placement. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
• hite roll restructuring: at least 0.75 mL but rarely more than ork, N : Thieme; 2018.)
1.25 mL
• Lower lip rim: more than 0.75 but less than 1.25 mL
• Upper lip body: at least 1.5 mL and rarely up to 4 mL maximum
• Lower lip body: place slightly more than twice the volume
placed in the body of the upper lip

Placement
Begin by placing fat into the white roll of the upper lip. Placement
into the white roll is the most technically challenging part of the
procedure and requires that fat be placed immediately deep to
the mucosa and vermilion. Using the Coleman Style III cannula,
extend the tip nearly to the opposite commissure and withdraw
the tip slowly while applying gentle pressure on the 1-mL syringe
(Fig. 45.21). Complete this from the opposite commissure. To
a b
Fig. 45.20 Level of infiltration at the lips. (a) Incorrect placement into
muscle is shown on the left. (b) Correct technique requires placement
superficial to the muscle and just deep to the mucosa and vermilion.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
Thieme; 2018.)

562
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
Fig. 45.21 Placement pattern into the white roll of the upper lip.
(Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
Thieme; 2018.)
placement at the right and left regions of the upper lip, leaving a
slight depression between the lateral regions and central tubercle
(Fig. 45.23). During placement, small lumps are well tolerated, but
large ones are not.
Postoperative Care
o special dressings are required after fat grafting to the lip. The
lips should be kept moist with Aquaphor (Beiersdorf Inc., ilton,
CT) while healing. et mucosa now exposed to ambient air may
undergo keratinization and ultimately become dry mucosa or
vermilion. During this process, peeling may occur, and it will
be helpful to use Aquaphor or similar ointments. There are no
restrictions to lip movement; in fact, movement of the mouth
will promote lymphatic drainage. However, do not massage the
lips in the first few weeks after the procedure. Counsel patients
that recovery may be more difficult compared with fat grafting
in other regions given the degree of swelling typical of the lip
area (Fig. 45.24).
Results
A 50-year-old woman presented with thin lips and a desire to
restore them to the fullness of youth (Fig. 45.25). The lower lip
was no longer dominant, and she generally lacked vermilion
show. After meticulous preoperative planning, emphasis was
placed on everting tissue more than adding volume (Fig. 45.26).
At the lower lip, 6 mL were placed, followed by 1.1 mL caudal to
the white roll, and 2.5 mL in central and lateral regions of the
upper lip, with some fat feathered in between. An additional 1.4
mL was placed at the base of the philtral columns. As expected,
postoperative edema was significant and discernible for several
weeks (Fig. 45.27). The patient stated that she noted changes in
the size and texture of her lips for up to 8 months. The patient’s
results were stable at 1 (Fig. 45.28b,e) and 8 (Fig. 45.28c,f) years
postoperative. The author has since modified his practice and
would currently use less than half of the volume placed in the
philtral columns and less than 1 mL at the white roll.
A 24-year-old woman presented with a desire for fuller
lips. A total of 40 mL of fat was harvested from her lower back.
Fig. 45.22 Placement pattern into the lower lips. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a–c) The
technique for the white roll of the lower lip is nearly identical to that of
the upper lip. (d–f) Emphasize the right and left tubercles during lower
lip placement.
Refinement yielded 10 mL of fat, which was placed into the lips
as follows: 1 mL into the white roll of the upper lip; 1 mL into the
border of the lower lip; 2.3 mL in the body of the upper lip; and
2 mL into the body of the lower lip. Images are shown at 1 year
postoperatively (Fig. 45.29).
Complications
Postoperative swelling may lead to spontaneous lacerations in
the lip, which can be closed with simple interrupted sutures but
will usually heal without intervention other than the generous
application of a lubricant such as Aquaphor (Fig. 45.30). The
author has witnessed this only in the lower lip. Lacerations limit
the volume of fat that can be grafted, hence the recommendation
to begin fat placement in the lower lip. Pyogenic granulomas
may form after fat grafting to the lip due to the local trauma (Fig.
45.31). These can be excised. Lip necrosis is a possible compli-
cation of fat grafting to the lip, but highly unlikely when using a
blunt Coleman Style III cannula. The author has never personally
seen this complication.
Patients who have previously had lip augmentation with
permanent fillers such as Gore-Tex ( . L. Gore and Associates,
ewark, DE), silicone, dermal fat graft, or fascia grafts present
additional challenges. If possible, the author prefers to remove
563
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 45.23 Upper lip placement pattern. Highlight the central tubercles and lateral prominences, leaving a slight depression between these two
regions. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
Thieme; 2018.)

Fig. 45.24 Postoperative edema. Counsel the patient on the anticipated severity and duration of edema. (Reproduced with permission from
Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)

564
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face

Fig. 45.25 Aging lips. Preoperative images obtained for fat grafting
to the lips in a 50-year-old woman. (Reproduced with permission Fig. 45.26 Lip markings for fat grafting plan. (Reproduced with
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From
Regeneration, 2nd ed. New ork, N : Thieme; 2018.) Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)

Fig. 45.27 Postoperative edema after fat grafting to the lips. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a) Four days postoperative, edema is prominent. (b) By day 17, swelling has
subsided but is still present. (c) At 1 year postoperative, no residual edema is visible.

Fig. 45.28 (a-f) Results of fat grafting to the lips in a 50-year-old woman. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat
Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a,d) Preoperative. (b,e) 1 year postoperative. (c,f) 8 years postoperative.

565
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 45.29 Fat grafting to the lips in a 24-year-old woman. Results are shown at 1 year postoperative. A total of 6.3 mL of fat was placed throughout
the lips. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N :
Thieme; 2018.)

Fig. 45.30 Postoperative splitting of the lip. These lacerations may Fig. 45.31 Pyogenic granuloma of the lip, which can be treated with
require simple interrupted sutures. (Reproduced with permission excision. (Reproduced with permission from Coleman SR, Mazzola RF,
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork,
Regeneration, 2nd ed. New ork, N : Thieme; 2018.) N : Thieme; 2018.)

these substances. If they are left behind, the lip may have an Conclusions
unnatural feel. Fillers such as Artecoll (Artes Medical, San Diego,
ith careful preoperative planning, fat grafting to the lips can
CA), Dermalive (Dermatech, Paris, France), and polyacrylamide
help improve lip eversion and vermilion show. Superficial lay-
gel cannot be removed. Patients with these fillers require careful
ering of fat immediately deep to the mucosa and vermilion will
planning to avoid making the lips appear worse.
help achieve this effect.

566
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face

45.2.3 Nasolabial Folds and on their orientation. As aging occurs, subcutaneous fullness is
lost and these lines may become fixed in place, resulting in the
Marionette Grooves unintended projection of emotions (Fig. 45.32).

Aesthetic and Anatomic Considerations Indications and Patient Selection

The nasolabial folds run from just superolateral to the nasal ala
The main indication for structural fat grafting to the nasolabial
to the corners of the mouth. Also known as smile lines, they
folds and marionette grooves is aging. However, the mere pres-
can range from superficial creases to deep grooves and are one
ence of these lines is not an indication for the procedure. Older
of the most prominent signs of facial aging. Marionette, or labio-
individuals with deep or prominent folds, which may convey
mandibular, grooves run from the lateral oral commissures to
a fixed expression, would best benefit from the procedure.
the mandible. Nasolabial folds are particularly important in the
Additionally, younger patients with deep folds that make them
expression of a range of emotions, from joy to disgust, depending

Fig. 45.32 Age-related changes at the nasolabial folds and marionette grooves. (Reproduced with permission from Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)

567
 VIII Surgical Rejuvenation of the Face and Neck
appear older would also be appropriate candidates. Fat grafting
will be able to soften these folds but might not eliminate them
altogether, especially in patients who had them at a younger
age. Request younger photos of the patient to help manage
expectations. Also be wary of overcorrection, which may leave
the patient with a balloonlike appearance and exacerbate nearby
lines, such as those in the cheek.
Technical Approach
Incisions and Markings
Arrows in green indicate the depth of the folds and areas of
placement. Incisions can be made midmalar, at the lateral com-
missures, or at the lateral chin/mandibular border. The chin inci-
sion can be used for longitudinal placement along the fold, while
the midmalar incision can be used for perpendicular placement.
An incision near the commissure may be used for an additional
placement angle (Fig. 45.33).
Cannulas
The most commonly used cannulas are the 6- (mini), 7-, and 9-cm
Style II Coleman cannulas. These will facilitate dissection and
prevent intravascular injection. However, if significant fibrous
adhesions are encountered, a Style III cannula or V-dissector may
be used to assist in undermining the tissue. The author generally
recommends use of the Style II cannula when possible, given that
grafts placed with finer cannulas are more poorly integrated and
may be visible as a delineated mound in the superficial skin.
e e In r i n
Fat may be placed from the subcutaneous to intramuscular
planes, but it should primarily be concentrated in the immedi-
ately subdermal plane. This will improve the overall skin quality
and help lessen the severity of the groove. If further softening
of either the nasolabial folds or marionette grooves is required,
Fig. 45.33 Markings and incisions sites for placement at the nasolabial
folds and marionette grooves. Red circles indicate incision sites
(midmalar, commissure, lateral chin). Green lines indicate areas of
placement. (Reproduced with permission from Coleman SR, Mazzola
RF, Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New
ork, N : Thieme; 2018.)
568
fat may also be placed intradermally with sharp needles (Fig.
45.34).
Volumes
Infiltration of the nasolabial fold may require as little as 2 mL
of fat if the crease is minimal. However, if there is significant
premaxillary deficiency, up to 11 mL may be required. Smaller
volumes, such as 1 to 3 mL, will suffice in the marionette grooves,
although they are difficult to eliminate regardless of volume or
technique.
Placement
The key to successful fat grafting in the nasolabial folds and
marionette grooves is the placement into various subcutaneous
planes throughout the fold instead of into a single crease. The
most common mistake in this region is to place into the deepest
part of the fold without feathering into surrounding areas, which
yields an isolated, circumscribed correction that may promote
wrinkles in surrounding areas (Fig. 45.35).
From the midmalar incision, begin placing fat perpendicular
to the nasolabial fold. Longitudinal placement will be utilized
eventually, but it is the perpendicular placement that bolsters
the nasolabial fold and prevents deepening of the crease. Advance
the cannula past the medial border of the fold, using the opposite
hand to guide the tip of the cannula (Fig. 45.36a). Begin cephalad,
placing a majority of the fat medial to the fold. The lateral portion
of the fold will already have more bulk in the cephalad position.
Deposit 0.033 to 0.1 mL with each retreat of the cannula. As place-
ment progresses caudally, begin placing fat both medially and
laterally to the fold (Fig. 45.36b–f). Throughout placement, use a
fanlike approach and progress from deep to superficial in several
layers while remaining perpendicular. If the fold curves inward
as it extends caudally, use the lateral chin incision to maintain
perpendicular access.
Fig. 45.34 Levels of infiltration at the nasolabial folds and marionette
grooves. The primary level is immediately subdermal. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
Fig. 45.35 Unwanted postoperative outcome. A circumscribed cor-
rection is visible (green arrow) due to excessively superficial placement
without adequate feathering into surrounding areas. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
ext, begin placing longitudinally into the nasolabial fold from
inferiorly (Fig. 45.36g,h). Continue to use blunt instruments for
placement, and use the V-dissector when necessary. Passes of
the cannula can extend the length of the fold, depositing 0.05 to
0.2 mL with each pass, moving from deep to superficial. As when
placing perpendicularly, be sure to place lateral to the fold, both
to prevent isolated fatty placement and to promote integration
into the surrounding tissues. Palpate along the fold to check for
integrity during the placement process. Use the pinch test to
determine whether the nasolabial fold can be re-created. If the
fold is recreated by digital manipulation, additional placement
will be required. However, if no fold can be created, the end point
has been reached (Fig. 45.36i).
To place fat into the marionette grooves, begin from the
midmalar region, again guiding the cannula with the opposite
hand and protecting against perforation of the oral mucosa (Fig.
45.36j). Longer cannulas will be required to extend to the more
inferior region of the marionette grooves. Use the same placement
principles to place fat perpendicularly from several directions. Be
careful to not overcorrect, as this region may enlarge in some indi-
viduals. To manage expectations effectively, remember to counsel
the patient that structural fat grafting of the marionette grooves
will likely not eliminate them entirely. Textural improvements
may be more appreciable than structural ones, even with multiple
interventions.
Postoperative Care
o special postoperative care is required in this region. o
special dressing is used, and massage of the area is not recom-
mended. The recovery is often brief and more easily tolerated
than grafting to regions such as the lips and periorbital tissues.
Results
A 51-year-old woman presented for correction of her nasolabial
folds. She had undergone fat grafting 3 years prior by a different
plastic surgeon and was disappointed that the correction did
not last (Fig. 45.37). She had some early wasting of the anterior
buccal region, which would be accentuated by fat grafting to the
nasolabial region; therefore, it was decided to place fat into the
buccal region also. Her nasolabial folds naturally extended into the
marionette grooves. Preoperatively, the patient supplied a photo
of herself at age 16 (Fig. 45.38a) to compare to her present images
(Fig. 45.38b). Even her younger photo demonstrated the presence
of nasolabial folds. This proved useful during the preoperative
consult to explain that the fold might not be fully ablated. Into
each of the nasolabial folds, 5 mL of fat was placed. An additional
2.4 mL was placed into the marionette grooves and lower nasola-
bial folds. The buccal region received 2.6 mL on the right and 3 mL
on the left, while the outer upper lip also received 0.6 mL and 0.5
mL on the right and left, respectively (Fig. 45.39). Postoperatively,
the patient demonstrated significant softening of the nasolabial
folds and a pleasing contour of the buccal region (Fig. 45.40a–d).
ote that smiling photographs should also be taken to ensure that
the correction permits a normal-appearing smile.
Complications
The most common mistake is undercorrection or failure of the
initial correction. Avoid the impulse to overcorrect, as this could
lead to fat migration, necrosis, or an unnatural or overfilled facial
appearance. It is much preferable to perform multiple smaller
surgeries than to risk the consequences of overcorrection.
Infections due to perforation of the oral mucosa are possible,
but rare. Use the opposite hand to guide the cannula tip during
placement to prevent perforation.
Conclusions
The nasolabial folds and marionette grooves are early visible
signs of aging and can be improved through structural fat
grafting with a complex matrix of support, whereby at least two
layers are placed in different directions. Intradermal placement
may also serve a role in softening deep creases.
569
 VIII Surgical Rejuvenation of the Face and Neck

a b c

d e f

g h i

Fig. 45.36 Placement pattern at the nasolabial folds and marionette grooves. (Reproduced with permission from Coleman SR, Mazzola RF, Pu
LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a) Stabilize the cannula tip with the opposite hand. (b–d)
Approach from the midmalar incision, placing perpendicular to the nasolabial fold, (e,f) progressing caudally. (g,h) The fold can also be approached
longitudinally from the inferior lateral chin incision. (i) Inability to re-create the fold with digital manipulation means that grafting is complete in this
region. (j) Approach the marionette region from the same midmalar incision.

570
 45 Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face
Fig. 45.37 Nasolabial folds. Preoperative image of 51-year-old woman
consulting for correction of prominent nasolabial folds. (Reproduced
with permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
Fig. 45.39 Surgical plan. Markings are shown for fat grafting to the
nasolabial folds and marionette grooves. (Reproduced with permission
from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection: From Filling to
Regeneration, 2nd ed. New ork, N : Thieme; 2018.)
45.3 Concluding Thoughts
Structural fat grafting to the hand and face offers a reliable
solution to restore youth, improve skin quality, and aestheti-
cally enhance aging tissues. Adherence to the principles of the
Coleman technique will ensure long-lasting, visible results and
improved patient outcomes.
Clinical Caveats
• Harvested fat is a living tissue and requires nutrients from
host tissue for survival.
• Conceal incisions in wrinkles, folds, or hirsute regions when
possible.
• Deep fat grafts against bone or cartilage enhance structural
support, intermediate-layer grafts provide projection, and
more superficial fat placement results in improved skin qual-
ity and reduction of lines and folds.
Fig. 45.38 Preoperative reference photos. Using a photo of (a) the
patient at a younger age to compare to (b) the present can help in
counseling a patient on the degree of nasolabial fold correction to
expect. (Reproduced with permission from Coleman SR, Mazzola RF,
Pu LL, eds. Fat Injection: From Filling to Regeneration, 2nd ed. New ork,
N : Thieme; 2018.)
Fig. 45.40 Preoperative vs. postoperative results. (Reproduced with
permission from Coleman SR, Mazzola RF, Pu LL, eds. Fat Injection:
From Filling to Regeneration, 2nd ed. New ork, N : Thieme; 2018.) (a,
c) The nasolabial folds are prominent preoperatively, while (b, d) the
postoperative images show a softer, more relaxed face with gentler
nasolabial folds.
• The goal of fat grafting to the hand is to increase the subcu-
taneous fullness over time. Upon palpation, fat will feel like
thickened skin, not like fat.
• Large weight changes may be reflected in transplanted tissue.
• When performing fat grafting in several locations, place fat
in the lips last to avoid contaminating other areas of the face
or body.
• At the lips, place fat deep to the mucosa in order to increase
vermilion show and eversion. Placement at the cutaneous
portion of the lip will only increase projection.
• Fat grafting to the nasolabial folds and marionette grooves
requires feathering into surrounding tissues to prevent visibly
circumscribed fat. Placement should always begin perpendic-
ular to the fold.
571
 VIII Surgical Rejuvenation of the Face and Neck
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 46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting

46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting

Patrick Tonnard, Alexis Verpaele, and Igor Pellegatta

Abstract
hen different surgical techniques in facial rejuvenation are
compared, one is focused on the result without considering the
global risk–benefit ratio associated with any surgical interven-
tion. Some techniques can produce superb results, but the trade-
off may be a high complication rate or a prolonged postoperative
recovery. Today, many patients prefer a simpler path to rejuvena-
tion. e believe that to have a happy patient, it is not always the
most aggressive and extensive surgery that delivers the greatest
patient satisfaction. The appeal of the minimal-access cranial
suspension (MACS) lift lies primarily in the fact that it strikes
the right balance, offering a stable, natural facial rejuvenation
through a simple and safe procedure. The operation takes only 2 a b
to 2.5 hours to perform and can be done with a local anesthetic
Fig. 46.1 (a) Basic principle of minimal-access cranial suspension
in an outpatient setting. In comparison with a classic facelift, (MACS) lift compared with (b) traditional extended facelift.
the MACS lift has a quicker recovery time and a lower morbidity
rate, with a final scar that is significantly shorter. The MACS lift
provides a powerful correction of submental and upper neck
laxity, correction of a blunted submental angle, restoration of a
well-defined jawline by correction of the jowls, restoration of the the earlobe with vertical skin redraping, eliminating the need for
midfacial volume, and correction of the nasolabial folds. Patients retroauricular dissection in the vast majority of cases (Fig. 46.2).
who are seeking improvement of one or more of these features The MACS lift is aimed at obtaining an antigravitational volume
are good candidates for a simple or extended MACS lift proce- redistribution in the upper neck and face by suspending the soft
dure. Adjunctive procedures to enhance the results may include tissues of the face, working in the superficial subcutaneous plane
upper and lower blepharoplasty, microfat grafting, short-scar without any deeper undermining. The skin excess is redraped in a
temporal lifting, and anterior and posterior cervicoplasty. vertical direction and resected in the temporal region.
In recent years the concept of volumetric rejuvenation has
gained worldwide acceptance. e now know that the restoration
Keywords
of facial volumes is more important than the amount of skin
Short scar facelift, MACS lift, rejuvenation, facial plastic surgery, resected and the tension on the skin and SMAS.
fat grafting, nanofat, cell therapy, S IF, micrograft Facial aging is the combined result of sagginess and deflation.
Hence, to obtain a more natural result and restore the correct
volume in the facial subunits, in recent years we have also real-
46.1 Basic Concepts ized that simultaneous fat grafting at the time of surgical facelift
Traditional facelift designs all have an oblique vector of traction results in a younger appearance to the patient.
on the superficial musculoaponeurotic system (SMAS), which
can be divided into a horizontal and a vertical component. In
recent years, more emphasis has been put on reorienting this
46.2 Overview of Technique
vector in a more vertical direction (Fig. 46.1). The key concept underlying the MACS lift procedure is the verti-
In classic facelifting, the direction of skin redraping still follows cal suspension of sagged facial soft tissues with slowly resorbable
an oblique vector. The horizontal component of the vector of monofilament purse-string sutures. These are strongly anchored
traction on the SMAS and on the skin does not rejuvenate the face; to the deep temporal muscle fascia through a preauricular and
rather, it tends to flatten the face and put it under tension. temporal prehairline incision. Excess skin is excised in the
ith the minimal-access cranial suspension (MACS) lift, the temporal region after pure vertical redraping of the skin flap.
vertical rejuvenating vector is the only vector applied on the deep Submental suction lipectomy nearly always precedes the lifting
tissues as well as on the overlying skin. The MACS lift eliminates procedure. The extent of the skin undermining is just sufficient
the horizontal vector of traction; it can therefore be considered a for placing the purse-string sutures. In our previous works, we
pure vertical-vector facelift technique. mentioned two variations of the procedure:
hen lateral skin redraping is performed, as in classic facelifts,
a dog-ear is created at the earlobe, necessitating redraping with • C C , in which two purse-string
a retroauricular flap dissection. o dog-ear is produced under sutures are placed for correction of the neck and the lower

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 VIII Surgical Rejuvenation of the Face and Neck
third of the face (cervicomental angle, jowls, and marionette
grooves)
• C C , in which a supplementary
third purse-string suture was placed to suspend the malar fat
pad; this suture had an added impact on the nasolabial groove,
midface, and lower eyelid
owadays, we strongly believe that MACS lift, combined with
midfacial fat grafting to replace the third purse-string suture by
augmentation of the deflated areas with fat graft, gives better
results regarding the harmonious full-face rejuvenation aspect.
46.3 MACS Lift
ith the MACS lift approach, the incision begins at the lower
limit of the earlobe, extends preauricularly to the temporal hair-
line, and traces the temporal hairline along the sideburn up to the
level of the lateral canthus. The skin is undermined at a subcuta-
neous level over 5 to 6 cm in an anterior direction. The inferior
limit of undermining goes as caudal as necessary to visualize the
Fig. 46.2 Different ways of skin excision (a) in a classical facelift and
(b) in a minimal-access cranial suspension (MACS) lift.
574
lateral border of the platysma muscle. Usually the undermining is
marked 2 to 3 cm below the mandibular angle (Fig. 46.3).
The first purse-string suture is anchored to the deep temporal
muscle fascia 1 cm in front of the helical rim and 1 cm above the
zygomatic arch. It runs downward toward the mandibular angle,
as care is taken to incorporate 2 to 3 firm bites in the craniolateral
border of the platysma muscle, and then it turns upward as a
narrow U-shaped loop toward the original anchor point. The suture
is firmly woven into the SMAS tissue, which is not undermined.
hen this purse-string suture is tightened, the lateral portion of
the platysma is pulled upward. This suture, when combined with
a closed-suction lipectomy, produces a dramatic correction of the
cervicomental angle and contour of the upper neck.
The second purse-string suture starts at the same anchor point
on the deep temporal muscle fascia, extends more obliquely toward
the jowls ( 30 from the first suture), and follows the borders of
the undermining as a more open, O-shaped, purse-string loop. It
ends at the original anchor point. hen this suture is tightened,
the SMAS is placed under concentric tension, producing a lifting
to the jowl, the marionette groove, and the oral commissure.
Fig. 46.3 (a) Incision on simple minimal-access cranial suspension
(S-MACS) lift. (b) The different areas where the two purse strings have
effect during the surgical procedure.

The short-scar MACS lift will adequately treat 90 of our
patient population. hen the limits of the MACS lift procedure
are reached, ancillary procedures will supplement this procedure.
Care is taken not to overtreat any patient.
46.3.1 Indications and Contraindications
The ideal patient for a surgeon’s initial MACS lift case is a 45- to
50-year-old woman whose main complaint is a moderate submen-
tal laxity with a blunted cervicomental angle but without obvious
platysmal bands. owls, marionette grooves, and nasolabial folds
are developing but disturb the patient mainly when she bends
forward. This is a frequent complaint in middle-aged women who
discover these signs of aging in the lower third of the face. This
type of patient is ideally suited for treatment with MACS lift.
Nevertheless, patients in the sixth decade or older are also
benefiting from the safety and the low complication rate of the
MACS lift technique. In this category, additional measures can be
indicated to enhance the effect on platysmal bands or important
skin excess. The vertical vector warrants the preservation of a
natural appearance.
The mild jowling and central anterior neck laxity shown by the
patient in Fig. 46.4 make her an ideal candidate for correction by
a MACS lift.
Combination of a MACS lift with fat grafting is particularly
appropriate for a patient who needs correction of the upper half
of the nasolabial folds and the midface or other areas that appear
deflated. The need for the adjunctive fat grafting is determined not
only by age but also by the bony anatomy of the face (Fig. 46.5).
A person with a poorly developed malar eminence will be subject
to earlier midfacial aging than one with strong malar relief. This is
also often related to poor lower lid support.
In classic teaching, smoking is considered an absolute contrain-
dication for facelift surgery. Because of the limited subcutaneous
dissection and the absence of multiplanar dissection in a MACS
lift, we consider smoking to be a relative contraindication. For
Fig. 46.4 Preoperative pictures of an ideal candidate for minimal-access cranial suspension (MACS) lift.
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
the same reason, combining the MACS lift with skin resurfacing
techniques is safe and well tolerated.
As a general rule, only patients with no major medical history of
disease or cardiovascular risk factors are selected for outpatient,
office-based surgery. The decision whether to perform the MACS
lift with local or with general anesthesia depends on the surgeon’s
and patient’s preferences.
46.3.2 Pertinent Anatomy
Two permanent purse-string sutures (three in the former
extended MACS lift) are woven into the deep subcutaneous
tissues, which consist of parotid fascia and SMAS in the preau-
ricular and cheek area (Fig. 46.6). The sutures are anchored into
the deep temporalis muscle fascia to ensure a strong hold.
The main danger zone in the placement of sutures is located
on the zygomatic arch, halfway between the ear and the lateral
orbital rim. This zone is completely avoided, because no suture
crosses the zygomatic arch (Fig. 46.7). The anchor point of the
two sutures is located posterior to the frontal branch of the facial
nerve. The first loop is directed vertically downward and reaches
the lateral edge of the platysma muscle in the region of the man-
dibular angle. The marginal mandibular branch of the facial nerve
is out of danger for entrapment by the purse-string suture, since
it runs more anteriorly.
The second purse-string suture loop runs at an angle of 25 to
30 and reaches to 1 fo 2 cm above the mandibular border.
46.3.3 Preoperative Assessment and
Planning
Communication with the Patient
Generally, it is very important to listen carefully to the patient’s
wishes in the first clinical consultation. e start by inquiring
what bothers the patient and what has prompted this visit.
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 VIII Surgical Rejuvenation of the Face and Neck
a b
Fig. 46.5 Benefits of combination of minimal-access cranial suspen-
sion (MACS) lift with malar fat grafting. (a) For a younger patient, it will
correct the malar insufficiency and flattening of the lateral cheek. (b)
In an older patient, it will also correct the nasolabial folds and midfacial
hollowing.
hen asked what they are seeking, most patients consulting
for facial rejuvenation demonstrate a maneuver that they have
repeatedly executed before their mirrors: they push the skin of
the mandibular angle upward. This maneuver has a beneficial
effect on the neck and on the jowling (Fig. 46.8). A MACS lift
acts primarily on the lower half of the face, the upper neck and
submental areas, jowls, marionette grooves, and lower cheeks.
It is important to explain the concept of MACS lift intervention
to the patient. To do this, it is helpful to simulate the feasible
Fig. 46.7 Representation of the major danger zone for the frontal
branch of the facial nerve.
576
Fig. 46.6 Representation of the direction and the anchorage in the
deep subcutaneous tissue.
correction on the facial features with the patient looking in the
mirror and the physician standing behind. This will give the
patient an idea of the possibilities and limitations of the tech-
nique. The patient will learn that the MACS lift is a lifting pro-
cedure that addresses the neck and lower two-thirds of the face,
without having an influence on the forehead. The patient will also
understand that the main goals are to restore the facial volume;
to get rid of most of the facial laxity; and, in combination with
fat grafting, to restore the correct, balanced proportion involving
facial deflation phenomenon.
Fig. 46.8 Upward pushing maneuver that patients usually show when
they try to explain the desired result in the lower half of the face.

In some cases, ancillary procedures to the eyelids and peri-
oral and neck areas can be proposed, but the patients must be
informed of the cumulative morbidity to be expected. Once the
surgeon understands the patient’s expectations, a treatment plan
can be designed and customized to meet patient goals.
All patients are fully informed of the details of the proposed
procedure, including the benefits, limitations, risks, time of
surgery, expected morbidity and recovery, and potential for prob-
lems and complications. This informed consent is provided both
verbally and in written documents given to the patient.
Photography
A standardized series of six pictures of the patient is taken:
frontal (Fig. 46.9), lateral (Fig. 46.10), oblique (Fig. 46.11), lateral
with neck flexed (Fig. 46.12), and closeups of the lower and upper
halves of the face (Fig. 46.13).
46.3.4 Operative Technique
Preoperative Markings
On the day of surgery, any makeup is removed by the nurse, and
a new set of pictures is taken as previously described. The patient
sits upright in front of the surgeon for the initial markings.
Fig. 46.9 The frontal view shows the face from the top of the head
down to the sternal notch. (Reproduced with permission from Tonnard
PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New York,
N : Thieme Medical Publishers, 2018.)
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
Submental liposuction is planned for almost every patient. Fat
tends to accumulate in this area, so even in slim patients, lipo-
suction in this region helps enhance the cervicomental angle.
The patient is asked to make a double chin, and the area where
excess fat is palpated is marked with a pencil. Care is taken to
include the lateral wings of the submental fat, which go as far as
the infralobular area, and the lower pole of the jowls.
Anesthesia and Surgical Setting
e prefer to perform the MACS lift with the patient under gen-
eral anesthesia. This procedure can also be performed using a
local anesthetic with sedation.
The MACS lift is designed to be performed in a private surgical
office by one surgeon and one nurse.
Markings and Incisions
ith the patient supine on the operating table, marking starts
at the lower limit of the lobule, extending up in the preauricular
crease. At the level of the incisura intertragica, the marking
makes a 90 turn backward to preserve the integrity of this ana-
tomic landmark. Markings then follow the posterior edge of the
tragus, ascending toward the helical root. Because there is a dis-
tinct color difference between the cheek skin and the auricular
skin, it is essential that the markings precisely follow this line of
Fig. 46.10 Perfect perpendicular lateral view should show only one
eyebrow, with the patient gazing straight forward.
577
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 46.11 The oblique view has the tip of the nose just within the Fig. 46.12 An extra side view picture is taken with the patient looking
contour of the opposite cheek to demonstrate the distribution of the down at the knees, producing a double chin. We refer to this as the
facial volumes. “Bruce Connell view,” because he has pointed out its importance.

demarcation. At the superior limit of the ear, the marking traces

the small hairless recess between the sideburn and the auricle
and then turns downward to follow the inferior implantation of
the sideburn (Fig. 46.14).
The horizontal marking then continues forward in a zigzag
pattern 2 mm within the lower and anterior implantation of the
sideburn. This zigzag pattern increases the length of the temporal
incision for better congruence with the length of the cheek flap
(Fig. 46.15). The total length of the incision will not exceed 7 to 9
cm, depending on the dimensions of the auricle (vertical branch
a
of the incision) and the width of the sideburn (horizontal branch
of the incision).
The surgeon palpates the mandibular angle with an index
finger and marks it as the lowest point of the undermining. The
extent of the undermining is marked starting from the lowest
point of the incision at the lobule, directed toward the marking of
the mandibular angle, then curving anteriorly to a point 5 to 6 cm
in front of the ear. ext, the marking is directed toward the upper
end of the incision (Fig. 46.16).
hen adjunctive procedures are planned (such as an upper/
lower blepharoplasty, fat grafting, short-scar temporal lifting, b
or anterior/posterior cervicoplasty), they are marked together
Fig. 46.13 (a) A close-up view of the lower face is taken to focus on the
with the MACS lift markings. (For detailed descriptions, see the contour of the jaw line, marionette grooves, and nasolabial folds and to
individual adjunctive procedures later in this chapter.) demonstrate any perioral rhytids (the “bar code”). (b) A close-up view
The subcutaneous plane is infiltrated with the preferred of the upper half of the face reveals detailed information about the
upper and lower eyelids; tear troughs; and periorbital fold, grooves,
solution of local anesthetic. ormally 30 to 40 mL of solution is and wrinkles.

578
 46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting

injected per cheek and in the submental area, which gives a mod-
erate degree of tumescence. At the end of the cheek infiltration,
a distinct blanching is visible in the previously infiltrated areas.
Suction Lipectomy
e prefer to use a 3-mm spatula cannula with one opening. The
opening is always directed downward, not toward the skin, to
avoid dermal damage. Two or three incisions are used to criss-
cross the marked area optimally. The lipectomy is performed in
a preplatysmal plane under tactile guidance of the nondominant
hand. The endpoint is a skin flap of 3 to 4 mm thickness, not less,
to preserve the softness of the cervical contours.
The tragal incision is made exactly on the edge of the tragus. An
incision placed too anterior to the tragus will leave a visible color
difference between the pale tragus skin and the slightly darker
cheek skin.
At the sideburn, the blade is inclined to an angle of 30 to
the skin so that the incision goes obliquely through the dermis,
perpendicular to the hair shafts. The incision follows the marked
zigzag pattern 2 mm within the hairline (Fig. 46.17).
An oblique incision within the hairline will allow hair to grow
through the scar. After hair regrowth, the final scar will be hidden
a few millimeters within the hairline and become virtually invis-
ible (Fig. 46.18).

Incision
The incision starts at the lobule and continues along the previ-
ously described markings. The surgeon carefully respects the
incisura intertragica by making a distinct 90 step at the begin-
ning of the tragus.

Fig. 46.15 igzag pattern within lower anterior border of sideburn.

Fig. 46.14 Marking for minimal-access cranial suspension (MACS) lift

surgical project. Note the zigzag marking on the temporal area.

b
Fig. 46.16 Marking of the dissection of the deep subcutaneous tissue Fig. 46.17 (a,b) Incision of the markings previously done; note the
on the skin. inclination of the blade.

579
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 46.18 Illustrative representation of the angle of the incision along the hairline.

Flap Creation
Blind undermining of the skin is performed with Freeman– aye
facelift scissors, and the dissection proceeds in a subcutaneous
plane (Fig. 46.19). The scissors points are directed toward the
skin to ensure that the surgeon has visual and palpable control
over the thickness of the cheek flap. Most of the dissection is
accomplished by spreading maneuvers with the scissors. Care is
taken to create a flap sufficiently thick to mask small irregulari-
ties of the underlying layer.
After the flap is created, hemostasis is achieved by direct coag-
ulation with microneedle cautery under direct illumination by a
lighted retractor or a headlight.
First Purse-String Suture: The Vertical Loop
The initial purse-string suture will be fixed to the deep tem-
poralis fascia at a point 1 cm above the zygomatic arch and 1
cm in front of the helical rim. (The zygomatic arch is marked in
Fig. 46.20 for demonstration purposes.) An extra dose of local
anesthetic is injected at the anchor point (note the dot) down to
the temporal bone; then the needle is withdrawn, and all layers
of tissues are infiltrated.
ith the Stevens scissors in the spreading mode, a 0.5-cm-
diameter window is made in the SMAS/parotid fascia to visualize
the deep temporal muscle fascia (Fig. 46.21). It should be iden-
tified as a distinct, white, shiny layer. A 0 polydioxanone suture
(PDS) on a big C3 needle is used to perform the suspension of the
sagging facial and neck soft tissues.
The first bite starts in the window where we visualize the deep
temporal fascia and goes down to the temporal bone (Fig. 46.22).
The needle is oriented toward the tragus, so there is no danger of
damaging any facial nerve branch. The frontal branch of the facial
nerve runs deep in this region and becomes superficial several
centimeters more anteriorly. Firm bites approximately 1 to 1.5
cm long and 0.5 cm deep are taken in the SMAS tissue/parotid
fascia in the upper two-thirds and platysma in the lower third.
ith every bite, it is essential to confirm that the needle enters

Fig. 46.20 Markings of the zygomatic arch. Note the dot that indicates
Fig. 46.19 Undermining from the short-scar preauricular incision. the exact anchor point of deep temporalis fascia.

580

a substantial part of the SMAS tissue so that the suture will not
pull through.
The suturing goes down toward the region of the mandibular
angle to the lower limit of the undermining. In this region, direct
visualization by means of a headlight or a lighted retractor is help-
ful. It is essential to identify the cranial border of the platysma and
to place two or three firm bites in this structure before inverting
the direction of the suture.
hen the cranial platysma is included in the flap, the suturing
is turned upward and continued toward the starting point.
This procedure creates a narrow U-shaped purse-string loop
about 1 cm wide and results in a vertical suspension of the
platysma and a restoration of the cervicomental angle. After the
first purse-string suture is tied, some obvious skin dimples might
occur at the mandibular angle. Most of these will disappear with
the vertical redraping of the skin, but some will have to be freed
with scissors (Fig. 46.23).
Second Purse-String Suture: The Oblique Loop
The second suture originates from the same location on the deep
temporal fascia. This purse-string suture forms a wider loop,
Fig. 46.21 Opening with Stevens scissors to the deep plane where the
suture is to be anchored.
Fig. 46.22 Demonstration of first bites in the deep temporal muscle
fascia.
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
directed toward the jowls, at an angle of 30 with the vertical.
This loop is more O-shaped than the U-shaped vertical loop
in order to prevent linear traction on the subcutaneous tissue,
which could be visible through the skin.
The loop follows the borders of the anterior undermining in the
lower part of the cheek. Short bites of 1 cm maximum are taken
in the parotid fascia and the SMAS tissue (Fig. 46.24). The second
loop is also tied under maximal tension. It results in a concentric
lifting of the jowls, the lower cheek, and the oral commissures.
Sometimes bulging is unavoidable after pulling the two purse-
string sutures. To correct this issue, we mold the deep subcuta-
neous tissue with resorbable 4–0 Vicryl sutures, and we remove
with scissors the caudal excess part (Fig. 46.25).
Skin Redraping and Resection
One of the most important features in the short-scar facelift is
the vertical redraping of the skin. This provides a lock to the
subcutaneous sculpturing work in the cheek. Because the vector
of the subcutaneous lifting is almost purely vertical, the redrap-
ing and resection of the skin in the same direction will seal the
underlying suspension effect. Vertical redraping also prevents
b
Fig. 46.23 (a) Representation of the marked first purse-string suture.
(b) Limits of the dissection in the mandibular area (on the right).
581
 VIII Surgical Rejuvenation of the Face and Neck

a
Fig. 46.24 Second purse-string suture in a surgical view.

formation of dog-ears at the lobule region. The earlobe is pulled

upward by the suspension sutures and will have to be set back in
the cheek flap, taking the place of any dog-ears.
hen vertical redraping of the skin is performed, the need for
retroauricular skin redraping will be avoided or limited to the few
cases with extreme neck skin laxity.
The skin flap is put under moderate vertical tension, and the skin
excess is determined with the help of the Pitanguy or D’Assumpcao
forceps (Fig. 46.26). The skin marking is incised with the knife,
and the excess is excised with the scissors. The skin resection on
the cheek flap is carried out in linear fashion and will be sutured
to the zigzag border of the temporal hairline incision. The zigzag b
incision will now open up when coapting with the linear cheek Fig. 46.25 (a,b) Shaping and correction of the bulge after pulling the
flap, thereby compensating for the incongruence in length of both two purse-string sutures.
borders and reducing possible dog-ears. Closure with interrupted
4–0 Vicryl buried sutures is started from the superior end of the
incision backward to avoid dog-ears in this section.
The lateral part of the cheek flap is trimmed only minimally just
to coapt with the preauricular incision (Fig. 46.27). Absolutely no
traction is exerted on this part of the incision. The skin is incised
with the knife, and the flap is resected with the scissors. The
earlobe is pulled upward by the action of the suspension sutures
and the redraping of the skin in the vertical direction. To put the
earlobe back into its natural position, a small segment of skin has
to be excised anterior to the earlobe. It is preferable to underre-
sect rather than to overresect in this area to avoid postoperative
position changes of the earlobe. The earlobe should be angled 15
posteriorly for a natural appearance.
The horizontal limb of the incision is sutured with a running
5–0 nylon horizontal mattress suture, taking bigger bites on the
cheek flap side than on the temporal side to compensate for the
final incongruence in length between the two sides (Fig. 46.28).
A 10-gauge soft silicone drain is inserted for active drainage Fig. 46.26 Marking and excision of the skin in the temporal region.
and directed toward the frontoparietal area covered by hair (Fig.
46.29). In earlier years, we exteriorized it in the retroauricular
area. The disadvantage of that was that at the time of the drain
drain is removed, the cheek flap stays attached and the chances
removal, the cheek flap could be degloved, as happened a few
of hematoma are reduced. The rest of the suturing is done with
times. For this reason, we now prefer to exteriorize the drain in the
running and separated 6–0 nylon sutures.
temporal area and place the drain completely vertical. hen the

582

Fig. 46.27 Removal of the skin excess in the preauricular region.
Fig. 46.29 Insertion of 10-gauge soft silicone drain placed in frontopa-
rietal region.
46.3.5 Case Study
The 46-year-old woman shown in Fig. 46.30a presented with
combined deflated and ptotic facial features. There was a dis-
crete ptosis of the eyebrow tail, with significant hollowing of the
upper eyelid. The lower eyelid was empty, without significant
laxity. The midface was deflated and ptotic, resulting in a heavy
nasolabial fold (Fig. 46.31a,c,e,h). The corners of the mouth
continued into an incipient marionette groove. The definition of
the jawline was disturbed by marked jowling. She also requested
a reduction rhinoplasty.
Analysis of her photograph in her late 20s (Fig. 46.30b) revealed
a general oval shape of her face. The youthful fullness of the upper
eyelids and midface was striking compared with the empty look
in her 40s. ote the absence of nasojugal and nasolabial folds and
marionette grooves in her earlier photo.
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
Fig. 46.28 Horizontal mattress suture on the limb of temporal region
where the skin was resected.
Surgical Plan
• MACS lift
• Short-scar temporal lift
• Microfat grafting of the medial upper eyelid hollow (1.5 mL),
the malar and infraorbital area (10 mL), the nasolabial fold
with subcision (3 mL), and the marionette groove (2.5 mL); in
total, 34 mL of fat grafted
• Pinch lower blepharoplasty
• Open rhinoplasty
Results
The results after 1 year (Fig. 46.31b,d,f,h) show a replenishment
of her eyelids and midface, with a general triangularization of
her face as a result of the cranial shift of soft tissue volumes. The
nasolabial folds, marionette grooves, and jowls are corrected.
Note the resemblance to her youthful picture.
46.3.6 Postoperative Care
The patient is instructed to take the following medications:
• Oral ampicillin 500 mg every 6 hours, beginning the morning
of surgery and continuing for 4 days
• Continue any home medication
The patient is instructed to respect the following guidelines:
• Stay in the company of a friend or relative for the first 24 hours
• Relax in a quiet environment
• Avoid stressful activities
• Avoid bending forward and Valsalva maneuvers
• Sleep with the head slightly elevated
• A soft diet is recommended, since mouth opening is painful
the first 5 days because of traction on the temporalis muscles
The patient is also informed about normal postoperative dis-
comfort, swelling, and ecchymosis, especially in the eyelids. The
583
 VIII Surgical Rejuvenation of the Face and Neck

patient is instructed to contact the surgeon if any of the following Bad scarring is not always controllable by the surgeon. Scarring
conditions develop: problems can involve hypertrophy, hypotrophy, or dystrophy, but
most of the time they are a result of poor design of the placement
• Rapidly increasing swelling and/or pain in the cheek area, of the incision or an incorrect insetting of the earlobe.
which could indicate a postoperative hematoma
• Pain or increasing discomfort in the resurfaced area
• A temperature greater than 38 C (100.4 F)
• Any visual impairment

46.3.7 Problems and Complications

As any surgery, facelift involves specific potential complications.
Usually, the most frequent complication is hematoma, which
usually does not cause permanent damage but is disturbing
for both the patient and the surgeon because it requires
reintervention.
The occurrence of paralysis of a facial nerve branch depends
on the technique. Avoiding dissection in proximity of facial nerve
branches makes the procedure less likely to cause nerve damage.
Skin slough as consequence of skin ischemia can have several
causes: the extent of skin undermining, the thickness of the skin
Fig. 46.30 (a) Woman aged 46 presenting facial aging due to sagging
flap, the amount of traction on the skin, external or internal pres-
and deflation. (b) The same patient in her 20s.
sure, and heavy smoker.

Fig. 46.31 (a,c,e,g) Preoperative and (b,d,f,h) 1-year postoperative picture series of 46-year-old woman who underwent minimal-access cranial
suspension (MACS) lift, temporal lift, open rhinoplasty, and other ancillary procedures as described in the text.

584

Infection is not so common but can lead to terrible conse-
quences, such as hypertrophic scars and alopecia.
As far as our experience is concerned, we have not encountered
major complication such as skin slough, permanent facial palsy, or
unacceptable scarring.
Our incidence of hematoma was 1.1 , mostly in patients under
anticoagulant therapies. Among our early cases with the former
extended MACS lift, we experienced a case of temporary paralysis
of the frontal branch of the facial nerve, from which the patient
promptly recovered after 6 weeks.
Other minor problems, such as palpability of the knot, were
encountered in few cases.
46.4 Ancillary Procedures
46.4.1 Anterior Neck
Preoperatively, the surgeon assesses the patient’s facial and cer-
vical redundancy by digitally lifting the facial skin upward at the
mandibular angle region. If this maneuver produces correction
of visible platysma bands, one can be confident that the MACS
lift will adequately tackle this problem. If platysma muscle is
not easily visualized with the standard dissection, it is possible
to dissect the flap under the mandibular angle further and grab
more distal bites proceeding ventrally. The shape of the loop will
resemble a hockey stick. Usually this little modification of the
technique is very useful to improve mild platysmal banding.
If the platysmal bands are not corrected with this preoperative
maneuver, an anterior cervicoplasty is added at the end of the
MACS lift procedure. Because suturing together platysmal bands
on the midline counteracts the lifting effect on the cheeks, the
neck work is delayed until the facelift procedure is completed. At
the end of a MACS lift procedure, the lateral parts of the platysma
are so tightly pulled upward by the vertical purse-string sutures
that it is virtually impossible to bring the medial borders of the
platysma together to the midline. Therefore, we perform open
resection of the medial bands of the platysma at the end of the
procedure. A resection of about 1 cm of medial muscle border is
carried out, with or without a horizontal relaxation incision at the
level of the hyoid. Conservative open resection of subplatysmal fat
is done when indicated.
46.4.2 Posterior Neck
The limits of MACS lifting depend on the amount of skin excess
in the neck as well as on the quality of the skin. Problems can
arise when dealing with thin, sun-damaged neck skin with a
significant number of wrinkles down to the clavicular region. In
these cases, after vertical skin redraping, vertical skin folds will
begin to appear in the infralobular neck region. These folds are
aesthetically unacceptable and need to be corrected at the end
of the procedure with a posterior cervicoplasty. This maneuver
consists of tension-free redraping of the skin in an occipital
direction from a prehairline posterior neck incision. A 5-cm
incision is designed in a zigzag pattern at the occipital hairline.
The area of skin undermining is designed to reach 1 cm beyond
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
the anterior most infralobular skin fold. The skin flap is created
by blind scissors dissection in a superficial subcutaneous level.
The skin is redraped in an occipital direction, and the skin
excess is resected. The skin is approximated with buried 4–0
Vicryl sutures and finished with a running 4–0 nylon horizontal
mattress suture.
In a case with important subplatysmal fat accumulation, an
open anterior neckplasty can be performed. This includes a sub-
platysmal fat resection under direct vision, followed when needed
by an approximation of the preplatysmal edges. In cases with
important platysmal banding or neck laxity, a neck lift according
to Dr. Mario Pelle Ceravolo is added to the MACS lift procedure.
46.4.3 Forehead
Indications for brow lifting are very surgeon-dependent. Some
surgeons believe that everyone needs one; others and we fall
into this category are more conservative in their approach and
do not routinely elevate every patient’s eyebrows.
Many procedures are available for forehead correction, ranging
from open foreheadplasty to endoscopic brow lift or limited-
incision temporal lifting techniques. ith the introduction of
botulinum toxin A into our practice, our indications for surgical
brow lifting have diminished impressively. Almost every patient
is offered botulinum toxin treatment before or after surgery.
It completes the treatment, optimizes the result, and leads to
improved patient satisfaction. Furthermore, temporal lift usually
can address the problem in the lateral part of the brows.
46.4.4 Short-Scar Temporal Lift
hen we analyze patients’ photographs in their 20s and 30s,
the vast majority of photos show full upper eyelids, with only a
minimal show of the eyelid above the cilia. The medial part of the
eyebrow usually is relatively low, and the lateral third is at the
same level or even higher than the medial third.
ith aging, the tail of the eyebrow descends to a variable
degree, depending on the underlying anatomy of the frontalis
muscle. The part of the population that has a frontalis muscle
insertion extending to the tail of the eyebrow will have less
descent of this part of the eyebrow and often will respond very
well to a chemodenervation with botulinum toxin of the temporal
portion of the orbicularis oculi muscle.
However, most people do not have good support of the lateral
third of the eyebrow and develop a degree of temporal hooding
with time. It is this deformity that we aim to correct with the
short-scar temporal lift. Additionally, when a vertical facelift of
any kind is performed, the problem of temporal hooding is aggra-
vated by a gathering of skin in the paracanthal region. If too much
skin redundancy appears in the paracanthal area when simulating
the vertical lift, the patient is counseled about the necessity of a
temporal lift.
To address these problems, a modified Fogli’s temporal lift by
fasciapexy is performed. The principle of this operation is basi-
cally the same as for a subcutaneous forehead lift, limited to the
lateral third of the forehead, in which the galea is used as a vehicle
to suspend the ptotic temporal tissue and provide a tension-free
skin closure in the temporal hair-bearing skin.
585
 VIII Surgical Rejuvenation of the Face and Neck

Technique
The subcutaneous part of the temporal undermining is per-
formed from the MACS lift incision in continuity with the subcu-
taneous cheek skin undermining. It stops at a level at least 2 cm
above the tail of the eyebrow.
The temporal lift is done after the loop sutures are placed, but
before the final redraping and resection of the cheek and lower
eyelid skin, to reduce dog-ear formation in the temporal and
paracanthal region.

Markings
hen a temporal lift is planned in combination with a MACS lift,
Fig. 46.32 Planning and marking of temporal lift with a minimal-ac-
the markings are adapted so that the subcutaneous dissection of cess cranial suspension (MACS) lift: the upper line within the temporal
the cheek is extended over the temporal region to a level at least area is the skin incision. The lower line marks the galea transection.
2 cm above the tail of the eyebrow. The skin incision is marked
horizontally in the temporal hair-bearing skin (Fig. 46.32).
From here a subgaleal undermining is performed downward to
a level about 2 cm above the tail of the eyebrow (Fig. 46.33).
Here the galea is transected with the tip of the scissors from
deep to superficial, to fall into the previously undermined subcu-
taneous tissue. This maneuver protects against possible damage to
the frontal branch of the facial nerve, which runs the undersurface
of the temporoparietal fascia, about 2 cm cranial to the tail of the
eyebrow.
Two U-shaped Vicryl 2–0 sutures are placed between the cra-
nial edge of the transected galea and the galea at the site of the
skin incision.
Tying these knots will produce a bulging of skin, which will
disappear after 6 to 8 weeks when the Vicryl sutures lose their
strength. After the knots are firmly tied, a few millimeters of skin
are resected to minimize skin bulges, and the incision is closed
with 3–0 running nylon suture.
For the medial part of the forehead, botulinum toxin therapy
is recommended, because it is an effective way of treating gla-
Fig. 46.33 Subgaleal undermining during surgery and a visual
bellar and frontal grooves without the need for further surgical representation of the correct plane of dissection toward deep adipose
procedures. tissue.

46.4.5 Microfat Grafting

Deflation through loss of subcutaneous fat is a recognized caus-
ative factor in facial aging. Guided by early patient photographs
(age 20–30), we decide which areas need volumetric restoration
by additional fat grafting. Experience has taught us that almost
every patient loses volume in the nasojugal and nasolabial folds
and marionette grooves. About 50 of these individuals will
benefit from adding volume to the malar area and the medial
upper eyelid.

Technique
Fat grafting is performed before the MACS lift. This minimizes
the cold ischemia time of the prepared fat grafts. At this stage,
there is also no distortion of the face by edema resulting from
the surgery.
The fat is usually harvested by the assistant at the time of
infiltration of local anesthetic to the face. The abdomen is the pre-
ferred donor site because of its ease of access. A multiholed grater
cannula (Tulip Medical, San Diego, CA) with 1-mm sharp holes is
Fig. 46.34 (a) Multiholed cannula used for harvesting the fat. (b)
Rinsing technique.
used for fat harvesting (Fig. 46.34). The fat parcels harvested this
way are small enough to be placed with a 0.9-mm or even 0.7-mm
grafting cannula.
The fat is then strained through a sterile nylon cloth and rinsed
with normal saline solution. Then the fat is collected in 10-mL
syringes for final transfer to 1-mL Luer lock syringes.

586

The fat is injected using 0.9- to 0.7-mm-diameter blunt cannu-
las with one small hole on the side. No incision is needed to insert
the cannula. A puncture with an 18-gauge needle works well. The
puncture hole need not be closed.
46.4.6 Augmentation Blepharoplasty
The concept of augmentation blepharoplasty is based on the
hypothesis that periorbital aging is essentially a deflation phe-
nomenon. This has led to a paradigm shift from resection toward
filling in periorbital rejuvenation (Fig. 46.35; Fig. 46.36).
46.4.7 Sharp-Needle Intradermal Fat
Grafting
rinkles can be treated by filling subdermal or intradermal
planes. Filling in the subdermal plane is used to treat folds or
deep wrinkles that result from underlying volume depletion.
Conversely, fine wrinkles are treated with intradermal injections
because they result from changes in the skin itself.
The quest to find the ideal dermal filler is ongoing. In 2008 we
started using fine-particle microfat for intradermal injection into
facial rhytids with the intent of achieving a permanent correction
without the perils of a synthetic permanent filler. This sharp-
needle intradermal fat injection method was published under
the acronym S IF.
Indications and Contraindications
hether the targeted wrinkle is treatable with S IF depends
on the skin thickness, mobility, and quality. Dynamic wrinkles
in the glabella will primarily need chemodenervation by botu-
linum toxin. Residual rhytids can later be additionally treated
with S IF.
Atrophic craquel of the skin of the lower eyelids is usually not
a good indication for a filler nor for S IF. Deep folds such as the
nasolabial folds and marionette grooves are more amenable to
blunt-cannula microfat grafting with or without subcision.
Thus the gross indications for S IF are quite similar to those for
superficial resorbable synthetic filler treatment. S IF is typically a
technique for correcting superficial dermal damage or deformities
Fig. 46.35 Markings of microfat grafting of the infrabrow area and
malar in green.
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
such as rhytids, acne scars, and atrophic scars, but not for deep
volume correction.
The amount of microfat required for intradermal fat injections
is very small (ranging from 0.1 to 0.5 mL according to the length of
the rhytid). If intradermal fat transfer is performed without deep
lipofilling, harvesting the fat is not time consuming (2.5–25 mL of
lipoaspirate is sufficient in most cases).
However, S IF is usually applied as a supplementary and final
act after blunt-cannula microfat grafting of the deep folds (such
as nasolabial folds) or in conjunction with any surgical facial
rejuvenation procedure. In some cases, intradermal fat injection is
combined with laser resurfacing or croton oil peeling during the
same procedure.
Contraindications for S IF are atrophic skin conditions (such
as result from steroid use and diabetes), bleeding disorders and
anticoagulant use, and smoking.
Fat Harvesting Technique
In the S IF procedure the material injected is actually microfat,
harvested and prepared in the same manner as for deep volu-
metric blunt-cannula microfat grafting.
Injection Technique
Injection must be performed in a superficial dermal plane. The
skin rhytid is pinched parallel between the thumb and index
finger. Linear thread injection of the fat is performed as the
needle is withdrawn.
Blanching of the skin over the injected wrinkle is the endpoint
of injection. A slight overcorrection is advised, because blanch-
ing and overcorrection will normalize within a few hours after
resorption of the interstitial fluid. In thinner skin such as the neck,
the overcorrection may remain visible for more than a week but
always subsides eventually.
Deep wrinkles, sharp folds, or acne scars may require a subci-
sion maneuver for separating the skin from its deep attachments
to achieve an optimal result. Subcision is performed with an
18-gauge needle.
Results
As in any microfat grafting procedure, after S IF a variable
resorption of the injected fat occurs, which stabilizes after 4
Fig. 46.36 Marking and guideline for volume distribution of malar
augmentation.
587
 VIII Surgical Rejuvenation of the Face and Neck

months. The degree of resorption varies from patient to patient
and is also correlated with the mobility of the treated area.
Perioral wrinkles usually show a higher resorption rate than a
glabella that has been immobilized with botulinum toxin.
The result seen after 4 months can be considered as consolidated.
The simplicity of the surgery and the easy recovery convinces
most patients of the possibilities of the procedure, and the thresh-
old for them to come back for treatment of any new rhytids is low.
Contrary to popular belief, intradermal fat grafting can be
performed safely with a sharp needle, as long as it is done in a
superficial dermal plane upon needle withdrawal, epinephrine
infiltration, and low-pressure injection together with pinching
of the skin. The harvesting and injection techniques should be
performed with precision to achieve optimal results and prevent
complications.

46.4.8 Nanofat
Case Study: SNIF in Anterior Neck Rhytids
ith the nanofat grafting technique, we inject regenerative cells
The 44-year-old woman in Fig. 46.37 presented for neck rejuve-
and elements in the clinical setting after processing adipose
nation. She was treated solely with 6.5 mL of S IF into the hor-
tissue with a very simple mechanical manipulation. This tech-
izontal rhytids and 18 mL of nanofat in the whole anterior neck
nique destroys the mature adipocytes and leaves the complex
region. o surgical lifting was performed. The ridges of the S IF
mixture of perivascular smaller-sized cellular components intact
injections and the edematous aspect of the whole anterior neck
and in their native paracrine environment. anofat grafting may
skin are common and disappear within the following weeks. At 6
open possibilities of adipose tissue as a primary source of mes-
months follow-up, she has a marked reduction of the horizontal
enchymal cells and stromal vascular fraction (SVF) in biocellular
rhytids and an improvement of the general neck skin quality.
therapies in the future.

Problems and Complications Indications and Contraindications

Very few, minimal problems (redness, swelling, and bruising)
anofat is not a soft tissue filler; hardly any viable adipocytes
have been encountered with S IF; bruising is most common.
are present in the injectable substance. Nanofat is applicable in a
o surface irregularities such as lumpiness or unevenness were
wide range of indications to improve the skin quality.
observed in this series. o hypertrophy of the fat graft resulted
There are three categories of indications for the use of nanofat:
from weight gain. Although one patient lost a significant amount
of body weight, her results remained stable. The problems that 1. Trophic skin changes caused by age and sun damage
are possible with classic nonmicrofat grafting, such as palpable 2. Pigmentary skin conditions
nodules, firmness, fat necrosis, and fat cysts, were not seen in the 3. Scarring and atrophic skin conditions
S IF population.

Fig. 46.37 (a,d,f) Preoperatively at age 47 years. (b) The immediate intraoperative result. (c) At 6 days postoperative. (e,g) At 6 months postopera-
tive. (Reproduced with permission from Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers,
2018.)

588

Presently nanofat is an integral component of our facial reju-
venation strategy, and we offer it to all of our patients. onfacial
areas such as the neck, the d collet area, and the hands can also
greatly benefit from the use of nanofat grafting, sometimes in
combination with microfat or S IF.
Because of the simplicity and safety of the procedure, nanofat
grafting has no specific contraindications.
Preoperative Planning and Preparation
Microfat is harvested with the multiholed microcannulas and
processed as described previously in the chapter. The rinsed and
filtered microfat is then transferred into 10-mL Luer lock syringes
and mechanically emulsified. Emulsification of the fat is achieved
by vigorously shifting the microfat between two 10-mL syringes,
connected to each other by a 2.4-mm-diameter (purple) female-
to-female Luer lock connector (Fig. 46.38). After 30 passes the
fat becomes more liquid and whitish. This number of passes is
arbitrary but has proven to be effective in our experience. This
process is then repeated with the 1.2-mm-diameter (green) con-
nector, also for 30 passes. This ensures that even the most fibrous
fat can be emulsified and that no viable adipocytes remain in the
resulting nanofat. The change in color is a result of the emulsifi-
cation of the grafted material. After the emulsification process
the fatty liquid is passed through a strainer cartridge with a dual
400/600-micron filter. This maneuver removes connective tissue
remnants that could block the fine 27-gauge needle. The e uent
is the end product, nanofat. It is transferred from the 10-mL Luer
lock syringes into 1-mL syringes for injection.
Technique
Because nanofat grafting is a very superficial treatment, topical
anesthesia is usually sufficient for treatment of the periorbital
Fig. 46.38 Tools used for nanofat processing. Luer-to-Luer connectors,
2.4- and 1.2-mm diameter, for emulsification. Tulip Nanotransfer for
straining emulsified fat through a 400/600-micron filter.
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
skin, the neck, or the d collet . Alternatively, a local nerve block
or infiltration anesthesia can be applied. If general anesthesia
is used, typically no extra infiltration for vasoconstriction is
necessary.
anofat was designed to be injectable through fine (27-gauge)
needles. This allows very superficial skin injection in the super-
ficial reticular and papillary dermis. The zones marked for treat-
ment are injected with a threading technique upon withdrawal
of the needle. This further reduces the risk of an intravascular
injection, which is very unlikely in these superficial skin layers.
The needle is inserted with the bevel up and may be bent 60
to facilitate the ease of manipulation. The nanofat is injected in
adjacent fan-shaped patterns.
Results
As mentioned previously, nanofat is not a soft tissue filler.
anofat is applicable in a wide range of indications in which
improvement of the skin quality is desired, including generalized
facial skin improvement, repairing craquel d periorbital and
perioral skin, atrophic lip mucosa enhancement, removing lower
eyelid dark circles, correcting sun-damaged skin of the d collet ,
improvement of the dorsum of the hands, and scar improvement.
Case Study: Full-Face Nanofat Treatment
The 41-year-old woman in Fig. 46.39 requested noninvasive facial
rejuvenation. e proposed an upper and lower augmentation
blepharoplasty with chemical browlift by botulinum toxin and
full-face nanofat grafting. The upper blepharoplasty consisted
of resection of skin and microfat grafting of the medial hollow
(1.5 mL per side). Tear trough and orbitomalar groove correction
consisted of microfat grafting of the orbitomalar area (7 mL per
side). Botulinum toxin was injected into the corrugator and pro-
cerus muscle (21 Dysport units per side) and frontal muscle (31.5
Dysport units). Full-face nanofat grafting was performed in an
immediately subdermal level (different from the classic nanofat
injection described previously). A total of 22 mL of nanofat was
injected.
Case Study: Neck Nanofat Treatment
The 71-year-old woman in Fig. 46.40 attended a consultation
for facial rejuvenation. She had a MACS lift with centrofacial
rejuvenation by microfat grafting and erbium laser resurfacing.
The laxity of the skin was corrected by the lifting procedure,
but the enhancement of the quality of the skin is a result of the
nanofat injection. The disappearance of the solar keratosis in the
postoperative images and the long-term stability after 3 years
are notable. For the neck correction, 6 mL of S IF (see Fig. 46.37)
was injected through a 23-gauge needle into the horizontal
rhytids, and the whole anterior neck area was injected with 15
mL of nanofat through a 27-gauge needle.
Problems and Complications
There are very few complications with nanofat grafting. However,
one in particular deserves discussion: in our early series of dark
circle treatment, we had four patients who experienced a per-
sistent yellow discoloration at the injection site. This problem
589
 VIII Surgical Rejuvenation of the Face and Neck

a b c

d e f
Fig. 46.39 A 41 -year-old woman who had upper and lower augmentation blepharoplasty, botulinum toxin injection, and full-face nanofat injection.
(a,d) Preoperative. (b,e) At 6 months postoperative. (c,f) At 24 months postoperative. (Reproduced with permission from Tonnard PL, Verpaele AM,
Bensimon RH. Centrofacial Rejuvenation. New ork, N : Thieme Medical Publishers, 2018.)

has occurred only in the lower eyelid, not in any of the other
areas treated.
To prevent this problem, we developed the two-stage sequen-
tial emulsification process, which involves 30 passes through a
2.4-mm Luer-to-Luer connector, followed by a second 30 passes
through a 1.2-mm Luer-to-Luer connector, as described previ-
ously. The persisting adipose show has not reoccurred with this
method.
Obviously, all precautions recommended for preventing intra-
vascular injection should be taken, such as infiltration with local
anesthetic with epinephrine, injection upon withdrawal only,
injection under low pressure, and small aliquots per passage. This
is valid for any injectable.
46.5 Putting It All Together
46.5.1 Case Study
The 51-year-old woman in Fig. 46.41, a smoker, presented for
a facial rejuvenation procedure (Fig. 46.41a). After the consul-
tation, she decided to postpone the surgery and underwent a
gastric bypass procedure because she felt slightly overweight.
She lost 20 kg in 3 years, and the result of the weight loss on
her facial appearance was evident: she appeared to have aged
15 years in the 3-year period (Fig. 46.41b). At that time, at the
age of 54, she again presented for facial rejuvenation. Compared
with her appearance at the age of 28 years (Fig. 46.41c), the

590
 46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting

line, and neck laxity with platysmal bands, especially on the left
side. Fine wrinkles in the frontal, glabellar, and perioral areas
appear together with a lengthening of the vertical height of the
upper lip and loss of definition of the lip contours.

Nonsurgical Plan
The nonsurgical treatment plan consisted of the following:

• Smoking cessation
• A Retin-A skin care program
• Botulinum toxin in the glabellar and frontal area

Surgical Plan
The surgical treatment involved the following:

• Simple MACS lift with retroauricular incision

• Open neck procedure with platysmarrhaphy and partial tran-
section of the platysma at the level of the hyoid
Fig. 46.40 A 71-year-old woman who had a minimal-access cranial sus- • Short-scar temporal lift
pension (MACS) lift with centrofacial rejuvenation by microfat grafting • Upper augmentation blepharoplasty with skin-only resection
and erbium laser resurfacing for facial rejuvenation. (a) Preoperative.
(b) At 3 months postoperative. (c) At 3 years postoperative. (d) At 4 • Lower skin-pinch blepharoplasty
years postoperative. (Reproduced with permission from Tonnard PL,
Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New ork, N :
• Microfat grafting, 80 mL, harvested from the abdomen
Thieme Medical Publishers, 2018.) Infrabrow: 2 mL/side
Malar: 13 mL/side
asolabial fold: 1.5 mL (including 0.25 mL after subcision)
centrofacial deflation is obvious in her upper eyelids, midface, Marionette grooves: 2.5 mL/side
and perioral area. Sagging of the peripheral area is visible, with • S IF, 21-gauge needle:
drooping of the tail of the eyebrow, loss of definition of the jowl Upper white roll: 1.3 mL

Fig. 46.41 Preoperative views of patient in case study. (a) At age 51 years, before gastric bypass surgery. (b) At age 54 years, after losing 20 kg. (c)
At age 28 years for comparison. (Reproduced with permission from Tonnard PL, Verpaele AM, Bensimon RH. Centrofacial Rejuvenation. New ork, N :
Thieme Medical Publishers, 2018.)

591
 VIII Surgical Rejuvenation of the Face and Neck

Lower white roll: 1.0 mL perioral area. The effect of the lip lift is seen by the shortening
Philtrum: 0.4 mL of the vertical height of the upper lip. The S IF to the white
roll and the philtral columns restores the definition of the lip
• S IF, 23-gauge needle:
contours to her younger appearance. The glabellar and frontal
Barcode (upper lip): 1.2 mL
rhytids are eradicated by the synergistic effect of botulinum
Frontal wrinkles: 2.0 mL toxin and S IF. In the profile view in downward gaze (the Bruce
Glabella: 0.5 mL Connell view), the restoration of the cervicomental angle and
Cheek rhytids: 2.3 mL the stable correction of the platysmal banding are evident. The
asolabial rhytids: 2.0 mL improvement in the quality of the neck skin is a result of the
microfat in the horizontal rhytids and nanofat in the whole
• anofat in the anterior neck area (17 mL)
anterior surface of the neck.
• Lip lift hen the effect of the lifting procedure in the peripheral
part of the face is compared with the effect of the centrofacial
rejuvenation, the centrofacial rejuvenation is clearly much more
Postoperative Result
important than the actual lifting procedure (Fig. 46.43). Both
The 1-year postoperative result demonstrates the correction
techniques work synergistically toward a total natural facial
of the neck laxity with restoration of the cervicomental angle
rejuvenation.
(Fig. 46.42). Mandibular definition is restored by correction
of the jowling. The degree of platysmal banding required a
platysmarrhaphy and consequently a full facelift incision. Most
important was the correction of the volumetric deflation of
the centrofacial area. Compared with her appearance at age
28 years, the rejuvenation is very natural, with the essential
replenishment of the upper eyelids, the malar area, and the

a b c

d e

Fig. 46.43 (a,b) Effect of the peripheral lifting procedure, which

f g
Fig. 46.42 (a,d,f) Preoperative views. (b,e,g) At 1 year postoperative.
(c) The top right photo is a comparison of the patient at age 28 years.
is limited to the definition of the jawline and the lower neck. The
centrofacial area has been masked in black. (c,d) Effect of the
centrofacial rejuvenation (augmentation blepharoplasty and perioral
replenishment), which clearly has more rejuvenating power than
mere lifting. The peripheral facelifting areas have been masked in
black. (Reproduced with permission from Tonnard PL, Verpaele AM,
Bensimon RH. Centrofacial Rejuvenation. New ork, N : Thieme Medical
Publishers, 2018.)

592

Clinical Caveats
• Synergy between fat grafting and lifting is a powerful tool to
correct facial aging.
• Facial aging is the result of sagginess and deflation and the
quality of the soft tissues.
• A short-scar facelift is not a classic facelift with a short scar.
• The only rejuvenating vector is the vertical one. The hori-
zontal vector does not rejuvenate the face but puts the face
under tension and causes flattening of the face.
• The vertical vector should work on the deep tissues and on
the skin.
• Purse-string sutures strongly anchored to the deep tempo-
ral fascia, as used in the MACS lift, are a facial sculpturing
technique that cause multiple microimbrications in the
subcutaneous tissue.
• After vertical redraping of the skin flap, the skin is resected
in the temporal region. This skin resection will act as a lock
of the microimbrication result on the subcutaneous facial
tissues.
• Skin suturing starts from superior to inferior to prevent and
treat dog-ear formation in the temporal area.
• Lipofilling can be frequently implemented in all its different
techniques: microfat grafting for volume restoration of the
facial tissues, SNIF as correction of deep rhytides, and nanofat
as regenerative tool for skin quality.
Suggested Reading
[1] Baker DC. Commentary on: Marchac D. Against the visible short scar face lift.
Aesthet Surg J 2008;28(2):209–210
2 Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):509–513
3 Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, tem-
poral, and upper face lift. Plast Reconstr Surg 1996;97(5):928–937
4 Carniol P , Ganc DT. Is there an ideal facelift procedure Curr Opin Otolaryngol
Head Neck Surg 2007;15(4):244–252
5 Coleman SR, Mazzola RE. Fat Grafting: From Filling to Regeneration. St Louis, MO:
uality Medical Publishing; 2009
6 Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol
Surg 2000;26(12):1107–1112
[7] Feldman JJ. Necklift. St Louis, MO: uality Medical Publishing; 2006
[8] Finger ER. A 5-year study of the transmalar subperiosteal midface lift with
minimal skin and superficial musculoaponeurotic system dissection: a durable,
natural-appearing lift with less surgery and recovery time. Plast Reconstr Surg
2001;107(5):1273–1283, discussion 1284
[9] Fulton E, Saylan , Helton P, Rahimi AD, Golshani M. The S-lift facelift featuring
the U-suture and O-suture combined with skin resurfacing. Dermatol Surg
2001;27(1):18–22
46 The MACS Lift Short-Scar Rhytidectomy with Fat Grafting
10 Furnas D . The retaining ligaments of the cheek. Plast Reconstr Surg
1989;83(1):11–16
[11] Furnas D . Strategies for nasolabial levitation. Clin Plast Surg 1995;22(2):265–
278
12 Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal
midface plane. Plast Reconstr Surg 1998;102(5):1646.1657
13 Hester TR, Codner MA, McCord CD. The centrofacial approach for correction of
facial aging using the transblepharoplasty subperiosteal cheek-lift. Aesthet Surg J
1996;16(1):51–58
14 Hunstad P. A systematic approach to MACS-lift operative techniques. In:
Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Tech-
niques. St. Louis, MO: uality Medical Publishing; 2007:75–114
15 ewell ML. The MACS-lift short-scar face lift: technical and strategic consider-
ations. In: Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies
and Techniques. St. Louis, MO: uality Medical Publishing; 2007:183–234
16 aram AM, ayak LM, Lam SM. Short-scar purse-string facelift. Facial Plast Surg
Clin North Am 2009;17(4):549–556, vii
[17] estemont P. Description and critical analysis of the Tonnard and Ver-
paele’s technique for malar suspension in French . Ann Chir Plast Esthet
2009;54(5):421–424
[18] nize DM. Limited incision submental lipectomy and platysmaplasty. Plast
Reconstr Surg 1998;101(2):473–481
[19] Matarasso A, Elkwood A, Rankin M, Elkowitz M. ational plastic surgery survey:
face lift techniques and complications. Plast Reconstr Surg 2000;106(5):1185–
1195, discussion 1196
20 ahai F. Short-scar face lift: indications and technical considerations. In: Tonnard
PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques. St.
Louis, MO: uality Medical Publishing; 2007:45–74
21 Pessa E. An algorithm of facial aging: verification of Lambros’s theory by
three-dimensional stereolithography, with reference to the pathogenesis of
midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast
Reconstr Surg 2000;106(2):479–488, discussion 489–490
22 Pessa E. The potential role of stereolithography in the study of facial aging. Am J
Orthod Dentofacial Orthop 2001;119(2):117–120
23 Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMA-
Sectomy: evolution and application. Aesthet Surg J 2001;21(1):14–26
24 Ramirez OM, Pozner . Subperiosteal minimally invasive laser endoscopic rhyt-
idectomy: the SMILE facelift. Aesthetic Plast Surg 1996;20(6):463–470
25 Stuzin M, Baker T , Gordon HL, Baker TM. Extended SMAS dissection as an
approach to midface rejuvenation. Clin Plast Surg 1995;22(2):295–311
26 Tonnard P, Verpaele AM. 300 MACS-lift short scar rhytidectomies: analysis of
results and complications. Eur J Plast Surg 2005;28(3):198–205
27 Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J
2007;27(2):188–198
28 Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a
modified S-lift. Plast Reconstr Surg 2002;109(6):2074–2086
29 Tonnard PL, Verpaele AM, eds. The MACS-Lift: Short-Scar Rhytidectomy. St. Louis,
MO: uality Medical Publishing; 2004
30 Tonnard PL, Verpaele AM. Refining the MACS-lift technique and defining its
limits. In: Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies
and Techniques. St. Louis, MO: uality Medical Publishing; 2007:115–182
31 Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies and
Techniques. St. Louis, MO: uality Medical Publishing; 2007
32 Verpaele A, Tonnard P. Lower third of the face: indications and limitations of the
minimal access cranial suspension lift. Clin Plast Surg 2008;35(4):645–659, vii
593
 VIII Surgical Rejuvenation of the Face and Neck
47 Short-Scar Rhytidectomy
Daniel C. Baker
Abstract
A review of the surgeon’s 25-year experience with short-scar
rhytidectomy is presented. The main advantage is avoiding
retroauricular scars, which disrupt the posterior hairline. This
technique is mainly applicable for younger women with good
skin elasticity and minimal cervical laxity. The indications and
limitations as well as long-term results are presented.
Keywords
rhytidectomy, less invasive, shorter incisions, preserves hair-
lines, ponytail-friendly
47.1 Introduction
Rhytidectomy is a procedure that continues to evolve as surgeons
seek to offer patients natural rejuvenation with reduced morbidity.
Over the years I have witnessed an evolution of techniques ranging
from basic skin lifts to superficial musculoaponeurotic system
(SMAS) procedures to even more complex deep-plane procedures
in search of an operation that reliably restores facial form with min-
imal morbidity. More recently, the need for extensive incisions for
rhytidectomy has also been questioned. It has become increasingly
clear that not all patients require the full classic temporal preauric-
ular and retroauricular incisions. The incisions, as well as the planes
or levels of facial dissection, should be individualized for each
patient, in keeping with the physical changes related to aging and
the desired result. As more patients seek facial rejuvenation at an
earlier age, the need for surgical solutions that are less invasive and
that involve less downtime is becoming increasingly important.
My approach to rhytidectomy has evolved over time. During my
plastic surgery residency in the late 1970s, the rhytidectomy that
I was taught was a combination of extensive defatting of the neck
with complete platysma muscle transection, plicating the medial
borders and pulling laterally. This was presented as the only way
to achieve the “best results.” However, after many years of patient
complaints, complications, and overoperated necks, I decided
to abandon most of these techniques in favor of my current
approach a short-scar rhytidectomy with lateral SMASectomy or
SMAS plication in selected cases.
Today there are a variety of rhytidectomy techniques that pro-
duce excellent results. Each surgeon must adopt a technique that
serves his or her patients well and that ideally is safe, consistent,
and applicable to a variety of anatomic problems. For me, the
short-scar rhytidectomy is a versatile technique that provides
the solution I have been seeking for a wide range of problems for
patients of various ages, without the downside of more traditional
procedures. ith this approach I am confident of obtaining con-
sistently good results with shorter scars, minimal risk of compli-
cations, reduced morbidity, and speedy postoperative recovery.
It is a quick, safe, and reproducible operation that combines the
594
versatility of traditional SMAS flap undermining with the safety
and rapidity of SMAS plication or lateral SMASectomy.
47.2 Evolution of Technique
47.2.1 SMAS
In 1976 the work of Mitz and Peyronie helped popularize the
concept of the SMAS. ith this approach, the lateral SMAS was dis-
sected directly overlying the parotid gland. I performed this type of
SMAS dissection in the late 1970s and continued to do so into the
mid-1980s. Generally I was disappointed with the effects of a simple
elevation and tightening of the lateral superficial fascia, because I
saw little appreciable difference in overall facial contour, regardless
of whether a lateral SMAS dissection had been performed.
Increasing experience with SMAS dissection convinced me that
the mobile SMAS anterior to the parotid gland would have to be
elevated if the superficial fascia were to effect a change in facial
contour. However, this more extensive SMAS dissection places
the facial nerve branches in greater jeopardy. Additionally, the
superficial fascia tends to thin out as it is dissected more anteri-
orly, making the SMAS more prone to tears. Because thinning and
tearing after SMAS flap elevation was a common occurrence, com-
pounded when significant tension placed on the SMAS flap during
suturing resulted in additional tears, I concluded that extensive
SMAS dissection was not warranted in most patients and offered
little long-term benefit in comparison with SMAS plication.
47.2.2 Lateral SMASectomy
In 1992 I discovered the benefits of the lateral SMASectomy as an
alternative to formally elevating the superficial fascia. ith this
approach, a portion of the SMAS is removed in the region directly
overlying the anterior edge of the parotid gland at the interface of
the fixed and mobile SMAS (Fig. 47.1). Excision of the superficial
fascia in this region secures the mobile anterior SMAS to the fixed
portion of the superficial fascia overlying the parotid gland. The
SMASectomy is performed in a direction parallel to the nasolabial
fold to ensure that the vectors of elevation after SMAS closure will
lie perpendicular or more vertical to the nasolabial fold, thereby
producing improvement in this fold as well as in the jowl, jawline,
and midface (Fig. 47.2).
47.2.3 Twenty-First Century: Less
Invasive Techniques, Short-Scar
Facelifts, and Return to Plication
Thus lateral SMASectomy became the foundation for my evolv-
ing facelift technique. This was then combined with a short-scar
approach, which addressed patient concerns about scarring and
morbidity. The lateral SMASectomy also served as a debulking

Fig. 47.1 Lateral SMASectomy. A portion of the superficial muscu-
loaponeurotic system (SMAS) is removed in the region directly overly-
ing the anterior edge of the parotid gland at the interface of the fixed
and mobile SMAS. (Adapted with permission from Baker DC. Minimal
incision rhytidectomy (short-scar face lift) with lateral SMASectomy:
evolution and application. Aesthet Surg J. 2001; 21:14-31.)
Fig. 47.2 The SMASectomy is performed in a direction parallel to the nasolabial fold to ensure that the vectors of elevation after superficial muscu-
loaponeurotic system (SMAS) closure will lie perpendicular or more vertical to the nasolabial fold, thereby producing improvement in this fold as well
as in the jowl, jawline, and midface.
47 Short-Scar Rhytidectomy
in full-faced patients, but in thin faces I continued to perform
SMAS plication.
47.2.4 Short-Scar Rhytidectomy
The concept of mini-lifts or reduced-incision facelifts is not
new. Mini-lifts have been performed for almost a century; the
first description of such a procedure was by Passot in 1919.
These early operations were usually preauricular skin excisions
with minimal undermining, resulting in minimal, short-lived
improvement. More recently, the S-lift concept and the MACS lift
techniques with suspension sutures have gained popularity.
Although most classic facelift incisions heal well and patients
are happy, hairline disruptions like those shown in Fig. 47.3 are
deforming and difficult to correct.
My first experience with short-scar rhytidectomy was in
1990, when I operated on a young woman who had submental
and submandibular fat and early jowling but good cervical skin
595
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 47.3 Hairline disruptions after facelift.
elasticity. I performed lipoplasty of the neck and jowls with wide
subcutaneous undermining in the face, detaching the malar and
masseterocutaneous ligaments. A SMAS plication was done, with
no retroauricular scars. The result was excellent, and this experi-
ence prompted me to adopt this procedure for all of my younger
patients with similar anatomic features.
In 1992 I began to incorporate the lateral SMASectomy tech-
nique into the facelift operation for women in their 40s. I noticed
that vertical elevation of the face had a beneficial effect on the
cervical skin. Lax cervical skin was tightened because the soft tis-
sues of the face and neck are linked anatomically. Between 1990
and 1998 I performed this operation, which had no retroauricular
scars, on a total of 204 young female patients. The results were
ponytail-friendly for these young, active women.
As I gained experience with this operation and its potential
benefits, I extended its application to older patients who demon-
strated greater degrees of jowling and cervical laxity. ith these
patients, more extensive undermining was required in the neck
and over the sternocleidomastoid and submandibular regions and
usually required a short retroauricular incision. This undermining
exposed the platysma muscle in the neck, thereby facilitating ele-
vation at the posterior muscle, continuous with the SMASectomy.
Between 1990 and 2009 I performed more than 3,000 short-
scar rhytidectomies with lateral SMASectomy or SMAS plication
in patients ranging in age from 35 to 84. These patients exhibited
596
a variety of facial aging changes and neck deformities. Today I can
safely say that this procedure is as reliable and safe as other facelift
procedures. It is also reproducible by most plastic surgeons with
generally consistent results in properly selected patients. However,
it is not applicable to all patients, particularly those with excessive
cervical laxity and poor skin elasticity. As I have gained more
experience, my criteria for the best candidates have become more
stringent. Today I rarely compromise the result for a shorter scar.
47.3 Advantages and Disadvantages
47.3.1 Lateral SMASectomy
Lateral SMASectomy has several advantages over traditional
SMAS elevation. Because the procedure does not require tradi-
tional SMAS flap elevation, there is less concern about tearing
of the superficial fascia. The potential for facial nerve injury is
reduced because most of the deep dissection is over the parotid
gland. If the SMASectomy is performed anterior to the parotid
gland, the deep fascia will similarly provide protection for the
facial nerve branches as long as resection of the superficial
fascia is done precisely and the deep facial fascia is not violated.
Because SMAS flaps have not been elevated, they tend to hold
suture fixation more strongly, and thus the potential for postop-
erative dehiscence and relapse of contour is decreased.
A lateral SMASectomy or SMAS plication is performed at the
interface of the superficial fascia fixed by the retaining ligaments
and the more mobile anterior superficial facial fascia.
On closure, this brings the mobile SMAS up to the junction of
the fixed SMAS, producing a durable elevation of both superficial
fascia and facial fat. In thin-faced individuals, no SMAS or fat is
removed; instead, the lax SMAS is imbricated and plicated to
recontour atrophic areas in the face and to correct the midface
and nasolabial folds.
47.3.2 Short-Scar Facelift
The primary advantage of a short-scar rhytidectomy is that it allows
patients who wear their hair pulled up or back to do so. Any retro-
auricular scarring or disruption of the posterior hairline makes such
patients unhappy. In addition, the operation involves less dissection
and is less invasive than traditional procedures; presumably this
causes less pain and results in a shorter healing time. In patients
who develop hematomas, evacuation is easier with less morbidity.
There are disadvantages as well. This technique is not suitable
for all patients, especially those with severe cervical skin laxity.
Because the technique requires a significant vertical lift, strict
attention must be paid to minimizing temporal hairline shifts. In
certain patients an anterior hairline incision must be used. Fitting
dog-ears into the temporal and earlobe areas can be a challenge,
and these areas take more time to soften and flatten. Exposure
of the neck with the short-scar technique is limited, sometimes
making the operation technically more difficult.
These advantages and disadvantages are summarized in Table
47.1. I do not use this technique in every patient, and there is still
the occasional patient (usually with a very thin face) who has an
excellent result with only a skin undermining and redraping pro-
cedure. There are other patients with severe cervicofacial laxity
 47 Short-Scar Rhytidectomy

Table 47.1 Advantages and disadvantages of minimal-incision still good. They have early jowling, often with submental and
rhytidectomy submandibular fat. Microgenia may also be present (Fig. 47.4).
Anatomical region Cranial nerve innervations These patients can be effectively treated with closed lipoplasty
of the neck and jowls, wide subcutaneous skin undermining, and
• Less dissection • Requires more vertical skin lift
lateral SMASectomy or plication. o retroauricular incision is nec-
• Less invasive • Difficult to fit in “dog-ears” in temporal and
• Less scarring earlobe areas essary to improve the neck and face. If indicated, a chin implant
• Avoids posterior • Requires time for temporal hairline scar to will enhance the result (Fig. 47.5).
hairline smooth The 48-year-old exercise trainer shown in Fig. 47.6 had early
distortion • Requires time for retroauricular sulcus/earlobe jowling and cervicofacial laxity. Her face was thin and her body fat
• Allows easier scar to smooth
was low. At work she always wore her hair in a ponytail and was
hematoma • Occasionally causes skin fold at base of earlobe
greatly concerned about retroauricular scars and posterior hairline
evacuation • Is not applicable to patients with severe
• Neck exposure cervical laxity and poor skin elasticity disruption. Her presentation made her a type I ( ideal ) candidate for
• Ponytail-friendly short-scar rhytidectomy. Her thin face and hollow cheeks were best
treated with plication and imbrication to augment and recontour her
face. Her 1-year postoperative results demonstrate an overall change
and loss of elasticity who benefit from a classic rhytidectomy in her facial shape to oval, with correction of the jowls and midface
operation with retroauricular scars. Most classic rhytidectomy and enhancement of her cheekbones. The lateral view shows correc-
incisions, if well placed and closed without tension, will heal well tion of the neck, with preservation of the hairline and imperceptible
with minimal scarring. scars. Her 10-year postop demonstrates face longevity.

47.4 Preoperative Assessment Type II: The Good Candidate

47.4.1 ien r e
Based on my surgical experience with this procedure, I have clas-
sified candidates for this procedure into four types as follows.
Type I: The Ideal Candidate
Ideal candidates for a short-scar rhytidectomy are usually in
their early to late 40s, with signs of aging primarily in the face.
Although they may have slight cervical laxity, skin elasticity is
These patients are usually in their late 40s to late 50s with mod-
erate jowling and cervical skin laxity (Fig. 47.7). Submandibular
and submental fat is usually present, and they may have
microgenia. Medial platysma bands are not present on normal
animation. I do not evaluate the platysma on forced animation or
on the basis of static photographs; often what may appear to be
significant platysma bands represent laxity only, which can be
corrected with a lateral pull.
Closed lipoplasty of the neck and jowls along with lateral
SMASectomy or plication produces a good result in these patients.

Fig. 47.4 Types of patients for short-scar rhytidectomy. Type I: the ideal candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

597
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 47.5 Closed lipoplasty of the neck and jowls, wide subcutaneous
skin undermining, and lateral SMASectomy or plication. No retroauric-
ular incision is necessary to improve the neck and face. If indicated, a
chin implant will enhance the result.

Fig. 47.6 Long-term follow-up. Plication only, closed neck. (a) Anterior
views. (b) Lateral views.

Fig. 47.7 Types of patients for short-scar rhytidectomy. Type II: the good candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

598

If indicated, a chin implant will enhance the result. Usually a
retroauricular incision is not required. However, if a dog-ear is
present at the earlobe, it can be corrected with a short retroauric-
ular incision (Fig. 47.8).
This 59-year-old woman had moderate jowling and cervico-
facial laxity with minimal submental fat. Excess skin and fat of
the upper and lower eyelids was present. She represented a type
II ( good ) candidate for short-scar rhytidectomy. To maintain
facial fat and restore facial fullness, plication of the SMAS and
platysma was performed. Her 5-year postoperative result
demonstrates reestablishment of a youthful, oval facial shape,
enhancement of the submalar region and cheekbones, and cor-
rection of the oral commissures. The lateral view demonstrates
correction of the cervical laxity and jawline, with preservation
of the hairline. Her 13-year follow-up demonstrates the lon-
gevity of her first short-scar lift and 2-year postop secondary
short-scar lift.
Type III: The Fair Candidate
Fair candidates are usually in their late 50s, 60s, or early 70s.
They exhibit significant jowling, moderate cervical laxity, and
Fig. 47.8 Closed lipoplasty of the neck and jowls along with lateral SMASectomy or plication produces a good result in these patients. If indicated, a
chin implant will enhance the result. (a) Anterior views. (b) Anteroinferior views. (c) Lateral views. (d) In life.
47 Short-Scar Rhytidectomy
submental and submandibular fat. Significant medial platysma
bands, active on natural animation, may also be present (Fig.
47.9).
The approach to type III patients is via an open submental
incision connecting subcutaneous undermining with the face and
lateral neck. Open lipoplasty of submental and submandibular fat
is performed to expose the platysma muscle. A 4- to 5-cm wedge
of platysma is removed at the level of the hyoid. The medial
borders of the platysma muscle are approximated to define the
cervicomental angle. Lateral suturing of the platysma to the
mastoid periosteum enhances the jawline. If redundant skin is
present at the earlobe after redraping, it can be removed with a
short retroauricular incision. It must be emphasized that in a type
III patient the neck improvement and its longevity are usually not
as successful as when a classic rhytidectomy with retroauricular
scars is performed.
The 60-year-old woman shown in Fig. 47.10 had significant
jowling and cervicofacial laxity with microgenia. She had excess
skin and fat of her upper eyelids and represented a type III ( fair )
candidate for short-scar rhytidectomy. A lateral SMASectomy
was performed to reduce jowl and cheek fullness. An upper
599
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 47.9 Types of patients for short-scar rhytidectomy. Type III: the fair candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

a b

c d e f
Fig. 47.10 (a,c,e) This 60-year-old woman with significant jowling and cervicofacial laxity with microgenia, and with excess skin and fat of her upper
eyelids, represented a type III (“fair”) candidate for short-scar rhytidectomy. After lateral SMASectomy, upper blepharoplasty, and chin implant
placement, her 1-year postoperative results demonstrate improvement (b) in the facial shape, (d) midface, and (e) neck.

600
 47 Short-Scar Rhytidectomy

blepharoplasty was also performed and a chin implant placed.
Her 1-year postoperative results demonstrate improvement in the
facial shape and midface, with enhancement of the cheekbones.
eck improvement resulted from midline platysma approxima-
tion and a chin implant. o subplatysmal work was done. A rhyt-
idectomy cannot eliminate deep rhytids from the commissures
and jowl area.
The 53-year-old woman shown in Fig. 47.11 had always had
submental fullness and lacked cervicomental definition. She rep-
resented a type III ( fair ) candidate for short-scar rhytidectomy.
Her 1-year postoperative results demonstrate improvement in the
neck and jowls and reshaping of the face. Despite the fact that no
subplatysmal work was done, the lateral view demonstrates over-
resection of subcutaneous fat, leaving a slight submental hollow
and a prominent, ptotic chin.
Type IV: The Poor Candidate
Poor candidates are usually in their 60s and 70s, with signif-
icant jowling and active, lax platysma bands. Skin folds and
deep creases below the cricoid cartilage are often present, and
cervical skin elasticity is poor. Although these patients are not
good candidates for a short-scar rhytidectomy, this operation
can be offered to them as a compromise solution that keeps open
the option of extending the retroauricular incision if necessary.
Laterally and posteriorly, it is usually necessary to undermine
over the mastoid and sternocleidomastoid muscles to obtain
proper skin redraping. Excess cervical skin must be tailored into
the retroauricular sulcus (Fig. 47.12).
The short-scar technique is a compromise in these patients,
and the improvement in the neck is rarely as good as would be
obtained with a classic rhytidectomy with wide anterior and
posterior cervical undermining and redraping.
The 60-year-old woman shown in Fig. 47.13 demonstrated
cervical laxity below the cricoid, extending to the sternal notch.
She was a poor candidate for a short-scar facelift, which would
have compromised the improvement of her cervical laxity.
Although the patient had a nice improvement after undergoing
a short-scar rhytidectomy, the postoperative result demon-
strated persistent cervical laxity extending to the sternal notch.
The patient was not happy and required neck revision with a
classic retroauricular incision. This much cervical laxity can be
corrected only with wide through-and-through undermining
and removal of excess skin through the retroauricular occipital
incision.

a b

c d e f
Fig. 47.11 (a,c,e) This 53-year-old woman, who had always had submental fullness and lacked cervicomental definition, represented a type III (“fair”)
candidate for short-scar rhytidectomy. (b,d,f) Her 1-year postoperative results demonstrate improvement in the neck and jowls and reshaping of the
face, with overresection of subcutaneous fat, leaving a slight submental hollow and a prominent, ptotic chin.

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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 47.12 Types of patients for short-scar rhytidectomy. Type IV: the poor candidate. (Adapted with permission from Baker DC. Minimal incision
rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

Fig. 47.13 This 60-year-old woman, with cervical laxity below the cricoid extending to the sternal notch, was a poor candidate for a short-scar
facelift, which would have compromised the improvement of her cervical laxity. Postoperative result after short-scar rhytidectomy showed improve-
ment, but the cervical laxity persisted. Patient required neck revision with a classic retroauricular incision. (Reproduced with permission from Baker
DC. Lateral SMASectomy, Plication and Short Scar Facelifts: Indications and Techniques. Clin Plast Surg. Facelifts II. 2008; 35(4):533-550.)

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47.5 Operative Technique
47.5.1 Anesthesia
In virtually all of the facelifts I perform, the patient is under
monitored intravenous propofol sedation. Patients are given oral
clonidine, 0.1 to 0.2 mg, 30 minutes before surgery to control
their blood pressure. The face and neck are infiltrated with local
anesthetic, 0.5 lidocaine with 1:200,000 epinephrine, through a
22-gauge spinal needle. I inject the face before I scrub to provide
the requisite 10 minutes for vasoconstriction to occur.
47.5.2 Incisions
hen the temporal hairline shift is minimal, the preferred
incision is placed well within the temporal hair. ith this inci-
sion it is often necessary to excise a triangle of skin below the
temporal sideburn at the level of the superior root of the helix
(Fig. 47.14).
hen a larger skin shift is anticipated (frequently the lift is
more vertical with a shortscar rhytidectomy) or the distance
between the lateral canthus and the temporal hairline is greater
than 5 cm, the incision is made a few millimeters within the tem-
poral hairline. Although this is a compromise, the alternative of a
receding temporal hairline is rarely acceptable to female patients.
hen the incisions are executed properly (it is essential to bevel
the incision at least 45 through the hair follicles as well as the
Fig. 47.14 When the temporal hairline shift is minimal, the preferred incision is placed well within the temporal hair. With this incision it is often
necessary to excise a triangle of skin below the temporal sideburn at the level of the superior root of the helix. (Adapted with permission from Baker
DC. Minimal incision rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)
47 Short-Scar Rhytidectomy
redraped flap so that hair can grow through the incision), these
scars heal well and are easy to revise or camouflage. The only
exception might be in a patient with deeply pigmented skin, in
whom the scar will contrast and appear as a white line.
The choice of preauricular incision is left to the surgeon.
hen executed properly, all of these incisions heal well and are
imperceptible. I usually prefer a curved incision anterior to the
helix and continue inferiorly anterior to the tragus in a natural
skinfold. This preserves the thin, pale, hairless tragal skin and
its demarcation from the cheek skin, which usually is coarser,
thicker, and darker and has lanugo hairs. I perform intratragal
incisions in patients in whom the cheek and tragal skin is similar
and the tragal cartilage is not sharp or prominent. Closure must
be without tension and the flap overlying the tragus defatted to
the dermis.
In a short-scar rhytidectomy, I try to end the incision at the base
of the earlobe. This is usually possible in type I or II patients, but
in type III or IV patients a shorter retroauricular incision is often
necessary to correct a dog-ear after the facial flap rotation.
47.5.3 Skin Flap Elevation
All skin flap undermining is carried out under direct visualization
with scissors dissection to minimize trauma to the subdermal
plexus and preserve a significant layer of subcutaneous fat on
the undersurface of the flap. I prefer subcutaneous dissection in
the temporal region, because the skin seems to redrape better. I
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 VIII Surgical Rejuvenation of the Face and Neck
believe that hair loss results primarily from tension rather than
superficial undermining. Subcutaneous dissection in the tempo-
ral region must be performed carefully to avoid penetrating the
superficial temporal fascia, which protects the frontal branch of
the facial nerve. All dermal attachments between the orbicularis
oculi muscle and the skin are separated up to the lateral canthus.
Dissection extends across the zygoma to release the zygomatic
ligaments but stops several centimeters short of the nasolabial
fold. I have never believed that further dissection provides signif-
icant benefits; on the contrary, the only result is increased bleed-
ing. In the cheek, dissection releases the masseteric–cutaneous
ligaments and, if necessary, the mandibular ligaments.
Subcutaneous dissection continues over the angle of the man-
dible and sternocleidomastoid for 5 to 6 cm into the neck. This
exposes the posterior half of the platysma muscle. If a submental
incision has been made, the facial and lateral neck dissection is
connected through and through to the submental dissection
(Fig. 47.15).
Fig. 47.15 Subcutaneous dissection continues over the angle of the mandible and sternocleidomastoid for 5 to 6 cm into the neck, exposing the
posterior half of the platysma muscle. If a submental incision has been made, the facial and lateral neck dissection is connected through and through
to the submental dissection.
604
47.5.4 Defatting the Neck and Jowls
The extent of subcutaneous undermining in the temporal area,
cheek, and lateral neck is shown. If excess fat is present, closed or
open liposuction superficial to the platysma is performed in the
submental and submandibular areas. hen necessary, medial
platysma approximation is done through the submental incision.
henever possible, I prefer closed suction-assisted lipoplasty
in the neck and jowls. A 2.4-mm Mercedes-tip cannula is used;
it is kept under constant, steady motion in the subcutaneous
space. A 3- to 5-mm layer of subcutaneous fat is left on the
undersurface of the cervical skin. If the jowls are suctioned, this is
always done conservatively. Subplatysmal fat is rarely suctioned
or removed, because the facial nerves run just beneath the pla-
tysma. Additionally, any patient with significant subplatysmal fat
probably has a fat, round face, so removing subplatysmal fat could
create an overoperated look. This, of course, is a personal aesthetic
surgical judgment.
 47 Short-Scar Rhytidectomy

Lipoplasty is usually performed before elevating the skin
flaps, taking care not to oversuction the portion of the SMAS-
platysma that will be elevated over the mandible with the lateral
SMASectomy.
47.5.5 Open Submental Incision with
Medial Platysma Approximation
After many years, I now open the neck only when prominent
active platysma bands are present. I have found that I can
achieve excellent results with closed lipoplasty and a strong
lateral platysma vector. Therefore, in type III and IV patients
with active platysma bands on animation, the medial approx-
imation provides another vector to enhance the cervicomental
recontouring.
I prefer to make the submental incision in the submental crease.
The subcutaneous dissection is performed with the patient’s neck
hyperextended. Undermining is usually to the level of the thyroid
cartilage and the angle of the mandible. Suction-assisted lipoplasty
is then performed with a large, single-hole cannula under direct
vision. Direct fat excision is carried out, if necessary, but to avoid
creating depressions, subplatysma fat is rarely removed.
The medial borders of the platysma muscle are identified and
elevated for several centimeters. To break the continuity of the
bands, a wedge of muscle is removed at the level of the hyoid
bone. The medial borders of the muscle are then sutured together
with interrupted buried 3–0 polydioxanone sutures (PDS).
The submental incision is left open to allow a final confirmation
of hemostasis and recontouring after communication with the facial
dissection and completion of the lateral SMASectomy (Fig. 47.16).

Fig. 47.16 The submental incision is left open to allow a final confirmation hemostasis and recontouring after communication with the facial dissec-
tion and completion of the lateral SMASectomy. Abbreviation: SMAS, superficial musculoaponeurotic system. (Adapted with permission from Baker
DC. Minimal incision rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

605
 VIII Surgical Rejuvenation of the Face and Neck

47.5.6 Lateral SMAS Plication
In the SMAS–platysma resection, the level of resection is super-
ficial to the parotid masseteric fascia, which overlies the facial
nerve branches. The outline of the SMASectomy is marked on
a tangent from the lateral malar eminence to the angle of the
mandible, essentially in the region along the anterior edge of the
parotid gland. In most patients this involves a line of resection
extending from the lateral aspect of the malar eminence toward
the tail of the parotid gland. Frequently, orbicularis oculi muscle
fibers are exposed at the superior limit of the excision. Usually
a 2- to 4-cm segment of superficial fascia is excised, depending
on the degree of SMAS–platysma laxity and debulking required
(Fig. 47.17).
In a SMAS resection, I like to pick up the superficial fascia in
the region of the tail of the parotid gland, extending the resection
from inferior to superior in a controlled fashion. hen SMAS
resection is being performed, it is important to keep the dissec-
tion superficial to the deep fascia and avoid dissection into the
parotid parenchyma. The size of the parotid gland varies from
patient to patient; consequently, the amount of protection needed
for the underlying facial nerve branches will also vary. Despite
this, as long as the dissection is carried superficial to the deep
facial fascia, ensuring that only the superficial fascia is resected,
facial nerve injury as well as parotid injury will be prevented. In
essence, this is a resection of the superficial fascia in the same
plane of dissection in which one would normally raise a SMAS
flap (Fig. 47.18).
47.5.7 Vectors
The following vectors are illustrated: (1) vectors of elevation of
the SMAS–platysma and (2) vectors of superolateral elevation of
the SMAS–platysma and medial approximation of the anterior
platysma in the submental area above the hyoid bone. The
various vectors accomplish corrections of the anterior neck, cer-
vicomental angle, jowls, and nasolabial folds. The first key suture
grasps the platysma at the angle of the mandible and advances
it in a posterosuperior direction; it is secured with figure-of-
eight 2–0 Maxon sutures to the fixed lateral SMAS overlying
the parotid gland. This lifts the cervical platysma and cervical
skin, helps define the jawline, and improves contouring in the
submandibular region (Fig. 47.16).
The lines of closure of the lateral SMAS–platysma in the cheek
and the lateral neck and medial platysma approximation in
the submental area are depicted. Excess fat in the mastoid and
submandibular areas is removed by liposuction. After SMAS
resection, interrupted 3–0 and 4–0 PDS buried sutures are used

Fig. 47.17 In the superficial musculoaponeurotic system (SMAS)-platysma resection, the level of resection is superficial to the parotid masseteric
fascia, which overlies the facial nerve branches. The outline of the SMASectomy is marked on a tangent from the lateral malar eminence to the angle
of the mandible, essentially in the region along the anterior edge of the parotid gland. In most patients this involves a line of resection extending
from the lateral aspect of the malar eminence toward the tail of the parotid gland. Frequently, orbicularis oculi muscle fibers are exposed at the
superior limit of the excision. Usually a 2- to 4-cm segment of superficial fascia is excised, depending on the degree of SMAS–platysma laxity and
debulking required.

606
 47 Short-Scar Rhytidectomy

Fig. 47.18 When superficial musculoaponeurotic system (SMAS) resection is being performed, it is important to keep the dissection superficial to the
deep fascia and avoid dissection into the parotid parenchyma. The size of the parotid gland varies from patient to patient; consequently, the amount
of protection needed for the underlying facial nerve branches will also vary. (Adapted with permission from Baker DC. Minimal incision rhytidectomy
(short-scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001; 21:14-31.)

to close the SMASectomy; the fixed lateral SMAS is evenly sutured
to the more mobile anterior superficial fascia. The last suture lifts
the malar fat pad, securing it to the malar fascia. It is important to
obtain a secure fixation to prevent postoperative dehiscence and
relapse of the facial contour.
If firm monofilament sutures are used, such as PDS or Maxon,
the sutures should be buried and the sharp ends on the knot
trimmed. Final contouring of any SMAS or fat irregularities along
the suture line is completed with scissors. Fat can also be trimmed
at the sternomandibular trough; final contouring is accomplished
with liposuction.
47.5.8 Skin Closure, Temporal Fascia, and
Earlobe Dog-Ears
After SMAS and platysma approximation, some tethering of the
skin might appear at the anterior extent of the subcutaneous
dissection because of the pull of the underlying SMAS. This can
also occur in the lower eyelid with elevation of the malar fat pad.
Further subcutaneous undermining is necessary to free these
tethers, allowing the skin to redrape.
Facial skin redraping is done with a less vertical vector than
with the SMAS. The first key skin suture rotates the facial flap
posteriorly to redrape the midface, jowls, and submandibular
skin. Suture fixation is at the level of the insertion of the superior
helix. I like to use a buried 3–0 PDS through the temporal fascia
with a generous bite of dermis on the skin flap. The closure is
performed with minimal tension. Staples are used to close any
incisions in the hair. A wedge is usually removed at the level of
the sideburn to preserve the hairline. If an anterior hairline inci-
sion has been made, I like to close it with buried 5–0 Monocryl
sutures and 5–0 nylon sutures. Extra time and attention must
be spent on this closure to eliminate any dog-ears and obtain
the finest scar. Beveling the facial flap will enhance hair growth
through the scar.
Excess skin is then trimmed from the facial flap so that there is
no tension on the preauricular closure. ound edges should be
kissing without sutures. Trimming at the earlobe must also be
without tension, and the skin flap is tucked under the lobe with
4–0 PDS, taking a bite of earlobe dermis, cheek flap dermis, and
conchal perichondrium to minimize any tension. A small dog-
ear might be present behind the earlobe; this is easily trimmed
and tailored into a short incision in the retroauricular sulcus. A
closed suction drain is usually brought out through a separate
stab wound in the retroauricular sulcus to drain the neck, and a
Penrose drain is placed through the temporal incision to drain the
face (Fig. 47.5).
47.6 Complications
Table 47.2 summarizes the complications of short-scar rhytid-
ectomy in my series, which are consistent with those of other
standard facelift operations. Despite special attention to blood
pressure control in the postoperative period, the hematoma rate
is still 1.5 . The most common problems are the need for minor
revisions of the earlobe and temporal hairline scars, but these

607
 VIII Surgical Rejuvenation of the Face and Neck

Table 47.2 Complications of the short-scar facelift are far less significant than when I was revising retroauricular
scars or trying to repair posterior hairlines.
Complication Frequency (%)
Hematoma 1.5
Facial paralysis (all resolved in 2 months) 0.3 47.7 Outcomes
Infection (abscess) 0.8
In properly selected patients, the results and longevity are
Skin slough (minor) 1.0 similar to what is achieved with classic rhytidectomies. Type I
Hypertrophic scars 2.0 and II patients who have returned at 8 to 13 years for secondary
Suture granuloma (PDS) 3.5 lifts were very pleased with the results of the first operation. The
shortscar technique was used for all secondary lifts. For type
Earlobe deformity 0.8
III and IV patients, the result in the neck will not be as good as
Retroauricular pleating 2.0 when classic retroauricular incisions are made. This category of
Temporal hairline scar revision 3.0 patients is more likely to require some type of neck revision. The
Cervical tightening/platysmaplasty in poorly selected 2.0 limitations must be discussed preoperatively (Fig. 47.19).
patients Of the short-scar rhytidectomies I performed from 1990 to
2017, all but 30 were performed on women. Because a man’s neck
usually has a thicker layer of skin and muscle, few male patients
are candidates for this procedure.
After 25 years and 3,000 short-scar rhytidectomies, I have
implemented stricter indications:

Fig. 47.19 Short-scar face and neck lift, plication only. Pre- and postoperative. (a) Anterior views. (b) Anteroinferior views. (c) Lateral views.

608

• oung
• Good skin elasticity
• Minimal cervical laxity
• Open neck for platysma
• Rarely compromise the result for a short scar
47.8 rre ing e iffi u e photos. They want to maintain how they have looked for the pre-
Still the Biggest Challenge
“You are only as young as your neck. The goal of neck-contouring
surgery should be a graceful-looking neck, attractive by virtue of
its simplicity rather than its complexity.
hy many surgeons prefer not to open the neck is obvious: less
dissection, less bleeding, less complications such as hematomas.
But in my hands, trying to correct platysma bands and thick
necks only by suturing the platysma laterally usually results in
suboptimal neck contouring, recurrent platysma cords, and early
recurrence of neck deformities. Undercorrected necks are the
most common complaint from patients who consult with me after
having surgery from another plastic surgeon. They usually say,
My doctor did not correct my neck. For 35 years this has been
the most common mistake requiring a major revision after 1–1.5
years. I have not yet found an effective, long-lasting technique to
correct neck deformities without a submental incision and direct
platysmaplasty with neck sculpting. Today I continue to open the
neck on all patients with active platysma cords that contribute to
the neck deformity.
47.9 Facelift Longevity
Patients often ask, Doctor, how long will my face- and neck lift
last
hen I see patients with good skin elasticity, I usually tell them
the facelift I perform will last 10 to 15 years. Over that period of
time they will get a certain amount of relaxation, but having done
Fig. 47.20 Short-scar face and open-neck platysmaplasty. (a) Anterior views. (c) Lateral views.
47 Short-Scar Rhytidectomy
this for more than 35 years (over 8,000 facelifts), I have a good
idea of the longevity a particular patient will get. Many patients
have returned to me for a second facelift, and some for a third
facelift (Fig. 47.20).
Patients usually come back because they have some skin
relaxation, but when I compare their appearance 10 to 15 years
after the original facelift surgery, they still show improvements in
the facial, jowl, and neck areas compared with their preoperative
vious 10 to 15 years, so they often have a second facelift and get
another 10 to 15 years looking their best. I have a group of patients
who have had three facelifts and are well into their 80s. They do
not look perpetually 40 to 50, but they look younger than their
age, and naturally so. e all live much longer today, and this group
of patients remains active well into their late 80s (Fig. 47.21).
Today I restore the facial foundation with SMAS flaps and plica-
tion. I sculpt the neck with platysma muscle flaps and defatting.
I restore facial volume with autologous fat grafting and fillers. All
this is accomplished before redraping and removing excess skin.
Simultaneously I can do full face resurfacing with peels and lasers
and utilize botulinum toxin for wrinkles previously resistant to
treatment. I usually combine all these procedures with the facelift
surgery to obtain the maximum facial improvement with a natural
appearance. One of the most common compliments my patients’
hear from their friends is ou lost weight, you look great.
47.10 Unnatural Results
Today most of the patients I see who look unnatural are not the
result of bad plastic surgery. These patients present with over-
filled, overtoxined, overpeeled, overlasered, distorted faces that
the lay population mistakes for bad plastic surgery. They have
lips like guppies and faces shaped like Avatar. Their faces are so
overfilled that their smile is restricted. This is not the result of
surgery Many patients have had these noninvasive treatments,
spending years and great amounts of money for disappointing,
poor, unnatural results. Their cost and recovery downtime are
609
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 47.21 Short-scar face- and neck lift, closed neck, plication; upper and lower blepharoplasty. (a) Anterior and (b) lateral views pre- and 10 years
postoperative and pre–secondary facelift; (c) anterior and (d) lateral views preoperative and 3 years post secondary facelift; (e) face and neck scars.
often significantly greater than having a surgical face- and neck
lift, which gives superior, longer-lasting results.
47.11 The Gold Standard for Facial
Rejuvenation
I tell my patients that a well performed face- and neck lift, com-
bined with fat grafting or fillers and skin resurfacing, will last
between 10 and 15 years, giving them a more natural look, and
will be far less expensive than fillers, botulinum toxin, and laser
treatments over the same period.
e as plastic surgeons have the ability to accomplish a superior
natural facial rejuvenation in a more economical way than our
nonsurgical colleagues. The fillers and laser and noninvasive
techniques are good adjuncts to our surgery and are certainly
beneficial, prolonging our results and postponing surgery, but
they are not a substitute for well-performed surgery.
610
47.12 Concluding Thoughts
The short-scar rhytidectomy is an excellent facelift technique for
younger patients with good skin elasticity and minimal cervical
laxity. Older patients with excessive cervical laxity and poor
skin elasticity do not get optimal results from this technique, so
it is a compromise for them. Rarely will I sacrifice the result for
a shorter scar.
Although the debate continues about which rhytidectomy
technique yields the best results, there is no single technique
that is best. Most techniques are variations on a basic theme.
hat has clearly evolved in the 21st century is the trend toward
less invasive procedures with low morbidity, short recovery,
and minimal scars. Most patients are happy with these new
simpler techniques. I believe that deeply invasive, more rad-
ical techniques do not give better or longer-lasting results.
Results and longevity are more surgeon-dependent than
technique-dependent.

Clinical Caveats
Suggested Reading
• When the temporal hairline shift is assessed as minimal, the
preferred incision is well within the temporal hair.
• The temporal hairline incision allows a more vertical elevation
of the facial flap while preserving the hairline.
• All skin flap undermining is carried out under direct vision
(with scissors dissection) to minimize trauma to the subder-
mal plexus and preserve a significant layer of subcutaneous
fat on the undersurface of the flap.
• Subcutaneous dissection in the temporal region must be
performed carefully to avoid penetrating the superficial tem-
poral fascia, which protects the frontal branch of the facial
nerve.
• Whenever possible, I prefer to use closed suction-assisted
lipoplasty in the neck and jowls.
• I usually perform lipoplasty before elevating the skin flaps. In
doing so, I am careful not to oversuction the portion of the
SMAS-platysma that will be elevated over the mandible with
the lateral SMASectomy.
• When SMAS resection is being performed, it is important to
keep the dissection superficial to the deep fascia and avoid
dissection into the parotid parenchyma. Because the size of
the parotid gland varies from patient to patient, the amount
of protection for the underlying facial nerve branches will
also vary.
• After SMAS resection, interrupted 3–0 PDS buried sutures are
used to close the SMASectomy, the fixed lateral SMAS being
evenly sutured to the more mobile anterior superficial fascia.
The last suture lifts the malar fat pad, securing it to the malar
fascia. It is important to obtain a secure fixation to prevent
postoperative dehiscence and relapse of facial contour.
47 Short-Scar Rhytidectomy
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lifts with differing techniques: a 10-year follow-up. Plast Reconstr Surg
2009;123(3):1025–1033, discussion 1034–1036
2 Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg
1983;10(3):543–562
3 Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg
1994;93(7):1498–1499
4 Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):509–513
5 Baker D. Rhytidectomy with lateral SMASectomy. Facial Plast Surg
2000;16(3):209–213
6 Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications and
techniques. Clin Plast Surg 2008;35(4):533–550, vi
[7] Baker DC. Short scar facelift. In: Aston S, Steinbrech D, alden , eds. Advances in
Aesthetic Surgery. London, U : Elsevier Ltd; 2009
[8] Baker DC, Aston S , Guy CL, Rees TD. The male rhytidectomy. Plast Reconstr Surg
1977;60(4):514–522
[9] Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas.
Plast Reconstr Surg 2005;115(7):2119–2122, discussion 2123
10 Baker DC, Stefani A, Chiu ES. Reducing the incidence of hematoma requiring
surgical evacuation following male rhytidectomy: a 30-year review of 985 cases.
Plast Reconstr Surg 2005;116(7):1973–1985, discussion 1986–1987
[11] Baker DC, Conley . Avoiding facial nerve injuries in rhytidectomy. Anatomical
variations and pitfalls. Plast Reconstr Surg 1979;64(6):781–795
12 Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle
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13 Connell BF. Cervical lift: Surgical correction of fat contour problems combined
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14 Marchac D, Brady A, Chiou P. Face lifts with hidden scars: the vertical U incision.
Plast Reconstr Surg 2002;109(7):2539–2551, discussion 2552–2554
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parotid and cheek area. Plast Reconstr Surg 1976;58(1):80–88
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[17] Saylan . The S-lift: less is more. Aesthetic Surg J 1999;19:406–409
[18] Tonnard L, Verpaele AM. The MACS-Lift: Short-Scar Rhytidectomy. St. Louis, MO:
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[19] Tonnard L, Verpaele AM. Short-Scar Face Lift: Operative Strategies and Techniques.
St. Louis, MO: uality Medical Publishing; 2007
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 VIII Surgical Rejuvenation of the Face and Neck
48 Extended SMAS Technique in Facial Rejuvenation
James M. Stuzin
Abstract
There are many options for the surgical rejuvenation of the face.
Superficial musculoaponeurotic system (SMAS) management
is an integral part of most if not all techniques. In this chapter
I describe my extended SMAS technique, including anatomic
considerations, volume management, and ancillary procedures.
Keywords
facial aging, facial anatomy, facial ligaments, facial fat com-
partments, facial muscles, facelift, facial shaping, high SMAS
techniques
48.1 Introduction
Surgical rejuvenation of the aging face has become one of the
most frequently performed surgical procedures in the United
States. Facelifting, introduced as a skin-tightening procedure
in the early 1900s, has technically matured during the past
quarter-century. This evolution is directly related to scientific
investigation of facial soft tissue anatomy, resulting in a better
understanding of the changes that occur with aging. Over the
past 40 years, a number of procedures have been developed with
a variety of technical approaches to reconstruct aging-related
anatomic changes.
hen the facelift was first developed, both patients and
surgeons focused on the laxity that occurs with facial aging, and
efforts were directed to tightening what was loose rather than
to restoring the shape of the face hence the term facelift (rather
than facialplasty), a mechanical term that implies a procedure to
lift what has fallen. Unfortunately, this mechanical approach often
produced a tight, operated look the wind-tunnel appearance
that has so often been associated with surgical rejuvenation of the
aging face. Today, based on a better understanding of facial soft
tissue anatomy and the anatomic changes that occur during aging,
facelifting has developed into both a reconstructive procedure
(to reconstruct the anatomic changes from aging) and a more
artistically defined technique that attempts to enhance facial
appearance while minimizing any signs that a surgical procedure
has been performed.
There are many treatment goals for facelifting other than simply
correcting the hallmarks of the aging face, including improvement
of the nasolabial folds, jowls, and cervical contour. A facelift
must also address the aesthetic concepts of improving shape and
bringing out the beauty of the face that existed during youth. The
surgeon attempting to meet these goals must have a thorough
understanding of facial soft tissue anatomy, the anatomic and
aesthetic changes that occur from aging, and the ideal facial shape
that can be obtained for a particular patient. The design of the
surgical access incisions must minimize scar perceptibility and
avoid hairline distortion to prevent surgical stigmata.
612
Aging in the face is complex and multifactorial, and plastic
surgeons may encounter a number of challenges, including the
following:
• The dermal component of aging related to intrinsic and extrin-
sic skin changes (dermal elastosis)
• Descent of facial fat
• Facial deflation, which tends to be compartment-specific
• Radial expansion as facial fat becomes centrifugally situated
away from the facial skeleton
• Cervical and jawline contour
All of these factors influence facial shape with aging. Individual
patients exhibit various degrees of all these problems, and each
component of the aging face should be addressed according to a
patient’s specific needs.
Patient photos taken during youth and as the individual has
grown older are very helpful in determining how a patient has
aged. outhful photos usually reveal the location of the volumetric
highlights present, document areas that have deflated over time,
and indicate both the position and vector of facial fat descent.
These factors illustrate patient-specific changes in facial shape and
clarify the possible methods for repositioning facial fat to improve
and restore shape. From my perspective, restoring facial shape is a
more worthy aesthetic goal than attempting to tighten a loose face.
48.2 Pertinent Anatomy
The anatomy that allows a facelift to be performed safely is the
arrangement of the facial soft tissue in concentric layers. This
arrangement allows dissection within one anatomic plane to pro-
ceed completely separate from structures lying within another
anatomic plane. The layers of the face are the skin; subcutaneous
fat; superficial facial fascia, or superficial musculoaponeurotic
system (SMAS); mimetic muscles; parotidomasseteric fascia
(deep facial fascia); and plane of the facial nerve, parotid duct,
buccal fat pad, and facial artery and vein (Fig. 48.1).
A surgeon attempting to master sub-SMAS dissection must
understand the following anatomic components of facial soft
tissue anatomy.
48.2.1 Anatomic Consistency
Although the thickness of the various layers differ from patient
to patient, structures within each layer are anatomically consis-
tent. Considered two-dimensionally, the facial nerve exhibits a
variety of branching patterns, but on a three-dimensional basis,
the facial nerve always lies within a specific anatomic plane. This
arrangement allows the surgeon to perform extensive sub-SMAS
dissection safely, as long as the dissection proceeds at a level
superficial to the plane of the facial nerve.

Fig. 48.1 Facial anatomy. Abbreviation: SMAS, superficial musculoaponeurotic system.
48.2.2 SMAS Thickness
The thickness of the SMAS may vary significantly from patient
to patient as well as from one region of the face to another.
Overlying the parotid gland, within the temporal region (tem-
poroparietal fascia), and within the scalp (galea), the SMAS is a
substantial, discrete layer. As the SMAS is traced anteriorly in
the face, overlying the masseter and buccal fat pad and into the
malar region, it tends to become thinner and less substantial.
Elevating the SMAS in these areas requires precise dissection so
the flap is thick enough to be useful in facial contouring.
48.2.3 Muscle Layers
The muscles of facial expression are arranged in four overlap-
ping anatomic layers. The muscles that are encountered during
a facelift procedure include the platysma, orbicularis oculi,
zygomaticus major and minor, and risorius muscles, which are
all superficial mimetic muscles. The deeply situated mimetic
muscles are the buccinator and mentalis muscles. Most of the
muscles of facial expression lie superficial to the plane of the
facial nerve and therefore receive their innervation along their
deep surfaces. The only muscles within the facial soft tissue
architecture that lie deep to the plane of the facial nerve are
the mentalis, buccinator, and levator anguli oris muscles; they
receive their innervation along their superficial surfaces.
In the cadaver dissection of the facial nerve shown in Fig. 48.2, it
can be seen that the area directly overlying the zygomatic buttress
48 Extended SMAS Technique in Facial Rejuvenation
is devoid of motor branches, and the only nerves in this region are
sensory branches. For this reason, dissection in the malar area is
quite safe the malar eminence represents a watershed between
the frontal branches of the facial nerve, lying superiorly, and the
zygomatic branches of the facial nerve, which lie just inferior to
the zygomatic buttress.
The cadaver dissection shown in Fig. 48.3 shows the path of the
marginal mandibular nerve. The depressor anguli oris muscle has
been divided so that the nerve can be seen lying along the deep
surface of this muscle. The depressor anguli oris and the depressor
inferioris muscles are typical of facial muscles that lie superficial
to the plane of the facial nerve and receive their innervation along
their deep surfaces.
48.2.4 Anatomic Facial Units
The muscles of facial expression that are situated superficially
within the facial soft tissue architecture are invested by the
superficial fascia. Invested means that the superficial fascia
lines both the superficial and deep surfaces of these muscles. This
SMAS–mimetic muscle complex thus forms a single anatomic
and functional unit that moves facial skin during animation.
48.2.5 Facial Fascia
Deep to the SMAS–mimetic muscle complex lies the deep facial
fascia. The deep facial fascia is a continuation of the superficial
layer of the deep cervical fascia cephalad into the face. here
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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 48.2 Cadaver dissection of the facial nerve.
this fascial layer is identified, it is given specific nomenclature.
Overlying the parotid gland, the deep fascia is called the parotid
fascia or parotid capsule; overlying the masseter muscle, it is
called the masseteric fascia; and in the temporal region, it is
called the deep temporal fascia.
The cadaver dissection shown in Fig. 48.4 on the left is seen after
SMAS and platysma elevation within the cheek; the underlying
parotid gland, the anterior border of the parotid (marked in ink),
and the parotidomasseteric fascia (held in forceps) are exposed.
fi f f f f
branches within the cheek lie deep to this layer. Typically, these
nerve branches course deep to the deep fascia until they reach
the muscles of facial expression, at which point they penetrate the
deep fascia to innervate these mimetic muscles along their deep
surfaces. In the cadaver dissection on the right, the parotidomas-
seteric fascia has been elevated to expose the underlying masseter
muscle and the marginal mandibular nerve as it crosses the facial
artery and vein.
The essential point regarding the architectural arrangement
of the facial soft tissue is that there is a superficial component of
the facial soft tissue that is defined by the superficial facial fascia
and includes the SMAS and those components that move facial
skin (including superficially situated mimetic muscle invested by
the SMAS, the subcutaneous fat, and skin). In contrast, the deeper
component of the facial soft tissue is defined by the deep facial
fascia and the structures related to the deep fascia, including the
614
Fig. 48.3 Cadaver dissection showing the path of the marginal
mandibular nerve.
relatively fixed structures of the face, such as the parotid gland,
masseter muscle, periosteum of the facial bones, and facial nerve
branches. As the face ages, many of the shape changes noted are
associated with a change in the anatomic relationship between the
superficial and deep facial fascia. ith age and loss of ligamentous
support, facial fat descends in the plane between superficial and
deep facial fascia, thereby justifying reelevation of fat through
sub-SMAS dissection to improve facial shape. Similarly, a loss of
ligament support allows the mobile superficial unit of facial soft
tissue to expand radially outward from the deep fascia, accounting
for the loss of angularity in facial shape noted from youth to middle
age. The forces of facial expression remain the primary agent for
radial expansion as the superficial fat loses its deep attachments,
and radial expansion often dominates the shape changes noted
within the submalar region, jowl, and jawline in the aging face.
48.2.6 Facial Fat Compartments
As described by Rohrich and Pessa in 2007, facial fat is not a
homogenous but rather is separated into specific compartments,
with each compartment having specific septal boundaries. Facial
fat compartments exist both superficial and deep to the SMAS.
The superficial facial fat, which lies within the subcutaneous
plane, is superficial to the SMAS and can be manipulated and
repositioned in a SMAS facelift. Deep fat compartments are sit-
uated more anteriorly in the cheek and overly the periosteum of

Fig. 48.4 (Left) Cadaver dissection after SMAS and platysma elevation
within the cheek, exposing the parotid gland and the parotidomasse-
teric fascia. (Right) After elevation of parotidomasseteric fascia, expos-
ing masseter muscle and marginal mandibular nerve. (Reproduced
with permission from Stuzin JM, Baker TJ, Gordon HL. The
relationship of the superficial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg. 1992; 89:441-449.)
the orbit and midface (maxilla, zygoma, and piriform aperture)
lying deep to the mimetic muscles. The deep fat of the cheek
is contiguous with the deep fat of the lower lid, known as the
sub–orbicularis oculi fat (SOOF), and blends the lower lid with
the cheek in youth. Deep malar fat along the anterior maxilla
and zygoma contributes to anterior malar projection in youth.
Of note, both the superficial and deep fat compartments deflate
over time and are responsible for many features of the aging face.
48.2.7 e Su er i i This compartment directly overlies the parotid gland, and as the
Compartments
Superficial facial fat is separated into specific compartments
by the extension of the deeper retaining ligaments through the
cheek to insert into the skin. Rather than being diffuse in their
penetration of the SMAS, the retaining ligaments form specific
fibrous septa between compartments. These junctional boundar-
ies are also the location of vascular perforators. Clinically, while
performing subcutaneous dissection of the cheek, encountering
numerous perforators during dissection indicates an anatomic
transition from one superficial fat compartment to the next.
hile there are many superficial fat compartments, the five
compartments that the plastic surgeon encounters in a facelift
are the (1) lateral compartment, (2) middle compartment, (3)
superficial malar compartment, (4) jowl compartment, and (5)
nasolabial fold compartment. If the dissection is performed under
direct visualization aided by transillumination, it is possible for the
surgeon to recognize which compartment is being dissected as well
as when the transition between compartments occurs (Fig. 48.5).
Lateral Compartment
The lateral compartment is located in the preauricular region,
tends to be narrow and thin, and follows the superficial temporal
48 Extended SMAS Technique in Facial Rejuvenation
Fig. 48.5 The superficial facial fat compartments are situated in the
subcutaneous plane, partitioned by the terminal extensions of the
retaining ligaments. The five superficial compartments of the cheek
from lateral to medial are (1) lateral, (2) middle, (3) malar, (4) jowl,
and (5) nasolabial. Each compartment has its own septal boundaries,
a separate perforator blood supply, and its own tendency to deflation
in aging.
artery cephalically. Typically the lateral compartment is only 3
to 5 cm in width and consists of dense, vascular, and fibrous fat.
dissection proceeds anterior to the parotid, the middle compart-
ment is encountered and the dissection becomes less fibrous.
Middle Compartment
The middle fat compartment lies medial to the parotid and
lateral to the anterior boarder of the masseter. This compart-
ment typically is thicker, less fibrous, and less vascular than the
lateral compartment and is the compartment where most of the
subcutaneous dissection of the cheek is performed in a facelift.
Because this large compartment is thick and avascular, it tends
to be easy to dissect. The anterior border of the middle compart-
ment is bounded by the masseteric ligaments and superiorly
by the zygomatic ligaments, such that the anterior boundary is
adjacent to the lateral malar and jowl compartments. In dissect-
ing between the middle, malar, and jowl compartments, fibrous
terminal ligamentous fibers separating these compartments
are encountered, and the dissection is frequently vascular as
the surgeon encounters the ascending perforators between
compartments. Once the dissection proceeds anteriorly into the
malar and jowl compartments, the surgeon again encounters,
thick easily dissected fat. The transition between the middle,
malar, and jowl compartments anatomically demarcates the
transition between the fixed and mobile regions of the cheek.
615
 VIII Surgical Rejuvenation of the Face and Neck
Typically, I terminate my subcutaneous dissection once the
undermining proceeds anterior to the transition between the
middle, malar, and jowl compartments. At this location the skin
flap has been released from the retaining ligaments of the lateral
cheek, and further dissection is unnecessary. Recognizing which
fat compartment is being dissected, as well as the location where
the transition between the fixed and mobile compartments of
the cheek is located during surgery, provides a patient-specific
anatomic landmark for the degree of subcutaneous dissection
required for skin flap release. I have found that increasing preci-
sion in terms of the degree of dissection required improves both
aesthetic control and lessens the morbidity of the procedure,
leading to a quicker recovery and an overall more consistent result
(Fig. 48.6).
Su er i r m r men
The superficial malar compartment is situated along the lateral
aspect of the zygomatic eminence and extends anteriorly toward
the paranasal region, providing volume to the anterior cheek.
This compartment is situated superficial to the orbicularis oculi
and elevators of the upper lip. In dissecting from the lateral cheek
(middle compartment), the malar compartment is identified as
the surgeon encounters numerous perforators from the trans-
verse facial artery as well as dense fibrous zygomatic ligaments
Fig. 48.6 The middle fat compartment (dark color) is situated between
the lateral, malar, and jowl compartments. This compartment consists
of thick, less vascular fat and is the compartment where most of the
subcutaneous dissection is performed in a facelift. Once the skin flap
dissection proceeds into the malar and jowl compartments, the flap is
released from the retaining ligaments of the lateral cheek and further
dissection is unnecessary.
616
(termed McGregor’s patch). The upper masseteric ligaments are
similarly encountered along the inferior aspect of the zygoma,
and the combination of dense fibrous fat with vascularity can
make it difficult to identify the subcutaneous plane accurately
in this region. As the zygomatic branches of the facial nerve
are superficially positioned just deep to the SMAS lateral to the
zygoma, accurate plane identification is an important safety
consideration (Fig. 48.7).
Jowl Compartment
The jowl compartment consists of fluffy, thick fat and is situated
between the mandibular ligaments and the masseteric ligaments
overlying the facial portion of the platysma. owl fat tends to be
avascular and easy to dissect. In aging, attenuation of support
from the masseteric ligaments allows the platysma and overlying
jowl fat to descend into the neck, which obscures the definition
of the mandibular border. As the jowl compartment tends not to
deflate in aging, jowl descent accompanied by adjacent perioral
deflation is responsible for this fat compartment becoming more
apparent in middle age and elderly patients.
Nasolabial Fold Compartment
The nasolabial fold compartment sits just lateral to the naso-
labial fold and anterior to the malar compartment. This fat
compartment typically consists of thick dense fat and rarely
deflates in aging. For this reason, the nasolabial compartment
typically becomes more obvious in aging as the adjacent malar
compartment and perioral regions deflate.
Fig. 48.7 Cadaver dissection at the junction between the middle
and malar compartments along the lateral zygoma. When transiting
compartments, retaining ligaments are encountered as well as vascular
perforators. The scissors in this photograph are situated where the
zygomatic ligaments inset into the skin (separating the superior aspect
of the middle compartment from the lateral malar compartment).
The density of ligaments in this region can obscure proper plane
identification, and it is safer to dissect superficially along the transition
point between the middle and malar compartments, as the zygomatic
motor branches lie directly deep to the superficial musculoaponeurotic
system (SMAS) in this location. Notice the numerous vascular perfo-
rators present at this location, typical of vascular perforators located
along transition points between compartments. Once the subcuta-
neous dissection proceeds anterior to the middle compartment, the
mobile region of the cheek is encountered.
 48 Extended SMAS Technique in Facial Rejuvenation

48.2.8 Deep Facial Fat Compartments

The deep compartments of the cheek lie deep to mimetic muscles
and overlie the periosteum of the orbit, midface, and piriform
aperture. The deep facial fat compartment (SOOF), which affects
lower lid morphology, is situated deep to the orbicularis oculi
and is divided into a lateral and medial component. The anterior
cheek is supported by the deep malar fat pad, which similarly has
a medial and lateral component. The medial component of deep
malar fat is situated along the piriform aperture and blends the
perioral region with the cheek in youth. The lateral component
of deep malar fat contributes to anterior malar projection and
blends the anterior cheek with the lateral cheek where it abuts
the buccal extension of the buccal fat pad. This lateral compo-
nent also abuts the orbit, blending the eyelid and cheek in youth
(Fig. 48.8).
The surgical importance of differentiating between superficial
and deep deflation is that superficial deflation can be improved by
repositioning superficial fat via the SMAS, while deep deflation
requires volumetric augmentation for correction.
Fig. 48.8 The deep malar compartment overlies the periosteum of
48.2.9 Retaining Ligaments the anterior cheek, deep to the mimetic muscles. The deep malar
compartment exhibits a medial and lateral component and abuts
the sub–orbicularis oculi fat (SOOF) compartment of the lower lid.
Communication between the superficial and deep facial fascia The medial component abuts the piriform aperture and provides
occurs at the level of the retaining ligaments. These structures volumetric blending between the perioral region and anterior cheek in
fix facial soft tissue in a normal anatomic position, resisting grav- youth. Similarly, the lateral component abuts the lower lid and SOOF,
providing volumetric blending across the lid–cheek junction in youth.
itational forces. Retaining ligaments exist in specific locations
of the face, including (1) the malar area, where they are called
zygomatic ligaments; (2) along the anterior border of the masse-
ter muscle, forming the masseteric–cutaneous ligaments; (3) over (4) in the parasymphysial and symphysial region of the mandible,
the parotid gland, forming the parotid–cutaneous ligaments; and where they are called mandibular ligaments (Fig. 48.9).

Fig. 48.9 Retaining ligaments. (Adapted with permission from Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced facial
contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000; 105:290-301.)

617
 VIII Surgical Rejuvenation of the Face and Neck
There are two types of retaining ligaments, as defined by their
origins. The osteocutaneous ligaments are a series of fibrous
bands that run from periosteum to dermis. The zygomatic and
mandibular ligaments are examples of these structures.
The second system of supporting ligaments is formed by a
coalescence of the superficial and deep facial fascia in certain
regions of the face (the parotid–cutaneous ligaments and the mas-
seteric–cutaneous ligaments). These fascial connections, which
fix both superficial and deep fascia to underlying facial structures,
such as the parotid gland and masseter muscle, similarly lend
support against gravitational forces through fibrous septa that
extend into the dermis. Attenuation of support from the retaining
ligaments is responsible for many of the features of facial aging.
In the evolution of midface aging, the zygomatic– and masse-
teric–cutaneous ligaments are particularly important. The zygo-
matic ligaments originate from the periosteum of the malar region
as a series of fibrous septa that begin laterally in the region where
the zygomatic arch joins the body of the zygoma and permeate the
malar pad (fibrous McGregor’s patch). The zygomatic ligaments tend
Fig. 48.10 Attenuation of the zygomatic ligamentous support
suspending the malar pad and the medial cheek leads to an inferior
migration of these soft tissues adjacent to the line of the muscular
fixation of the nasolabial fold. This deepens with aging, and an
accumulation of cheek soft tissue lateral to the nasolabial line also
contributes to fold prominence. The nasolabial fat compartment rarely
deflates in aging. (Reproduced with permission from Stuzin JM,
Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr
Surg. 1992; 89:441-449.)
618
to be stout laterally and weaken medially. The zygomatic ligaments
fix the malar pad to the underlying zygomatic eminence in a youth-
ful face, providing volumetric highlights in a youthful angular face.
The malar region is predominantly affected by deflation in
aging, leading to loss of volume overlying the lateral zygoma.
Additionally, attenuation of the zygomatic ligamentous support
suspending the malar pad and the medial cheek leads to an infe-
rior migration of these soft tissues adjacent to the line of the mus-
cular fixation of the nasolabial fold. ot only does the fold deepen
with aging, but an accumulation of cheek soft tissue lateral to the
nasolabial line also accounts for fold prominence. As noted, the
nasolabial fat compartment rarely deflates in aging (Fig. 48.10).
The masseteric–cutaneous ligaments are a series of fibrous
bands that extend along the entire anterior border of the masseter
muscle and provide soft tissue support in the submalar region of
the cheek. These fibers are identified superiorly in the malar area,
where they mingle with the zygomatic ligaments and extend
along the anterior border of the masseter as far inferiorly as the
mandibular border. These fibers represent coalescence between
the superficial and deep fasciae, extending from the masseter
muscle vertically to insert into the overlying dermis. hen an
individual is young, the masseteric ligaments support the soft
tissues of the medial cheek superiorly above the mandibular
border and internally to conform to the deep fascia overlying the
buccinators.
Fig. 48.11 Attenuation of support from the masseteric ligaments allows
the soft tissues of the lower cheek and the facial portion of the platysma
to descend inferiorly, leading to the formation of the facial jowl.
(Reproduced with permission from Stuzin JM, Baker TJ, Gordon HL.
The relationship of the superficial and deep facial fascias: relevance
to rhytidectomy and aging. Plast Reconstr Surg. 1992; 89:441-449.)
 48 Extended SMAS Technique in Facial Rejuvenation

Attenuation of support from the masseteric ligaments allows

the soft tissues of the lower cheek and the facial portion of the
platysma to descend inferiorly, leading to the formation of the
facial jowl. In addition, loss of this ligamentous support allows the
submalar fat and jowl fat to radially expand outward from the deep
fascia and mandible, obscuring jawline definition (Fig. 48.11).

48.2.10 Facial Nerve Danger Zones

Facial nerve injury is a feared complication in performing facial
aesthetic and reconstructive procedures. hile most facial
nerve branches are protected, as they are situated deep to the
deep fascia as they traverse the cheek, there are specific regions
of the cheek where facial nerve branches are superficially posi- a
tioned and more prone to injury. These danger zones are typically
located at regions of transition between facial fat compartments
and are characterized by nerve branches situated in the sub-
SMAS plane between superficial and deep fascia. Recognition of
the plane of dissection when dissecting within the danger zones
remains a key element in preventing inadvertent motor branch
injury (Fig. 48.12).

Frontal Branch
After exiting the parotid, the frontal branch overlies the peri-
osteum of the zygomatic arch. Cephalad to the zygomatic arch
the frontal branch travels in the plane between the SMAS (tem-
poroparietal fascia) and deep temporal fascia, invested in sub-
SMAS fat.
The frontal branch becomes more superficial as it traverses the
temporal region and approaches the frontalis, where this mimetic
muscle receives its innervation. As the frontal branch lies just
deep to the SMAS as it approaches the frontalis, dissection deep
to the SMAS in this region can produce a motor branch injury.

Zygomatic Branch
After exiting the parotid, the zygomatic branch lies deep to the
deep fascia and overlies the masseter. As it approaches the zygo-
maticus major muscle, the zygomatic branch typically pene-
trates the deep fascia and becomes situated in the plane between
superficial and deep fascia just inferolateral to the zygomatic
eminence. In subcutaneous undermining of the cheek, the region
lateral to the zygomatic eminence is both fibrous and bloody, as
zygomatic ligaments, upper masseteric ligaments, and perfora-
tors from the transverse facial artery traverse this region. For this
reason the proper plane of dissection can be difficult to identify.
As the zygomatic branch is superficially situated in this location,
inadvertent dissection, deep to the SMAS in this location, can
produce a motor branch injury resulting in upper lip weakness.
Proper plane identification is essential in this region of the cheek,
and it is often helpful to dissect the less fibrous areas of the cheek
both superior and inferior to the zygomatic eminence to ensure
accurate plane identification prior to dissecting in this danger
zone (Fig. 48.13).
Marginal and Cervical Branches
The cervical branch exits the tail of the parotid and almost
immediately is situated in the plane between superficial and
b
Fig. 48.12 (a) In this cadaver dissection, the areas of facial nerve
danger zones representing the superficially situated frontal branch,
zygomatic branch, and cervical branch are noted (black X). Cephalical
red dots represent the path of the parietal and frontal branches of
the superficial temporal artery. The red dots anteriorly in the cheek
represent the junction between the fixed and mobile regions of the
cheek, demarcated by the position of the lateral zygomatic ligaments
and masseteric ligaments. In terms of danger zones, the frontal branch
is superficially positioned within the temporal region as it approaches
the frontalis. The zygomatic branch is at greatest jeopardy just lateral
to the zygomatic eminence, where it is juxtaposed to the merging
of the zygomatic and upper masseteric ligaments. The cervical
branch is at greatest jeopardy along the mandibular angle, where
it is juxtaposed to the caudal masseteric ligaments. Proper plane
identification and inadvertent dissection deep to the superficial mus-
culoaponeurotic system (SMAS) should be avoided in these regions.
(b) Artist’s illustration of the facial nerve danger zones of the lateral
cheek. Danger zones represent regions where facial nerve branches
are superficially positioned, in the plane between the SMAS and deep
fascia. Inadvertent dissection deep to the SMAS in these areas may
result in motor branch injury.

619
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 48.13 This cadaver photograph shows both the zygomatic and
buccal branches as they traverse the cheek. The lower black arrow
points to the major buccal branch, which parallels the parotid duct
and lies deep to the deep fascia in this location. The upper arrow points
to the zygomatic branch, which innervates the zygomaticus major
(held by forceps) just lateral to the zygomatic eminene. Note that this
branch penetrates the deep fascia in close proximity to the transverse
facial artery and lies in the plane between superficial and deep fascia
in this location. As this region tends to be fibrous (zygomatic and
upper masseteric ligaments) and bloody (from perforators from the
transverse facial artery), plane identification can be difficult. When in
doubt, dissect superficially to avoid inadvertent dissection below the
superficial musculoaponeurotic system within this danger zone.

deep fascia. It typically traverses the lower cheek deep to both

SMAS and platysma before innervating this muscle along its
deep surface. The cervical branch is at greatest risk of injury
adjacent to the mandibular angle and caudal mesenteric lig-
aments. The caudal mesenteric ligaments tend to have stout
fibers and typically form a firm attachment between the skin of
the lower cheek, the platysma, and the underlying periosteum.
As a result of this adherence along the angle of the mandible,
the region of the caudal masseter represents a danger zone, as
inadvertent dissection deep to the platysma will result in cervi-
Fig. 48.14 (a) Cadaver dissection illustrating the relationship of
cal branch injury. The key to safety in subcutaneous dissection the marginal and cervical branches adjacent to the caudal border
when transiting from the cheek to the neck is accurate plane of the masseter. Note that the cervical branch (lower arrow) is more
identification to ensure that the dissection is carried superficial superficial than the marginal branch and lies just deep to the platysma
(between superficial and deep fasciae) before innervating this muscle.
to the platysma.
The marginal branch (upper arrow) lies deep to the deep fascia as it
The marginal branch exits the tail of the parotid and is situated crosses the facial artery and vein, and it tends to stay deep until it
deep to the deep fascia, typically invested in sub-SMAS fat. The reaches the depressor anguli oris and inferioris, which are innervated
along their deep surfaces. (b) Artist’s illustration demonstrating the
marginal branch remains deep to the deep fascia as it crosses
depth relationship between the marginal and cervical branches along
the facial artery and vein and becomes superficial only when it the caudal border of the masseter. At this location, the cervical branch
reaches the depressors of the lower lip, which are innervated lies just deep to the platysma in the plane below the superficial mus-
along their deep surfaces. Because of the deep position of the culoaponeurotic system, while the marginal branch is situated deep to
the deep fascia. Because of its more protected position, the marginal
marginal branch as it transits across the cheek, it is infrequently branch is rarely injured in a facelift.
injured in subcutaneous dissection. The marginal branch is at
greater risk in sub-SMAS dissection if the dissection is carried
anteriorly as far forward as the facial artery and vein (which is not
necessary for adequate SMAS release). In this location, the caudal 48.3 Aesthetic Analysis and
masseteric ligaments are dense, and the proper plane of dissection
can appear obscure. Accurate release of the SMAS anterior to the Treatment Planning
tail of the parotid and utilizing blunt dissection once the SMAS
As the face ages, facial shape changes. Some of these changes
has been freed from the parotid tail will protect the underlying
can be addressed in a straightforward manner, whereas others
marginal branch (Fig. 48.14).
present difficult technical challenges. A paradox for me has

620

always been that facial anatomy (in terms of basic soft tissue
architecture) is essentially unchanged from youth to middle
age, but facial appearance changes greatly over time and is
patient-specific. Although each face ages differently, there are
common features in all of them.
48.3.1 Descent and Radial Expansion
of Facial Fat
As the face ages, facial fat descends as well as becoming situated
outward from the facial skeleton and deep fascia, in what is
termed radial expansion. Facial fat descent predominantly affects
the lower cheek and jowl, while radial expansion is noted along
the nasolabial fold, submalar region, and jowl. Fat descent as
well as the outward migration of fat produces the bottom-heavy
square shape noted in middle age. As an example, in the photo-
graph taken at age 25 in Fig. 48.15, the patient exhibits a youthful
face full of well-supported facial fat, situated overlying the malar
eminence and along the lateral cheek as well as the preparotid
region. In addition, there is a concavity or depression overlying
the buccal recess just anterior to the masseter muscle as the
superficial fat and skin of the submalar region are bound to the
deep fascia and buccinator in youth. The combination of fullness
in the malar region and lateral cheek and a concavity overlying
the buccal recess accounts for the angular, tapered appearance
of the youthful face. In the same woman at age 55, the aesthetic
effect of facial fat descent and radial expansion of the submalar
region and jowl becomes obvious.
Typically, faces in middle age are square, with little differential
between malar highlights (which deflate) and midfacial fat. As
facial fat becomes situated more inferiorly in the face, the face
appears visually longer. The aesthetic consequences of loss of
facial angularity with aging are as important as the depth of the
nasolabial fold and jowling. For me, an improvement of facial
shape is one of the primary goals of facial rejuvenation.
Fig. 48.15 Descent and radial expansion of facial fat. (Adapted with
permission from Stuzin JM, Baker TJ, Baker TM. Refinements in face
lifting: enhanced facial contour using Vicryl mesh incorporated
into SMAS fixation. Plast Reconstr Surg. 2000; 105:290-301.)
48 Extended SMAS Technique in Facial Rejuvenation
48.3.2 ume nd i e i n
outhful faces are full of well-supported fat. Deflation occurs
over time, and it tends to be most apparent in areas of the face
that have a high density of retaining ligaments (the lateral malar
eminence, preparotid area, lateral and infraorbital rim, and
lateral chin). outhful faces have a smooth contour between the
aesthetic subunits. Middle-aged faces, as a result of both defla-
tion and radial expansion, develop demarcation lines between
adjacent regions of the cheek. An appropriate aesthetic treat-
ment plan requires repositioning of the descended soft tissue
into areas of facial deflation to improve shape, not only to restore
the volume of youth but also to blunt the demarcation lines
between aesthetic subunits. Volumetric augmentation through
autologous fat injection or other injectable soft tissue fillers is an
ancillary procedure that can be useful for augmenting areas of
deflation not corrected by fat repositioning via the SMAS.
Deflation is a complex process that tends to be regional and
age-specific. The aesthetic significance of fat compartmentaliza-
tion is that deflation tends to occur within a specific compartment
of the cheek, rather than homogeneously across the entire cheek
with age.
At the risk of oversimplification, deflation tends to occur earli-
est within regions of high ligamentous density, which are situated
predominantly in the lateral cheek. The lateral cheek tends to
show signs of deflation in the fourth decade, while malar deflation
is more apparent in the fifth to sixth decade. From a fat compart-
ment perspective, the lateral and middle fat compartments tend
to deflate a decade earlier than the malar compartment, while the
jowl and nasolabial compartments rarely deflate with age.
The 42-year-old patient shown in Fig. 48.16 has signs of early
facial aging resulting primarily from lateral cheek deflation and
a b
Fig. 48.16 Patient aged 42 with signs of early facial aging resulting
primarily from lateral and middle compartment deflation and radial
expansion along the jawline but little evidence of malar deflation. She
is seen (a) before and (b) after a face- and neck lift. Anteriorly situated
fat was brought into the upper lateral midface, where it filled the areas
of deflation, thereby blunting the demarcation lines between aesthetic
subunits. The change in facial shape is evident; her face appears more
structured and supported after facial fat repositioning. (Reproduced
with permission from Stuzin JM. Restoring facial shape in face
lifting: the role of skeletal support in facial analysis and midface
soft-tissue repositioning. Plast Reconstr Surg. 2007; 119:362-376.)
621
 VIII Surgical Rejuvenation of the Face and Neck
radial expansion along the jawline. Deflation has occurred in the
lateral and middle compartments but she exhibits little evidence
of malar deflation. She underwent a face- and neck lift. Anteriorly
situated fat was brought into the upper lateral midface, where
it filled the areas of deflation, thereby blunting the demarcation
lines between aesthetic subunits. The change in facial shape is
evident; her face appears more structured and supported after
facial fat repositioning.
Medial cheek and malar deflation (both superficial and deep
compartments) tends to occur later in life and is responsible
not only for the loss of volumetric support within the anterior
cheek but also for the development of the infraorbital V deformity
(resulting primarily from deep malar deflation). Deflation in this
region results in an apparent increase in the vertical length of the
lower lid as the lid–cheek junction visually descends inferiorly
into the anterior cheek. The correction of deep malar deflation
requires volume augmentation, while superficial malar deflation
can be improved through the repositioning of fat via the SMAS.
A variant of deflation develops in some faces in the submalar
region lateral to the oral commissure. In these type of patients,
Fig. 48.17 Cadaver dissection illustrating the muscular insertions into
the oral commissure and modiolus. (Reproduced with permission
from Lambros V, Stuzin JM. The cross-cheek depression: surgical
cause and effect in the development of the “joker line” and its
treatment. Plast Reconstr Surg. 2008; 122:1543- 1552.)
622
deflation results in an accentuation of submalar concavity, which
becomes more obvious after the vertical soft tissue shifts associ-
ated with a facelift. The accentuation of the submalar deflation
lateral to the oral commissure can result in the development of
joker lines, or cross-cheek depressions, which visually appear as if
the lateral commissure has been pulled into the cheek. Avoidance
of vertical soft tissue repositioning in conjunction with volume
addition in the submalar recess lateral to the oral commissure can
help prevent the creation of postoperative cross-cheek depres-
sions. Preoperative recognition of this form of submalar deflation
and the tendency to develop cross-cheek depressions is the key in
preventing this unattractive but all too common surgical stigma
associated with facelifting.
The cadaver dissection shown in Fig. 48.17 illustrates the mus-
cular insertions into the oral commissure and modiolus. The small
arrow overlies the facial portion of the platysma and points to the
risorius muscle; the large arrow points to the depressor anguli oris
muscle, where it merges with the platysma. Superiorly, the inser-
tion of the zygomaticus major into the lateral commissure can be
seen, with a slip of muscle inserting inferiorly into the modulus.
Fig. 48.18 Man aged 59 who lost 41 kg (90 pounds) after a gastric
bypass procedure. There are areas of deflation along the infraorbital
rim, lateral orbital rim, and malar region. Also noticeable is the
apparent length of the lower lid from the infraorbital V deformity in
association with deep malar deflation. (Reproduced with permission
from Stuzin JM. Restoring facial shape in face lifting: the role of
skeletal support in facial analysis and midface soft-tissue reposi-
tioning. Plast Reconstr Surg. 2007; 119:362-376.)
 48 Extended SMAS Technique in Facial Rejuvenation

Preoperative deflation in the region just lateral to the oral com-

missure, in the area between the elevator and the depressors of
the lip, can be accentuated in the vertical shifts associated with
facelifting. More oblique vectors and volume augmentation to
this region will prevent the creation of postoperative cross-cheek
depressions. The key to prevention is preoperative recognition
and adjusting the treatment plan accordingly.
The 59-year-old man shown in Fig. 48.18 has lost 41 kg (90
pounds) after a gastric bypass procedure. There are areas of defla-
tion along the infraorbital rim, lateral orbital rim, and malar region.
Also noticeable is the apparent length of the lower lid from the
infraorbital V deformity in association with deep malar deflation.
The radial expansion of skin and fat lateral to the nasolabial fold is
most marked on the right side. ot only does the malar fat deflate
and descend, but also attenuation of the retinacular connections
between skin, fat, and deep facial fascia lateral to the nasolabial
line allows centrifugal prolapse of soft tissue, which accentuates
the nasolabial prominence. This patient’s postoperative results
show that the deflated areas have been improved by repositioning
fat into them. The nasolabial folds are improved after malar pad
repositioning, but the correction is incomplete, especially on the
right. Malar pad elevation helps flatten the prominent nasolabial
fold and improve the infraorbital V deformity, but it often leads
to incomplete correction of radial expansion, with the skin lateral
to the nasolabial line remaining prolapsed from its attachments
to the facial skeleton. Deep malar fat grafting (which was not
performed in this patient) would have provided improved resto-
ration of anterior malar volume and improved blending of contour
between the lower lid and cheek.

48.3.3 The Role of Skeletal Support
in Formulating a Surgical
Treatment Plan
Facial shape and contour are intuitively evaluated when the
surgeon analyzes a patient for facial rejuvenation. Often the
two-dimensional considerations seen in photographs are the
easiest aspects of aging to identify, and factors such as nasolabial
fold depth, jowl prominence, and cervical contour become the
primary focus for improving the appearance of a middle-aged
face. Although these factors are certainly important for treat-
ment planning, the more subtle, three-dimensional qualities of
facial shape are equally important and are greatly influenced by
underlying skeletal support.
There are several major factors that I have found helpful to con-
sider when evaluating facial shape during preoperative analysis.
Facial Width, Bizygomatic Diameter,
and Malar Volume
The emphasis of facelifting over the past 30 years has been on
malar pad elevation. Although malar pad elevation and res-
toration of malar highlights is important for improving facial
shape, it needs to be patient-specific. Many patients present
preoperatively with wide faces, strong malar eminences, and
large malar volume with little evidence of malar fat descent. In
these individuals it is necessary to evaluate preoperatively the
degree of malar pad elevation required to improve facial shape.
Fig. 48.19 Patients who exhibit strong malar eminences and wide
bizygomatic diameter often benefit from having malar highlights
restored but usually do not require significant enhancement of
malar volume, because that causes a wide face to appear even wider
postoperatively. Shaping in these faces usually focuses on improving
the lower two-thirds of the cheek, specifically addressing jowl fat
repositioning as well as creating submalar hollowing to improve
the aesthetic relationship between malar and submalar regions.
(Reproduced with permission from Stuzin JM. Restoring facial
shape in face lifting: the role of skeletal support in facial analysis
and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;
119:362-376.)
Facial width and bizygomatic diameter reflect the underlying
degree of skeletal support. Patients who exhibit strong malar
eminences and wide bizygomatic diameter often benefit from
having malar highlights restored but usually do not require
significant enhancement of malar volume, because that causes a
wide face to appear even wider postoperatively. Shaping in these
faces usually focuses on improving the lower two-thirds of the
cheek, specifically addressing jowl fat repositioning as well as
creating submalar hollowing to improve the aesthetic relationship
between malar and submalar regions (Fig. 48.19).
Facial Length and the Relative Vertical Heights
of the Lower and Middle Thirds of the Face
Compared with wide faces, patients who present with vertical
maxillary excess often have long, thin faces on front view. As
facial fat descends, it becomes situated anteriorly and inferiorly,
making the face appear even longer.

623
 VIII Surgical Rejuvenation of the Face and Neck
Long, thin faces often benefit from an enhancement of malar
volume. SMAS dissection and facial fat repositioning anteriorly
over the zygomatic eminence allow the surgeon to restore malar
volume, thereby increasing bizygomatic diameter. hen malar
volume is enhanced, the face appears wider. Volume augmenta-
tion to the deep malar compartment is often helpful in improving
facial shape in the long thin face (Fig. 48.20).
Convexity of the Malar Region Juxtaposed
with the Concavity of the Submalar Region
In youth, facial fat is situated over the malar and preparotid
region. Malar fullness is juxtaposed to a concavity in the subma-
lar region overlying the buccinator muscle. As patients age, the
relationship between the malar and submalar regions changes,
and facial shape changes with it. In most patients, the lateral
malar region deflates with aging while the submalar region
radially expands outward, resulting in little differential noted
between lateral malar highlights and submalar fullness. As the
aesthetic relationship between the malar and submalar region
a b
c d
Fig. 48.20 (a,c) Long, thin faces often benefit from an enhancement
of malar volume. (b,d) Superficial musculoaponeurotic system
dissection and facial fat repositioning anteriorly over the zygomatic
eminence enable the surgeon to restore malar volume, thereby
increasing bizygomatic diameter. When malar volume is enhanced, the
face appears wider. (Reproduced with permission from Stuzin JM.
Restoring facial shape in face lifting: the role of skeletal support in
facial analysis and midface soft-tissue repositioning. Plast Reconstr
Surg. 2007; 119:362-376.)
624
changes, there is a loss of the angular, tapered shape of youth,
making middle-aged faces appear oval, square, or bottom heavy.
Preoperatively, the face of the patient shown in Fig. 48.21 is
oval as a result of malar deflation. Evaluating the relationship
between the malar and submalar regions on the front view, for
me, is an essential component of aesthetic treatment planning.
For many patients, restoring this relationship by increasing malar
highlights and malar volume and reconstructing the concavity
in the submalar region by internal fat repositioning becomes a
central component of improving facial shape.
a b
Fig. 48.21 (a) Oval face due to malar deflation. Evaluating the rela-
tionship between the malar and submalar regions on the front view is
an essential component of aesthetic treatment planning. (b) For many
patients, restoring this relationship by increasing malar highlights and
malar volume and reconstructing the concavity in the submalar region
by internal fat repositioning become a central component of improving
facial shape. (Reproduced with permission from Stuzin JM.
Restoring facial shape in face lifting: the role of skeletal support in
facial analysis and midface soft-tissue repositioning. Plast Reconstr
Surg. 2007; 119:362-376.)
a b
Fig. 48.22 (a) Preoperatively, this patient shows a blunting of
the relationship between the malar and submalar regions. (b)
Postoperatively, enhancing malar volume and the bizygomatic
diameter and restoring the concavity within the submalar region
have made her face appear more angular as well as shorter vertically.
(Reproduced with permission from Stuzin JM. Restoring facial
shape in face lifting: the role of skeletal support in facial analysis
and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;
119:362-376.)
 48 Extended SMAS Technique in Facial Rejuvenation

Preoperatively, the patient shown in Fig. 48.22 shows a blunt- flatness in the lateral midface overlying the masseter and parotid.
ing of the relationship between the malar and submalar regions. This imparts a tight, unnatural appearance to the face. The effect
Postoperatively, enhancing malar volume and the bizygomatic of scar perceptibility is evident when strong skin tension is used
diameter, and restoring the concavity within the submalar region in an attempt to contour the face.
have made her face appear more angular as well as shorter
vertically.
48.4.1 Surgical Technique:
Vertical Height of the Mandibular Ramus and Extended SMAS Dissection
Horizontal Length of the Mandibular Body Most patients who have enough laxity to justify a facelift will
benefit from tightening the superficial fascial layer. Restoring
The vertical height of the mandibular ramus and the horizontal
support to the underlying deeper facial soft tissues has become
length of the mandibular body provide skeletal support for the
a key part of my approach to improve facial aging. If the SMAS is
lower two-thirds of the face. Patients who present with a normal
thin and tenuous, plication of this layer is an alternative to formal
mandibular ramus height, as well as adequate horizontal length
SMAS elevation. However, in my opinion, better contouring, more
of the mandibular body, usually have excellent skeletal support
aesthetic control and longer-lasting results are obtained after a
for soft tissue repositioning and are, therefore, less of a surgical
formal dissection of the superficial fascia from the restraint of
challenge. Patients with a short mandibular ramus, an open man-
the retaining ligaments.
dibular plane angle, and a short length of the mandibular body
In skin flap dissection, it is important to develop uniform
typically have poor skeletal support for midface and perioral
skin flaps during the subcutaneous undermining, taking care to
soft tissue repositioning. These patients are a greater surgical
leave some intact fat along the superficial surface of the SMAS,
challenge for restoring facial shape, and they often benefit from
especially where the SMAS is to be dissected. If the skin flaps are
volumetric augmentation, either alloplastic or autogenous, to
dissected so that no fat is left along the superficial surface of the
enhance skeletal support.

48.4 i eren i e r r
Redraping SMAS Dissection
and Skin Flap
Dermal elastosis and skin laxity in an aging face often do not
occur in the same direction or at the same rate as the descent
of fat and other factors affecting the superficial fascia. The main
advantages of performing skin dissection separate from SMAS
dissection is that it allows these two layers to be draped along
vectors that are independent of one another. Another advantage
of a two-layer SMAS facelift is that the contouring tension is
placed on the superficial fascia, thereby allowing the surgeon
to use less tension for skin closure. This also improves control
over scar perceptibility. In my experience, facial fat is usually Fig. 48.23 Vectors for redraping superficial musculoaponeurotic
system dissection and skin flap.
repositioned in a more vertical vector than skin flap redraping.
Strong vertical shifting of the cervicofacial flap is traditional in
many facelift techniques and is required in short scar facelifts
that lack a postauricular incision. Although skin tightening can
produce a dramatic improvement in facial laxity, the aesthetic
effects of vertical skin vectoring, unfortunately, have been poorly
defined. Specifically, when skin is shifted in a cephalad direction,
the effect of skin tension commonly produces an accentuation of
flatness in the preparotid region, an area that typically deflates
with aging. In my opinion, vertical skin shift often produces an
unnatural tightness, accounting for the typical surgical appear-
ance associated with rhytidectomy. If the surgeon has been
successful in repositioning descended facial fat, strong vertical
skin tension is neither desirable nor required to enhance the
postoperative result (Fig. 48.23).
The two patients shown in Fig. 48.24 show the effect of vertical
rotation of the cervicofacial flap associated with hairline distor-
tion. A skin flap that is overrotated in a cephalad direction not only Fig. 48.24 Effect of vertical rotation of the cervicofacial flap associated
can compromise the temporal hairline but also tends to produce with hairline distortion.

625
 VIII Surgical Rejuvenation of the Face and Neck
SMAS, then the SMAS becomes more difficult to raise, being thin,
tenuous, and prone to tearing. In a SMAS-type facelift, much of
the contouring is obtained by elevation and fixation of the SMAS
layer. The more substantial the SMAS flap, the better the surgical
and aesthetic control in the result.
I carry the subcutaneous skin flap dissection into the malar
region just past the restraint of the lateral zygomatic ligaments.
This represents the subcutaneous junction between the superior
middle and malar fat compartments. Caudally, the subcutaneous
undermining carries the skin flap dissection from the middle into
the lower malar and jowl fat compartments, just anterior to the
restraint of the masseteric ligaments. From an anatomic perspec-
tive, this skin flap dissection is carried anteriorly to the junction
between the fixed and mobile regions of the cheek.
Accuracy in the degree of subcutaneous dissection provides
more aesthetic control, and overdissection of the skin flap should
be avoided, as it is unnecessary to recruit skin and increases
the morbidity of the procedure. Limiting skin flap elevation just
past the restraint of the retaining ligaments provides adequate
flap release as well as better aesthetic control by preserving the
attachments that go from SMAS to the facial skin via the reti-
nacula cutis anteriorly. The preservation of these attachments,
followed by adequate release of the SMAS, enables the surgeon
Fig. 48.25 The incision design for the extended superficial muscu-
loaponeurotic system (SMAS) dissection represents an extension of a
standard lateral SMAS dissection.
626
to reposition anteriorly displaced fat and skin as a composite unit
through SMAS rotation. Preserving the medial retinacular fibers
by limiting overdissection of the skin flap provides for more con-
trol in correction of radial expansion through internal fat and skin
repositioning via the SMAS.
48.4.2 SMAS Elevation
The dissection of the superficial fascia allows the surgeon to
reelevate the jowl and descended malar fat upward into the
face as well as internally reposition fat closer to the deep fascia
and facial skeleton. The aesthetic basis of an extended SMAS
dissection, a variation of high SMAS techniques, is that both the
anterior and lateral cheek are repositioned as a unit, independent
of skin flap redraping.
The incision design for the extended SMAS dissection rep-
resents an extension of a standard lateral SMAS dissection. The
malar aspect of the dissection allows for the repositioning of facial
fat along the infraorbital and lateral orbital rim, as well as restor-
ing lateral malar volume. The SMAS dissection just lateral to the
zygomatic eminence provides access to the masseteric ligaments
to allow jowl fat elevation and to restore submalar concavity. The
dissection laterally in the cheek frees the SMAS from the parotid
and sternocleidomastoid, improving mandibular border contour
(Fig. 48.25).
The incisions for the extended SMAS dissection begin in the
preauricular region approximately 1 cm inferior to the zygomatic
arch, caudal to the path of the frontal branch. This horizontal
incision is continued several centimeters forward to the region
where the zygomatic arch joins the body of the zygoma. At this
point, the malar extension of the SMAS dissection begins with the
incision angling superiorly over the malar eminence toward the
lateral canthus for a distance of 3 to 4 cm. On reaching the edge
Fig. 48.26 To obtain mobility of the superficial fascia in an extended
superficial musculoaponeurotic system (SMAS) dissection, the surgeon
must mobilize the SMAS peripheral to the restraint of the retaining
ligaments. To ensure adequate flap mobility, the SMAS needs to be
completely dissected from the underlying parotid gland including the
accessory lobe, from the superior masseteric ligaments, and from the
lateral zygomatic ligaments. (Left figure adapted with permission
from Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg. 2000; 105:290-301.)

of the subcutaneous skin flap in the region of the lateral orbit, the
incision is carried inferiorly at a 90 angle toward the superior
aspect of the nasolabial fold. The malar incision design parallels
the cephalad boarder of the lateral malar pad, which is usually
apparent overlying the malar eminence. A vertical incision is
designed along the preauricular region, extending along the lat-
eral border of the platysma, carrying the incision 6 to 8 cm below
the mandibular border.
To obtain mobility of the superficial fascia in an extended SMAS
dissection, the surgeon must mobilize the SMAS peripheral to
the restraint of the retaining ligaments. To ensure adequate flap
mobility, the SMAS needs to be completely dissected from the
underlying parotid gland, including the accessory lobe, from the
superior masseteric ligaments, and from the lateral zygomatic
ligaments (Fig. 48.26).
The SMAS in the malar region is elevated in continuity with
the SMAS of the cheek. In elevating the malar portion of the
SMAS dissection, the fibers of the orbicularis oculi, as well as the
zygomaticus major and minor, are usually evident, and the flap
is elevated directly along the superficial surface of these muscles.
It is important to carry the dissection directly external to these
muscle fibers, where a natural plane exists, remembering that
the facial nerve branches lie deep to these muscular bellies. The
malar SMAS is elevated until the flap is freed from the underlying
zygomatic eminence.
Completely freeing the SMAS from the lateral zygomatic attach-
ments is an important technical point in obtaining the mobility
necessary to reposition the malar soft tissue superiorly. Similarly,
to obtain adequate SMAS mobility of the lower cheek and jowl
requires a division of the stout fibers of the upper masseteric
ligaments. Dissection the SMAS from the parotid and ligaments
along the anterior boarder of the sternocleidomastoid completes
the SMAS release. Once free from ligamentous attachments, the
SMAS dissection becomes less fibrous and traction of the SMAS
demonstrates unrestricted cheek movement.
In terms of technical difficulty, elevating the SMAS just lateral
to the zygoma is the most difficult aspect of an extended SMAS
dissection, as the SMAS is thin in this region and the nerve
branches are close.
From an anatomic perspective, in dissecting the SMAS over the
parotid, accessory lobe of the parotid, or lateral zygoma, the nerve
branches are deep and protected. ust lateral to the zygoma, in
the region of the upper masseteric ligaments, the nerve branches
are relatively less protected. Proceed carefully in this region and
stop the dissection as soon as the upper masseteric ligaments are
divided and the SMAS becomes mobile. I prefer to perform this
segment of an extended SMAS dissection last, after I have elevated
the SMAS both laterally and medially. I find it best to perform flap
dissection in regions where the depth of dissection is more easily
clarified before extending flap elevation lateral to the zygoma.
Proceed carefully in this portion of the SMAS elevation.
Repositioning and closure of the SMAS is then performed. The
malar SMAS flap is advanced superolaterally over the zygomatic
prominence in a direction perpendicular to the nasolabial fold
and usually paralleling the zygomaticus major muscle.
Once the malar flap is secure, the cheek–SMAS flap is typically
repositioned vertically. I prefer vertical vectors of the lateral
SMAS, as this produces a more defined contour along the jaw-
line and jowl. If the SMAS has been freed from the parotid and
48 Extended SMAS Technique in Facial Rejuvenation
ligaments along the anterior border of the sternocleidomastoid,
a suture placed in the preauricular region will typically vertically
elevate the lateral SMAS 5 to 7 cm. The SMAS flap is then carefully
secured with multiple interrupted buried sutures. Occasionally
skin dimpling is noted after securing the SMAS flap; this results
from the forces of SMAS rotation on resuspended facial skin. Skin
dimpling is treated by simply performing a bit more subcutaneous
undermining before skin flap redraping.
As I have gained more experience with this procedure, I realize
that the most important aspect of an extended SMAS facelift is
not the SMAS dissection but rather the suturing of the SMAS.
Dissecting the SMAS free from the restraint of the retaining liga-
ments is a permissive factor, providing the surgeon more control
in fat repositioning. How the SMAS is sutured determines both
the location and volume of fat repositioned (this volume is located
adjacent to the suture line) and affects the internal repositioning
of fat and correction of radial expansion. I spend as much time
suturing the SMAS accurately as I do dissecting it.
After proper contouring of the SMAS, the facial skin flaps are
rotated and closed in the direction decided based on preoperative
evaluation. In general, I prefer more lateral vectors in redraping
the skin, with most of the redundant skin removed over the ear
and the temporal hairline not shifted cephalically. The skin flaps
are inset with a minimum degree of tension placed along the key
sutures, and then the skin flaps are trimmed with a degree of
redundancy between the key sutures to minimize tension along
the incision sites. I favor restoring contour facelifting through
deep layer support, placing the tension on the SMAS and platysma
closure, and minimizing the tension on skin flap closure to obtain
consistency in terms of scar perceptibility. Stated in other terms,
facial contouring is restored through deep layer support rather
than through tension in skin flap redraping.
To summarize, the key points in mobilizing the superficial
fascia from the restraint of the retaining ligaments of the cheek
are as follows:
• The SMAS overlying the parotid gland and malar eminence tends
to be substantial and easy to dissect, with both the parotid and
zygomaticus major and minor muscles protecting the underly-
ing facial nerve branches. These areas are very safe regions to
begin SMAS elevation and delineate the sub-SMAS plane.
• The thinnest fascial component of an extended SMAS dissec-
tion is in the region just lateral to the zygomatic eminence,
where the SMAS splits to invest the elevators of the upper lip.
Dissecting the skin flap thinly in this region leaves a substan-
tial amount of subcutaneous fat intact along the surface of the
superficial fascia, providing greater ease of SMAS dissection
and minimizing the possibility of tearing at this location.
• The most difficult portion of an extended SMAS dissection is
freeing the superficial fascia from the restraint of the superior
masseteric ligaments, which are lateral to the zygomatic
eminence. If these ligaments are not mobilized, restricted
movement is noted in the portion of superficial fascia that
affects contouring along the lower cheek and anterior jowl.
The zygomatic branches of the facial nerve are in close prox-
imity to the upper masseteric ligaments. At times it can prove
difficult to differentiate between ligaments and facial nerve
branches. Caution is essential in this region of dissection; if
the anatomy is unclear, limit dissection in this region.
627
 VIII Surgical Rejuvenation of the Face and Neck
48.4.3 Vectors of Fat Elevation:
Facial Asymmetry
All patients exhibit some degree of facial asymmetry. Commonly,
one side of the face is vertically longer, and the short side of the
face is usually wider than the long side. Malar highlights are typ-
ically more superiorly located on the long side of the face, and,
with age, facial fat tends to descend in a more vertical direction
on the long side. As facial asymmetry and facial skeletal config-
uration are asymmetric in most individuals, it follows that the
vectors of fat elevation (SMAS repositioning) should be specific
for the right and the left side of the face.
The vector in which the SMAS is repositioned has a significant
impact on the location and volume of elevated facial fat, thereby
influencing facial shape. Decisions regarding the direction of
SMAS vectoring for the right and left sides of the face are best
determined preoperatively, as it is very difficult to make aesthetic
vector judgments intraoperatively with the patient recumbent.
SMAS vectors influence postoperative facial shape. Vertical
SMAS repositioning typically provides a larger amount of fat
for enhancing the malar eminence and allows for a reduction in
fullness within the submalar region as fat is forced vertically along
the concavity of the buccinator. For this reason, vertical SMAS
vectors are often indicated to reshape round, full faces, allowing
them to appear more tapered and thinner postoperatively. In the
patient shown in Fig. 48.27, a small amount of jowl defatting
through needle aspiration was also performed.
If the SMAS is vectored more obliquely, there is less volume of fat
brought into the malar region and a greater volume of fat repositioned
into the submalar region. Oblique SMAS repositioning is therefore
helpful in elderly patients who appear gaunt over the buccal recess,
as it allows the surgeon to enhance the submalar region volumet-
rically. Volume addition to augment the submalar region is helpful
in these type of deflated faces to blend the cheek with the perioral
region and prevent occurrence of cross-cheek depressions.
The patient shown in Fig. 48.28 exhibited asymmetry in the
submalar region preoperatively. The area appeared hollow and
Fig. 48.27 In this patient, a small amount of jowl defatting through
needle aspiration was also performed as well as superficial muscu-
loaponeurotic system repositioning. (Reproduced with permission
from Stuzin JM. Restoring facial shape in face lifting: the role of
skeletal support in facial analysis and midface soft-tissue reposi-
tioning. Plast Reconstr Surg. 2007; 119:362-376.)
628
concave on the right and fuller on the left side. For this reason, the
SMAS was vectored obliquely on the right to enhance the subma-
lar region volumetrically; it was vertically vectored on the left to
restore submalar hollowing and balance the two sides of her face.
48.4.4 SMAS Fixation
In a two-layer SMAS-type facelift, the tension of contouring is
placed on the superficial fascia rather than on the skin envelope.
Thus the fascial quality and tensile strength of the superficial
fascia have an influence on both the longevity of the result and
the volume of fat, which can be repositioned intraoperatively and
maintained postoperatively. In other words, soft tissue quality
influences long-term contour and is the primary reason facelifts
in young patients are more predictable.
I have come to realize that the predominant factor in improving
shape is the method in which the superficial fascia is secured, as
well as how the SMAS is sutured affects facial shape:
• Adding more sutures enables the surgeon to stack volume along
the suture line, which is located in the lateral cheek and along
the lateral malar eminence, both regions that deflate in aging.
• As the superficial fascia is sutured, facial fat is not only repo-
sitioned vertically but also repositioned internally, forcing the
soft tissue to conform to the underlying deep facial structures.
This provides the surgeon greater control in improving radial
expansion, something especially evident in the submalar region.
The excess SMAS, rather than being excised, is typically rolled
onto itself to form a double layer of SMAS thickness so as to aid in
secure fixation. An added benefit of preserving the excess SMAS
is that it allows stacking of vascularized fat over the zygomatic
eminence, highlighting the malar region and serving as an autoge-
nous malar augmentation (Fig. 48.29).
a b
Fig. 48.28 (a) Patient with preoperative asymmetry in the submalar
regions, which appeared hollow and concave on the right and fuller on
the left side. (b) For this reason, the superficial musculoaponeurotic
system was vectored obliquely on the right to enhance the submalar
region volumetrically; it was vertically vectored on the left to
restore submalar hollowing and balance the two sides of her face.
(Reproduced with permission from Stuzin JM. Restoring facial
shape in face lifting: the role of skeletal support in facial analysis
and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;
119:362-376.)

48.4.5 Correction of Platysma Bands
and Cervical Obliquity
The best approach to the anterior platysma is through a sub-
mental incision placed just caudal to the submental skin crease.
If this crease is deep, the skin cephalad is elevated toward the
base of the chin pad and along the caudal mandibular border to
free the crease from the mandibular ligaments. This softens the
appearance of the submental crease and allows better blending
between the chin and the neck. The cervical skin is carefully
elevated, and the dissection is carried inferiorly in the neck.
hen the platysma muscle is exposed anteriorly, most patients
exhibit a decussation of platysmal fibers across the midline, at
least for a few centimeters below the mentum. If platysma band
surgery is planned, these decussating fibers should be sharply
divided with scissor dissection in the midline. Then the medial
edge of the platysma is mobilized from the mentum inferiorly,
typically as low as the skin flap dissection. Mobilization, usually
performed using a combination of sharp and blunt dissections,
separates the platysma from the underlying subplatysmal fat,
the anterior belly of the digastric muscle, and the strap muscles
overlying the thyroid cartilage. At times numerous small venules
are encountered within the subplatysmal fat, and careful hemo-
stasis must be obtained. After mobilization of the medial edges
of the platysma, the subplatysmal fat is contoured according to
preoperative planning. I typically am conservative in subplatysma
fat removal and most commonly resect fat at the level of the hyoid
to deepen the cervical mental angle.
Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline
to estimate the amount of excess muscle present. Muscle excess
varies from patient to patient. A portion of the medial edge can be
excised to remove redundancy within the platysma. A conserva-
tive resection is performed to avoid undue tension at the time of
suture plication (Fig. 48.30).
Muscular plication consists of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extending
at least to the level several centimeters caudal to the hyoid. This
Fig. 48.29 Excess superficial musculoaponeurotic system tissue, rather
than being excised, is typically rolled onto itself to form a double layer
of fascia thickness so as to aid in secure fixation. (Left figure adapted
with permission from Stuzin JM, Baker TJ, Baker TM. Refinements in
face lifting: enhanced facial contour using Vicryl mesh incorporated
into SMAS fixation. Plast Reconstr Surg. 2000; 105:290-301.)
48 Extended SMAS Technique in Facial Rejuvenation
longer plication enhances the surgeon’s ability to contour the
platysma so that it conforms to the floor of the mouth and the
thyroid cartilage. Suture placement back from the leading edge
of the muscle, in areas of intact muscular fascia, is an important
technical point in preventing suture pull-through postoperatively
(Fig. 48.31).
After edge-to-edge approximation of the platysma, some
form of muscular release is performed. This muscular release
commonly involves a partial transection of the platysma muscle,
with the myotomy performed inferiorly within the neck. This
usually consists of a horizontal cut extending from the midline a
distance of 5 to 7 cm, until the platysmaplasty appears to conform
to the floor of the mouth without tension. Division of not only the
muscle, but also the SMAS lining the posterior surface of the pla-
tysma, is an important technical point in adding the prevention of
band recurrence (Fig. 48.32).
Platysma transection is an effective technique for treating
platysma bands and obtaining improved cervical contour. This
procedure must be performed meticulously. Early experience
with transection was fraught with complications; specifically,
if the transection was performed at a high level, it could cause
unveiling of the submaxillary glands and denervation of the
platysma, leading to lower lip dysfunction. Also, obvious contour
depressions associated with divided muscular edges could occur
in an overly thin neck.
The key to platysma transection is that the transection be
performed low in the neck, where the muscle tends to be thin,
often as inferior as the midthyroid cartilage. Preservation of pre-
platysmal fat overlying where the transection is performed is an
important factor in preventing surface irregularities in the region
where the muscle is divided.
Fig. 48.30 Following mobilization, the medial edge of the platysma
muscle is grasped on either side and overlapped in the midline to
estimate the amount of excess muscle present. Muscle excess varies
from patient to patient. A portion of the medial edge can be excised to
remove redundancy within the platysma. A conservative resection is
performed to avoid undue tension at the time of suture plication.
629
 VIII Surgical Rejuvenation of the Face and Neck
The muscular release after platysma transection serves many
purposes:
• It alleviates tension along the medial portion of the platysma
transection following plication.
• It allows the platysma to shift superiorly, producing a deeper
cervicomental angle.
• It prevents the conversion of two platysmal bands to a single
band after edge-to-edge approximation, which can be visible
when the neck is extended.
Fig. 48.31 Muscular plication, consisting of edge-to-edge approximation
using multiple interrupted sutures at the mentum and extending at
least to the level several centimeters caudal to the hyoid, enhancing the
surgeon’s ability to contour the platysma so that it conforms to the floor
of the mouth and the thyroid cartilage. Suture placement back from the
leading edge of the muscle, in areas of intact muscular fascia, is an import-
ant technical point in preventing suture pull-through postoperatively.
Fig. 48.33 How facial fat reelevation influences cervical appearance.
(Adapted with permission from Stuzin JM, Baker TJ, Baker TM.
Refinements in face lifting: enhanced facial contour using Vicryl
mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;
105:290-301.)
630
48.4.6 Sequence of SMAS Fixation
versus Platysmaplasty
Because the SMAS and the platysma lie in the same anatomic
layer, if platysmaplasty is performed before the SMAS dissection,
it can adversely affect facial contour. hen the platysmaplasty is
performed first, the descended jowl fat is locked down into the
neck, and movement of the superficial fascia diminishes follow-
ing elevation of the SMAS. This diminished movement tends to
lessen the surgeon’s ability to modify facial shape. If the SMAS
fixation is performed before the platysmaplasty, descended jowl
fat is repositioned cephalad into the cheek, which improves
laxity along both the jawline as well as the neck. After the SMAS
has been securely sutured bilaterally, the mandibular border
will appear more defined, making cervical contouring less
demanding. hen performing platysmaplasty subsequent to
Fig. 48.32 After edge-to-edge approximation of the platysma,
some form of muscular release is performed. This muscular release
commonly involves a partial transection of the platysma muscle, with
the myotomy performed inferiorly within the neck.
Fig. 48.34 Result after extended superficial musculoaponeurotic
system repositioning and platysmaplasty. (Adapted with permission
from Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg. 2000; 105:290-301.)

a b
Fig. 48.35 Patient (a) before and (b) after an extended superficial
musculoaponeurotic system (SMAS) dissection. By reelevating
descended facial fat back up toward the malar region and lateral
midface and securing it there intraoperatively, her facial shape is
improved. The mandibular border has been enhanced through SMAS
repositioning and platysmaplasty.
SMAS fixation, the surgeon will notice less redundancy along the
medial borders of the platysma; there is also less need to resect
muscle at the time of platysmaplasty. The enhanced contour
effects of extended SMAS dissection, associated with precise
platysmaplasty, tend to diminish the need to remove cervical fat.
In general, the neck and jawline appear softer if preplatysmal fat
is preserved when contouring the neck.
The patient shown in Fig. 48.33 illustrates how facial fat reele-
vation influences cervical appearance. Sequencing errors can lead
to loss of contour; I prefer to perform SMAS elevation and fixation
before performing platysmaplasty. As the facial fat and skin are
reelevated upward into the midface through SMAS rotation, the
mandibular border becomes more distinct, making cervical con-
touring more predictable.
The woman shown in Fig. 48.34 demonstrates the result after
extended SMAS repositioning and platysmaplasty.
The patient in Fig. 48.35 is shown before and after an extended
SMAS dissection. By reelevating descended facial fat back up toward
the malar region and lateral midface and securing it there intraop-
eratively, her facial shape is improved. The mandibular border has
been enhanced through SMAS repositioning and platysmaplasty.
48.4.7 Incisions
The importance of incision quality cannot be overemphasized
in diminishing signs that the patient has undergone a surgical
procedure. One of the major advantages of a two-layer facelift is
that the tension of contouring is along the superficial fascia, and
thus there is less need to redrape the skin flap with great force.
Decreased tension on the key sutures in both the preauricular
and postauricular region provides greater control over scar per-
ceptibility. If the incisions are artistically designed, patients can
typically wear their hair up off their ears without the obvious
stigma that a facelift has been performed.
Many authors have described the salient factors regarding
incision design; these main points should be emphasized:
48 Extended SMAS Technique in Facial Rejuvenation
Fig. 48.36 Standard tragal incision with preservation of the incisura of
the tragus. The incision is carried around the earlobe approximately 1
to 2 mm caudal to the junction of the earlobe with the cheek skin.
• Tragal incisions, placed at the margin of the tragus rather
than preauricularly, are preferable, because the color differ-
ence between the pale skin of the ear and the blush skin of
the cheek is usually better camouflaged when the incision is
brought internally into the ear.
• Tragal incisions are more demanding than preauricular
incisions, requiring precise design and placement so that the
tragus is not distorted. The aesthetic unit of the tragus is rect-
angular, as opposed to semilunar. If the surgeon designs the
tragal incision properly, respecting the incisura of the tragus,
the tragus will appear normal in its shape postoperatively,
exhibiting both a visual beginning at its junction with the
helix and a visual ending along the preserved incisura.
• Detached earlobes tend to appear more natural than attached
earlobes. If a small cuff of cheek skin is left attached to the
earlobe, it will allow surgical rotation of the skin up under the
earlobe during skin flap redraping, with suturing of the ear-
lobe distinct from the cheek flap. The earlobe should be inset
in an axis posterior to the axis of the pinna, thereby avoiding
a pixie deformity.
The intraoperative photograph in Fig. 48.36 illustrates the
standard tragal incision with preservation of the incisura of the
tragus. The incision is carried around the earlobe approximately 1
to 2 mm caudal to the junction of the earlobe with the cheek skin.
In Fig. 48.37, a preauricular incision is shown at left, 2 months
postoperatively. Again, the problem with preauricular incisions is
631
 VIII Surgical Rejuvenation of the Face and Neck
a b
Fig. 48.37 (a) Preauricular incision 2 months postoperative. (b) Tragal incision 5 months postoperative, patterned after the methods shown in the
Fig. 48.36. (c) Well-designed and inset tragal incision producing an imperceptible, normal-appearing tragus that exhibits both a visual beginning and
end and a detached-appearing earlobe
that the difference in color between the skin of the cheek and the
skin of the ear is more visible in this anterior incision location.
In the center, a tragal incision is seen 5 months postoperatively;
this incision was patterned after the methods shown in Fig. 48.36.
At right, a well-designed and inset tragal incision should produce
an imperceptible, normal-appearing tragus that exhibits both a
visual beginning and end and a detached-appearing earlobe.
There is an increasing public demand for facial rejuvenation at
earlier ages, when facial laxity is often minimal. This places the
onus on the surgeon to create incisions that are imperceptible if
these procedures are to be justified. o matter how well deep-
layer support is obtained and facial contour improved by SMAS
elevation and platysmaplasty, if the incision is obvious, the scar
quality poor, the hairline disturbed, or the earlobe deformed, the
overall result will be disappointing.
48.5 Concluding Thoughts
From a personal perspective, after close to three decades of
striving to improve techniques in facial rejuvenation, it is
my firm conviction that improving technical control when
contouring the superficial facial fascia and platysma provides
a more consistent, aesthetically pleasing result that is natural
in appearance. To perform a successful two-layer SMAS-type
facelift, the surgeon must not only understand facial soft tissue
anatomy but also perform a procedure that demands technical
precision. A two-layer SMAS-type facelift is a time-consuming
operation, with both the skin flap elevation and the dissection of
the SMAS requiring meticulous, accurate dissection. Obtaining
consistency with this procedure is challenging because of the
variability among individuals in the thickness of subcutaneous
fat and the SMAS and the variability of facial shape that must
be contoured. After precise dissection, secure fixation of both
the SMAS and platysma is essential to maintain the desired
postoperative shape. Ensuring meticulous hemostasis, followed
632
c
by careful skin flap inset, are required to minimize postoperative
scar perceptibility and ensure a rapid postoperative recovery.
Despite these demands, I have found the extended SMAS tech-
nique to be rewarding, with a high degree of patient satisfaction. All
techniques have advantages and disadvantages. For me, the biggest
advantage of the extended SMAS technique remains its aesthetic
versatility, allowing the surgeon to vary the contouring aspects of
the procedure according to the aesthetic needs of the patient.
Clinical Caveats
• Patient selection is probably the most critical factor in deter-
mining the success of a proposed aesthetic procedure.
• The anatomic arrangement of the facial soft tissues as a
series of concentric layers is key to the safety of rhytidectomy
procedures. This concentric arrangement allows dissection
within one anatomic plane to proceed completely indepen-
dent of structures lying within another anatomic plane.
• Improving technical control when contouring the superficial
facial fascia and platysma provides a more consistent, aes-
thetically pleasing, nonsurgical-looking result.
• The surgical significance of the deep facial fascia is that all the
facial nerve branches within the cheek lie deep to the deep
facial fascia.
• Although aging is a complex process, many of the stigmata
developing in the aging face involve a change in the relation-
ship between the superficial and deep facial fascia, with the
superficial unit of the facial soft tissue descending inferiorly in
relation to the fixed deeper structures of the face.
• The importance of the zygomatic ligaments lies in their abil-
ity to suspend malar soft tissue superiorly over the zygomatic
eminence. With aging, malar support commonly attenuates,
leading to an inferior migration of malar soft tissue. Dermal
elastosis and attenuation of support from retaining ligaments,
associated with both deflation and radial expansion, are the

main components that must be addressed to reconstruct the
anatomic changes resulting from aging.
• The principal advantage of performing skin undermining
separately from SMAS dissection is that it allows these two
layers to be redraped along vectors that are independent of
one another.
• The significance of the retaining ligaments is their location,
which determines the degree of surgical dissection necessary
in face lifting.
• In facelifting, it would seem that wide mobilization and
aggressive dissection would improve contour, but my expe-
rience with wide dissection has led me to a contrary view. I
have found that wide dissection peripheral to the restraint of
the retaining ligaments is counterproductive in an extended
SMAS facelift technique.
• A facelift can be considered an aesthetically reconstructive
procedure in that facial soft tissue anatomy is restored to a
state resembling its structure before the degenerative effects
of aging occurred.
• More than any other factors, skin quality and elasticity
have perhaps the greatest influence on outcome after a
rhytidectomy.
• Buccal fat removal tends to reduce facial fullness, but rarely
does it improve prominent jowls.
• In most patients, jowling can be improved through SMAS
rotation. In some patients jowl fat removal is helpful.
• The prominent nasolabial fold requires restoration of malar
support to produce a lasting change in contour. In my expe-
rience, extending the cheek SMAS dissection into the malar
region to restore malar support has been helpful in improving
prominent nasolabial folds. Volume addition medial to the
fold is helpful in blending the cheek with the perioral region.
• Correction of the obtuse neck involves restoration of skin
tone, contouring of regional lipodystrophy, and restoration
of platysma support.
• One of the major advantages of a two-layer facelift is that the
tension of contouring is along the superficial fascia, and thus
there is less need to redrape the skin flap with great force.
• The importance of incision quality cannot be overemphasized
in diminishing the signs that the patient has undergone a
surgical procedure.
• The postauricular incision extends along the postauricular
groove, not up onto the conchal surface.
• Because the SMAS and platysma represent the same ana-
tomic layer, if platysmaplasty is performed before the SMAS
dissection, it can adversely affect facial contour. Contouring
the platysma after SMAS fixation leads to more control in
shaping both the cheek and neck.
• In skin flap dissection, it is important to develop uniform skin
flaps during the subcutaneous undermining, taking care to
leave some fat intact along the superficial surface of the SMAS,
especially in the regions where the SMAS is to be dissected.
• The SMAS overlying the parotid gland and malar eminence
tends to be substantial and easy to dissect, with both the
parotid and zygomaticus major and minor muscles protect-
ing the underlying facial nerve branches. These areas are
very safe regions to begin SMAS elevation and delineate the
sub-SMAS plane.
48 Extended SMAS Technique in Facial Rejuvenation
• Because the SMAS and platysma are in the same layer, what
the surgeon does in the face influences the contour in the
neck.
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Clin Plast Surg 1983;10(3):429–440
21 Rogers BO. A brief history of cosmetic surgery. Surg Clin North Am
1971;51(2):265–288
22 Rohrich R , Pessa E. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119(7):2219–2227,
discussion 2228–2231
23 Rohrich R , Stuzin M, Dayan E, Ross EV, eds. Facial Danger Zones: Staying Safe
with Surgery, Fillers, and Non-Invasive Devices. ew ork, : Thieme; 2019
24 Skoog T. fi . Philadelphia, PA: B
Saunders; 1974
25 Stuzin M. Restoring facial shape in face lifting: the role of skeletal support
in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg
2007;119(1):362–376, discussion 377–378
26 Stuzin M, Baker T , Baker TM. Refinements in face lifting: enhanced facial
contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg
2000;105(1):290–301
27 Stuzin M, Baker T , Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg
1992;89(3):441–449, discussion 450–451
28 Stuzin M, Baker T , Gordon HL, Baker TM. Extended SMAS dissection as an
approach to midface rejuvenation. Clin Plast Surg 1995;22(2):295–311
633
 VIII Surgical Rejuvenation of the Face and Neck
49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the
Midface, Cheek, and Jawline
Timothy Marten and Dino Elyassnia
Abstract
The traditional low cheek superficial musculoaponeurotic
system (SMAS) flap, elevated below the zygomatic arch, suffers
the drawback that it cannot, by design, exert an effect on tissues of
the midface and infraorbital region. Low designs target the lower
cheek and jowl only and produce no improvement in the upper
anterior cheek and midface area. Planning the flap higher, along
the zygomatic arch, and extending the dissection medially in an
extended SMAS fashion to mobilize midface tissue overcomes
this problem and allows a combined, simultaneous single-flap
lifting of the jawline, cheek, and midface. An improved outcome
is obtained, and no separate midface lift procedure is needed.
Keywords
facelift, superficial musculoaponeurotic system, high SMAS,
midface lift, extended SMAS, lamellar dissection, bidirectional
facelift, SMAS vector, trifurcated SMAS, postauricular trans-
position flap, facelift incisions, concealed-incision facelift,
retrotragal incision, earlobe reconfiguration, earlobe reduction,
earlobe insetting, Marten facelift marker, Ristow’s triangle,
aging face, facelift anesthesia, short-scar facelift, lateral sweep,
hairline displacement, chopped-off tragus, retracted tragus,
pixie ear
49.1 Introduction
Traditional facelift techniques have relied upon the tightening
of thin flaps of aging skin to elevate and support sagging, deeper
facial tissue. Although initial results from these procedures
often appeared good, early recurrence of the original problems
was common, and poor scars and healing problems were fre-
quently seen as a result of obligatory wide flap undermining and
unavoidable skin flap tension. These procedures also typically
produced an easily recognized tight or facelifted look, which
was usually exacerbated by subsequent similarly performed
procedures.
As plastic surgeons have pursued more natural-appearing
and long-lasting outcomes, our understanding of the facial aging
process and the underlying anatomy responsible for the associ-
ated changes has improved and facelift techniques have evolved.
Experience has since confirmed that an attractive and natural-
appearing result is not possible without diverting tension from
the skin to the superficial musculoaponeurotic system (SMAS)
and platysma and without addressing other deep-layer structures
and the aging midface.
634
49.2 Fundamental Concepts in
Rejuvenation of the Face
49.2.1 Recognizing the Aging Changes
of the Face
Recognizing the components of the aging changes of the face
and appreciating the underlying anatomic abnormalities is
essential to properly advising patients and fundamental to the
planning of any surgical repair. Careful analysis will reveal that
most patient problems will fall into three broad categories: (1)
aging and breakdown of the skin and skin surface; (2) facial
sagging, skin redundancy, and loss of youthful facial contour;
and (3) facial wasting, atrophy, and/or age-related lipodystro-
phy. Proper treatment will depend upon the types of problems
present, the patient’s priorities, and the time, trouble, and
expense the patient is willing to invest to obtain the desired
improvement.
Patients primarily concerned with surface aging of their face
may not require formal surgical procedures and may achieve the
type of improvement they desire through salon care and derma-
tologic surface treatments of the skin. These treatments include
skin peels, skin resurfacing, chemodenervation (neurotoxin injec-
tions), and various forms of cutaneous laser and other treatments
designed to remove or reduce age spots, telangiectasias, wrinkles,
and other age-related skin surface imperfections.
Patients primarily concerned with facial sagging, skin excess,
and loss of facial contour will achieve minimal ultimate improve-
ment, however, if only surface treatments are employed, and
they will require formal surgical lifts, in which sagging tissue is
repositioned and redundant tissue is excised, if these problems
are to be properly corrected and an attractive and natural-
appearing improvement is to be obtained. The misapplication
of surface treatments of the skin to the sagging face with excess
tissue will produce little more than a smooth but saggy face
with no improvement in contour. This sort of smooth-saggy
look, typically seen in older patients who have undergone laser
resurfacing or deep skin peels, is inconsistent with a natural
appearance, as patients with loss of facial contour generally
also have concomitant skin surface aging. It is arguably more
attractive and natural appearing to have a well-contoured face
with a few wrinkles and surface imperfections than a smooth
but saggy one.
Similarly, the misapplication of filler or fat injections to the
sagging face with excess skin and an overly large skin envelope
may produce a smoother face but at the same time an objection-
ably large, heavy, and unfeminine-appearing one. One must also
keep in mind that despite industry efforts to make us believe
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
otherwise, fillers lift radially that is, in an outward direction
not vertically. Suggesting that fillers lift the face vertically may
be one of the most deceptive and most thoughtlessly repeated
mischaracterizations we make to ourselves and our patients.
Many if not most of the changes associated with loss of facial
contour, however, represent primarily “deep-layer” problems that
will not be adequately corrected with traditional skin only or
low-SMAS techniques. Regrettably, many surgeons unfamiliar
with deep-layer techniques, and other physicians insufficiently
trained to perform them, often perform skin-only facelifts or
mini-lifts and resort to misguided and misapplied ancillary
procedures in an ultimately futile effort to overcome the short-
comings of these methods.
Patients with significant facial atrophy and age-related
facial wasting will generally achieve suboptimal improvement
from both surface treatments of facial skin and surgical lifts.
Smoothing skin will not hide a drawn appearance caused by
loss of facial volume, and it is difficult to create natural and
attractive contours by lifting and repositioning tissues that have
abnormally thinned with age. Restoring lost facial volume with
autologous fat grafting is a powerful technique that has gained
widespread acceptance and is now acknowledged by most plastic
surgeons and other physicians engaged in treating the aging face
as the missing link in facial rejuvenation and it comprises the
most important advance in aesthetic surgery in several decades
or more. Properly performed, the addition of fat to areas of the
face that have atrophied as a result of age or disease can produce
a significant and sustained improvement in appearance unob-
tainable by other means. In addition, autologous fat grafting may
represent the first true antiaging therapy that plastic surgeons
have to offer, in that there is a growing body of evidence that
adult stem cells transferred with fat exert a regenerative effect
on tissues in areas adjacent to areas where fat is injected, includ-
ing overlying skin.
Age-related facial atrophy rarely exists as an isolated event in
the healthy patient, however, and thus patients troubled by it are
not always logically or appropriately treated by fat grafting alone.
Isolated fat grafting is also arguably of questionable benefit to
the patient troubled by significant facial sagging and skin redun-
dancy. Although aggressive filling of the sagging face with fat can
produce improved contour and a smoother appearance, it gen-
erally results in an unusually large, overfilled face that appears
both unnatural and unfeminine. Such an overfilled face is hard
to correct in an attractive manner at a later date, and it is both
more logical and practical to perform fat grafting in conjunction
with formal surgical lifts if needed, or after ptotic tissue has been
repositioned and redundant tissue has been removed. hen a
high-SMAS technique is used in conjunction with fat grafting,
both loss of facial contour and facial atrophy can be corrected,
and optimal improvement in the patient’s appearance can be
obtained.
49.2.2 Panfacial Rejuvenation
Rarely does isolated aging occur in the lower face and neck, and
many patients requesting primary facelift procedures often
need to undergo some sort of forehead and eyelid surgery, and
often procedures to improve the appearance of their mouth as
well, if they have not already done so. Many are confused by the
term facelift, however, and take it to imply that improvements
will be made comprehensively in all areas. These patients must
be counseled carefully, as the facelift itself will produce little if
any improvement in upper face and neck problems (or perioral
wrinkling and deflation) but rather tends to unmask and draw
attention to them.
It is not uncommon for patients concerned with aging in their
lower face and neck to question the need to undergo forehead
surgery. Many unconsciously optimize their forehead appearance
when looking in a mirror by raising their eyebrows, or they try to
conceal forehead ptosis by aggressive plucking of their lateral eye-
brows or the wearing of forehead-concealing hairstyles. Although
chemodenervation with botulinum toxin injections can smooth
forehead expression lines and, in some cases, be used to produce
some lateral brow elevation, it cannot correct advanced brow
ptosis or compensate for temporal tissue compression resulting
from raising the upper cheek during a facelift. Failure to recognize
forehead ptosis and properly advise patients regarding its signif-
icance and perform forehead surgery when needed can result
in a disharmonious appearance often referred to as the young
face old forehead deformity.
It is also not uncommon for patients to request that surgery be
performed upon their neck only. Although such a plan is accept-
able for some men, failure to restore attractive cheek contour and
lift sagging jowls concomitantly in women generally results in an
unnatural and unfeminine appearance. In addition, if an aggres-
sive “corset” platysmaplasty is performed as part of an isolated
neck lift, sagging in the cheeks and jowl area can be accentuated,
as platysma tightening exerts a downward pull on tissue in these
areas.
Facelift surgery can unmask other existing age-related problems
and create a need to perform additional procedures. This is com-
monly seen in the lower eyelid area, where the ptotic cheek often
smooths the lower lid skin preoperatively by dragging it inferiorly.
A properly executed repositioning of the midface and malar fat will
often result in some lower lid wrinkling and redundancy not present
before surgery. This can be demonstrated prior to the procedure to
the patient by elevating the cheek to the predicted postoperative
position while the patient holds a hand mirror, pointing out to
the patient the resulting wrinkling in the lower lid area. In these
cases some excision of lower lid skin must be made (or resurfacing
performed), even if the lid appears smooth before surgery, if lower
lid wrinkling is to be avoided postoperatively. It is also for this
reason that lower blepharoplasty should arguably be performed
after facelift surgery is complete, and not at the beginning of the
procedure.
49.2.3 Why Use the SMAS?
The fundamental flaw in skin-only facelifts ( mini-lifts,
“franchise facelifts,” “infomercial facelifts,” and similar limited
and predictably problematic “one-layer” procedures) is the
fact that skin was meant to serve a covering function and not a
structural or supporting one. Skin is an inherently elastic tissue
and was intended to stretch and move as we eat, speak, emote,
and express ourselves. It was not intended to support sagging
muscle, fat, and other structures lying underneath it that pre-
dictably descend with age. Attempts to use skin as the vehicle
to lift sagging deep-layer tissues by removing and tightening it
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 VIII Surgical Rejuvenation of the Face and Neck
corrupts its covering function and results in abnormal skin ten-
sion and related secondary problems including, but not limited
to, poor scars, tragal retraction, earlobe malposition, and a tight
and unnatural appearance. Skin tension also flattens contour,
rather than restoring it, and because skin stretches as tension
is applied, objectionable temple, sideburn, and occipital hairline
displacement is common when skin-only techniques are used.
In addition, because skin is inherently elastic and not capable of
providing a sustained support of deep facial tissues, the results
of most skin-only facelifts and similar mini-lifts are usually
short-lived.
Using the SMAS to lift sagging facial tissues and to restore lost
facial contour circumvents the problems associated with skin-only
lifts, as it is an inelastic structural fascial layer that is attached to
and envelops facial tissues sagging with age, and it is capable of
providing sustained foundational support to them. Although skin
is excised in SMAS procedures, and proper excision will provide
an improved result, only skin that is truly redundant is removed,
and closure can be made under normal skin tension. Facial skin so
treated will distribute itself naturally over new contours created
by SMAS repositioning and is capable of some self-repair and
contraction. This averts a tight, pulled, or lifted appearance,
provides for optimal wound healing and inconspicuous scars, and
adds further to the end result.
Using the SMAS provides a means by which sustained support
can be obtained from a structural tissue layer and one in which
tension can be transferred away from the skin. This results in a
soft, natural facial appearance with high-quality scars, and it often
triples or even quadruples the life span of improvement obtained.
Diverting tension to the SMAS and platysma and away from the
skin also preserves natural preauricular contours and minimizes
displacement of temporal and sideburn hairlines. In addition,
unlike skin-only facelifts, in which subsequent procedures worsen
skin tightness and problems associated with it, SMAS facelifts,
if skillfully performed, can be repeated as often as needed and
desired by the patient without producing skin tightness and
abnormal appearances. This removes the “two-facelift limit” set
by many surgeons performing one-layer skin-only procedures,
and it allows patients to undergo procedures at an earlier age and
more frequently, if desired.
Experience has shown that sustained and attractive support
of the deep layers of the face cannot be predictably obtained by
the placement of “suspension” and “cable” sutures, even if soft,
partially elastic, and absorbable materials are used, and the list of
failed products and techniques of these kinds is now quite long.
These suture lift procedures have led to a variety of significant
problems for many patients including suture extrusion, traction
dimples, visible bowstringing, puppet lines, joker lines, nerve
injuries, facial dyskinesias, chronic pain syndromes, and a wide
variety of abnormal appearances during animation. Suspension
sutures and implantable straps placed in the neck can also create
bunching and tissue irregularities and a tight or choking feeling
that is disturbing to patients and can result in difficulties in speak-
ing and swallowing. In at least one instance a cervical suspension
suture placed by an unknown surgeon precipitated lightheaded-
ness and syncope in a patient when her head was turned and her
neck flexed, necessitating its removal. In addition, if large, stiff,
permanent sutures or strap-type devices are used, the suture
knots and the sutures and straps themselves can often be felt
636
beneath the skin. In some cases the suture knots or implantable
straps can erode overlying skin or scalp, again necessitating their
removal.
The fundamental flaw in suture lifts and the use of suspension
sutures and implantable facial straps is that they rely on a small,
rigid thread or strap to support a large area of delicate, inherently
soft, mobile facial tissue. Over time these sutures or devices typi-
cally cheese-wire through tissues they were intended to support
and can injure important neuromuscular structures. Suspension
sutures and implantable straps also prevent natural depression
and downward movement of facial tissues, impeding certain
expressions, creating unnatural appearances, and precipitating
disturbing sensations.
Unlike suspension suture placement, SMAS elevation enables
a balanced and secure elevation of facial tissues without dis-
ruption of their natural relationships or facial muscle action.
Tissue anchoring is achieved through direct tissue contact and
healing, not distant point suspension by a suture, barbed thread,
or purported microplication of facial tissues. SMAS elevation
also allows natural gliding and depression of tissue and more
natural appearances in animation that these other, ill-conceived
techniques do not.
The periosteum has been advocated by some as the layer
beneath which facelift dissection should be performed and the
vehicle by which sagging deep facial tissues should be elevated.
hen properly performed, such procedures divert some tension
away from the skin and avoid many of the problems associated
with skin-only procedures. Improvement in the infraorbital and
upper midface areas may also be obtained in some cases when
the procedures are properly designed. The periosteal layer is a
conceptually illogical choice for overall rejuvenation of the face,
however, in that it is densely adherent to the facial skeleton and
does not significantly descend as part of the aging process. It is
also not closely associated with the intermediate layers of the
face, where most of the aging is known to occur, and its dissec-
tion typically results in prolonged swelling and induration and
generally portends a longer period of recovery for the patient
after the procedure. In addition, many subperiosteal facelift
techniques rely on the concomitant use of suspension sutures
and thus often share many of the problems related to these pro-
cedures. Unlike the periosteum, the SMAS is closely associated
with tissues that descend as the face ages and actually envelops
many, if not most, of those of concern. It is thus arguably a more
logical layer to use to restore facial tissues to a more youthful
position.
49.2.4 Why Use a SMAS Flap?
Despite the significant and time-tested advantages the SMAS
flap has made available to surgeons performing facial rejuve-
nation procedures, and the breakthrough in improvement in
appearance and longevity it has provided, as plastic surgeons
have sought to simplify the SMAS technique with the goal of
obtaining the benefits, or at least some of the benefits, of SMAS
flap surgery without the need to formally raise a SMAS flap. In
these procedures the SMAS is variously plicated, folded upon
itself, gathered with sutures, microplicated with purse-string
suspension sutures, or strip-excised ( SMASectomy ), and
no flap is dissected. Although these procedures are appealing
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
in their ostensible simplicity, experience has shown that the
placement of the multiple sutures now known to be necessary
in many of these procedures typically encompasses almost as
much time as that required to raise and suspend a SMAS flap. It
has also been seen that suture plication and SMAS strip excision
do not avert risk to facial nerves and other important structures
such as the parotid duct, as these structures have been injured
in plication procedures and other non–SMAS flap techniques.
As a practical matter, the biggest problem with plication and
SMAS strip excision procedures may rest in the fact that they are
destructive to the SMAS layer and compromise it, or even render
it useless for future use as a formal flap, and we have encountered
a number of patients who have suffered this problem. Typically
such patients are younger and have been convinced that they did
not need formal SMAS flap dissection and that SMAS plication
or microplication would suffice, but they have not obtained the
outcome and/or longevity they had hoped for. hen a secondary
procedure is then performed in these patients, the SMAS layer
is often compromised or unusable for a formal SMAS flap proce-
dure. The patient’s only option under such situations is another
plication, and each successive such procedure further disrupts
and compromises the SMAS layer. In contrast, experience has
shown that a SMAS flap, when skillfully performed, can be read-
ily raised in secondary and tertiary procedures in many patients
and that SMAS flap elevation does not limit a patient’s future
options for treatment. This arguably is particularly important
to younger patients, who, predictably, will be undergoing future
facelift procedures.
49.2.5 SMAS and the Midface
The midface is generally defined as an inverted triangular area
situated over the anterior upper cheek that is bounded by the
zygomaticus major muscle laterally, the nasolabial fold medi-
ally, and the infraorbital rim/orbitomalar ligament superiorly.
In healthy, youthful-appearing individuals, this area is full and
is confluent with the adjacent cheek and lower eyelid. As one
ages, however, and as men and women enter their early midlife
and beyond, there is generally a descent of midface tissues and
a loss of volume, resulting in hollowing and flattening of this
area. Over time this results in a loss of the smooth and youthful
transition from the lower eyelid to cheek and, eventually, an ill,
haggard, and elderly appearance. hile atrophy often plays a
dominant role in this process, this change is often mistakenly
referred to by many surgeons as midface ptosis. As the mid-
face descends and cheek volume diminishes, normal orbital fat
may appear to have grown (pseudoherniation) and may mis-
takenly be targeted for removal by a blepharoplasty procedure
(Fig. 49.1).
The recognition of midface ptosis as a significant component
of the changes occurring in the aging face, combined with the
realization that the traditional SMAS facelift produces little
or no improvement in the midface region, has led to a variety
of procedures designed to specifically target the midface area.
Many of these techniques were popular in the past as isolated
procedures or were performed in conjunction with lower eyelid
surgery. Although there is merit in the idea of rejuvenating the
midface, a consensus of opinion as to how and when it should
best be performed has never been reached, and routine isolated
a b
Fig. 49.1 Treating cheek “ptosis” and pseudoherniation of lower
eyelid fat. As the cheek atrophies and descends with age, the lower
eyelid fat “bags” become more exposed and prominent in a process
known as “pseudoherniation.” (a) Patient with ptotic and atrophic
cheek. The lower lid fat, while actually normal is size, is exposed and
appears ostensibly as a large “bag.” Removing this fat by performing
a traditional blepharoplasty procedure would lower the lid–cheek
junction and create a hollow and elderly appearance. (b) Same patient
seen after high–SMAS facelift and fat injections to the cheeks but no
blepharoplasty or fat removal from the lower eyelid. Pseudoherniated
lower eyelid fat has been disguised by lifting, filling, and reconstituting
the cheek. This produces a more youthful, fit, and attractive appear-
ance than removing lower lid fat would have. Note that the upper orbit
has been replenished with fat injections as well. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
midface lift procedures have been largely abandoned. Most
midface lift procedures have a steep learning curve and have
been fraught with complications, especially those performed
through a blepharoplasty incision. These complications include
lid retraction, ectropion, canthal displacement, and related
corneal exposure and dry eye problems. As a result, many mid-
face lift techniques came necessarily to incorporate potentially
problematic aggressive adjunctive surgical maneuvers, including
canthotomies, canthoplasties, and orbicularis oculi muscle
suspensions to reduce the likelihood these problems will occur.
However, these maneuvers are technically demanding and often
result in a changed look that is disturbing to many patients. In
addition, they carry a high risk of significant and troublesome
complications of their own.
Many other arguments can be made against the use of isolated
midface lift procedures, including the fact that attractive rejuve-
nation of the face is possible without complete elimination of the
nasolabial fold. Most patients with nasolabial folds can be seen to
have had them when they were young, and their presence reflects
the patient’s anatomic makeup and not a specific age-related
undesirable change. In such cases it is neither necessary nor
desirable to efface these folds completely, as they are an inherent
and appropriate feature of the patient’s face. As a practical matter,
however, it is now acknowledged by most surgeons still perform-
ing midface lifts, or having had experience with them, that most
of the improvement obtained by the procedure consists only of
elevation of the lid–cheek junction, not correction of the naso-
labial fold. Midface lifts also produce a subtle improvement not
always noticed or appreciated by the patient. Because of this, time
in the operating room is often arguably better spent on lower-risk
maneuvers that result in more noticeable improvement of higher
priority to patients.
Careful evaluation of most patients who need or request
a midface lift will show that they also need a facelift. It is rare
to encounter a patient with midface aging who does not also
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 VIII Surgical Rejuvenation of the Face and Neck

have sagging in the cheek and jowl, and midface lifts are as a
result arguably more logically performed in conjunction with
a formal facelift procedure. hen they are performed together,
improvement is more balanced and comprehensive, and a more
harmonious and natural appearing result is usually obtained.
Healing is also faster and complications are less likely if midface
improvement can be obtained through the facelift incision rather
than through a blepharoplasty or intraoral approach.
Analysis of the aging face will also show that midface lifts
are also generally conceptually flawed in that they erroneously
assume the problem seen in the anterior upper cheek to be solely
one of tissue sagging and ptosis. Failure to acknowledge the fact
that atrophy is present to a significant degree in most cases has
led to general disappointment for both patients and surgeons
following many procedures once initial swelling has subsided, and
this realization has resulted in the addition of dermis fat grafts,
orbital fat transposition, “septal resets,” and similar maneuvers
to midface lift procedures. It is questionable and remains to
be answered, however, whether these procedures can produce a
restoration of lost volume as simply, naturally, and effectively as
can be obtained with autologous fat grafting. The current trend
increasingly seems to strongly favor a filling rather than a lift-
ing approach.
is anatomically sound and clinically safe. For many if not most
patients, the repositioning of midface tissues obtained with a
high SMAS flap will be satisfactory, and no additional or separate
midface lift procedure will be required (Fig. 49.3).
49.2.7 The Extended SMAS Concept
The extended SMAS concept is integral to the high-SMAS tech-
nique and the means by which midface tissues are liberated
and allowed to be elevated in an integrated fashion when a high
SMAS flap is raised (Fig. 49.4).
The extended SMAS concept, however, as set forth by Stuzin, is
not synonymous and should not be confused with the “extended
SMAS facelift technique, the latter being the name Stuzin gave
to his personal facelift technique in which a low SMAS flap is
dissected but a more medially situated tab of SMAS tissue is
created over the lateral zygoma as part of the low SMAS flap that,
he asserts, can be used to lift midface tissues.

49.2.6 Why Use a “High SMAS”?

The conventional low cheek SMAS flap, elevated below the
zygomatic arch, suffers from the drawback that it cannot, by
design, have an impact on tissues of the midface and infraor-
bital region. Low designs target only the lower cheek and jowl
and produce little if any improvement in the upper anterior
cheek area. Planning the flap higher, along the border of the
zygomatic arch, and extending the dissection medially in an
extended SMAS fashion to mobilize midface tissue overcomes
this problem and produces an improved result (Fig. 49.2). This is
the fundamental concept behind the high-SMAS idea: planning
the flap higher provides the biomechanical means by which a
combined and simultaneous lift of the midface, lower cheek, and
jowl can be obtained with a single flap and avoids the need to
perform a separate midface lift procedure.
More specifically, benefits of a high-SMAS plan include resto-
ration of youthful upper cheek contour, an aesthetically signifi-
cant fill of the infraorbital region, increased support of the lower
eyelid, improved posture of the mouth, and improved correction
of the nasolabial fold that cannot be obtained when a traditional
low-SMAS procedure is performed. High-SMAS procedures are
also readily combined with midface fat grafting, since midface
and infraorbital tissue planes are not opened or dissected. This
averts the need to perform complex and potentially problematic
procedures in which orbital fat is transposed, the orbital septum Fig. 49.2 “High”- and “low”–superficial musculoaponeurotic system
reset, or free grafts placed. (SMAS) techniques compared. (a) Plan for low-SMAS procedure.
Note that the upper border of the flap lies below the zygomatic
At least part of the past popularity of low-SMAS designs can
arch. (b) Low SMAS flap after dissection and suspension. Area of flap
be attributed to concerns regarding anatomic constraints about effect (green solid circle) is limited to the lower cheek and jowl, and
the zygomatic arch and laudable and well-intended efforts to no improvement is obtained in the midface, infraorbital, or perioral
regions (black dashed circle). (c) Plan for high-SMAS procedure. Note
design flaps that could be dissected safely without risk of injury
that the upper border of the flap lies over the zygomatic arch. (d) High
to the frontal branch of the facial nerve. Published studies and a SMAS flap after dissection and suspension. Area of flap effect (green
reappraisal of the assumption of the need for a low dissection, solid circle) includes not only both the cheek and jowl but the midface,
along with a careful consideration of the actual anatomy of the infraorbital, and perioral regions (black dashed circle) is well. (Copyright
© Timothy Marten.)
nerve over the arch, has shown, however, that a high dissection

638
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
a b
Fig. 49.3 High–SMAS facelift. (a) Woman aged 47 before surgery.
Note loss of youthful contour. (b) Same patient 1 year and 3 months
after high-SMAS facelift, neck lift, forehead lift, upper and lower eye
lifts, and fat injections. Sagging tissues have been repositioned, youth-
ful jaw line contour restored, and redundant skin excised without a
tight or pulled appearance. (Procedure performed by Timothy Marten,
MD, FACS. Copyright © Timothy Marten.)
Stuzin’s extended SMAS concept was a groundbreaking one that
clarified certain anatomic realities that had gone unrecognized by
other surgeons employing SMAS techniques, and it comprised a
new and important approach in treatment of the midface during
facelift procedures that remains germane to this day.
Traditional SMAS dissections targeted largely the lower-cheek
SMAS and platysma and focused on releasing more inferiorly situ-
ated masseteric–cutaneous ligaments restraining the lower cheek
and posterior jaw line areas (Fig. 49.4a). These types of dissections
were likely undertaken in large part because they were relatively
easier to perform as compared with dissecting more superiorly,
and perhaps due to the hyperfocus on the jaw line, and lack of
awareness of the need to reposition the midface as well, that was
prevalent at that time.
In the extended SMAS approach, dissection is limited in the
lower cheek to the release of the masseteric–cutaneous liga-
ments that are situated along the anterior border of the parotid,
in recognition of the fact that a more extensive dissection serves
no purpose and does not provide an improved release, and focus
is instead directed more superiorly to release the zygomatic
ligaments situated near the origin of the zygomaticus major
muscle and their confluence with upper masseteric–cutane-
ous ligaments situated just inferior to them, as was not done
in traditional, nonextended SMAS dissections (Fig. 49.4b).
Extending the SMAS flap dissection up onto the zygoma and
into this area and releasing these more superiorly situated
ligaments restraining the upper SMAS, while perhaps more
tedious, resulted in a release of the upper cheek and midface
that provided a more comprehensive effect of the SMAS flap
and a more balanced and complete lift of the face. ithout an
extended SMAS dissection, the full potential of a high SMAS flap
will not be realized.
Fig. 49.4 The “extended SMAS” concept. (a) Traditional (but incorrect)
area of SMAS undermining (brown shaded area). A lack of understand-
ing of the presence and location of the ligaments restraining the SMAS
layer led to an unnecessary overdissection of the SMAS-platysma
inferiorly well into the neck, where no ligaments are present, and an
underdissection in the upper cheek, where the zygomatic ligaments
restrain the upper cheek and midface (red arrow). (b) Extended SMAS
dissection. Dissection is limited in the inferior SMAS–platysma to the
release of the masseteric–cutaneous ligaments (small black squares
along the anterior border of the parotid) and extended into the upper
cheek and midface to release the zygomatic ligaments (small black
circles located near the origin of the zygomaticus major muscle at tip of
red arrow). Although more tedious, the release of the upper cheek and
midface obtained when an extended dissection is performed gives the
SMAS flap a more comprehensive effect and provides a more balanced
and complete lift of the face. (Copyright © Timothy Marten.)
49.2.8 Lamellar Dissection and
Bidirectional Tissue Shifts
A number of specific strategies that have been devised for uti-
lization of the SMAS that merit consideration (Fig. 49.5). These
include “deep-plane” and “composite” one-layer dissections,
in which the SMAS and skin are elevated as a single unit and
advanced along the same vector (Fig. 49.5c), and “lamellar”
dissections, in which skin and SMAS are elevated as two separate
lamellae, or layers, and advanced bidirectionally along different
vectors and under different tension loads (Fig. 49.5a,b).
Deep-plane and composite-type dissections have the potential
advantage that they are quicker to perform and result in a com-
paratively thicker, arguably more durable and better vascularized
flap composed of both skin and SMAS. These dissections have
the distinct disadvantage, however, that they constitute unidi-
rectional lifts, in which the skin and SMAS must be advanced
the same amount in the same direction (along the same vector)
and suspended under more or less the same amount of tension.
Because skin and SMAS age at different rates and along some-
what different vectors, however, optimal treatment of each layer
is generally not possible when these types of dissections are
performed, and skin overshifting, skin overtightening, temporal
hairline displacement, wrinkle shift from the neck to the cheek,
and other objectionable occurrences and unnatural appearances
can result. In addition, if the orbicularis oculi is included in a
composite flap as delineated in the procedure design, the muscles’
motor nerve supply can be compromised and lid dysfunction,
nerve cross-regeneration, and other disturbing and objectionable
abnormalities can occur.
Two-layer, lamellar dissections offer the distinct advantage that
skin and SMAS can be advanced different amounts, along separate
vectors, and suspended under different amounts of tension in
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.5 Lamellar dissection and bidirectional tissue shift. (a) Two-layer lamellar dissections, in which the skin and SMAS are dissected as two
separate layers, offer the distinct advantage over one-layer deep-plane and composite dissections in that each layer is advanced independently along
a separate vector and suspended under a different degree of tension. (b) When a lamellar dissection is performed, the SMAS can be advanced more
vertically along a vector parallel to the long axis of the zygomaticus major muscle (white arrow) while the skin can be allowed to flow more naturally
posteriorly more perpendicular to the nasolabial fold (solid black arrow). (c) When a deep-plane or composite dissection is made the skin and superfi-
cial musculoaponeurotic system (SMAS) can be moved only along the same vector and the same distance. (Copyright © Timothy Marten.)

pursuit of optimal artistic and aesthetic goals. This bidirectional
lift” allows each of these layers to be addressed individually,
and overly vertical skin shifts, counterproductive skin tension,
unwanted and objectionable hairline displacement, and wrinkle
shifts” can be better avoided. This, in turn, results in a more nat-
ural appearance, a more comprehensive rejuvenation, and fewer
secondary irregularities.
Two-layer lamellar techniques suffer the potential drawbacks
that the skin and SMAS flaps are thinner, arguably more fragile,
and less well vascularized and that the dissection is technically
more demanding and time-consuming to perform.
49.2.9 Lateral Sweep
Traditional skin-only facelifts and low-SMAS procedures
typically result in overtightening of the lateral cheek skin and
provide little support to the midface, lateral perioral, and jowl
areas. Over time, these unsupported tissues continue to descend
in a disproportionate fashion while the lateral face remains tight,
resulting in a characteristic and unnatural-appearing underreju-
venated mouth and objectionable tight and swept-up appear-
ance on the jawline and lateral face, often pejoratively referred to
as lateral sweep (Fig. 49.6).
Although unsupported tissue in the lateral perioral and jowl
areas largely responsible for this problem is actually anteriorly
situated, and perhaps the problem would be more correctly
thought of anatomically as an anterior phenomenon, this
objectionable-appearing occurrence has nonetheless come to
be known as lateral sweep due to the adjacent and abnormal
preauricular tightness. Lateral sweep is generally most apparent
in the lateral view when the patient looks down. In this position
lateral facial tightness is increased by the better tissue fixation
and exaggerated SMAS support in the preauricular area, and the
“sweep” appearance on the lateral face is accentuated by the com-
paratively poor or nonexistent support of the more anteromedial
midface and lateral perioral areas.
Lateral sweep is an unavoidable and inevitable consequence of
all traditional skin-lift and low-SMAS deep-plane and composite-
type procedures that are not designed and carried out in a way that
supports the midface and lateral perioral area. These skin-only
and low deep-layer procedures are incapable of providing uniform
support to both the anterior and lateral cheek and are biogeomet-
rically inclined to produce an unbalanced and unnatural appear-
ance. Lateral sweep is also typically seen when a vertical vector
is used when shifting the skin flap in older patients with aging
inelastic skin or in younger patients who have had a remote facelift
in which a vertical skin flap vector was used. A high SMAS flap,
in contrast, provides simultaneous and uniform one-flap support
of the lateral facial, midface, and perioral areas, and this results
in a more balanced, comprehensive, and natural rejuvenation and
minimizes the chance the lateral sweep will occur.
Lateral sweep can result when a high-SMAS technique is used
if the lateral perioral region is overdissected subcutaneously and
ligamentous attachments between the SMAS and the skin in the
lateral perioral region are mistakenly and inappropriately divided.
These ligaments are the means by which the high SMAS flap sup-
ports the lateral perioral area, and overdissection of this sort is
a common error made by surgeons who mistakenly assume that
extended skin undermining will help improve the nasolabial fold
and/or allow the excision of more facial skin. This is not a flaw
in the high-SMAS concept or technique; it is merely a failure to
perform the procedure correctly.
49.2.10 Misapplication of
Ancillary Procedures
Many, if not most, of the changes associated with loss of facial
contour as one ages represent primarily deep-layer problems
that will be inadequately corrected with traditional skin-only
or low-SMAS techniques. Regrettably, surgeons unfamiliar with
deep-layer techniques, or insufficiently trained to perform them,
are increasingly performing skin-only facelifts or mini-lifts in

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 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

conjunction with misguided and misapplied ancillary procedures
to overcome the considerable shortcomings of such plans. These
procedures include facial liposuction, inappropriate extraction of
buccal fat, malarplasty ( cheek implant ), submalarplasty ( sub-
malar implant ), geniomandibular groove augmentation ( pre-
jowl implant ), polytetrafluoroethylene (PTFE; e.g., Gore-Tex, .
L. Gore and Associates, ewark, DE) implantation, and various
types of conceptually flawed suspension and/or barbed and
cupped suture placement. Although some of these procedures
are at times indicated and indeed of benefit to certain patients,
they will be unnecessary in the majority of cases if a high-SMAS
facelift and deep-layer rejuvenation is performed.
49.3 Preoperative Planning
It is not possible to design or use a universal facelift technique,
as each patient will present with a unique set of problems that
require precise anatomic diagnosis and an appropriately planned
and individualized surgical repair. Committed study, careful
planning, and avoidance of a formula technique will maximize
improvement, limit complications, and minimize secondary
irregularities commonly seen following one-size-fits-all
procedures.
redundancy over the upper cheek along the vector of skin flap ele-
vation and, thus, the skin shift and superior displacement of the
temporal tuft of hair ( sideburn ) that will occur when the facelift
flap is lifted. This can be gauged by simply pinching up redun-
dant skin along the predicted superolateral vector of skin shift
and assessing the amount present. The surgeon’s estimate of skin
redundancy over the cheek, when considered in conjunction with
the amount of existing temporal “skin show” and temple-sideburn
hair present, enables rational selection of the best site for placement
of the temporal incision.
In patients in whom minimal or modest skin shift is predicted
to occur and for whom lush temporal scalp and sideburn hair
is present, the temporal portion of the facelift incision can be
placed in the traditional location 4 to 5 cm within the temporal
scalp, extending superiorly up from the anterior superior aspect
of the ear (Fig. 49.9). hile individual circumstances will vary
and the decision about where the incision be placed should be
based on the circumstances present and not arbitrarily based on
age, typically patients in whom this incision plan is indicated are
under 45 years old.

49.3.1 Incision Planning

One of prospective facelift patients’ most commonly expressed
fears is having an obvious scar that can be seen by others. A poorly
concealed scar, or other stigmata related to imprudent incision
planning, can give rise to self-consciousness, embarrassment,
shame, humiliation, and social dysfunction. A poorly planned
incision can place strain on relationships, limit the potential for
future relationships, and even interfere with a patient’s potential
for professional advancement. Scar visibility, or the lack of it,
is part of our professional signature and is often regarded as
a marker for how skillfully the rest of the procedure was per-
formed. If an otherwise well-performed facelift is accompanied
by a poorly concealed scar or other stigmata related to poor
incision planning, our patients will feel we have failed them.

Planning the Temple Incision

The temporal portion of the facelift incision has traditionally
been placed within the temporal scalp in a well-intended, but
all too often counterproductive attempt to hide the resulting
scar. hen cheek skin redundancy is small and abundant temple
and sideburn hair is present, such a plan can be used without
producing objectionable sideburn elevation and temporal hair-
line displacement. Patients best suited for this incision plan are
usually younger and troubled only by mild to moderate cheek
laxity. In older patients, however, who typically experience
Fig. 49.6 Lateral sweep. Traditional skin-only facelifts and low–super-
larger skin shifts and who typically have sparse temple hair, such ficial musculoaponeurotic system (SMAS) procedures typically result in
a plan can result in unnatural and telltale sideburn elevation and overtightening of the preauricular cheek skin and provide little support
displacement of the temporal hairline (Fig. 49.7). to the lateral perioral and jowl areas. In time, these unsupported
tissues continue to descend in a disproportionate fashion, while the
Proper analysis, careful planning, and the use of an incision
lateral face remains tight, resulting in a characteristic and objection-
along the hairline, when indicated, can avert this problem without able “swept-up” appearance of the skin over the jawline, often referred
compromising the overall outcome of the procedure (Fig. 49.8). to as “lateral sweep. ” (Procedure performed by an unknown surgeon.
Copyright © Timothy Marten.)
In choosing the location of the temporal portion of the facelift
incision, it is important for the surgeon to estimate the skin

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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 49.7 Displacement of the sideburn and temple hair due to poor
incision planning. (a,b) The temporal portion of the facelift incision
was made in the temporal scalp in a well-intended but conceptually
flawed effort to hide the resulting scar. Because cheek flap redundancy
was large and skin elasticity poor, advancement of the cheek skin flap
has resulted in objectionable and telltale hairline displacement. An
incision along the hairline (black dotted line in c) would have prevented
this occurrence. (c) Deconstruction of the cause of the temporal
hairline displacement seen in parts a and b. The operating surgeon
made a well-intended effort to hide the temporal portion of the facelift
incision in the temporal scalp (red dotted line) but underestimated
or did not appreciate the amount of skin redundancy over the upper
lateral cheek. When the facelift skin flap was advanced (black arrow),
skin was moved into an area where scalp and hair should be present.
The black dotted line shows the incision plan that would have pre-
vented this occurrence. (Procedures performed by unknown surgeons.
Copyright © Timothy Marten.)
Fig. 49.8 (a–c) Healed incisions along the temporal hairline. The use of
an incision along the hairline, when indicated, can prevent hairline and
sideburn displacement without compromising the end result. Although
a fine scar is present along the hairline in each of these patients, it
is not evident upon casual inspection. Note the preservation of lush
temple hair and a full, youthful, natural-appearing sideburn (compare
with Fig. 49.7). (Procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)
In patients in whom more significant temporal skin shift is
predicted to occur and in whom less abundant temporal-sideburn
hair is present and the sideburn is predicted to be displaced above
the level of the junction of the root of the helix with the cheek,
consideration should be given to placing the incision along the
hairline (Fig. 49.8, Fig. 49.10) rather than within the temporal
scalp. This incision plan will accommodate large posterior-
superior skin flap shifts and allows maximum improvement in the
upper lateral face to be made. If it is made with care and closed
under no tension, the resulting scar is usually inconspicuous and
far less troublesome for the patient or obvious to others (see Fig.
49.8) than is a displaced hairline (see Fig. 49.7).
hile individual circumstances will vary and the decision as to
where the incision will be placed should be based on the circum-
stances present and not arbitrarily based on age, typically patients
in whom this incision plan is indicated are over 45 years old.
642
Fig. 49.9 Plan for incision on temporal scalp. This plan should be
used for patients with modest skin excess and who have abundant
temporal-sideburn hair and thus are predicted to have minimal or
modest superior and posterior shift of sideburn and temple hair after
elevation of the facelift skin flap. It will not be appropriate for most
patients, especially older patients and patients undergoing secondary
or tertiary procedures. The dotted red line shows the incision location.
A small anterior protrusion should be made part of the design where
the ear joins the temporal scalp, as shown, to prevent the advance-
ment of skin into this area, which should consist of hair bearing scalp.
Black dotted line shows location of pre-auricular part of the facelift
incision. The incision should then extend superiorly along a vertical
line dropped through the auditory meatus (white line). In certain cases
the incision may extend higher or lower than shown, depending on the
amount of excess skin present in the upper lateral face. (Copyright ©
Timothy Marten.)
In light of the preceding discussion it can be seen that the plan
for the location of the temporal portion of the facelift incision
cannot be arbitrary and must be based on the patient’s individual
anatomy and tissue condition, and options for its placement should
be discussed with any patient in whom significant elevation of the
sideburn or displacement of the temporal hairline might occur.
Other but arguably less important considerations include the
patient’s skin type, eye color, ancestry, and age, as patients with
lighter complexions, light-colored eyes, who are over 50 years old
and of Northern European ancestry typically form better scars
than patients with darker complexions, darker eye color, who are
under 50 years old or of Mediterranean, Middle Eastern, Asian,
or African ancestry. In all, incision placement is best presented to
the patient as a choice between two imperfect alternatives, and it
is wise to leave the final decision as to where the incision will be
located to the patient after appropriate discussion has taken place.
Placing the incision in a traditional location within the temporal
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.10 Plan for incision along the temporal hairline: female
vs. male patients. An incision along the temporal hairline should
be considered whenever the surgeon’s assessment predicts that
Fig. 49.11 Traditional vs. “concealed” preauricular incision plans. (a)
objectionable superior and posterior displacement of the sideburn and
The traditional (but generally incorrect) location of the preauricular
temple hair will occur. This incision plan is usually indicated in older
incision places the scar in an area open to inspection by others and
patients and almost always indicated in patients undergoing secondary
“brands” the patient as having had facelift surgery. Makeup will not
or tertiary procedures. In certain cases the incision may extend more
conceal a scar in this location, as the scar is smooth and the skin on
superiorly or inferiorly than shown depending on the amount of excess
either side of it is not. Making the incision in this location will also
skin present in the upper lateral face (see also Fig. 49.37). (a) Temple
typically culminates in a difference of skin color on each side of the
hairline incision plan for the female patient (dotted red line). Note that
resulting scar, which is an additional telltale tipoff that surgery has
incision is planned as a soft curve to evoke a feminine appearance
been performed. (b) The “concealed” or “retrotragal” incision plan
extending inferiorly to a point approximately half the height of the
places the incision along natural anatomic contours in the helical–facial
anterior helix (solid white lines). Dotted black lines show typical posi-
sulcus, along the margin of the tragus, and in the lobular facial sulcus,
tion of preauricular incision in the female patient. (b) Temple hairline
concealing the preauricular scar and disguising differences in color and
incision plan for the male patient (dotted red line). Note that incision is
skin texture on each side of it as natural anatomic interfaces. While
planned with a more rectangular masculine shape extending inferiorly
cheek skin is advanced onto the tragus, a better overall concealment
to a point approximately half the height of the anterior helix (solid
of the scar is obtained (see also Fig. 49.12, Fig. 49.13, Fig. 49.14).
white lines). Dotted black lines show typical position of preauricular
(Copyright © Timothy Marten.)
incisions in a male patient. An incision plan that sets the male sideburn
more inferiorly than shown may compromise the blood supply to the
prehelical part of the facelift skin flap. Such a plan also requires the
patient to wear a long sideburn from his surgery date forward if the
scar is not to show. (Copyright © Timothy Marten.) area are made well anterior to the anterior border of the helix
and continued inferiorly, anterior to the tragus, and anterior and
inferior to the lobular–facial junction (Fig. 49.11).
This design, however, works well only for the older or unusual
scalp (see Fig. 49.9) will help conceal the scar, but often at the
patient with cheek and tragal skin of similar characteristics
expense of a large and objectionable displacement of the sideburn
who, in addition, exhibits favorable healing. Unfortunately, most
and temporal hairline (see Fig. 49.7) and compromised improve-
patients have a marked gradient of color, texture, and surface
ment over the upper lateral face. Inappropriate use of a temple
irregularities over these areas, and a telltale mismatch will be
scalp incision inevitably results in an objectionable, unnatural, and
evident, even in the presence of an inconspicuous scar. For these
“facelifted” appearance that is immediately obvious, even upon a
reasons, and in all but the unusual case, the preauricular portion
casual glance and at a distance. An incision along the sideburn and
of the facelift incision should be precisely placed along the posterior
temporal hairline (see Fig. 49.10), however, will prevent hairline
margin of the tragus (in a “retrotragal” position) rather than in the
elevation and displacement, and although a scar will be present
pretragal sulcus (Fig. 49.11b). In this location a mismatch of color,
where the incision was made, it is usually inconspicuous and will
texture, or surface irregularities will not be noticed and the scar, if
not be noticed by others if closed under no tension and otherwise
visible, will appear to be a tragal highlight (Fig. 49.12).
carried out technically correctly. In addition, although a subop-
In addition, and despite some claims to the contrary, a properly
timally healed incision along the hairline can be concealed with
planned and executed incision along the margin of the tragus that
makeup or revised, a significantly elevated and displaced hairline
is closed under no tension will not produce tragal retraction or
is difficult to conceal and is a challenge to surgically correct. It
other telltale anatomic irregularity (Fig. 49.13).
has been our experience that most patients are disturbed by the
In the male patient a similar incision plan is used (Fig. 49.14).
prospect of elevation and displacement of their sideburn hair and
In many cases, skin flap shifts will be modest and such that beard
recognize such occurrences as objectionable and tell-tale signs
hair will not be retroposteriorly displaced enough to be advanced
that a facelift has been performed. hen counseled properly and
onto the tragus itself. In cases where larger skin flap shifts occur
given the choice, most will readily consent to incision placement
(typically older men), the tragus can be kept free of beard hair
along their hairline when indicated.
when a retrotragal incision is used by intraoperative destruction
of beard follicles from the underside of the tragal flap when
Planning the Preauricular Incision indicated.
Open to scrutiny, the preauricular region exists as a frequent The preauricular incision consists of three component inci-
point of reference for those seeking to identify a facelift patient sions: (1) a prehelical incision, (2) the tragal incision, and (3) a
and in essence arguably constitutes the signature (or lack prelobular incision. Careful attention to the planning of each must
thereof) of the surgeon’s work. Traditionally incisions in this be undertaken if a well-concealed scar and natural appearance is

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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 49.12 Pretragal and concealed (retrotragal) scars compared.
(a) Pretragal incision has healed satisfactorily with an acceptable scar
but the scar is plainly visible due to differences of color and texture
on each side of it and exists as a telltale sign that a facelift has been
performed. (Surgery performed by an unknown surgeon.) (b) Same
patient after secondary facelift in which the incision was moved to the
posterior margin of the tragus (retrotragal position). Color and texture
differences, and the scar itself, are now hidden along natural anatomic
interfaces, and no telltale sign that a facelift has been performed is
present. (Surgery performed by Timothy Marten, MD, FACS. Copyright
© Timothy Marten.)
Fig. 49.14 (a–c) Healed retrotragal facelift scars in male patients.
A retrotragal placement of the preauricular portion of the facelift
incision has resulted in an inconspicuous and well-concealed scar. In
the upper third, the scar sits in the interface between the helix and the
cheek and the scar appears to be a reflected highlight of the anterior
helical border. In the middle third, the scar sits along the poster margin
of the tragus and cannot be seen. Some coarse and bearded skin has
been shifted up against and onto the tragus in b and c, but this is
less obvious than the presence of a pretragal scar with a gradient of
color and texture on each side of it. In the lower third, the scar sits in
a well-concealed location 2 to 3 mm outside the lobular–facial sulcus
but far enough away from it that shaving in that area is not difficult.
(Surgery performed by Timothy Marten, MD, FACS. Copyright ©
Timothy Marten.)
to be obtained. The superior, prehelical portion of the preauricu-
lar incision should be planned as a soft curve paralleling the curve
of the anterior border of the helix. This will result in a natural
appearing width to the helix in keeping with the rest of the ear
and the resultant scar, if visible, will appear to be a helical high-
light and/or the natural anatomic transition from smooth pinker
skin of the helix to the paler, coarser skin of the cheek (Fig. 49.15,
Fig. 49.16).
644
Fig. 49.13 (a–c) Healed retrotragal incisions. Close-up views of facelift
patients with preauricular incisions along the margin of the tragus in
a retrotragal position. Scars are well concealed, no tragal distortion is
present, and a normal pretragal sulcus can be seen. While cheek skin
has been advanced onto the tragus, a more natural appearance and
better concealed scar is present than if a pretragal incision had been
used (see also Fig. 49.12b). (Surgeries performed by Timothy Marten,
MD, FACS. Copyright © Timothy Marten.)
Fig. 49.15 Optimal position of prehelical part of the preauricular inci-
sion. The prehelical portion of the preauricular incision (red dotted line)
should be planned as a soft curve paralleling the curve of the anterior
border of the helix. This will result in a natural-appearing “width” to
the helix, in keeping with the rest of the ear (black dotted lines), and
the resultant scar, if visible, will appear to be a helical highlight and be
disguised as the natural transition between the smooth pinker skin of
the helix and the coarser, paler skin of the cheek. (Surgery performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
If the prehelical portion of the preauricular incision is placed
too far anteriorly or is situated so that it encroaches on the helix
itself, the illusion of the scar as an anatomic interface and/or
reflected highlight is lost (Fig. 49.16).
As the tragus is approached, the mark for incision is carried
into the depression superior to it and then continued along its
posterior margin. In this location the scar, if visible, will appear as
a natural highlight (Fig. 49.17).
Although an incision along the posterior margin of the tragus
is often referred to as a retrotragal incision, it is unnecessary
and an error to place this incision in a true retrotragal position
on the inner surface of the tragus. This usually results in a bulky,
amorphous-appearing tragus and obliteration of tragal anatomy.
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.16 Improper and proper placement of prehelical scar. Often the prehelical portion of the preauricular scar is poorly situated, and the illusion
of it as an anatomic feature is lost. (a) The prehelical incision has been made too far anteriorly, and the illusion of the scar as an anatomic feature is
lost. (Surgery performed by unknown surgeon.) (b) The prehelical incision has been made too far posteriorly and has obliterated the helical facial
sulcus and has encroached on part of the helix itself. (Surgery performed by unknown surgeon.) (c) A patient with a properly planned and executed
prehelical incision. The scar has been placed directly in the helical–facial sulcus. In this location a transition of color and texture is expected, and the
scar appears to be a natural anatomic feature (see also Fig. 49.15). (Surgery performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

Fig. 49.17 Optimal position of the preauricular incision. (a) Placing the preauricular scar along natural anatomic interfaces (red dotted line) places
transitions of color and texture in locations where the eye is expecting to see them, and the scar itself, if seen, will appear as a reflected highlight (see
Fig. 49.12b). (b) Note that the scar, although hypopigmented and situated on darker skin and visible, appears to the eye to be a reflected highlight
along the anterior border of the helix and the posterior margin of the tragus, and elsewhere where the incision was made. Note also how gradients of
color and texture on each side of the scar appear expected and natural. A similar illusion and concealment would not be present had the incision been
placed in a pretragal location. (Copyright © Timothy Marten.)

At the inferior portion of the tragus the incision must turn ante- Planning the Perilobular Incision
riorly and then again inferiorly, into the crease between anterior
To obtain a natural perilobular appearance, it is essential, in
lobule and cheek. If a more relaxed plan is made, or if a straight
cases where a naturally shaped earlobe is present, to preserve
line or lazy S incision plan is used, skin settling and scar con-
the natural sulcus between the earlobe and the cheek and to
traction will result in crowding of the incisura, obliteration of the
avoid destruction or excision of this aesthetically important
inferior tragal border, and a telltale elongated or chopped- off
anatomic subunit. This is accomplished by marking the incision
tragal appearance (Fig. 49.18).
1 to 2 mm inferior to this junction in women and 2 to 3 mm

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 VIII Surgical Rejuvenation of the Face and Neck

made to join thin, soft earlobe directly with coarse, thick cheek.
hen a square, attached, or large lobule is present, consid-
eration should be given to earlobe reconfiguration or earlobe
reduction when the earlobe is reset into the cheek skin flap (see
discussion later in this chapter; Fig. 49.62, Fig. 49.63).

Planning the Postauricular Incision

The postauricular portion of the facelift incision (Fig. 49.19) is
actually composed of three component incisions:
(1) A concho-mastoid incision extending in and along the
concho-mastoid sulcus (Fig. 49.19d, gray-dotted line). (2) A
trans-mastoid incision traversing horizontally across the mastoid
to the occipital scalp (see Fig 49.19d, red line). (3) An occipital
incision extending into the occipital scalp or along the occipital
hairline (Fig. 49.19d, white dotted line). A careful consideration
of the design of each is important if an overall well-concealed and
inconspicuous scar is to be obtained.

Fig. 49.18 “Chopped-off” tragus. The unnatural and objectionable-

appearing, elongated tragus with an indistinct inferior border that
results from poor incision planning, improper excision of skin at
the time of incision closure, and failure to provide SMAS support of
deep-layer facial tissues. (Note also unaesthetic and objectionable
displacement of sideburn hair due to improper planning of the
temporal portion of the facelift incision as well; see also Fig. 49.7.
(Surgery performed by an unknown surgeon. Copyright © Timothy
Marten.)
inferior to it in men. Placing the incision slightly more inferiorly
in men facilitates shaving postoperatively should bearded skin
be shifted superiorly against the incision, as it commonly will be.
In both cases, when a naturally shaped lobule is present, all other
factors being equal, a superior result will be obtained when such
a plan is used, in comparison with any plan in which the incision
is placed directly in the sulcus and an attempt is subsequently
Planning the Conchomastoid Portion of the
Postauricular Incision
Traditionally, the conchomastoid portion of the facelift incision
has been made up onto and over the posterior surface of the
concha. This was done as part of a well-intended but conceptually
flawed effort to offset inevitable descent of the postauricular skin
flap and inferior migration of the resulting scar, which occurred
when skin was forcefully advanced superiorly and suspended
under tension in a misguided attempt to improve neck contour by
skin flap tightening. Experienced surgeons have come to realize
that such a plan embodies numerous erroneous assumptions and
can result in many undesirable effects, including hypertrophic
scarring, postauricular webbing, and obliteration of the auricu-
lomastoid/conchomastoid sulcus.
The postauricular portion of the facelift incision should
instead be marked directly in the existing auriculomastoid

Fig. 49.19 Planning the position of the transmastoid part of the postauricular incision. Strategically placing the transmastoid part of the postauric-
ular incision conceals it and allows optimal excision of skin from the anterior neck. If it is placed too low, it is visible when the patient’s hair is worn
up or in a short hairstyle. If it is placed too high, the defect created will force an excessive vertical shift of the postauricular skin flap and compromise
improvement in the neck. (a) The point of divergence of the anterior and superior crura of the antihelix provides a useful guide for how high the
transmastoid part of the postauricular incision should be placed (red dot). (b) At this horizontal level (red line) the rim of the helix will typically “touch”
the occipital hairline in the lateral view. (c) A transmastoid scar placed at this level will cross over to the occipital scalp in a hidden location. Note that
if the incision were placed lower, the resulting scar would show. (d) Typical plan for the postauricular incision showing the transmastoid component
(red line) to be concealed. Gray dotted line shows location of the conchomastoid component incision hidden behind the ear and white dotted line the
occipital incision hidden along the occipital hairline. (Note: The patient shown has undergone a previous facelift, and it can be seen that his scars are
well concealed despite his very short “military-style” haircut. ) (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

646
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

(conchomastoid) sulcus in women and 2 to 3 mm posterior to it
in men, with the ear in its resting position or slightly retracted.
Placing the incision 2 to 3 mm posterior to the sulcus in men
prevents advancement of bearded skin against the concha and
facilitates shaving in this area. Such a plan places the scar along
or near a natural anatomic interface, where it will be difficult to
detect, even on close inspection. Marking must be made with the
ear resting near its natural anatomic position. If the ear is pulled for-
ward while marks are made, mastoid skin will be pulled anteriorly
over the posterior surface of the concha and the incision will end up
posterior to its intended location and outside the auriculomastoid
(conchomastoid) sulcus. Incorrect marking in this manner is one
of the most common causes of a poorly situated postauricular
(conchomastoid) scar.
Planning the Transmastoid Portion of the
Postauricular Incision
Considerable confusion exists among surgeons performing
facelift procedures as to what level the transmastoid part of the
postauricular facelift incision should cross over to the occipital
scalp, and as a result, this part of the incision is often not placed
strategically and in a manner that best conceals it or allows
optimal excision of skin from the anterior neck. If it is placed too
low, it will be visible when the patient’s hair is worn up or if the
patient wears a short hairstyle. If it is placed too high, the defect
created will force an overly vertical shift of the postauricular
skin flap and compromise improvement in the anterior neck and
submental region. Fortunately, if one assesses the goals sought
and employs simple logic in meeting them, rational and effective
placement of the transmastoid incision becomes possible.
A useful guide in siting the transmastoid part of the postau-
ricular incision is to envision a horizontal line through the point
at which the anterior and superior crura of the antihelix diverge
(red dot in Fig. 49.19a). Typically, at that level the rim of the helix
extends posteriorly back to the occipital hairline to the so-called
helix–hairline touch point (Fig. 49.19b), and a transmastoid
incision placed at that level will be hidden behind the ear in the
lateral view (Fig. 49.19c).
Planning the Occipital Portion of the Postauricular
Incision
Planning the location for the occipital portion of the facelift
incision is conceptually similar to that of the temple region, and
the incision plan must take into account and address similar
concerns of avoiding hairline displacement and scar visibility.
Traditionally this incision is arbitrarily placed low transversely,
into the occipital scalp, in a well-intended but almost always
counterproductive attempt to hide the resultant scar (Fig.
49.20a).
Regrettably, many other similarly conceptually flawed incision
plans that do not recognize tissue biogeometry of the postauricu-
lar area or provide for skin excision along a useful vector have been
advocated and are commonly used. A thoughtful consideration of
what one is trying to accomplish, however, enables one to employ
incision plans that are effective and rational.
For patients in whom neck skin redundancy is small and shifting
and excision of postauricular skin is not necessary, a traditional
postauricular incision plan (as shown in Fig. 49.20a) is appropri-
ate if its transmastoid portion is situated superiorly enough to
be concealed behind the ear (see preceding discussion) and will
result in a well-concealed scar. Patients in this category are usu-
ally young and troubled only by mild neck skin redundancy, and
in these situations the incision is used for access to the lateral neck
only (and access to the lateral platysmal border), not as a means

Fig. 49.20 Traditional plan for the occipital portion of the postauricular incision. (a) The incision is placed low transversely across the mastoid
extending into the occipital scalp in a well-intended but usually counterproductive attempt to hide the resultant scar. This incision should be used
only in younger patients for access to the lateral neck only and cannot be used to remove excess neck skin without producing hairline notching if the
postauricular skin flap is shifted along a proper posterior-superior vector. (b,c) Examples of hairline displacement caused by inappropriate use of the
incision plan shown in part a. (Procedures performed by unknown surgeons. Copyright © Timothy Marten.)

647
 VIII Surgical Rejuvenation of the Face and Neck
to remove any postauricular skin. Mistakenly using this incision
to excise skin along a posteriorly directed vector will predictably
result in the advancement of neck skin into the occipital scalp and
notching of the occipital hairline (Fig. 49.20b,c; Fig. 49.21a,b).
Similarly, using this incision to excise postauricular skin along a
superiorly directed vector will predictably result a wide transmas-
toid scar (Fig. 49.22). Skin excision along either vector using this
incision is conceptually flawed and the source of all-too-common
secondary facelift irregularities.
Although not all patients and their surgeons will recognize
these irregularities for what they are, most are nonetheless
aware that an unnatural appearance is present, especially those
patients who wear short hairstyles, wear their hair up or back,
or lead active lives and engage in activities that may displace
camouflaging wisps of remaining hair. Proper analysis, careful
planning, and the use of an incision along the hairline (Fig. 49.23),
when indicated and carried out in a technically correct manner,
will prevent this problem, and allow skin to be excised along a
Fig. 49.21 Understanding the cause of occipital hairline displacement.
(a) An example of avoidable notching and displacement of the occipital
hairline seen in a patient whose surgeon inappropriately used a tradi-
tional occipital incision plan (see also Fig. 49.20). (b) Deconstruction
of the occipital hairline displacement seen in part a. The surgeon made
a well-intended, but conceptually flawed attempt to hide the scar
in the occipital scalp (dotted red line) after underestimating the skin
redundancy in the upper lateral neck. Skin has been advanced (black
arrow) into a position where scalp hair should be and the hairline is
“notched.” The dotted black line shows the incision plan that would
have prevented the problem. (Procedure performed by unknown
surgeon. Copyright © Timothy Marten.)
Fig. 49.23 Plan for incision along the occipital hairline. This incision
plan allows skin to be excised along a proper posterosuperior vector,
prevents hairline displacement, and results in a well-concealed scar
if carried out in a technically correct fashion. Note that the incision
is planned so that its inferior portion typically turns posteriorly into
the occipital scalp at the junction of thick and thin hair but will vary in
length in accord with the amount of skin redundancy present in the
anterior neck area. (see Fig. 49.25) (a) Schematic of occipital hairline
incision plan. (b) Occipital hairline incision plan marked on a typical
patient. (Copyright © Timothy Marten.)
648
correct posterosuperior vector, while simultaneously producing a
well-concealed scar (Fig. 49.24; see also Fig. 49.19a).
In logically designing and deciding upon the proper position
of the occipital portion of the facelift incision, the surgeon must
gauge the degree of skin redundancy present on the anterior neck
and along the predicted posterosuperior direction of skin flap
shift. This can be accomplished by pinching up tissue over the
upper lateral neck along the superolateral vector along which it
will be advanced and estimating the amount of excess present. If
2 cm or less of excess neck skin is present, a traditional incision
across the mastoid extending posteriorly into the scalp at the level
of the mid–upper ear (Fig. 49.19a) will, in most cases, not result in
objectionable disruption of the occipital hairline and, if properly
designed and closed, should result in a scar no more visible than
in a short-scar procedure. As a practical matter, patients whose
tissue conditions are amenable to this incision plan are typically
under 40 years old. If more than 2 cm of neck skin redundancy is
present, however, the incision should be placed along the occipital
hairline but designed in such a manner that a telltale scar will
not be visible in front of the fine hair on the nape of the neck
(Fig. 49.23, Fig. 49.24). This can be accomplished by turning the
inferior portion of the incision back into the scalp at the junction
of thick and thin hair (Fig. 49.23b). This incision plan is typically
needed in patients over 40 years old if hairline displacement is
to be avoided and neck skin is to be excised along a proper and
useful vector.
The length of the occipital portion of the postauricular incision
will necessary vary depending on the quality of the patient’s
tissues and the amount of redundant skin present in the anterior
neck and submental area (size of wattle ), and small, medium,
b
a
Fig. 49.22 Understanding the cause of a wide and hypertrophic
postauricular scar. (a) An example of avoidable postauricular scar
widening and hypertrophy seen in a patient whose surgeon inappro-
priately excised skin along a superiorly directed vector. (red arrow in
b) (Procedure performed by unknown surgeon.) (b) Deconstruction
of the scar widening and hypertrophy seen in (a). The surgeon made
a well-intended, but conceptually flawed attempt to advance the
postauricular skin flap along a superiorly directed vector (red arrow),
typically in an effort to avoid occipital hairline displacement and recon-
stitute the occipital hairline. This erroneously assumed that excess
skin was present in the lower lateral neck (black circle) and produced a
false apparent redundancy of skin over the mastoid (skin shown in red
circle) due to the elevated position of the patient’s shoulder while lying
supine on the operating table. When the patient assumed an upright
position postoperatively and the shoulder dropped, a skin deficit was
created, and traction of the wound produced the wide and hypertro-
phic scar seen in (a). Gray circle shows actual area of neck skin excess,
and green arrow shows the proper vector of skin flap advancement if
optimal improvement in the anterior neck and submental region is
to be obtained. The green circle denotes the area where skin actually
should be excised (along an occipital hairline incision). No skin should
be excised in the area of the red circle. (Copyright © Timothy Marten.)
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

and long (length of incision along the occipital hairline) incision
plans are used as indicated (Fig. 49.25). In patients with good
tissue quality and minimal anterior neck and submental skin
excess ( small wattle ), a short incision along the hairline will
be indicated (Fig. 49.25a). In patients with modest loss of skin
quality and modest anterior neck and submental skin excess
( medium wattle ), a medium -length incision is made along
the occipital hairline (Fig. 49.25b). In elderly patients with poor
skin elasticity and a large anterior neck and submental skin excess
( large wattle ), a long incision along the occipital hairline will
be needed (Fig. 49.25c).
As is the case with temporal incision placement, options for the
placement of the occipital portion of the facelift incision should
be discussed with the patient and presented as a choice between
imperfect alternatives. Although an incision along the occipital
hairline is usually inconspicuous, even on close inspection, if
designed and carried out in a technically correct fashion, a scar
will undeniably be present where it was made. Placing the incision
into the occipital scalp may ostensibly help conceal the scar but
will usually do so at the expense of objectionable displacement
of the occipital hairline, an overly superiorly directed shift of
the postauricular skin flap, and a compromise in the amount of
neck skin excised. hile a suboptimally healed incision along
the occipital hairline can be revised or easily concealed with an
appropriate hairstyle, a significantly displaced hairline can be dif-
ficult to conceal and is a challenge to correct. Overall, it has been
our experience that most patients are disturbed by the prospect
of occipital hairline displacement and recognize it as a telltale sign
that a facelift has been performed. hen properly counseled and
given the choice, most will readily consent to an incision along the
hairline when indicated.
From a practical standpoint it must be acknowledged that
the traditional incision into the occipital scalp should be used for
f
fi
will require an incision along the occipital hairline if skin is to be

Fig. 49.24 Healed scars along the occipital hairline. Proper analysis, careful planning, and the use of an incision along the hairline when indicated, will
allow skin to be excised along a correct posterosuperior vector, while simultaneously preventing hairline notching and producing a well-concealed
scar. (a,b) Healed scars along the occipital hairline in two women. (c,d) Healed scars along the occipital hairline in two men. (Surgery performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

Fig. 49.25 Plan for length of incision along the occipital hairline. The length of the occipital portion of the postauricular incision (red dotted line) will
vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the submental area (size of the “wattle”). (a) In
patients with good tissue quality and minimal submental skin redundancy (“small wattle”), a “short” incision along the hairline will be indicated. (b)
In patients with modest loss of skin quality and modest submental redundancy (“medium wattle”), a “ medium” incision is made along the occipital
hairline. (c) In elderly patients with poor skin elasticity and a large submental skin excess (“large wattle”), a “long” incision along the occipital hairline
will be needed. (Copyright © Timothy Marten.)

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 VIII Surgical Rejuvenation of the Face and Neck
advanced and excised in a biogeometrically correct fashion and
hairline displacement is to be avoided.
Why Not Make the Postauricular Incision
Higher?
A variety of postauricular incision plans have been proposed and
published that utilize designs high up behind the ear, extending
in various patterns into the occipital scalp in a well-intended but
ultimately conceptually flawed attempt to better conceal the
resulting scar. These plans, however, do not recognize the tissue
biogeometry of the postauricular area and do not provide for
skin excision along a useful vector without resulting in hairline
displacement, and making the postauricular incision higher does
not hide the scar. A high postauricular incision plan, while
ostensibly a good idea, actually compounds the problem of
occipital hairline notching and displacement (Fig. 49.26).
The “Short-Scar” Facelift
The idea of shortening the incisions used to perform procedures
to rejuvenate the face is appealing to patients and surgeons alike.
Indeed, the first facelift procedures, performed some 100 years
ago, consisted of small excisions of skin near the ear and along
frontal and occipital hairlines. Regrettably, and despite the many
important advances in techniques to rejuvenate the face that
have been made over the past century, as nonplastic surgeons
have begun to perform aesthetic surgery procedures and market
their services, a new emphasis has been placed on arguably
ill-conceived short-scar procedures that are of questionable
benefit to patients but that are nonetheless appealing in concept
to almost anyone considering a facelift procedure. Although
some short-scar techniques, such as limited-incision forehead lift
and short-scar neck lift, have merit and have provided new and
better options for appropriate patients, skin redundancy remains
a consistent and undeniable problem for the surgeon seeking to
rejuvenate the face and neck, and, considered in conjunction
with overall failure of noninvasive skin-shrinking technolo-
gies, shorter incision plans involve significant compromises in
the overall improvement that can thus be obtained. (Table 49.1)
Fig. 49.26 Making the postauricular incision higher does not prevent hairline displacement. (a) A surgeon has made a well-intended but conceptually
flawed attempt to hide the postauricular scar by making it high over the mastoid and extending transversely high into the occipital scalp (red dotted
line). (b) Cervical skin has been advanced into an area where scalp should be (black arrow). (c) Black dotted line shows the original position of the
hairline and the place where the incision should have been made. A large and objectionable displacement of the occipital hairline is evident. It can
be seen that placing the incision higher compounds rather than reduces the problem of hairline displacement. (Surgery performed by an unknown
surgeon. Copyright © Timothy Marten.)
650
Short-scar incision plans suffer the significant drawback that
they limit access to deep-layer structures, the modification of
which form the foundation of the modern facelift procedure, and
prevent redundant skin from being shifted along proper vectors
that produce the most improvement and most natural appear-
ance. Typically, manipulations of deep-layer tissues performed
through short-scar incisions plans are markedly compromised
and result more often in damage to the SMAS layer than in a
useful repositioning of it. Shorter incisions also require that skin
be gathered up when sutured and prevent it from being excised in
a smooth, well-tailored couture fashion (Fig. 49.27).
A longer scar, conversely, provides proper access to the SMAS
and platysma, allows them to be used in an optimal manner,
and allows skin flaps to be shifted in a geometrically correct
fashion and skin to be excised in a well-tailored fashion without
objectionable puckering or gathering along incision lines (see Fig.
49.23, Fig. 49.24).
Ironically, most short-scar facelift procedures have placed
their focus on the postauricular area and seek to shorten the
postauricular portion of the facelift scar. This scar is situated in
a well-concealed area, and if tension is diverted to deep-layer
tissue, skin excision carefully planned and properly carried out,
and the incision closed under no tension, an inconspicuous scar
will almost always result. This scar is arguably less obvious, less
difficult to conceal, and less disturbing to the patient than is a
shorter but irregular and puckered postlobular scar. Shortening a
scar under these circumstances in a concealed area is of question-
able value to the patient.
Table 49.1 Drawbacks of “short-scar” procedures
• Scar shifted from concealed area behind ear to visible area in front of
temple hairline
• Skin flaps cannot be shifted in biogeometrically correct fashion of
maximum benefit to patient
• Compromised access to deep layers of the face
• Unaesthetic puckering and gathering of tissue common
• Amount of visible scar not really “shorter” than in properly performed
“long-scar” technique
• Reduced amount of redundant skin excised from face
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

always necessary and that it can be instead hidden in the temporal

Fig. 49.27 Puckering and pleating of skin behind the ear resulting
from “short-scar” facelift. (a) Arguably modest but unaesthetic
pleating behind lobule of a patient who has undergone a previous
“short-scar” facelift. Shortening the scar in the postauricular area has
prevented skin from being excised in a smooth, well-tailored fashion.
(b) Objectionable postauricular pleating as a result of an effort to
shorten the postauricular portion of the facelift incision. A longer
scar, even suboptimally healed, would arguably be far less obvious
and objectionable. (Procedures performed by unknown surgeons.
Courtesy of Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
Perhaps the most difficult-to-understand aspect of short-scar
incision plans is that to shorten the postauricular scar and min-
imize the resulting puckering and gathering behind the ear and
earlobe, the cheek skin flap is shifted along an overly superiorly
directed vector, necessitating a scar along the less well-concealed
sideburn and temporal hairline (Fig. 49.28).
Although an incision is often required in this area in many
patients to prevent temple hairline and sideburn displacement,
shortening a scar in a concealed area (the postauricular area) by
shifting it to a more visible area (the temple area) is arguably
of dubious value to the patient, who might not have required it.
Regrettably, and somewhat sadly, it is younger patients, whose
fears of long scars are preyed upon, who are typically desig-
nated as candidates for short-scar procedures. It is this group of
patients, however, who are disproportionately burdened by the
more visible scar along the temporal hairline, who likely would
not otherwise need it had a longer incision been made behind the
ear (Fig. 49.29).
Given the choice, it has been our experience that younger patients
are relieved to learn that a scar along the temporal hairline is not
scalp if an incision along the hairline behind the ear is made.
The ultimate fallacy about short-scar procedures involves the
notion of the length of the scar itself, and the fact that it is the
amount of visible scar that matters and whether the scar is con-
cealed. If the amount of scar present in potentially visible areas is
measured, there is no actual difference between that present in
typical short-scar and long-scar procedures (Fig. 49.30). In this
sense the short and long scars are the same length, and a short
scar is not really shorter (Table 49.1).
49.3.2 nning di i n e
SMAS and Platysma
All patients undergoing a facelift will benefit from a posterosupe-
rior advancement of the cheek SMAS, and this maneuver serves
as the fundamental step in natural-appearing and attractive reju-
venation of the face upon which all others are based (Fig. 49.3).
SMAS advancement provides a natural-appearing and long-last-
ing correction in the cheek and jowl, consolidates the lower face,
and provides a means to divert tension away from the skin. hen
a high-SMAS plan is used, improvement can be obtained in the
midface, infraorbital, and perioral areas without the need for
a separate midface lift procedure. For some patients SMAS flap
advancement alone will provide appropriate correction. Others,
however, will require additional maneuvers or modifications of
this step if their problems are to be adequately addressed.
49.4 Preoperative Preparations
All patients undergo a preoperative physical evaluation, and any
with significant medical problems must be cleared by their inter-
nist or personal physician before their procedure is performed.
Each patient is required to avoid agents known to cause platelet
dysfunction for 2 weeks prior to surgery, and a list of products
that contain aspirin and other medications and products that
have antiplatelet activity is provided.

Fig. 49.28 The short-scar facelift strategy and incision plan. (a) A typical early design of short-scar facelift incision plan (red dotted line). Note that
a postauricular incision is not used (pen mark on patient). When skin was shifted along an optimal vector for excising skin from the neck (blue arrow)
a dog-ear formed behind the lobule (see Fig. 49.27). (b) To avoid the postlobular dog-ear, the short-scar plan evolved to incorporate a superiorly
directed “vertical” shift of the cheek skin flap. When an incision hidden in the temporal scalp was used as shown (red dotted line), marked and objec-
tionable overelevation of the temple and sideburn hair occurred. (c) To avoid objectionable shift of temple and sideburn hair and to accommodate
large amounts of skin shifted into the temple area, the short-scar plan came to use an incision along the temple hairline (red dotted line). This in
essence resulted in shifting of the scar from the more concealed occipital hairline (mark on patient’s skin) to the more visible area on the temple
hairline (see also Fig. 49.29). (Copyright © Timothy Marten.)

651
 VIII Surgical Rejuvenation of the Face and Neck

b
Fig. 49.29 Short-scar and long-scar facelift incisions compared. (a) Long-scar incision plan that would be used in a younger patient. The temporal
portion of the incision (yellow dotted line) is concealed within the temporal scalp, and the resulting scar is not visible and not a concern to the patient.
The postauricular incision (red dotted line) is in a relatively concealed area (inset photo: white arrow). (b) Short-scar incision plan. The postauricular
incision has been eliminated and the incision shifted to a more visible area along the sideburn and temporal hairline that would typically be of more
concern to a younger patient (inset photo: white arrow). (Copyright © Timothy Marten.)

Fig. 49.30 A “short” scar is not really shorter. (a) Typical short-scar incision plan (dotted red line). The length of the scar is approximately 15 cm. (b)
Typical long-scar incision plan for a younger patient. A postauricular incision is present. The temporal portion of the incision (yellow dotted line) is
made within the temporal scalp and will result in a scar that is not visible and does not show. (c) Visible part of a “long”-scar plan when one does not
count the concealed temporal portion (dotted yellow line in part b). The visible scar is approximately 15 cm in length. There is no difference in the
amount of visible scar in most short- and “long”-scar plans. (Copyright © Timothy Marten.)

49.4.1 Smokers and Former Smokers 49.4.2 Ultrasonic and Radiofrequency

All patients who smoke are asked to quit 4 weeks before their “Skin-Shrinking” Treatments
procedure and are required to avoid smoking and all secondhand
Patients should be questioned carefully about previous nonin-
smoke for 2 weeks after. Patients who smoke, or have a signif-
vasive radiofrequency (RF) and ultrasonic skin-shrinking pro-
icant history of smoking but have quit, are advised in writing
cedures, as these treatments appear to damage skin subdermal
that their risk of serious complications, including poor healing,
microcirculation and compromise superficial microlymphatic
flap necrosis, skin slough, and thromboembolic phenomena is
vessels, and patients who have undergone these treatments seem
significantly higher than in nonsmokers. It is generally assumed,
to be compromised candidates for facelift procedures. Similarly,
however, that most patients will not cease smoking, and extra
patients who are longstanding filler users, especially if they have
care should be taken to be sure informed consent is complete in
used more inflammatory fillers such as poly-L-lactic acid (PLLA),
this regard.
are likely to have internal facial fibrosis and inflammatory
Fortunately, flap viability is dependent upon a variety of factors
changes, rendering them more challenging candidates as well.
other than smoking that are under the surgeon’s control and
The patient who has undergone facial ultrasonic and RF
that are minimized by the high-SMAS procedure design. These
skin-shrinking treatments is part of a growing body of patients
factors include the amount of tissue trauma during dissection, the
who seem to sustain clinically significant compromise of their
extent of skin undermining, and the amount of tension of the skin
skin microcirculation as a result of these and like treatments that
flap. Because the high-SMAS technique limits skin undermining,
puts them at greater risk of slough and healing-related problems
preserves important cheek perforators, and avoids tension on
following facelift procedures and suboptimal take when fat graft-
delicate cervicofacial skin flaps, a careful surgeon employing
ing is performed. Unlike when laser resurfacing is performed,
proper technique can operate with acceptable risk on smokers.
in skin-shrinking procedures energy is directed and dispersed
Smokers should always be approached with caution, however, and it
under the skin rather than on its surface, and energy meant to
should be recognized that these patients are suboptimal candidates
tighten the face appears to damage both subdermal microcir-
for surgery and are at increased risk for serious local and systemic
culation and adjacent superficial microlymphatic vessels. The
complications.

652
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
incidence of problems seems to parallel the number and intensity
of treatments the patient has undergone, which one would expect
to parallel the degree of compromise to their tissues. These
patients also seem to experience prolonged edema and a longer
period of recovery following facelift surgery.
Consideration should be given to advising, in writing, patients
who have undergone previous ultrasonic and RF “skin-shrinking”
treatments that their risk of serious complications, including poor
, , , fi
in patients who have not undergone these procedures, especially if
they have undergone multiple previous treatments. From the sur-
geon’s standpoint, these patients should be regarded, approached,
and treated as similar to smokers.
49.4.3 Chemical Treatment of Hair
All patients are instructed not to color, perm, relax, or other-
wise chemically treat their hair during the 2-week period before
and after surgery. Doing so can result in hair breakage and hair
loss.
49.4.4 Infection Prophylaxis
Patients are required to shampoo their hair and shower and
cleanse their skin with antibacterial soaps the night prior to
surgery, paying careful attention to the periauricular areas.
Consideration should also be given to preop chlorhexidine home
prep of the body if fat grafting is to be performed. Patients who
have a history of methicillin-resistant Staphylococcus aureus
(MRSA) infection, patients who are health care workers, and
other patients at risk of being MRSA carriers should be consid-
ered for MRSA testing and decolonization.
49.4.5 Allocating Operating Room Time
It is important that adequate OR time be allotted for contempo-
rary facelift procedures, as they are deceptively time-consuming
compared with traditional techniques. A high-SMAS facelift,
especially when performed in conjunction with forehead plasty,
eyelid surgery, fat injections, skin resurfacing, and other pro-
cedures, will often encompass up to 6 to 8 hours or more, even
when performed by a fast surgeon working with a well-orga-
nized and experienced OR team. Most surgeons we know who
perform these complicated combined procedures on a regular
basis have resigned themselves to this fact and have made
appropriate adjustments in their surgery schedules. Usually this
means allotting an entire day for the procedure. For difficult
procedures, or when additional surgery is requested (e.g., rhino-
plasty), it is recommended that the procedures be staged over 2
separate days.
It is prudent for any surgeon new to these techniques to consider
staging a full-face rejuvenation consisting of multiple procedures
over two separate days. This worked well for us early in our prac-
tices and is still recommended to certain patients with difficult or
unusual problems and those who request multiple ancillary pro-
cedures. Typically facelift, neck lift, and fat grafting are performed
the first day. The patient is then kept overnight and returned to
the OR the following day (or a few days later) for forehead plasty,
blepharoplasty, lip lift, otoplasty, skin resurfacing, and other like
requested procedures. Patient acceptance of this recommendation
will be high if it is presented to them as in their best interest and
part of the surgeon’s effort to ensure their safety and to provide
high-quality care.
49.5 Anesthesia
49.5.1 Anesthesia Considerations for
Facelift Procedures
hile it is possible to perform a limited procedure that one can
technically call a “facelift” under local anesthesia, any such pro-
cedure necessarily encompasses significant compromises in the
treatment of the SMAS and platysma that form the foundation
of the modern facelift and will typically not allow the perfor-
mance of important related and ancillary procedures including
comprehensive fat grafting, deep neck lifting, and often-needed
forehead surgery due to limits on the amount of local anesthetic
that can be administered and on the patient’s and surgeon’s
tolerance for the procedures’ complexity and length. Adding
oral and/or intravenous (IV) sedation ( conscious sedation ) to
procedures performed under local anesthesia can improve the
patient’s experience and facilitate the performance of more
comprehensive operations, but it negates many of the purported
advantages of a local technique. It also places the surgeon
in the role of anesthesiologist and in charge of monitoring the
patient and managing and treating intraoperative problems
(hypertension, arrhythmias, etc.).
Most modern facelift techniques, including the high-SMAS
procedure, are time-consuming and technically demanding and
arguably will test the patience and composure of almost any
surgeon. It is highly recommended that any surgeon new to these
techniques enlist the services of an anesthesiologist or competent
Certified Registered urse Anesthetist (CR A) as part of a team
approach to patient care. This is particularly important when the
procedure is to be performed upon a patient whom is apprehen-
sive or has a history of anesthetic difficulties, hypertension, or
other significant medical problems. This will avert the frustration
and aggravation of trying to perform a technically demanding
procedure while simultaneously being shouldered with the
responsibility of supervising the administration of an anesthetic,
monitoring the patient, and managing intraoperative problems.
49.5.2 Our Preferred Facelift Anesthesia
Technique
ot using local anesthesia does not automatically equate to
the need for general anesthesia, however, and formal general
anesthesia, in which patients are paralyzed, endotracheally
intubated, and placed on a ventilator, is not necessary and is
arguably not optimal for the performance of most facelift pro-
cedures. The majority of our facelifts are performed under deep
sedation administered by an anesthesiologist using a laryngeal
mask airway (LMA; Fig. 49.31).
The use of an LMA allows the patient to be heavily sedated
without compromise of their airway, but the patient need not
653
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 49.31 The flexible Laryngeal mask airway. An LMA maintains an
open airway during deep sedation but allows patients to breath spon-
taneously. When the flexible model shown is used and the breathing
circuit is draped separately, unobstructed access to the neck and
submental region can be obtained. (Copyright © Timothy Marten.)
receive muscle relaxants and can be allowed to breathe sponta-
neously. An LMA is also less likely to become dislodged during the
procedure than an endotracheal tube is, as well as less likely to
trigger coughing and bucking when the patient’s head is turned
or when the patient emerges from the anesthetic.
It is useful to modify the way in which the laryngeal mask is tra-
ditionally used when performing facelift procedures. Traditionally
the cuff of the LMA is inflated to create a seal so that a ventilator
can be used, positive pressure ventilation applied, and vapor
anesthetics administered. This is not necessary, however, when
patients are not paralyzed and are only heavily sedated, when
intravenous sedation is used rather than inhalation anesthetics,
and when the patient is allowed to breathe spontaneously. In such
cases the cuff of the LMA can be left uninflated or be minimally
inflated and the LMA left to function as simply a large oral airway.
ot inflating the cuff limits pressure in the hypopharynx and
related postoperative discomfort that can occur in the throat.
Some surgeons have expressed concern that the LMA, especially
with the cuff inflated, will cause distortion of the neck that would
result in confusion in decision making when performing deep
neck and other neck lift procedure maneuvers. e have found
this not to be the case, and while a bulge is often evident if the
LMA cuff is inflated, the surgeon can simply ignore it and carry out
all neck maneuvers as usual and as indicated. The bulge created
by the inflated cuff will not affect gauging the extent to which
deep-layer neck maneuvers are carried out (submandibular
gland reduction, subplatysmal fat resection, and digastric muscle
reduction) or interfere otherwise with the neck lift procedure
654
(platysmaplasty, platysmamyotomy, lateral platysma suspension
using a postauricular transposition flap, drain placement, etc.).
49.5.3 Preop Anesthesia Medications
Most patients receive preoperative medication tailored and
adjusted to their age, weight, height, personality, specific cir-
cumstances, and general health, and this regimen is modified
depending upon the type of anesthetic used. Typical preop
medications currently used for patients in good health without
contraindications and as appropriate for their weight and general
conditions include clonidine (1–3 mg orally), atenolol (12.5–25
mg orally), and midazolam 3 to 5 mg intramuscular (typically
deltoid injection). These medications should be administered
after all preop discussions have been made, patient questions
answered, and preoperative consents and other related paper-
work signed. Oral narcotics should not be given as part of the
premedication, as they commonly result in nausea and vomiting.
Cocaine, anticholinergics, and parasympathomimetics are also
avoided in our practices.
Antiemetics are given routinely in a preemptive fashion at the
beginning of each procedure and typically include ondansetron
(10 mg IV) and dexamethasone (3–5 mg IV). It should be noted
that dexamethasone is administered for its antiemetic properties
and not as a means to reduce swelling. Patients with a history
of motion sickness, perioperative nausea and vomiting, or other
risk factors are given medications to block the emetic reflex at
multiple levels that typically include aprepitant (Emend; 40 to 80
mg orally) and/or a scopolamine patch (placed on the upper inner
thigh).
49.5.4 Patient Monitoring During
Anesthesia
All patients are fully monitored with electrocardiography,
automatic sphygmomanometry, transcutaneous pulse oximetry,
and mainstream capnography. Perioperative blood pressure is
closely monitored and aggressively treated should it become
significantly elevated, especially in patients with existing hyper-
tension or a borderline condition. The latter group of patients
should be watched closely and treated preemptively, as they
typically become hypertensive once the surgery and anesthesia
are begun.
49.5.5 Method of Intraoperative
Sedation
The current mainstay of patient sedation during our facelift pro-
cedures is achieved using propofol. Typically a bolus (1–2 mg/kg)
is administered by the anesthesiologist prior to LMA insertion,
followed by a drip infusion administered via an infusion pump
depending on the patient’s circumstances and titrated to the his
or her needs (75–200 g/kg/min).
If fat grafting is being performed, fat harvesting is performed
at the beginning of the procedure and before the patient’s face
is prepped and draped, and the anesthesiologist may temporarily
inflate the cuff on the LMA so that an inhalation anesthetic (sevo-
flurane or similar) can be administered to provide a brief period of
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
deep sedation during that part of the procedure. The cuff is then
deflated or its pressure reduced before the face is prepped and the
patient draped for the facelift procedure.
In most cases the IV anesthetic infusion is titrated to a deeper
level for a brief period once the patient has been prepped and
draped to give the surgeon a few minutes of deep sedation in
which to perform local anesthetic nerve blocks and infiltrate all
proposed sites for incision with local anesthetic solution.
49.6 Surgical Technique
The sequence of events in the facelift procedure is outlined in
Table 49.2.
49.6.1 Patient Positioning, Urinary
Catheter Insertion, and Patient
Marking
The patient is placed supine on a warmed and well-padded,
slightly flexed operating table, and a special effort is made to
ensure and document that the elbows, heels, and other potential
pressure points are well protected. The patient’s lower extrem-
ities are then elevated and antiembolic pedal compression
devices applied. An indwelling, balloon-tipped urinary catheter
( Foley catheter ) is placed after sedation is begun or general
anesthesia administered. During this time, the facelift incision
plan is marked with a fine-tipped surgical marker after skin to
be marked is degreased with isopropyl alcohol. If fat grafting is
to be performed, fat is harvested at this time, before the face is
prepped and draped, and typically entails turning the patient into
a right and left lateral decubitus position. A temperature probe
is then taped in the axilla or groin, and the patient sufficiently
covered or a patient warming device applied, to allow the room
to be cooled for the comfort of the scrubbed team members.
49.6.2 Patient Prepping and Draping
After anesthesia is begun, fat has been harvested, the patient has
been positioned on the table, the urinary catheter placed, and
the incision plan marked as just described, a sterile prep drape
is then placed beneath the patient’s head, and bland ophthalmic
ointments instilled into each eye. Each patient then receives a
full prep of the entire scalp, face, ears, nose, neck, shoulders,
and upper chest with full-strength (1:750) benzalkonium chlo-
ride ( ephiran, Sanofi, Bridgewater, ) solution. Care is taken
to ensure that prep solution does not pool in the eye areas or
otherwise get into the eyes. The patient’s head is placed through
the opening of a disposable sterile split sheet, or a split, adhe-
sive-backed disposable sterile transverse laparotomy sheet (tails
facing the patient’s feet), leaving the entire head and neck region
unobscured from the clavicles up.
The breathing circuit is subsequently draped separately from
the patient by wrapping it with a sterile paper drape sheet and
securing it with 1-inch Steri-Strips (3M, St. Paul, M ), or by cover-
ing it with a sterile stockingette. This allows it to be moved during
the procedure as the patient’s head is turned from side to side and
away from the submental area when working in the neck through
the submental incision. hen drapes are applied in this manner,
it is not necessary to secure the LMA with tape or by other means
as long as its position is watched by the anesthesiologist and/
or other members of the OR team present. If an endotracheal
tube is used, it can be conveniently and effectively secured to
the upper lip skin with a TegaDerm (3M, St. Paul, M ) or similar
sterile adhesive-backed dressing. This method of prepping and
draping allows unimpaired examination of the cervical profile
in its entirety throughout the procedure and provides complete
access to all areas of the scalp. No head drapes are used, as they
will limit scalp access and make it difficult to determine hair shaft
inclination and make incisions properly.
After the general prep of the face is complete and drapes have
been applied, the posterior surface of the tragus and the auditory
canals are prepped with full-strength povidone-iodine using
cotton-tipped swabs by a scrubbed member of the surgical team.
Each nasal vestibule, the perioral area, and the gingivolabial sulci
are prepped with povidone–iodine as well. ittner peanut
sponges are then placed in each auditory meatus, and these
are changed as necessary during the procedure to prevent the
accumulation of blood in the auditory canals. If the patient’s face
and ear canals are small, the ittner sponges can be trimmed to
reduce their size slightly and obtain a better fit.
No hair is cut or shaved along any proposed site of incision.
Shaving or trimming hair will negate accurate assessment of hair
shaft inclination relative to the scalp and can result in incisions
that injure hair follicles. Tightly applied rubber bands, adhesive
tape, surgical lubricants, antibiotic ointment, and hair clips pro-
duce similar problems and should also be avoided for the same
reasons.
It is always an error to shave any area of the scalp before the
procedure, as this commits the surgeon to excision of the shaved
area, even if this is determined to be inappropriate intraopera-
tively. As a practical matter, in most well-planned facelifts, little if
any scalp tissue should actually be excised.
49.6.3 Administering Local Anesthesia
Local anesthetic is administered even if deep sedation or general
anesthesia is used. This limits stimulation of the patient and the
overall amount of anesthetic needed and significantly reduces,
or even often eliminates, the need for intraoperative narcotics.
A significant and helpful hemostatic effect is also obtained when
epinephrine/tranexamic acid–containing solutions are used.
Sensory nerve blocks are performed using 0.25 bupivacaine
with epinephrine 1:200,000 injected with a 25-gauge needle
attached to a 10-mL ring control syringe. Blocking major sensory
nerves allows the rest of the face to be injected with a reduced
degree of stimulation. Skin marked for incision is then infiltrated
with the same solution. If fat grafting is to be performed, it is
performed at this time in a dry field and prior to subcutaneous
infiltration of the face.
Once fat grafting is complete, areas where subcutaneous
dissection will be made are infiltrated with 0.1 lidocaine with
epinephrine 1:1,000,000) and tranexamic acid (1,000 mg per
500 mL of local anesthetic solution), taking care to ensure that
the total dose of lidocaine does not exceed 7 mg per kilogram
per 4 hours (Fig. 49.32). Infiltration of the preauricular cheek
and postauricular areas is carried out using a 22-gauge spinal
needle, as skin in these areas is typically adherent and resistant
655
 VIII Surgical Rejuvenation of the Face and Neck
Table 49.2 Sequence of events in facelift procedure, overview
1. Induce anesthesia.
2. Mark incisions while Foley catheter placed.
3. Harvest fat.
4. Position patient, prep face, drape.
5. Perform nerve blocks and inject incision sites with 0.25%
bupivicaine with epinephrine.
6. Inject fat.
7. Infiltrate skin to be subcutaneously undermined with 0.1%
lidocaine with epinephrine solution.
8. Raise skin flap on right side of face.
9. Raise skin flap on left side of face.
10. Raise SMAS flap on right side of face.
11. Raise SMAS flap on left side of face.
12. Make submental incision, subcutaneously undermine submen-
tal skin, and join with undermined skin made in lateral neck.
13. Incise platysma midline.
14. Elevate platysma on right over anterior belly of digastric to
submandibular gland (SMG).
15. Incise capsule of right SMG and mobilize SMG inside capsule
(mobilize more than planned resection).
16. Identify anterior belly of right digastric muscle near mentum.
17. Dissect under lateral border of right side of subplatysmal fat
pad among inferior surface of digastric to insertion on lateral
hyoid and carry into SMG capsule (Metzenbaum scissors).
18. Divide lateral border of subplatysmal fat over anterior belly
of digastric (using cautery).
19. Dissect right side of subplatysmal fat pad off anterior belly
of digastric and deep fascia with cautery (do not include
interdigastric fat).
20. Inject approximate line of resection of mobilized SMG and
anterior belly of right digastric with 0.25% bupivicaine with
epinephrine.
21. Repeat elevation of platysma on left side.
22. Incise capsule of left SMG and mobilize SMG inside capsule
(mobilize more than planned resection).
23. Identify anterior belly of left digastric muscle near mentum.
24. Dissect under lateral border of left side of subplatysmal fat
pad along inferior surface of digastric to insertion on lateral
hyoid and carry into SMG capsule (Metzenbaum scissors).
25. Excise subplatysmal fat pad, leaving interdigastric fat
between anterior digastric bellies and in suprahyoid sulcus.
26. Inject approximate line of resection of mobilized left SMG
and anterior belly of left digastric muscle with 0.25% bupiv-
icaine with epinephrine.
27. Resect protruding portion of right SMG along plane tangent
to ipsilateral border of mandible and anterior belly of ipsilat-
eral digastric muscle using cautery.
28. Resect protruding portion of right anterior digastric belly.
29. Resect protruding portion of left SMG along plane tangent
to ipsilateral border of mandible and anterior belly of ipsilat-
eral digastric muscle using cautery.
30. Resect protruding portion of left anterior digastric belly.
31. Raise and suspend superior margin of SMAS flap on side of
face that sags most, parallel to long axis of zygomaticus
major muscle.
32. Trim posterior margin of ipsilateral SMAS flap to match
cut edge beneath it and close over parotid gland under no
tension.
656
33. Raise and suspend superior margin of SMAS flap on oppo-
site side of face parallel to long axis of zygomaticus major
muscle.
34. Trim posterior margin of ipsilateral SMAS flap to match cut
edge beneath it; and close over parotid gland under no
tension.
35. Gauge platysma excess on medial platysmal borders and
excise.
36. Suture trimmed medial borders of platysma muscles edge
to edge in one layer with interrupted sutures from mentum
to mid–thyroid cartilage without invaginating tissue and
under normal muscle tension (perform platysmaplasty). Do
not tighten in corset fashion.
37. Suspend postauricular transposition flaps to mastoid fascia
on right and left side.
38. Perform chin augmentation if indicated.
39. Divide medial half of right and left platysma muscles at
level of midthyroid to cricoid cartilage through submental
incision (with electrocautery or Metzenbaum scissors).
40. Divide lateral half of right and left platysma muscles below
inferior aspect of postauricular transposition flaps through
postauricular incisions (with electrocautery or Metzenbaum
scissors).
41. Place subcutaneous and subplatysmal 10 French round
Jackson-Pratt drains.
42. Irrigate with antibiotic solution and make final check for
hemostasis.
43. Redrape skin on right side of face, gauge excess width in
supra-auricular area with facelift marker, and suspend under
normal skin tension at key point of anchoring above ear.
44. Anchor postauricular skin flap in apex of postauricular defect
at key point of anchoring behind ear without trimming
superior margin of skin flap.
45. Trim anterior edge of postauricular skin flap to match curve
of posterior concha and close with simple interrupted
sutures of 4–0 nylon.
46. Use facelift marker to gauge skin excess along occipital
portion of postauricular incision. Trim excess skin. Close
under no tension with a combination of half buried vertical
mattress sutures of 4–0 nylon and simple interrupted
sutures of 6–0 nylon.
47. Trim and close temporal incision under no tension.
48. Trim and close prehelical part of preauricular incision under
no tension.
49. Trim and close the prelobular part of preauricular incision
under no tension.
50. Trim and close the tragal incision under no tension and
maintaining skin to fill the pretragal sulcus.
51. Inset the lobule (perform earlobe reconfiguration or reduc-
tion if indicated).
52. Perform temple–forehead plasty as indicated.
53. Perform blepharoplasties as indicated.
54. Perform upper lip lift if indicated.
55. Close the submental incision.
56. Perform buccal fat reduction if indicated.
57. Perform perioral and/or lower eyelid laser resurfacing if
indicated (no lasering should be performed on cheek skin
that has been undermined).
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.32 Local anesthetic solutions. (a) Nerve blocks and incision sites: 0.25% bupivacaine with epinephrine. Maximum safe doses of bupivacaine
with epinephrine in mg: patient’s weight in kg 3. For example, for a typical 60-kg female patient, maximum dose equals 70 mL of 0.25% bupivacaine
with epinephrine. Rule of thumb: 1 mL of 0.25% bupivacaine with epinephrine per kilogram of body weight. (b) Subcutaneous infiltration with 0.1%
lidocaine with 1:1,000,000 epinephrine. Solution mixture: 50 mL of 1% lidocaine, 10 mL 0.25% bupivacaine, 1 g tranexamic acid, 1 ampoule epineph-
rine, in 500 mL normal saline. Maximum safe dose of lidocaine with epinephrine in mg: patient’s weight in kg 7. For 60-kg female patient, 150–200
mL of solution per side. (Copyright © Timothy Marten.)

to injection with a blunt cannula. Infiltration of the neck, sub- of the scalpel blade with the scalp must change correspondingly
mental, and anterior cheek regions are carried out with a 1.6-mm, as the incision is made, and the completed incision will be beveled
20-cm-long multihole blunt-tipped infiltration cannula. No direct to varying degrees and in different directions, if properly made.
fi f - Incisions made along skin-scalp interfaces should be beveled
fi slightly to the scalp side to leave one or two rows of hair follicles
of the procedure as just described. Approximately 150 to 200 cc of beneath the sutured incision. An exaggerated bevel, advocated by
dilute local anesthetic solution is infiltrated subcutaneously into some surgeons, is not needed and is typically counterproductive,
each side of the face and neck. as it usually results in regrowth of hair that is kinky and unruly
Maintenance of the local block is achieved by systematically and thus of concern to the patient.
reinfiltrating the key areas (pre- and postauricular regions)
midway during the procedure and readministering nerve blocks
f . This prevents loss of
49.6.5 Cheek and Neck Skin Flap
continuity of the local anesthetic effect and avoids stimulation Elevation
of the patient that would otherwise occur should reinjection be
After incisions are made, skin flaps are elevated according to the
delayed until after sensation has returned.
preoperative plan over the cheek and neck (see Fig. 49.31b, Fig.
49.34, Fig. 49.35). f f
49.6.4 Making Incisions
f
Incising the skin is a key step in which the surgeon exercises
is to be obtained. This “bidirectional” tissue shift is not possible
direct control over the quality of the resultant scar, and incisions
if a deep-plane or composite type dissection (elevation of a
should not be made in a casual or careless manner. All incisions
combined skin–SMAS flap) is made.
on the scalp must be made precisely parallel to hair follicles to
Correct positioning of the operating room lights and proper
avoid injury to them. A carelessly made incision will injure fol-
retraction by the assistant is required if proper dissection is to be
licles and can result in peri-incisional alopecia. Frequently this
made and potentially harmful trauma to the flaps is to be avoided.
is mistakenly attributed to the patient’s own poor healing and
Light should be placed on both sides of any skin flap being dissected
erroneously regarded as a wide scar.
to provide simultaneous direct and transmitted illumination, and
In most cases, follicles and hair shafts will be similarly inclined,
blind dissection should not be made. Light shone upon the skin
but this may not be true in the kinky- or curly-haired individual
surface (transillumination) will help define flap thickness, while
or when a patient’s hair is wet, saturated with surgical lubricants,
light shone underneath the skin flap upon the site of dissection
or restrained with drapes, tape, or rubber bands. For this reason
(direct illumination) allows identification of important structures.
fi
Too much direct illumination can obscure the transillumination
precisely parallel to hair follicles as it is made on the scalp. One
effect and must be avoided. This is particularly true of the bright
must also recognize that hair follicle inclination is not uniform
direct light emitted from fiberoptic headlights and fiberoptic
over the scalp and that follicles will be inclined differently at dif-
retractors. If they are to be used, their intensity should be reduced
ferent areas along the planned incision. Because of this, the angle
so that a proper and balanced illumination effect is obtained and

657
 VIII Surgical Rejuvenation of the Face and Neck
the transillumination effect is not lost while skin flaps are being
raised.
The circulating nurse or other unscrubbed team member
should be assigned the task of adjusting the overhead lights as
needed for the surgeon, and the importance of this assignment
should be emphasized. In time, a perceptive nurse or assistant will
need only watch the operative field to know when adjustment is
needed. If the circulating nurse is required to monitor the patient,
administer medication, leave the operating room frequently, or be
otherwise occupied, it is recommended that an additional staff
member be present.
Both surgeon and assistant should refrain from adjusting
overhead lights, as each will need both hands free for proper
retraction and dissection. Adjusting the lights with one hand while
retracting with the other is a common error that invariably results
delicate cervicofacial tissue.
Proper care of the patient and effective functioning of the
operating room team will require that two team members be
scrubbed with the surgeon throughout most of the procedure. One
scrubbed team member will be necessary to act as a “full-time”
surgical assistant, providing tissue retraction and exposure. This
is a key role that precludes the simultaneous passing of instru-
ments, loading of sutures into needle holders, tracking of sharps,
and maintenance of the instrument stand. A second scrubbed
team member should be present to oversee and carry out these
latter important secondary functions. Regardless of experience, or
claims to the contrary, is not possible for one person to assume
both roles effectively without compromising her or his role as an
assistant, disrupting work flow, and otherwise slowing down the
surgical procedure.
The preauricular cheek flap dissection is begun using a
fine-tipped Adson forceps and a small aye scissors or scalpel
to elevate skin off the tragus and the flap in the prehelical and
prelobular areas. Once the preauricular cheek flap edge has been
elevated, the forceps is set aside and gentle traction is applied by
the assistant with double-pronged skin hooks. A standard-pattern
medium Metzenbaum scissors is then used to establish the proper
plane further, and flap dissection is begun. Usually the preauricu-
lar scissors dissection is most easily begun, and the proper plane
most easily identified in the prelobular area.
Facelift skin flap dissection is most effectively performed when
surgeon and assistant work together as a carefully coordinated
team using a four-handed technique (Fig. 49.33). In this tech-
nique, the assistant applies gentle traction upon the skin flap
directed toward the surgeon with two 10-mm double-pronged
skin hooks. One skin hook retractor should be held in each hand,
as it is not possible for the assistant to provide proper retraction
using a one-handed technique (holding both retractors in one
hand). The surgeon then dissects while providing gentle counter-
traction toward the assistant with the fingertips of the opposite
(nondominant) hand on the skin surface.
As the dissection advances, one skin hook is exchanged for a
small Deaver, shaped 1-inch malleable, or similar retractor. The
remaining skin hook is used to drape the skin flap gently over the
retractor and keep it properly positioned upon it. This eliminates
the need for excessive traction force, minimizes tissue trauma,
and provides for optimal visualization under the skin flap.
658
The surgeon should always avoid retracting for her- or himself,
as this invariably leads to excessive tissue traction and rough
f , especially when exposure is limited or dis-
section becomes difficult. Retracting should instead always be
performed by a conscientious assistant capable of focusing his or
her attention on providing proper exposure while simultaneously
protecting delicate facial skin flaps. This assistant must ignore his
or her natural urge to help the surgeon by applying excessive
force when retracting. It must also be recognized that most hos-
pital and surgery center personnel are accustomed to assisting
surgeons in other specialties and have not been trained in proper
tissue-handling techniques. They are usually not aware that
improper retracting, excessive traction, and rough handling of the
f and can lead to flap compromise, tissue necrosis,
and skin slough. Time taken to teach them proper retracting and
tissue-handling techniques as just outlined is well spent.
Tissue trauma to skin flaps can be significantly reduced by
periodically moving the dissection from one area to another
and completing flap elevation in stages. This allows the tissue to
breathe and avoids prolonged traction upon and compromise of
any one area. Traction should also be released before retractors
are moved, however. If traction is not released, tissue will be
injured and the flap microcirculation will be compromised as the
retractor is moved from side to side beneath the skin flap.
It should be the responsibility of all OR team members to ensure
f
excessive traction, pinching, folding beneath retractors, or other
potentially harmful actions. It is not possible for the surgeon, who
is usually preoccupied with other aspects of the procedure, to be
always diligent in this regard.
Skin flaps should be elevated sharply under direct vision and
blind dissections avoided in most areas. This is particularly
important in the great auricular corridor, the preauricular
region, and the upper medial cheek, where an inadvertent deep
Fig. 49.33 “Four-Handed” Technique. The assistant applies gentle
traction upon the skin flap towards the surgeon with two 10 mm
double pronged skin hooks with one retractor held in each hand. The
surgeon then dissects while providing gentle counter traction towards
the assistant with the fingertips of the opposite hand. Properly orga-
nized teamwork facilitates flap dissection and reduces tissue trauma.
Optimal dissection is not possible if the surgeon retracts for her or
himself, or if the assistant tries to retract with both retractors held in
one hand. (Copyright © Timothy Marten.)
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
dissection can injure the great auricular nerve or the underlying
SMAS and compromise its use as a flap. It has been our observation
that many surgeons using non-SMAS facelift techniques engage in a
, and inspection of their
flaps after dissection often reveals that a portion of the SMAS
has been elevated as part of the skin flap. Adjustments to this
type of technique must be made if damage to the SMAS is to be
avoided and a SMAS flap to be used. It is also an error, however,
to dissect too close to the posterior surface of the skin flap, as this
can result in injury to subdermal microcirculation. Dissecting too
close to the underside of the skin flap is usually caused by using
aggressively patterned, pointed, serrated, and extra-sharp -type
surgical scissors. Meticulous attention to proper injection of
dilute local anesthetic solution into the subcutaneous plane with
a blunt-tipped injection cannula, as described in the preceding
section, preestablishes the proper plane of dissection and greatly
facilitates skin flap elevation in the proper plane.
Although subtle, some visual clues are helpful in determining
when the proper plane has been established and avoiding prob-
lems of a too-deep or too-superficial dissection. If skin flap dis-
section is made too deep and SMAS fibers are elevated with it, the
under surface of the skin flap will appear relatively smooth and
covered by streaks of fine white tissue. hen transilluminated,
flaps dissected in this manner will have a cloudy sky appearance
and appear relatively thick. If dissection is made in the proper
plane, however, the undersurface of the flap will have a character-
istic rough, pebbled, or cobblestone appearance and be more
yellow. Transillumination of a flap dissected in the correct plane
enhances this appearance.
Blind dissection made by pushing scissors, or blunt dissection
made using a scissors spreading technique, are unacceptably
traumatic to the subdermal microcirculation of the skin and
can result in flap compromise, damage to subdermal fat, and
unintended injury to the SMAS and platysma. This is particularly
likely when aggressively patterned, double-edged, serrated, or
extra-sharp -type scissors are used. After experimenting with
many scissors patterns, experience has shown that none is as
good or as forgiving as the standard medium curved Metzen-
baum type.
Postauricular skin flap undermining is most easily begun infe-
riorly if the occipital incision has been made along the occipital
hairline, or posteriorly if the incision has been made onto the
occipital scalp, as more subcutaneous fat is usually present in
these areas and the correct plane of dissection is most easily
identified there. Beginning dissection in these areas also helps
one identify the proper plane more superiorly and anteriorly in
the postauricular area where less subcutaneous fat is present and
the skin and fascia lie in close proximity and can be more tightly
bound. Careful infiltration of dilute local anesthetic into the plane
of dissection, as previously described, also facilitates dissection in
these and other areas of the face.
Once the correct plane of dissection has been established
in the postauricular area, two 10-mm double-pronged skin
hook retractors are placed and held by the assistant toward
the surgeon’s forehead, and Metzenbaum scissors are used to
elevate the postauricular skin flap. Postauricular flap elevation
should be performed under direct vision aided by transillu-
mination. Dissection in the postauricular area is most easily
performed when an incision along the occipital hairline is used
in an inferior-to-superior direction rather than in a posterior-to-
anterior one.
As dissection progresses anteriorly and inferiorly from the
postauricular region to the upper lateral neck, care must be taken
to avoid injury to the great auricular nerve, and dissection of this
area should be made under direct vision. This nerve provides sen-
sation to the lower two-thirds of the ear and travels superficially
superiorly in the upper lateral neck over the sternocleidomastoid
muscle fascia. The most superficial portion of the nerve is ana-
tomically constant and lies approximately 6.5 cm inferior to the
auditory meatus midway between the anterior and posterior
borders of the sternocleidomastoid muscle. It is helpful to mark
that spot preoperatively to guide one during dissection. If the
dissection is performed correctly, however, the nerve will lie deep
to the plane of skin flap dissection and will be covered by a thin
layer of subcutaneous fat and fascia, and it is neither necessary
nor advisable to attempt to specifically identify or isolate this
nerve through additional dissection.
Patients with thin faces, elderly patients, or those undergoing
secondary facelifts will not uncommonly have little subcutaneous
fat between the superficially situated portion of the great auric-
ular nerve and the skin, however. For this reason, extra caution
must be taken in these patients when elevating the skin flap in
this area, and a clear knowledge of nerve anatomy is required.
As dissection is continued farther anteriorly into the cervical
region and anterior to the external jugular vein, subcutaneous
fat generally becomes more abundant and is less tightly bound to
underlying tissues, and the flap is easier to dissect. Care should be
taken to remain in a subcutaneous plane, however, and to leave
the majority of the preplatysmal fat on the platysmal surface. This
makes fat excision and sculpting easier later in the procedure, if
required, and precludes the need for difficult and tedious excision
of fat from the undersurface of the cervical skin flap. In contrast
to the dissection of the cheek skin flap, in which a conscious effort
must be made to prevent the flap from becoming too thick, a
slightly deeper dissection should be made in the neck to preserve
a slightly thicker layer of subcutaneous fat. Preservation of a
thicker layer of fat helps avoid a hard or overresected appearance
in the cervicosubmental area and objectionable overexposure of
underlying neck anatomy. In fact, in many necks, and especially
in secondary procedures, the goal will often be to preserve all
subcutaneous fat present at this point in the procedure and to
resect none at that time.
If a submental incision is planned, subcutaneous dissection
of the anterior neck skin flap will be more easily and effectively
completed through it, rather than through the postauricular
incisions. Undermining of the submental crease and releasing the
submental and mandibular ligaments will also be easier through
the submental incision as well, and bleeding in these areas that is
frequently encountered more easily controlled.
Although subcutaneous undermining is necessary to achieve
an optimal result, it should not arbitrarily include the entire face.
If a SMAS dissection is planned, preservation of the anterior
platysma–cutaneous ligaments will allow attractive and youthful-
appearing elevation of perioral tissue that cannot be obtained
with a skin-only technique or when wide skin undermining is
performed (Fig. 49.34, Fig. 49.35).
The platysma–cutaneous ligaments anchor the dermis of the
perioral cheek to the SMAS and upper platysma and provide a
659
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.34 Extent of subcutaneous undermining. Shaded (yellow) area

shows area of subcutaneous skin flap undermining in (a) traditional
(incorrect) and (b) contemporary “extended” (correct) plans. Note
that the platysma-cutaneous ligaments (black dots in (b) are not
undermined and are preserved in the extended plan. Preservation
of platysma-cutaneous ligaments and proper elevation and fixation
of the SMAS provide a lift and support of lateral perioral tissues that
is lost if the cheek is over-dissected as shown in (a). Note also in the
extended undermining plan the temple is released (1) to accommodate
upper cheek and mid-face tissue shift, the zygomatic ligaments (2) are
divided to release upper cheek and mid-face, the mandibular ligaments
(3; see also Fig. 49.35) are divided to optimize improvement in the
jowl and along the jawline, and the submental restraining ligaments (4;
see also Fig. 49.35) are divided to soften the “double chin” and allow
the fat of the chin and the submental region to be blended once deep
layer neck maneuvers have been completed. These releases were not
made in traditional (a) skin undermining plans. (Copyright © Timothy
Marten.)
means of lifting and supporting the lateral perioral area without
overtightening the skin of the upper–lateral face. Preservation
of the platysma–cutaneous ligaments also preserves important
accompanying perforating vessels to the cheek flap. This reduces
the likelihood of skin slough and flap compromise.
If subcutaneous dissection is extended too far anteriorly and the
,
fi f and a
significant portion of the benefit of SMAS elevation and advance-
ment will be lost. ide cheek flap undermining and division of
the platysma–cutaneous ligaments are also the underlying cause
of the lateral sweep deformity (Fig. 49.6), as SMAS support of
sagging perioral tissues is lost when dissection is performed in
this manner.
49.6.6 Temple Dissection
The temple incision is made according to the preoperative plan
based on the redundancy present over the upper cheek and the
predicted degree of displacement of the sideburn and temporal
hairline (see preceding section).
hen a traditional incision on the temporal scalp is indicated
(most typically in patients under 45 years old), it is made pre-
cisely parallel to hair follicles. This will generally require that the
incision be beveled to varying degrees and in different directions
along its length, as hair follicles are not uniformly inclined over
the temporal scalp. The dissection is then deepened and carried
down through the galea aponeurotica ( superficial temporal
fascia”) to the fascia of the temporalis muscle and the tempo-
ral hair-bearing fasciocutaneous flap anterior to the incision
undermined. This dissection is usually easy to perform bluntly
with closed Metzenbaum scissors or blunt Boies elevator and
Fig. 49.35 Plan for subcutaneous undermining shown on patient.
Shaded (yellow) area shows area of subcutaneous skin flap under-
mining. Note that skin undermining is limited in the perioral cheek
to preserve the platysma-cutaneous ligaments but extends up along
and onto the inferior border of the jawline to release the mandibular
ligaments that contribute to jowl and prejowl groove formation, and
superiorly up onto the anterior-inferior chin to release the submental
retaining ligaments that contribute to a “double-chin” appearance. The
transverse solid purple line marked on the skin of the submental area
is the site where the submental incision will be made. The transverse
solid purple lines low on the anterior neck mark the location of the
cricoid cartilage. (Copyright © Timothy Marten.)
should be extended anteriorly to the lateral orbit, inferiorly to
the midtemple, and superiorly to the temporal line. The bridge
of fascia lying inferiorly between the subgaleal dissection in the
temple and the subcutaneous dissection in the cheek (mesotem-
poralis) can then be safely and conveniently partially divided
in a curvilinear fashion posterior to the temporal hairline if the
anatomy of the frontal branch of the facial nerve is understood
and the division made thoughtfully and in the correct location
(Fig. 49.36).
This bridge of tissue contains the anterior branch of the super-
ficial temporal artery, and it must be divided and ligated when
encountered, or thoroughly cauterized if the mesotemporalis is
divided. This is of no clinical consequence in the nonsmoking
patient without vascular disease, and it is a routine part of the
dissection of this area when conditions indicate that the temporal
portion of the facelift incision be placed within the temporal
scalp. The frontal branch of the facial nerve lies well anterior and
inferior to this chosen point of transition between planes, and this
dissection, when executed as described, is anatomically sound
and clinically safe. Frontal branch anatomy can be confusing, how-
ever, and any surgeon who is uncertain of the exact relationships in
this region should review them carefully and made a detailed study
(Fig. 49.36; see also Fig. 49.41 in the following section on SMAS
dissection) before undertaking this dissection.

660
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

a b
Fig. 49.36 (a,b) Dividing the mesotemporalis. When conditions dictate that the temporal portion of the facelift incision should be made within the
temporal scalp, the bridge of tissue situated between the subgaleal dissection in the temple and the subcutaneous dissection in the cheek (part a, white
arrow) can safely be divided posterior to the course of the frontal branch of the facial nerve (part b, dotted yellow line). This bridge of tissue contains the
anterior branch of the superficial temporal artery, which must be divided and cauterized or ligated (white arrows in part b). (Copyright © Timothy Marten.)

Partially dividing the bridge of tissue between the subgaleal
plane of the temple and the subcutaneous plane of the cheek
is an important maneuver that allows the two planes of dis-
section to be joined laterally. This, in turn facilitates exposure
in the upper cheek and lateral orbital area, dissection of the
SMAS, and redraping of the temporal portion of the facelift
flap. This strategy of dissection also protects hair follicles on
the undermined temporal scalp by moving the plane of dissec-
tion subgaleally and deep to them. Temporal skin can then be
undermined subcutaneously up to the lateral orbit, bringing
the dissections in the cheek and temple into wide continuity
(see Fig. 49.36b).
hen an incision along the temporal portion of the anterior
hairline is indicated (most patients over 45 years old), it is made
a few millimeters within it as a straight line with a slight bevel
toward the scalp side. Although advocated by some surgeons,
it is unnecessary and typically counterproductive to make this
incision in a zigzag or wavy fashion. Properly trimmed and
closed under no tension, a straight-line incision will produce the
best-concealed scar.
The superior extent of temporal hairline incision will nec-
essarily vary depending upon the amount of cheek skin shift
predicted and whether a forehead lift is to be concomitantly
performed if puckering and gathering are to be avoided in this
area. Often small superior extensions beyond what was marked
preoperatively are needed if a smooth and well-tailored closure
is to be obtained. This incision should be made no higher than
the junction of the temporal hairline with the frontotemporal
hairline, however. If it is carried more superiorly, the resulting
scar will usually be visible, as hair tends to grow posteriorly in
that area (Fig. 49.37).
After an incision along the temporal hairline has been made,
the temporal skin flap is carefully undermined subcutaneously
and joined with the subcutaneous dissection in the cheek. o
transition between planes is necessary when this incision plan is
used, no hair-bearing flaps are raised, and the superficial temporal
vessels and frontal branch of the facial nerve are left undisturbed,
beneath the superficial temporal fascia (Fig. 49.38).
49.6.7 SMAS Dissection
Once skin flaps have been elevated, they are retracted and the
zygomatic arch palpated. A line is then traced high over its
midportion in water-soluble surgical ink (methylene blue) from a
point just lateral to the infraorbital rim to a point approximately
1 cm anterior to the superior aspect of the tragus. This line lies
higher than the dissection made in deep-plane and other
low-SMAS techniques (and thus the origin of the name high-
SMAS ), and well above the malar origin of the zygomaticus
major muscle. The mark is then turned inferiorly and carried
over the preauricular portion of the parotid 1 to 1.5 cm anterior
to the ear. Inferior to the lobule, it is continued inferiorly and
slightly posteriorly to the anterior border of the sternocleido-
mastoid muscle to a point approximately 2 to 3 cm below the
mandibular border (Fig. 49.39).
A basic high flap of this type is used on most patients, and
several important advantages that arise from its design are worth
considering. First, f
and along the zygomatic arch, rather than inferior to it, expands the
f f
vector to be applied to it. Carrying the incision posteriorly and
inferiorly over the tail of the parotid to the anterior border of the
sternocleidomastoid muscle in the upper lateral neck also main-
tains a “safety zone” between the incision and the mandibular
margin and moves the dissection away from the point at which
the marginal mandibular nerve exits the anterior border of the
inferior portion of the parotid (Fig. 49.40). Placing the remaining
portion of the incision along the anterior border of the sterno-
cleidomastoid muscle places the dissection in a relatively thin
and avascular area of the platysma and along a line where the cut

661
 VIII Surgical Rejuvenation of the Face and Neck
a b c flap elevation is then begun using careful scissors or low-current
Fig. 49.37 Length of the temple hairline incision. The superior
extent of the temporal hairline incision will vary depending upon the
amount of cheek skin shift predicted (and whether a forehead lift is
to be concomitantly performed) if puckering and gathering are to
be avoided in this area. Note that a male patient is shown; in female
patients the incision should have a more rounded feminine design as
in Fig. 49.10a. (a) Superior extent of temple hairline incision when
modest cheek skin displacement is predicted (white dotted line). (b)
Superior extent of temple hairline incision when moderate cheek
skin displacement is predicted (white dotted line). The incision must
be made higher to accommodate the cheek skin shift, but it still is
situated in a well-concealed location. (c) Superior extent of temple
hairline incision when large cheek skin displacement is predicted (white
dotted line). This incision should be made no higher than the junction
of the temporal hairline with the frontotemporal hairline, however
(point shown by white arrow). If it is carried more superiorly along the
frontotemporal hairline (area designated by red X), the resulting scar
will usually be visible, as hair tends to grow posteriorly in that area.
(Copyright © Timothy Marten.)
edge, if visible through the skin after surgery, would appear to be
the anterior muscle border.
High SMAS flap elevation is begun by incising the SMAS layer
over the zygomatic arch. This is accomplished by grasping the
preauricular SMAS overlying the lateral arch with an Allis clamp
on each side of the marked line and lifting it up and away from
deeper tissues. An incision is then made with Metzenbaum scis-
sors or a needlepoint cautery, set on a low, eyelid coagulation
current setting, into the SMAS layer that has been lifted up and
continued medially 1 to 2 cm along the marked line in the tensed
plane. The Allis clamps are then released and reapplied incremen-
tally as the dissection proceeds further medially along the marked
line in the elevated and tensed plane in 1- to 2-cm segments in a
similar fashion using scissors or cautery. A considerable amount
of tissue lies over the lateral arch, and the frontal branch will be
safely concealed beneath half a centimeter or more of fibrous fat;
its path may be located using Pitanguy’s landmark (Fig. 49.41).
The margin for error may be reduced, however, in the thin, aged
patient with advanced facial atrophy and less soft tissue cover over
the arch or in a secondary procedure. Extra caution must be taken
under these circumstances.
Using a needle-tipped cautery set on the low eyelid coagula-
tion current setting to incise the SMAS layer can provide valuable
feedback and alert the surgeon when a motor nerve branch is
approached, as the cautery acts as a makeshift nerve stimulator.
hen dissection is advanced into proximity to a nerve, soft facial
twitching will be seen, and this should be watched for by both
the surgeons and the surgical assistant (who typically has a better
view of the patient’s face).
The preauricular limb of the SMAS incision, defining the flap’s
posterior margin, is then made using a similar technique over
the posterior parotid along the marked line in the preauricular
662
region. The dissection is continued inferiorly and posteriorly to
the anterior border of the sternocleidomastoid muscle to a point
approximately 2 to 3 cm below the mandibular margin. These two
incisions define the superior and posterior margins of the high
SMAS flap to be elevated (see Fig. 49.39).
After initial SMAS incisions have been completed as described,
the preauricular tissue constituting the posterior superior corner
of the of the SMAS flap is grasped with two Allis forceps, and
needle-tipped cautery dissection technique.
Undermining should be limited in the preparotid cheek and
upper lateral neck and more extensive over the zygoma and
upper midface (Fig. 49.42; see also Fig. 49.2, traditional versus
extended SMAS). Use of a needle-tipped cautery device set
on low coagulation current settings to raise the SMAS flap is a
convenient way for less experienced surgeons to make this dis-
section, as it serves as a make-shift nerve stimulator and when a
motor nerve is approached movement will be noticed before the
nerve is encountered, as previously described. The needle-tipped
low-coagulation-current cautery technique of flap elevation is
also useful in secondary and tertiary facelifts in which the SMAS
layer has been previously dissected as anatomy can be less clear
in those situations.
The SMAS, though substantial, is thinner than many surgeons
imagine it to be, and it is decidedly thinner and less substantial
than many other tissue layers typically dissected in plastic surgery
procedures. SMAS flap elevation will also entail dissection just
superficial to the plane of the facial nerves in close proximity to
important motor branches.
is safe, great care must be taken when dissecting more medially and
over the zygoma and anterior to the anterior border of the parotid
gland in the cheek and over the masseter muscle.
Sharp (not vertical-spreading) scissors or cautery dissection of
the high SMAS flap is usually required posteriorly over the parotid,
where the plane between parotid fascia and SMAS is often indis-
tinct. Vertical spreading, while advocated by some who perform
deep-plane procedures, is unacceptably traumatic, as the SMAS
flap does not have the reinforcement and backing of the skin seen
when deep-plane and composite dissections (skin and SMAS dis-
sected as a monolayer) are made. In some instances a portion of
the parotid fascia may be incidentally and/or unavoidably raised
with the SMAS flap and part of the lobular surface of the gland
may be exposed. This is usually of no clinical consequence and
should be used by the surgeon as a road sign in identifying the
proper plane of dissection situated slightly more superficially.
A separate and distinct plane does exist, however, medial to
the anterior border of the parotid between the SMAS-platysma
and the parotidomasseteric fascia. This plane is most easily
identified and established in the lower cheek, where it can usu-
ally be entered by gentle blunt dissection with scissors tips, low-
coagulation-current needle tip cautery, a fingertip, or with a
ittner ( peanut ) sponge. The parotidomasseteric fascia will
be seen as a thin, shiny, transparent, mobile layer covering the
masseter muscle, parotid duct, buccal fat, and the branches of
the facial nerve. Careful dissection on top of this layer is safe
and will not result in nerve injury, but great caution must be
exercised when dissecting sharply or with cautery, or when
clamping or coagulating in this area. Frequently, motor nerve
branches accompany perforating vessels, and each bleeding point
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
Fig. 49.38 Skin flap dissection with temporal hairline incision. When
an incision is made along the temporal hairline, all dissection is in a
subcutaneous plane and no transition between planes is necessary, no
hair-bearing flaps are raised, and the superficial temporal vessels are
left undisturbed. (Copyright © Timothy Marten.)
Fig. 49.40 Plan for posterior margin of the high SMAS flap and the
marginal mandibular nerve branch. The marginal mandibular branch
of the facial nerve (yellow line) emerges from the anterior border
of the inferior portion of the parotid gland (black line) well anterior
to the SMAS incision over the posterior jawline/ upper lateral neck
region. Note that mark for posterior incision curves posteriorly to
the anterior border of the sternocleidomastoid muscle and extends
2 to 3 cm inferior to the mandibular border. (Copyright © Timothy
Marten.)
f fi f jawline areas. These ligaments are often difficult to visualize
Blind clamping should not be performed, and low coagulation
current should always be used. The patient’s face should also be
carefully monitored whenever cauterization for bleeding is per-
formed and current discontinued immediately if facial twitching
is noted. Bleeding near a facial nerve branch, if encountered and
difficult to cauterize without facial twitching, is most safely
managed by applying a few minutes of direct pressure upon the
bleeding area.
Sub-SMAS dissection must generally be carried over the
anterior border of the parotid in the lower cheek to ensure that
masseteric–cutaneous ligaments tethering the SMAS are released
(region marked by small squares in Fig. 49.42) and if optimal
improvement is to be obtained in the lower cheek, jowl, and
Fig. 49.39 Markings for the high SMAS flap. The superior margin
of the high SMAS flap (methylene blue ink line) is marked over the
zygomatic arch (black lines) and not below it, starting at the level
of the infraorbital rim and extending posteriorly to a point approxi-
mately 1 cm anterior to the superior margin of the tragus. It is then
turned inferiorly in front of the ear and extends inferiorly and slightly
posteriorly to the anterior border of the sternocleidomastoid muscle
approximately 2 to 3 cm below the mandibular border. (Copyright ©
Timothy Marten.)
Fig. 49.41 Pitanguy’s landmark for the frontal branch of the facial
nerve (yellow dotted line) is a line extending from the inferior margin
of the tragus to a point 1.5 cm superior to the lateral eyebrow. It can
be seen that the nerve lies under the flap only at its upper lateral
most corner, where it is anatomically consistent at 9 mm deep and is
safely deep and posterior to all but the very first part of the SMAS flap
dissection. (Copyright © Timothy Marten.)
specifically and most easily identified by fingertip palpation along
the front of dissection. If these restraining attachments are not
released, an optimal SMAS effect will not be realized and minimal
overall benefit will be obtained.
As SMAS flap dissection is carried anteriorly and medially in
the upper cheek over the superior portion of the parotid and its
accessory lobe, the SMAS will be seen to thin and invest the lip
elevators. fi
to the superior portion of the zygomaticus major muscle, and the
muscle’s origin typically must be carefully exposed and partially
visualized if optimal improvement is to be obtained in the upper
cheek, infraorbital, and midface areas. ust at the malar origin of
the zygomaticus major muscle the zygomatic ligaments will be
663
 VIII Surgical Rejuvenation of the Face and Neck
encountered (region marked by small circles in Fig. 49.42). These
fibrous connections, extending between the periosteum and skin,
restrain the upper cheek and midface and must be divided in a
sub-SMAS plane. hen completely released, a dramatic liberation
of the flap and the upper cheek and midface will be obtained. The
lateral-most ligaments are typically more substantial and gener-
ally require sharp or cautery dissection and formal transection.
The ligaments lying more medially are generally softer and can
often be disrupted bluntly with open scissors tips, a ittner
sponge, or a fingertip.
Directly inferomedial to the origin of the zygomaticus major
muscle, and superomedial to the accessory lobe of the parotid and
the parotid duct, lies the zone of transition between the zygomatic
and masseteric–cutaneous ligaments, the most potentially dangerous
part of the SMAS dissection. Proper liberation and release of the
SMAS flap usually requires at least partial division of restraining
attachments in this area, but it moves the dissection into very close
proximity to the zygomatic branches of the facial nerve (Fig. 49.43).
Although experienced surgeons make this dissection appear
easy and frequently seem to minimize the risk involved, it is
often difficult for the less experienced surgeon to distinguish
between nerve branches and ligamentous attachments in this
area. Anatomic variations are also common in this region, and in
some cases nerves will penetrate the deep fascia early and travel
directly in a sub-SMAS plane or send a branch over the zygomat-
icus major to the orbicularis oculi. In these situations, traction
on the SMAS flap during dissection can tent up these branches,
placing them at even greater risk. It is highly recommended that
any surgeon uncertain of the anatomy of the facial nerve and its
variations or the exact relationships in this area review them and
study Fig. 49.43 carefully before undertaking this dissection.
Fig. 49.42 Extent of superficial musculoaponeurotic system (SMAS)
undermining. Complete release of the SMAS flap requires that both
the masseteric–cutaneous ligaments along the anterior border of
the parotid gland (small black squares) and the zygomatic ligaments
near the origin of the zygomatic major muscle (small black circles) be
released. Note that minimal undermining is needed inferiorly, because
there are no ligaments restraining the SMAS in that area, but a more
“extended” SMAS release is needed in the upper cheek and midface
area. The group of parallel lines shown in the cheek represents the
origin of the zygomaticus major muscle (see also Fig. 49.4). (Copyright
© Timothy Marten.)
664
A safe dissection of the submalar SMAS and proper release of
the zygomatic ligaments will require adequate light; an attentive
assistant; a well-organized surgical team; a dry field; and patience,
caution, and composure on the part of the surgeon. However, if
confusion is encountered or anatomy seems unclear, it is better to
limit dissection until additional experience and familiarity with this
anatomic region are obtained. No amount of improvement in facial
appearance is worth an injury to the facial nerve.
49.6.8 Techniques for SMAS Flap
Elevation
A helpful technique that we frequently use in making a safe sub-
SMAS dissection, as previously outlined, is to raise the SMAS flap
with a needle-tip cautery set on a low coagulation current setting
rather than scissors. hen such a technique is used, a gentle sep-
aration of the tissue layers can be made and when proximity to
motor nerve branches occurs, soft facial twitching will be noted.
hen dissection with cautery is brought into close proximity
to a motor nerve, a more marked twitching will be noted, and
additional caution should be exercised. If a question arises as to
whether an area of tissue contains a nerve branch or a ligament,
the surgeon can briefly apply a pulse of low cautery current near
the area in question. If it twitches, a nerve branch is likely pres-
ent and further dissection must be made with care. If no twitch
is seen, a nerve branch is not present and the dissection can be
continued further if indicated. earing low loupe magnification
(2.5 ) also helps the surgeon follow the correct plane and stay
on top of the shiny parotidomasseteric fascia that overlies the
facial nerve branches as they emerge from the anterior border
Fig. 49.43 Completed SMAS flap dissection. An extensively dissected
SMAS flap showing important surgical anatomy. Inferior to the origin
of the zygomaticus major muscle, and superomedial to the accessory
lobe of the parotid, lies the zone of transition (red circles) between
the zygomatic ligaments (blue circles) and the masseteric–cutaneous
ligaments (black circles) and the most potentially dangerous part
of the SMAS dissection. Proper release of the SMAS flap usually
requires at least partial division of restraining attachments in this
area of transition, with the dissection coming into close proximity to
zygomatic branches of the facial nerve. Care should be taken when
dissecting in this area. Other important anatomy shown includes the
origin of the zygomaticus major muscle, the origin of the zygomaticus
minor muscle, the malar fat pad, and the platysma. (Copyright ©
Timothy Marten.)
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

of the parotid and over the masseter muscle by providing the
surgeon better visualization of the tissue being dissected and the
structures that are present. Loupes and low-energy needle-tip
cautery dissection enable the surgeon to advance the front of
dissection incrementally by cutting only a thin veil of tissue at
a time and avoiding cutting a large amount that might contain
a nerve branch. The needle-tipped low-coagulation-current
cautery technique of flap elevation is also useful in secondary
and tertiary facelifts in which typically the SMAS layer has been
previously dissected and anatomy is less clear.
49.6.9 Assessing Completeness of SMAS
Flap Dissection
hile anatomy and anatomic structures provide important
signposts to the surgeon, as clinicians we seek a clinical result
(lift of facial tissues), and dissection of the SMAS flap and release
of retaining ligaments is continued until gentle traction on the
superior flap margin produces motion at the cheek, nasal ala,
philtrum, and stomal angle, and elevation and compression of
infraorbital and lower eyelid region. This “traction test” clinically
fi
of a complete dissection than any arbitrary anatomic endpoint.
If flap release is incomplete, residual tethering fibers should be
identified and carefully divided, and the traction test repeated.
hen dissection is complete, the malar pad and attached skin
will move freely as part of the high SMAS flap superiorly,
and no separate dissection of the malar pad (finger-assisted
malar elevation, FAME ), suture suspension of the midface
(minimal-access cranial suspension, MACS ), or subperiosteal
dissection ( midface lift ) is required.
49.6.10 SMAS Suspension and Proper
SMAS Vector
Once the SMAS flap has been elevated and adequately released
and all deep-layer neck maneuvers (subplatysal fat excision,
submandibular gland reduction, and partial digastric myectomy)
have been completed if indicated, the superior edge of the flap
is grasped and shifted variously to determine which direction
produces the best effect on the upper midface, cheek, and jowl.
In all but the unusual case this is along a posterosuperior vector
parallel to the long axis of the zygomaticus major muscle. If a ver-
tical or posterior vector is used, the function of the zygomaticus
major muscle will be corrupted and abnormal appearances
during animation may result (Fig. 49.44).
Management of the superior margin of the SMAS flap and
the technique of flap suspension is not arbitrary and will vary

a b c
Fig. 49.44 Proper and improper vectors of SMAS shift. (a) The proper direction of shift of the SMAS is along a vector parallel to the long axis of the
zygomaticus major muscle (green arrow). (b) If the SMAS is shifted along a posteriorly directed vector (red arrow) and not along the long axis of the
zygomatic major muscle, the muscle is pulled off its axis and its function compromised. This can result in deepening of the nasolabial fold, abnormal
appearances during facial movement, and a pulled “clown mouth” appearance, as pull is applied to the risorius muscle (black arrow). (c) An analogous
problem is encountered when a vertical vector (red arrow) is used in a “vertical facelift” and the zygomaticus major muscle is pulled medially off its
axis of function. A vertical vector also applies pull to the zygomaticus minor muscles and can result in a sneering appearance to the mouth (black
arrow). (Copyright © Timothy Marten.)

665
 VIII Surgical Rejuvenation of the Face and Neck
depending on the problems present, where the temporal incision
was made, and other considerations particular to the patient,
including sex, race, and overall facial morphology. Accordingly,
how the superior margin of the SMAS flap is suspended will
depend on the patient’s circumstances and the aesthetic outcome
desired, and it provides the surgeon an opportunity to improve
and optimize the patient’s appearance. There are three general
strategies used that allow facial shape and racial, ethnic, and
gender characteristics to be optimized.
SMAS Suspension in the Narrow Face
In many cases no trimming of the superior margin of the flap
is performed, as the overlapping tissue segment adds volume to
and restores lost projection over the lateral cheek and zygomatic
arch and ovalizes the Caucasian female face, restoring shape
lost with age.
SMAS Suspension When the Temporal Incision Is
on the Temporal Scalp
In situations where widening the interzygomatic distance and
ovalizing the face is desired and when the temporal part of
the facelift incision has been made on the temporal scalp (Fig.
49.9), the superior edge of the SMAS flap is raised along a vector
parallel to the long axis of the zygomaticus major muscle (see
Fig. 49.44a), up over the zygomatic arch and is anchored with
interrupted sutures of 3–0 polyglycolic acid (PGA; Vicryl,
Ethicon, Somerville, ) or other suture of choice, well over
the zygomatic arch, directly to the temporalis muscle fascia,
superior to the divided mesotemporalis. Suspension in this
manner is facilitated if the inferior border of the divided meso-
temporalis is gently pushed inferiorly as sutures are placed.
This scheme solidly suspends the midface, upper cheek, and
jowl with no risk of injury to the frontal branch of the facial
nerve (Fig. 49.45).
Avoiding “Smile Block”
o suturing is needed or should be performed over the zygoma
or along the infraorbital rim. These parts of the face are mobile
and need to move during animation and for natural expression.
Directly suspending the midface along the zygoma or infraorbital
rim can result in tissue tethering and dimpling upon animation,
often referred to as smile block.
If the mesotemporalis has been divided too high (above the
level of the helical–facial junction) and direct anchoring of the
SMAS flap to the temporalis muscle fascia is not possible even
when the mesotemporalis is pushed inferiorly, suspension can
still be made in this manner if sutures are allowed to bridge the
intervening gap or if a trifurcated SMAS flap is used (discussed
subsequently).
SMAS Suspension When the Temporal Incision
Is along Temporal Hairline
hen an incision along the temporal hairline is indicated and
temporal dissection is made in a subcutaneous plane, a meso-
temporalis will not be present, temporalis muscle fascia will
666
Fig. 49.45 High SMAS flap suspension when the temporal part of
the facelift incision has been made within the temporal scalp. (a) The
temporal portion of the facelift incision was made within the temporal
scalp (see Fig. 49.36, dividing the mesotemporalis). The SMAS flap has
been advanced superiorly, parallel to the long axis of the zygomaticus
major muscle (see Fig. 49.44, proper and improper vector of SMAS
shift), the mesotemporalis pushed inferiorly, and the flap is shown
being sutured directly to the temporalis muscle fascia. (b) Suspension
of the superior and posterior SMAS flap margins is complete (after the
posterior margin has been trimmed). Note that no suturing is required
over the anterior zygoma or along the infraorbital rim, as the midface
is included in the flap and rises with it. (Copyright © Timothy Marten.)
not be exposed, and the SMAS flap, when elevated, will often
impinge on the sideburn area when advanced superiorly. In
these cases an incision through the galea aponeurotica (galeot-
omy) can be made at the inferior edge of the sideburn to expose
the temporalis muscle fascia. If this galeotomy incision is
thoughtfully planned and dissection is carefully performed, the
superficial temporal artery can typically be preserved; however,
it should be noted that this vessel is routinely divided when the
mesotemporalis is divided in cases where the temporal part of
the facelift incision is made on the temporal scalp, and it can
be divided and ligated in this situation without concern as well.
Once the galeotomy has been performed, SMAS flap suspension
can then be made to the temporalis muscle fascia as previously
described (Fig. 49.46). This comprises the second method of
management and suspension of the superior margin of the
SMAS flap.
SMAS Suspension with a Trifurcated SMAS Flap
A useful and convenient variation of overlapping the superior
margin of the SMAS flap over the zygomatic arch and suspend-
ing it to the temporalis muscle fascia described in the two
preceding scenarios that can optimize support transmitted
to the upper cheek and midface is the trifurcated SMAS flap
(Fig. 49.47). The name comes from the idea that the main body
of the SMAS flap can be divided into three component parts
to optimize its effectiveness: a superior segment to optimize
support for the upper cheek and midface (discussed here), the
main body of the flap to support the mid–lower cheek and jowl,
and a postauricular transposition flap to support the lateral
border of the platysma in the upper lateral neck and along the
cervicomental angle (discussed subsequently). This flap is best
used in circumstances when a sturdy and robust SMAS flap
has been raised, and it is particularly useful when the superior
SMAS flap margin does not easily reach the exposed temporalis
muscle fascia. Conversely, it is less useful when the flap is thin
and fragile, or when it is easily raised to the point of suspension
on the temporalis muscle fascia.
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.46 (a) High SMAS flap suspension when the temporal portion of the facelift incision is made along the temporal hairline. A completed
high SMAS flap dissection in a patient who has a temporal hairline incision is shown. In this case the patient is male, and the incision has a more
masculine angular plan. For women, incisions should be planned with soft curves and made in a less angular fashion, as shown by dotted black
line. If the high SMAS flap were raised at this point, it would impinge on the sideburn area. (b) Temporal galeotomy to expose temporalis muscle
fascia for high SMAS flap anchoring. To avoid impingement on the sideburn and to facilitate firm anchoring of the high SMAS flap, the sideburn
is retracted with a double-pronged 10-mm skin hook, and the galea aponeurotica (superficial temporal fascia) is incised with electrocautery on
each side of the superficial temporal vessels to expose the temporalis muscle fascia. (c) Comparison of fascial exposure with temporal incision
within the temporal scalp vs. along the temporal hairline. (Left side) The superficial temporal fascia (galea) has been incised beneath the sideburn
and the sideburn reflected superiorly. This process exposes the temporalis muscle fascia, to which the SMAS will be anchored. Note that the
superficial temporal artery can often (but need not) be preserved as shown when this dissection is made. (Right side, above) Division of the meso-
temporalis when the temporal portion of the facelift incision (white dotted line) has been made in the temporal scalp (younger patients). (Right
side, below) Completion of division of the mesotemporalis (galeotomy). Note that the subgaleal plane in the temple and the subcutaneous plane
in the cheek have been united and the temporalis muscle fascia has been exposed, similarly to that shown at left, where the temporal portion
of the facelift incision is made along the temporal hairline. (d) Protection of the frontal branch of the facial nerve while performing temporal
galeotomy and exposing temporalis muscle fascia. The sideburn is retracted and the galeotomy completed with electrocautery on each side
of the superficial temporal vessels, preserving them to expose the temporal muscle fascia. Note that to avoid injury to the frontal branch of
the facial nerve (dotted orange line), the galeotomy must roughly follow the external contour of the sideburn and must not extend anteriorly to
the lateral canthus. (e) Anchoring the high SMAS flap to the temporalis muscle fascia exposed in steps a–d. The high SMAS flap has been raised
parallel to the long axis of the zygomaticus major muscle (see Fig. 49.43a) and its superior margin anchored to the temporalis muscle fascia
exposed in steps a through d with 3–0 Vicryl sutures (or other suture of choice). Black triangles represent approximate sites of suture placement.
Gently pushing the divided mesotemporalis inferiorly facilitates suture placement. “Trifurcating” the SMAS flap (see Fig. 49.47 and 49.48) also
facilitates high SMAS flap anchoring if the flap does not easily reach the galeotomy site. Note that no sutures are needed over the zygoma or
onto the anterior cheek, as the anterior portion of the flap and the midface ride up with the lateral part of the flap. (f) Completed anchoring
to the high SMAS flap. The SMAS flap has been advanced and its superior margin securely suspended to the temporalis muscle fascia. After
SMAS flap suspension, the reflected sideburn is returned to its original position (dotted black line) and reanchored there before skin trimming
and suturing in the temporal area is performed. Note that overlapping of SMAS widens the interzygomatic distance and “ovalizes” the face.
Dotted black line along the zygomatic arch shows where the high SMAS flap was harvested from and the degree of overlapping. (Copyright ©
Timothy Marten.)

To create a trifurcated SMAS flap, the SMAS flap, once dis-
sected and adequately released, is elevated parallel to the long
axis of the zygomaticus major muscle and an incision is made
2 to 3 cm into the posterior margin of the flap at the level from
which it was originally harvested, creating a tab of tissue that is
then rotated superiorly and anchored to the temporalis muscle
fascia. The cut edge from which the upper flap was separated is
then sutured to the cut edge overlying the zygomatic arch from
which the original flap was harvested (Fig. 49.48). Substantial
anchoring of the SMAS flap can be obtained in this manner,
and in many cases increased support of the anterior face can be
obtained.
SMAS Suspension When Interzygomatic
Widening Is Not Desired
hile overlapping the SMAS in the upper lateral face is benefi-
cial and will improve the shape and contour of the faces of many
patients undergoing facelift procedures, in patients with wide
faces and a small mandible, in many men, and in many patients
of Asian or Slavic ancestry, enhancement of the upper cheek and
arch and the broadening of the face obtained by overlapping
the SMAS as just described may not be aesthetically appropri-
ate, necessary, or desired. In such cases the redundant tissue
along the superior flap margin can be excised and discarded
(rather than overlapped as in the previous two methods of flap

667
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.47 Trifurcated high SMAS flap. (a) A high SMAS flap can be trifurcated into three component parts, the superior portion of which can
optimize support of the anterior face and facilitate suspension to the temporalis muscle fascia. The flap is raised superiorly after it has been dissected,
and an incision is made 2 to 3 cm into it as shown over the zygomatic arch (dotted red line). Black dotted line A shows the superior margin of the high
SMAS flap, black dotted line B shows the posterior margin of the flap, black dotted line C shows where the high SMAS flap will be trimmed to create the
postauricular transposition flap, and black dotted line D shows the approximate location of a partial platysma myotomy. (b) The three component
parts of the trifurcated SMAS flap are shown: (1) the superior portion, to be anchored to temporalis muscle fascia to suspend the midface; (2) the
main portion, to be anchored to the cut edges from which the flap was harvested, which suspends the lower cheek and jowl; and (3) the postauricular
transposition flap, created from excess tissue on the posterior margin of the flap that is left attached to the cervical platysma, which will be anchored
to mastoid fascia to suspend the lateral platysma border. (c) The trifurcated SMAS flap advanced and sutured. The red arrow shows the enhanced
vector of anchoring of the anterior face and midface that is provided by the superior segment of the flap. (Copyright © Timothy Marten.)

Fig. 49.48 Intraoperative example of trifurcated high SMAS flap. (a)
A high SMAS flap has been trifurcated into three component parts by
notching the superior part of the flap at the level from which it was
harvested over the zygomatic arch and excising the excess tissue on
the posterior margin of the flap but leaving it attached to the cervical
platysma. (b) The superior segment (1) has been sutured to temporalis
muscle fascia to suspend the midface, the middle segment (2) or main
portion has been sutured to the cut edge from which the flap was
harvested along the zygomatic arch to suspend the lower cheek and
jowl, and (3) the postauricular transposition flap, created from excess
tissue on the posterior margin of the flap that was left attached to
the cervical platysma and that has been sutured to mastoid fascia,
to suspend the lateral platysma border and define the cervicomental
angle. The white arrows show the component lift of each flap segment
on the face. (Copyright © Timothy Marten.)
suspension) and the superior flap margin sutured edge to edge
to the superior margin of the initial incision made in the SMAS
over the zygomatic arch, where the SMAS flap was harvested
(Fig. 49.49). This constitutes the third method of management
and suspension of the superior margin of the SMAS flap.
Trimming and Management of the
Posterior Margin of the SMAS Flap
Regardless of how the superior margin of the flap is suspended,
some trimming of the posterior margin of the cheek SMAS flap is
invariably subsequently required when the SMAS flap is advanced
along a proper vector parallel to the long axis of the zygomaticus
major muscle to allow an edge-to-edge approximation to the
Fig. 49.49 High SMAS flap suspension when facial widening is not
desired. (a) Close-up view of patient’s right face (head to the left
and chin to the right). The SMAS flap has been advanced superiorly,
the excess marked, and the excess tissue along the superior margin
of the SMAS flap is about to be excised. (b) Excision of the superior
and posterior SMAS flap margins is complete. Note that the trimmed
edge of superior margin of the SMAS flap can now be sutured to the
cut edge beneath it, from which the flap was harvested, avoiding any
increase in the interzygomatic distance or facial widening. (Copyright
© Timothy Marten.)
SMAS remnant in the preauricular region. Overlapping of the
SMAS in the preauricular area is functionally unproductive
and artistically inappropriate, as such arrangement lends no
additional support to the anterior face and obliterates natural
preauricular contours and the pretragal hollow.
Trimming of the posterior margin of the cheek SMAS flap should
be performed after the superior margin has been suspended
over the zygomatic arch by one of the three methods previously
outlined. Trimming is accomplished by carefully gauging the
redundancy present and tracing a line in marking ink over the cut
edge lying beneath it (Fig. 49.50a). The amount of tissue excised
will vary depending upon the size of a given face, the degree of
release of the flap and the chosen vector of advancement. It is
unproductive and an error, however, to place traction on the SMAS
in the preauricular region, and the posterior margin of the flap
should be trimmed carefully to avoid overexcision and a tight
closure. Posterior traction on the SMAS will result in pulling the
zygomaticus major muscle off its axis of function and subsequent

668
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.50 Management of the posterior margin of the flap. (a) The SMAS flap has been advanced along a vector parallel to the long axis of the
zygomaticus major muscle and suspended superiorly (in this case, the excess along the superior margin of the flap has been excised, and not
overlapped). Dotted black line shows the excess along the posterior edge of the flap to be separated from it. (b) The excess SMAS on the posterior
margin of the flap has been separated but left attached to the cervical platysma below the mandibular margin and transposed to the mastoid for use
as a postauricular transposition flap (PATF). (c) The posterior defect is closed edge to edge over the parotid gland with multiple interrupted sutures of
3–0 polyglycolic acid (PGA, Vicryl). If anterior platysmaplasty is performed, the PATF will be sutured to the mastoid after the platysmaplasty has been
completed. (Copyright © Timothy Marten.)

irregularities in animation, traction of the risorius muscle and
perioral distortion, a pulled look, an objectionable clown
mouth appearance,” herniation of buccal fat, and other undesir-
able appearances (Fig. 49.44b). No pull need be or should be placed
posteriorly on the SMAS.
Volume-Sparing Management of the
Posterior Margin of the SMAS Flap
After trimming of the posterior margin of the SMAS flap, the
cut edge is approximated to the preauricular remnant with
multiple interrupted sutures of 3–0 PGA suture (or other suture
of choice). These sutures consolidate the cheek, reconstitute the
SMAS layer, restore SMAS cover of the parotid gland, and help
support the superior suture line, but they should not be used to
put posterior traction on the SMAS flap.
In situations in which lateral facial and preauricular atrophy
and hollowing are present, a volume-sparing management
of the posterior margin of the SMAS flap can be used. In this
technique the redundant portion of the posterior margin of the
SMAS flap is not excised but instead is isolated yet left attached
to the body of the SMAS flap and folded upon itself to add volume
to the lateral face. The segment of tissue to be enfolded in the
volume-sparing technique is formed by placing light traction on
the posterior margin of the SMAS flap and cutting into it at the
level of the mid-lobule and that point anchored under no tension
with 3–0 PGA (suture or other suture of choice). A small triangle
of SMAS is then excised superiorly to optimize the shape of the
tissue segment to be enfolded. The tissue segment so defined is
then folded under the main body of the SMAS flap and the folded
edge sutured to the preauricular SMAS remnant, created when the
SMAS (Vicryl) flap was initially elevated, with simple interrupted
3–0 PGA Vicryl sutures (or other suture of choice). Management of
the posterior margin of the SMAS flap in a volume-sparing manner
as described does not preclude the formation of a postauricular
transposition flap (discussed subsequently).
Upon completion of suturing of the cheek SMAS, improved
facial contour should be seen, and a faint smile in the anesthetized
patient’s face should be evident. Usually elevation of the lid–cheek
junction and compression of lower eyelid tissue will also be seen
if a complete high SMAS effect has been achieved (Fig. 49.51).
49.6.11 Suspension of the
Lateral Platysma Border
Trimming the posterior margin of the SMAS flap can be per-
formed in a way that will provide added support to the upper
lateral neck and along the cervicomental angle by leaving the
segment of tissue separated from the posterior SMAS border
attached to the cervical platysma, transposing it to the mastoid
process, and using it as a (PATF;
Fig. 49.52).
A PATF improves neck contour by correcting horizontal platysma
redundancy and increasing anterior neck support. Frequently
this cannot be accomplished by lateral platysmapexy alone, due
to mobility of the tissues in the upper lateral neck. Suturing the
transposed segment of cheek SMAS to the mastoid fascia, while
leaving it attached to the cervical platysma, circumvents this
problem and produces an improved result. In addition, an autolo-
gous dynamic sling is created that tightens the anterior neck and
submental region when the patient looks down. This tightening
is obtained because the mastoid moves superiorly during neck
flexion and away from the anterior neck, pulling the transposed
flap, and attached tissue, with it.
hen a PATF is used, it must be carefully designed and its
effect tested intraoperatively. The SMAS must be incised and
the flap created in such a fashion that the flap exerts its effect
on the cervical platysma below the mandibular border and
along the cervicomental angle, and not more superiorly on the
SMAS in the cheek along the jawline (Fig. 49.53). PATF suspen-
sion is also best delayed until after anterior platysmaplasty is
completed, because if suspended first, the medial platysma
borders may be displaced to the extent that they cannot be
sutured together.
hen combined with an anterior platysmaplasty, the use of
a PATF creates a mastoid-to-mastoid sling of autologous tissue
along the cervicomental angle to deepen and accentuate it. This is

669
 VIII Surgical Rejuvenation of the Face and Neck
a more natural and better strategy than any attempt to accentuate
neck contour by the placement of suspension sutures or straps.
49.6.12 Drain Placement
Drains are used routinely, and experience has shown that
they reduce postoperative eccymosis and seromas and enable
patients to return to their work and social lives sooner. As a
practical matter, drains are particularly needed when deep neck
maneuvers (subplatysmal fat excision and submandibular gland
reduction) are performed. It should be acknowledged that drains
will not substitute for poor hemostasis, however, and will not
prevent hematoma formation.
Drain placement should be performed prior to skin flap
anchoring and incision closure. A 10 French round, end-
perforated ackson-Pratt-style closed-circuit suction drain is
placed subcutaneously across the anteroinferior neck through a
small stab incision on the occipital scalp 1 to 2 cm posterior to
the occipitomastoid incision. o drains are placed in the cheeks.
hen extensive modifications have been made to the anterior
cervical and submental regions, when the patient’s face is large
and the drain will not reach completely across to the other side, or
when complete dissection across the neck is not made, one drain
is placed subcutaneously on each side.
If concomitant neck lift has been performed that included sub-
plastysmal fat excision, submandibular gland reduction, and/or
digastric muscle reduction, a subplatysmal drain is required, and
a 10 French ackson-Pratt-style drain is placed in the subplatys-
mal space and exteriorized and anchored on the occipital scalp in
the postauricular area. Failure to place a subplatysmal drain when
deep-layer maneuvers (subplatysmal fat excision, submandibular
gland reduction, or partial digastric myotomy) are performed will
result in fluid collections (seromas, lymph fluid collections, and
sialomas) in the neck and submental regions in some patients,
and these in turn can result in prolonged cervical induration and
edema, delayed attainment of optimal neck contour, and perma-
nent lumps and other irregularities in the cervicosubmental area.
49.6.13 Skin Flap Repositioning and
Anchoring Suture Placement
hen trimming and suturing the skin flap, it must be remem-
bered that in the contemporary facelift procedure, contour is
created by modifying the SMAS and deep layers of the face and
that the purpose and goal of skin excision is to remove redundancy,
Skin was meant to serve a covering
function, not a structural or supporting one. Trying to lift the face
by tightening the skin is a conceptually flawed concept that will
corrupt the skin’s intended covering function and is destined to
produce poor scars and unnatural “facelifted” appearances.
Skin flap repositioning and suture placement at key points
of suspension should be performed with the patient’s head in a
neutral position (no flexion or extension), as flexion or extension
of the neck will influence the amount of skin excised.
Skin must also be shifted along a vector that is compatible with
its covering function and does not result in secondary irregular-
ities. Shifting skin along an overly vertical vector, or trimming
skin flaps so that incisions are closed under tension, will result in
670
Fig. 49.51 High superficial musculoaponeurotic system (SMAS) effect
seen on the operating table. The SMAS has been suspended on the
right side only and the skin has been laid back on the face but not
trimmed or sutured. The effect of high SMAS flap elevation can be
seen: the corner of the mouth on the right has been raised and the
posture of the mouth and perioral tissues on the right side improved;
the patient has upper dental show and appears to be smiling on the
right side (note that the patient is under anesthesia and that this is
purely the effect of SMAS flap elevation), the cheek on the right side
has been raised and is fuller and more projected than on the left,
and it can be seen that the lid–cheek junction has been raised on the
right side and that skin has been advanced into the right lower eyelid.
Compare these changes with the opposite (left) side, where the SMAS
flap has not yet been suspended. (Copyright © Timothy Marten.)
poor scars, a tight, unnatural appearance, and other objectionable
problems. Shifting skin too posteriorly can result in an insufficient
vertical repositioning of tissue, distortion of the mouth, and
typically results in a “pulled,” “wind-blown,” and objectionable
pulled mouth look.
Cheek skin flaps should be shifted along a vector roughly per-
pendicular to the nasolabial fold and along a distinctly different
and somewhat more posteriorly directed vector than the SMAS
(see Fig. 49.5 and accompanying discussion). hen this is done,
skin will lie more naturally over the tragal region once healing
is complete, and an improved effect will also be obtained in the
nasolabial area. The key concept to be kept in mind is that lift and
contour are created by SMAS repositioning and that only skin that
is truly redundant should be removed.
In the postauricular area, the postauricular skin flap should
be shifted along a vector parallel to the mandibular border. This
provides optimal improvement in the anterior neck and allows
maximum excision of skin flap redundancy without compromis-
ing the skin flap’s covering function. If the postauricular skin flap
is shifted along a more superiorly directed vector (parallel to the
long axis of the sternocleidomastoid muscle), improvement in
the anterior neck will be compromised, skin will be erroneously
excised over the apex of the occipitomastoid incision, and a wide
scar will be present once healing is complete (see Fig. 49.22).
Supra-auricular Skin Flap Anchoring
There are two points of initial skin flap anchoring that set the
stage for the remainder of the closure. The first point is located in
the supra-auricular area, where the most anterosuperior part of
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

a b c
Fig. 49.52 A postauricular transposition flap (PATF) can be created from the posterior margin of a SMAS flap, and the PATF can be used to effect
improvement in the neck. (a) Schematic plan for PATF. (b) After separation of excess tissue on the posterior margin of the SMAS flap and transposition
to the postauricular area. Note that the flap is left attached to the cervical platysma. Note also that to be effective, the flap must be created so that
it pulls under the mandibular border and not higher up along it. (c) After elevation and suturing of a SMAS flap and suturing of a PATF to the mastoid
fascia (typically some shortening of the flap is performed). In combination with anterior platysmaplasty (dashed line), a mastoid-to-mastoid sling of
autologous tissue that accentuates the cervicomental angle is created. Note that platysmaplasty should be performed first and then the suspension
of PATF is made. (Copyright © Timothy Marten.)

the ear joins the scalp. To set this point, the cheek skin flap should
be shifted along a vector roughly perpendicular to the nasolabial
fold, and skin redundancy is then gauged with a Marten facelift
marker (Medicon eG, Tuttlingen, Germany) or similar implement
(Fig. 49.54). A T-shaped incision is then made into the flap at the
marked point in such a manner that only excess skin is removed
and the flap is anchored under normal skin tension. Making the
incision in a T shape facilitates suture placement and simplifies
subsequent trimming of adjacent skin. The flap is then anchored
at this point with a half-buried vertical mattress suture of 4–0
nylon, with the knot tied on the scalp side. o deep sutures are
necessary or used.
a b
Postauricular Skin Flap Anchoring
Fig. 49.53 Improper and proper construction of the postauricular
The second point of initial skin flap anchoring is located in the transposition flap (PATF). (a) Improper design and construction of
postauricular area at the anterosuperior aspect of the trans- the PATF. The flap has been designed and constructed too superiorly
and pulls along the lower face and lateral mandibular border. Such
mastoid portion of the postauricular incision (black dot in Fig.
an arrangement does little to improve the neck and accentuate the
49.55). To set this point, the skin flap is placed over the ear and jawline. (b) Correct design and construction of the PATF. The flap has
shifted posteriorly and somewhat superiorly, roughly parallel to been designed and constructed more inferiorly so that its resultant
transverse neck creases and the mandibular border, and in such pull is below the mandible and along the cervicomental angle. Such
a design optimizes cervicosubmental contour. (Copyright © Timothy
a manner that skin is anchored under minimal or no tension and Marten.)
that little or no skin need be trimmed from the anterior border
f This provides optimal improvement in
the anterior neck and submental region, where it is needed most,
and allows maximum excision of skin flap redundancy without If the postauricular skin flap is anchored along a more superi-
shifting cervical skin and wrinkle lines onto the lower face and orly directed vector, less skin will be removed from the anterior
“lateral sweep” that occurs when a more vertical vector is used. neck and submental area (where it is needed most), improvement
The flap is then secured at this second point with a simple inter- in the anterior neck will be compromised, skin will be inappropri-
rupted suture of 4–0 nylon. o incision into the flap is necessary ately excised over the apex of the occipitomastoid incision, and a
at this point of suspension, no skin should be excised, and no wide scar will likely end up being present where the scar crosses
deep suture is needed or used. the mastoid area once healing is complete (see Fig. 49.22).

671
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 49.54 The facelift marker by Medicon. The use of a facelift flap
marker provides a reliable means for appropriate excisions of facial skin to
be made. The lower jaw of the instrument is designed to be placed with its
tip at the edge of the scalp side of the incision, where the tooth will hold it
in place. The skin flap is then pulled over the lower jaw of the instrument,
and when normal resting skin tension has been set, the instrument is
closed. On closing, the upper jaw of the instrument marks the precise
position of the edge of the scalp flap beneath it. (Top) Close-up view
of the instrument tip design. (Bottom) The instrument in use. (Marten
Marker, www.cmfmedicon.com. Copyright © Timothy Marten.)
Exteriorizing the Lobule
Once the two key anchoring sutures have been placed as just
described, the flap overlying the inferior portion of the ear
should be cautiously divided and the lobule exteriorized.
This is a key step in the procedure that must be performed with
great care if a visible perilobular scar, lobular malposition, and
objectionable secondary earlobe deformities are to be avoided.
Gauging the depth at which the incision should be made into
the flap is greatly facilitated by the use of a facelift marker (Fig.
49.54), and the incision should follow the rim of the helix to the
superior portion of the incisura intertragica (intertragal notch).
If the incision is made correctly, the apex of it should rest snugly
against the inferiormost portion of the conchal cartilage when
the lobule is subsequently exteriorized. If the incision into the
cheek flap is made too far anteriorly or inferiorly, however, artis-
tically appropriate resetting of the lobule will not be possible,
and the outcome of the overall procedure will be significantly
compromised.
49.6.14 Skin Flap Trimming and Closure
Trimming and Closure along the
Conchomastoid/Auriculomastoid Sulcus
Skin flap trimming and incision closure is typically begun in the
postauricular area along the conchomastoid/auriculomastoid
sulcus behind the ear after key anchoring sutures have been
placed and the lobule exteriorized, and it is usually performed
before trimming and closure of the preauricular and occipital
portion of the incision and insetting of the lobule. It is per-
formed by conservatively trimming the anterior border of the
672
Fig. 49.55 Incorrect trimming of postauricular skin flap. It is an error
to excise any skin over (superior to) the apex of the occipitomastoid
incision and shorten the postauricular flap along the long axis of the
sternocleidomastoid muscle. There is no true excess of skin along this
vector, nor any aesthetic benefit from shifting skin in this direction.
Excision of skin in this fashion is the underlying cause of hypertrophic
healing in the postauricular area and of a wide postauricular scar.
(Copyright © Timothy Marten.)
postauricular skin flap into a soft curve to match the curve of
the incision made in the conchomastoid/auriculomastoid sulcus.
o attempt should be made to excise large amounts of tissue
from this area, as that would require and force a counterpro-
ductive and overly superiorly directed vector of advancement
of the postauricular skin flap. The incision is then closed with
several interrupted sutures of 4–0 nylon. The closure need not be
watertight, and no deep suture is needed or used.
Little if any skin should be trimmed from the anterior margin of
conchomastoid/auriculomastoid
sulcus. If it appears that a large amount of skin needs to be excised
from this area, the postauricular flap has been shifted incorrectly
both too far anteriorly and superiorly. In such instances, the
previously placed anchoring sutures should be removed and the
flap readvanced along a more appropriate, and more posteriorly
directed, vector.
Closure of the Transmastoid Incision
It is an error to excise any skin over (superior to) the apex of the
transmastoid portion of the postauricular incision and to shorten
f -
toid muscle (see red arrow in Fig. 49.22b, Fig. 49.55), as is com-
monly practiced, and closure of the transmastoid portion of the
postauricular incision should be made without trimming any skin.
Despite an apparent redundancy in this area when the patient is
supine on the operating table, there is not a true skin excess at this
location. This pseudoexcess of skin results only from the patient’s
elevated shoulder position in the supine position. It will vanish
when the patient sits up and the shoulders drop to a normal posi-
tion. Skin along the long axis of the sternocleidomastoid muscle
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
is also needed for side-to-side head tilt. Inappropriate excision of
skin over the apex of the occipitomastoid defect along the transmas-
toid portion of the postauricular incision is the ultimate underlying
cause of hypertrophic healing and of a wide postauricular scar in
the area (see Fig. 49.22a). Closure of the transmastoid incision is
made with several half-buried vertical mattress sutures of 4–0
nylon (or other suture of choice) with the knots tied on the scalp
side. o deep sutures are necessary or used. If skin is trimmed
along this part of the incision, a wide and hypertrophic scar will
result regardless of whether deep sutures are placed or other like
maneuvers performed.
Trimming and Closure of the Occipital Incision
Trimming and closure of the occipital portion of the postau-
ricular incision should be performed after primary two-point
flap anchoring, exteriorization of the lobule, and conservative
trimming and closure of the incision along the conchomastoid/
auriculomastoid sulcus. If the occipital incision was made into
the occipital scalp (typically in patients under 40 years old; see
Fig. 49.20), it should be closed without the excision of skin or
scalp in one layer with multiple simple interrupted sutures of
4–0 nylon. This incision plan does not allow skin to be excised
without notching of the occipital hairline or counterproductive
advancement of the postauricular skin flap along an overly supe-
rior vector. In addition, because this incision is usually beveled
when properly made, staples will not usually provide precise
wound edge approximation, and sutures are generally required if
malalignment and stepoffs are to be avoided. Excision of skin and
scalp under this incision plan is one of the most common errors
made in facelift surgery.
If the occipital incision has been made along the occipital
hairline (typically in patients over 40 years old; see Fig. 49.23),
skin will be excised only along the posterior border of the postau-
ricular skin flap. A facelift marker should be used to gauge skin
Fig. 49.56 Trimming and closure of the occipital portion of the
postauricular incision. A facelift marker should be used to gauge skin
flap redundancy (see Fig. 49.54), and all points along the flap should
be intentionally trimmed with 2 to 3 mm of redundancy. If trimming
is performed correctly, wound edges should abut one another and no
gaps should be present before sutures are placed as shown. Note that
skin should be excised along the occipital hairline only and not above
the transmastoid portion of the postauricular incision. Note also that
the illustration shows the location of the second point of skin flap
suspension (white arrow). (Copyright © Timothy Marten.)
flap redundancy (see Fig. 49.54), and all points along the flap
should be intentionally trimmed with 2 to 3 mm of redundancy.
If trimming is performed correctly, wound edges should abut one
another, and no gaps should be present, before sutures are placed
(Fig. 49.56).
The incision is then closed in one layer with multiple half-bur-
ied vertical mattress sutures of 4–0 nylon with the knots tied on
the scalp side and simple interrupted sutures of 6–0 nylon (Fig.
49.57). o deep sutures are necessary or used. If skin is over-
trimmed along this part of the incision, a wide or hypertrophic
scar will result regardless of whether deep sutures are placed.
Staples should also not be used, as this incision, if properly made,
will be beveled. Attempts to staple a beveled incision closed will
typically result in wound edge malalignment and stepoffs, which
can be unaesthetic and troublesome for the patient.
This method of suturing will provide precise wound edge
alignment and prevents cross-hatched scars (suture marks). In
addition, if the incision is closed under no tension as described,
an inconspicuous scar will be obtained. If the surgeon does not
, ,
in such a way that the defect must be closed under tension, a
suboptimal scar will typically result regardless of how suturing is
performed and closure is made.
Micro Gathering of Occipital Wound Length
Discrepancy and Dog-Ear Management
If the postauricular skin flap is of good quality, it has been shifted
along a proper vector, and tissue is distributed appropriately
under no tension over the occipital area, little or no wound
length discrepancy should be seen and a precise fit should be
obtained in many cases (Fig. 49.56, Fig. 49.57). If postauricular
skin flap tissue quality is less than optimal, neck skin redundancy
is large, or the postauricular flap has been overshifted and
anchored under tension, a wound length discrepancy will be
present, with the skin flap side seen to be longer than the scalp
Fig. 49.57 Closure of the occipital portion of the postauricular
incision. The occipital portion of the postauricular incision when made
along the occipital hairline (typically in patients over 40 years old) is
closed after precise trimming so that wound edges abut one another
before sutures are placed with a combination of half-buried vertical
mattress sutures of 4–0 nylon with the knots tied on the scalp side
and simple interrupted sutures of 6–0 nylon to provide precise wound
edge alignment. (Copyright © Timothy Marten.)
673
 VIII Surgical Rejuvenation of the Face and Neck
side, and a dog-ear will often be present at the inferiormost
portion of the occipital incision. This should not be arbitrarily
chased down the occipital hairline, as an obvious scar in the
fine hair on the nape of the neck will typically result. A better
result is obtained under these circumstances if the wound length
discrepancy is managed in two ways. First, a significant portion
of the wound length discrepancy can be reduced by suture place-
ment in a manner that microgathers the longer skin flap side.
That is, the half-buried vertical mattress sutures of 4–0 nylon are
placed 10 mm apart on the scalp side but 12 to 14 mm apart on
the skin flap side (Fig. 49.58). ith each such suture placement
the wound length discrepancy is incrementally reduced. In most
cases, if this manner of suture placement is continued as one
proceeds inferiorly, by the time the inferiormost part of the inci-
sion is reached the majority of the wound length discrepancy has
been addressed and is no longer present, and typically what was
once a large dog-ear has been markedly reduced or eliminated.
The second maneuver used to address wound length discrep-
ancy along the occipital incision and the residual dog-ear still
present after microgathering of the majority of the discrepancy
on the skin flap side of the closure by the suture technique just
described is to inset the remaining dog ear posteriorly into the
occipital scalp, above the junction of thick and fine hair. This
typically requires a small extension of the incision inferiorly and
that a small ellipse of scalp then be excised from the scalp side
of the incision. This maneuver simultaneously lengthens the still-
slightly-shorter scalp side of the incision (a curve is longer than a
straight line), creates a cutout into which the dog ear can be inset,
and moves the end of the incision into dense hair where it is well
concealed (Fig. 49.59).
Trimming and Closure of the Temporal Incision
Once closure of the postauricular area has been completed,
attention is typically turned next to the temple area. If the
temporal portion of the facelift incision has been made in the
temporal scalp (see Fig. 49.9; typically patients under 45 years
old), the incision is closed in one layer, without excision of any
hair-bearing temporal tissue, with multiple simple interrupted
sutures of 4–0 nylon. A small amount of cheek skin and scalp only
will be excised, immediately above the ear at the completion of
the closure. It is clinically unproductive, a conceptual error, and
a serious technical mistake to excise scalp over the temple region
in attempt to improve the forehead, upper lateral face, or “crow’s
feet” area. o deep sutures are necessary or are used. In fact, if
skin is overtrimmed along this part of the incision, a wide scar
will result regardless of whether deep sutures are placed.
In most cases a modest wound length discrepancy will be
present, with the flap edge side longer than the scalp edge side,
and this can be managed by the microgathering technique dis-
cussed previously for management of wound length discrepancy
along the occipital hairline incision: simple interrupted sutures
of 4–0 nylon are placed 10 mm apart on the scalp side but 12 to
14 mm apart on the flap side. ith each such suture placement
the wound length discrepancy is incrementally reduced. In most
cases, if this manner of suture placement is continued as one pro-
ceeds superiorly, by the time the superiormost part of the incision
is reached, the majority of the wound length discrepancy has
674
Fig. 49.58 “Microgathering” of skin to reduce wound length
discrepancy along occipital incision. When the postauricular skin flap
is advanced along an optimal posterosuperior vector roughly parallel
to the mandibular border, a wound length discrepancy will typically
occur, with a longer incision on the skin flap side and a shorter incision
of the scalp side. This can be reduced by “micro-gathering” of the skin
on the flap side. This is accomplished by placing half-buried vertical
mattress sutures of 4–0 nylon with the knots tied on the scalp side 10
mm apart from each other on the scalp side and 12 to 14 mm apart
on the skin flap side. Each suture placement reduces wound length
discrepancy and the amount of dog-ear present at the inferiormost
part of the incision. (Copyright © Timothy Marten.)
been addressed and is no longer present. If not, the incision can
be extended superiorly slightly to allow a well-aligned closure.
Because the incision on the temporal scalp will be beveled when
properly made, sutures, and not staples, are generally required
to obtain a well-aligned wound and avoid malalignment and
stepoffs, which can be troublesome for patients.
If open forehead plasty is to be performed as part of the pro-
cedure, closure of the temporal portion of the facelift incision, if
made in this location, is delayed until after the forehead plasty
is complete. This preserves access to the upper lateral face and
affords precise realignment of tissue in this area.
If the temporal portion of the facelift incision has been made
along the temporal hairline (typically patients over 45 years old;
see Fig. 49.10), skin will be trimmed only when the incision is
closed. A facelift marker (see Fig. 49.54) should be used to gauge
temporal and subsideburn skin excess and the flap intentionally
trimmed with 2 to 3 mm of redundancy. If trimming is performed
correctly, wound edges should abut one another, and no gaps
should be present, before sutures are placed. The incision is then
closed in one layer with a combination of half-buried vertical
mattress sutures of 4–0 nylon with the knots on the scalp side and
simple interrupted sutures of 6–0 nylon. This plan will provide
precise wound edge alignment and will prevent cross-hatched
scars (suture marks).
o deep sutures are necessary or used. In fact, if skin is over-
trimmed along this part of the incision from the skin flap, a wide
scar will result regardless of whether deep sutures are placed.
Staples should not be used either, because this incision, if properly
made, will be beveled, and attempts to staple a beveled incision
closed will typically result in wound edge malalignment and
stepoffs that can be unaesthetic and troublesome for the patient.
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
Fig. 49.59 (a) Insetting the postauricular dog-ear at the inferior
aspect of the occipital incision. A wound length discrepancy is typically
present at the inferiormost aspect of the occipital portion of the
postauricular incision, resulting in a dog-ear at its inferior aspect on
the skin flap side. When a dog-ear does form, as shown, the redundant
tissue is best managed by insetting it into the occipital scalp (green
line). Trimming the dog-ear off in a traditional fashion (red line) will not
fully accommodate the wound length discrepancy present and will
move the scar into a more visible location in the fine hair on the nape
of the neck. (b) Lengthening the scalp side and creating an inset for
the dog-ear by excision of an ellipse of tissue from the scalp side. The
incision has been extended inferiorly a short distance parallel to the
hair follicles, and an ellipse of scalp tissue (in forceps) is excised from
the scalp flap side of the incision, into which the dog-ear will be inset
(note that the dog-ear itself on the neck side is only minimally trimmed
or not trimmed at all). This creates a curved, geometrically longer
(longer distance between two points) curved surface into which the
dog-ear will be fitted on the scalp side. (c) Ellipse of scalp excised and
dog-ear inset. The ellipse of tissue has been excised from the scalp side
of the incision and removed, and the wound length discrepancy has
as a result been eliminated. The dog-ear itself has been undermined
and released, but not trimmed (or trimmed only a small amount) and
has not been sutured. (d) Completed insetting of the dog-ear into the
inferior aspect of the occipital hairline incision. After suturing, it can
be seen that the dog-ear has been eliminated by insetting it into the
cutout made on the opposite, scalp side, and the inferiormost part of
the incision has been moved into thicker hair on the scalp, where it is
less visible than if it had been excised in a traditional fashion (red line in
a). (Copyright © Timothy Marten.)
Trimming and Closure of
the Preauricular Incision
Preauricular skin flap trimming and closure should be performed
next. Skin flap redundancy should be gauged using a facelift
marker (see Fig. 49.54) while the pretragal portion of the skin flap
is held down into the pretragal hollow with an instrument by the
assistant (Fig. 49.60a). This ensures that enough skin will be pres-
ent to fill the pretragal sulcus and to provide a natural transition
from the cheek to the ear once healing is complete. This is also
is a key step in avoiding retracted tragus and buried tragus
irregularities.
Using marks made with the facelift marker as points of refer-
ence, the prehelical portion of the cheek skin flap is trimmed first
with 2 to 3 mm of redundancy to form a soft curve that matches
the prehelical incision. If trimming is performed correctly, wound
edges should abut one another and no gaps should be present
before sutures are placed (Fig. 49.60b). In most cases the cheek
skin flap will be thicker than the fine skin along the anterior helix,
and approximating the thick cheek flap to the delicate skin of the
ear will obscure the natural prehelical sulcus and result in an
unnatural appearance. For this reason the edge of the cheek flap
should be defatted using a aye scissors or similar instrument to
match the fine skin on the helix. The incision is then closed in one
layer with multiple simple interrupted sutures of 6–0 nylon. o
deep sutures are necessary or used. As elsewhere, if skin is over-
trimmed from this part of the skin flap, a wide or hypertrophic
scar will result regardless of whether deep sutures are placed.
The prelobular (subtragal) portion of the cheek skin flap is
trimmed next, guided by the marks made with the facelift marker.
If trimming is performed correctly, 2 to 3 mm of redundancy
should be present, wound edges will abut one another, and no gaps
should be present before sutures are placed. In all but the unusual
case, the cheek skin flap will be much thicker than the fine skin
along the anterior lobule and approximating a thick cheek flap to
the delicate skin of the earlobe will obscure the natural contours
in that area and result in an unnatural appearance. For this reason
the edge of the cheek flap to be approximated to the anterior
border of the lobule should be defatted using a aye scissors or
similar instrument. The incision is then closed in one layer with
several simple interrupted sutures of 6–0 nylon. As elsewhere, no
deep sutures are necessary or used; if skin is overtrimmed along
this part of the incision, a wide or hypertrophic scar will result
regardless of whether deep sutures are placed.
Once the prehelical and prelobular areas have been closed, the
stage is set to trim the tragus. This must be performed with great
care while the assistant holds the pretragal portion of the skin
flap into the pretragal hollow (Fig. 49.60c). As elsewhere in the
preauricular closure, the tragal flap should be trimmed with 2 to 3
mm of redundancy, and the margin of the posterior border of the
tragal skin flap should be defatted using a aye scissors or similar
instrument to match the fine skin present along the margin of the
tragus. Closure is then made with simple interrupted sutures of
6–0 nylon. The tragal flap itself should not be thinned or defatted,
and no deep sutures are necessary. Trimming the tragal skin flap
too short is a serious artistic error that will result in tragal retrac-
tion and an unnatural chopped-off, buried, or retracted
tragal appearance (see Fig. 49.18).
r e e n gur i n nd edu i n
Before insetting the lobule into the cheek flap the surgeon
should consider its shape and size and the transition it made to
the cheek preoperatively to see whether it can be made more
youthful and natural appearing. Often the earlobe will be seen
to be suboptimally shaped, too large, or abnormally attached
to the cheek. In these situations an improved and more natural
appearance can be obtained by reconfiguring the earlobe before
insetting it into the cheek flap (Fig. 49.61).
Earlobe reconfiguration is begun by marking the redundant
portion on both the outer and inner sides of the lobule. Often the
existing pierced ear hole can be used as a radius about which the
line can be drawn (red dotted line in Fig. 49.61b). Once marked,
the lobule is hyperinflated with local anesthetic solution. This
makes incising the skin along the marked lines and resecting the
675
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.60 (a) Preserving a pretragal sulcus and avoiding the “buried tragus” and “retracted tragus” deformities. The cheek skin flap should be
held down into the pretragal sulcus by the assistant while the cheek skin flap is marked and subsequently trimmed by the surgeon if a natural and
aesthetic appearance is to be obtained. Note that a facelift marker is being used to mark the location of the superior aspect of the tragus and to
define and mark the amount of skin to be excised from the skin flap along the anterior border of the helix. (b) Trimming the prehelical skin flap. The
prehelical part of the preauricular incision has been trimmed. Note that the skin edges abut one another before any sutures are placed. (c) Trimming
the tragal skin flap. The prehelical and prelobular portions of the skin flap have been trimmed and sutured. Note that the surgical assistant holds skin
in the pretragal sulcus while the skin along the (retro) tragal part of the preauricular incision is trimmed by the surgeon. (d) Completed trimming of
the tragal skin flap. Note that following trimming of the tragal skin flap, the skin edges abut one another before any sutures are placed and that a
distinct depression is present in the pretragal sulcus. (e) Completed closure of the preauricular incision. Note that, following trimming and closure
of the component parts of the pretragal incision along the preauricular skin flap, a tension-free approximation of tissue has been made, natural
contours are present, incisions are situated along natural anatomic interfaces, and a distinct depression is present in the pretragal sulcus. (Copyright
© Timothy Marten.)

Fig. 49.61 Earlobe reconfiguration. The earlobe can be reconfigured
when unaesthetically and unnaturally shaped to provide a more
youthful and natural, rounded overall shape and to create a more
natural-appearing transition between the lobule and the cheek, even if
it was more inferiorly situated and square before surgery. (a) A patient
who has undergone a previous facelift. The earlobe is unnaturally square
in shape, is joined unaesthetically with the cheek, and appears heavy
and masculine. Note that the tragus has an unnatural “chopped-off”
appearance as well. (Procedure performed by an unknown surgeon.)
(b) The red dotted line shows the portion of the lobule that is excised to
obtain a more natural shape. The wound is then closed with a simple
running suture of 6–0 Prolene, and the resulting scar will be situated
on the lobule margin. (c) Same patient after secondary facelift that
included earlobe reconfiguration. The earlobe is smaller; has a more nat-
ural, rounded, feminine shape; and no longer has a telltale “attached”
appearance. The natural cleft between the lobule and the cheek has also
been reestablished, and the perilobular scar no longer sits in a visible
location and is tucked up into a location where it cannot be seen. The
“chopped-off” tragus has also been corrected. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
redundant tissue easier and reduces oozing from the cut edges. If
the earlobe is floppy and lacking in turgor, skin only can be excised
and the fat spared pushed into the lobule upon wound closure.
Closure is then made meticulously with a simple running suture
of 6–0 polypropylene (Prolene, Ethicon, Somerville, ) or other
suture of choice. Care should be taken to ensure that the closure
is not overly tight and that the wound edge is well approximated
and not scalloped. Once reconfigured, the lobule can then be inset
into the cheek as described subsequently.
A variation of earlobe reconfiguration is earlobe reduction, in
which the lobule is simply not reshaped but actually reduced in size.
In such cases a longer incision is made and a larger piece of tissue
is removed as appropriate for the situation and in keeping with the
characteristics of the rest of the ear. hen the earlobe is reduced,
often existing pierced ear holes are sacrificed or need to be punched
out with a biopsy punch and closed to avoid having them too close to
the margin of the reconstructed lobule. Reducing the earlobe when
it is overly large creates a more youthful and natural look, reduces
a grandfatherly or grandmotherly appearance, and helps avert a
telltale young face–old ear appearance (Fig. 49.62). Once reduced,
the lobule can then be inset into the cheek as described as follows.
Insetting the Lobule
There is nothing as telltale and aesthetically objectionable as
abnormal position of the earlobe following facelift surgery, and

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 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
for this reason
last step in the closure of the periauricular area. Cutting into and
trimming the cheek flap to inset the lobule must be performed
with great care and artistic sensitivity and should always be
performed incrementally in stages to prevent inadvertent over-
excision of cheek skin, which will result in an abnormal position
and configuration of the earlobe. If the surgeon overexcises skin
when insetting the earlobe, it will inevitably migrate inferiorly
into an unaesthetic position regardless of whether deep sutures
are placed, whether the earlobe is anchored to auricular carti-
lage, or whether other such attempts are made to suspend it.
The cheek flap should be trimmed and the earlobe inset in
such a manner that the lobule ends up situated in a posterior and
somewhat superior position, even it if was naturally in a more
anterior or inferior position and was square in shape before sur-
gery. This is because the long axis of the earlobe of an artistically
ideal, nonsurgical -appearing ear ideally sits approximately 15
degrees posterior to the long axis of the ear itself in the lateral
view (Fig. 49.63). As this angle is reduced or shifted anteriorly,
or if the lobule is mistakenly placed too far inferiorly, an old,
unnatural facelift look is produced (Fig. 49.64). Moreover, the
lobular–facial junction should sit in a concealed, elevated position
and not in a lower, more visible location (Fig. 49.65).
Insetting the lobule into the cheek so that its long axis sits pos-
terior to the long axis of the rest of the ear typically requires that
the lobule be released from tethering tissue, and this is typically
performed using electrocautery. It is then secured in two layers.
The first layer consists of several deep dermal sutures of 5–0
poliglecaprone 25 (Monocryl; Ethicon, Somerville, ) or similar
suture. These sutures provide initial alignment and protect the
incision from disruption during the first few weeks after surgery if
patients inadvertently pull clothing, jewelry, or other items off over
their heads and catch their earlobe while doing so. Final approxi-
mation is then made with simple interrupted sutures of 6–0 nylon.
If the lobule has been inset into the cheek flap correctly with
its long axis pushed slightly posterior to the long axis of the ear,
Fig. 49.63 Correct insetting of the lobule. The long axis of the earlobe
(red line) of an artistically ideal, “nonsurgical”-appearing ear ideally sits
approximately 15 posterior to the long axis of the ear itself (black line)
in the lateral view. (Procedure performed by Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)
a b
Fig. 49.62 Earlobe reduction. Reducing the earlobe when it is overly
large creates a more youthful and natural look and helps avert a telltale
“young face–old ear” appearance. (a) A patient seen preoperatively
with a large, “grandfatherly” earlobe. (b) Same patient after facelift
and related procedures that included earlobe reduction. The earlobe
is smaller and has a more youthful and natural appearance. (Procedure
performed by Timothy Marten, MD, FACS. Copyright © Timothy
Marten.)
a wound length discrepancy and skin redundancy will often be
present on the posterior surface of the ear at the lobular–conchal
junction. This is easily and conveniently managed and a couture
fit obtained by conservatively excising a triangle of skin ( Ristow’s
triangle ) corresponding to the tissue redundancy in this area.
Closure is made in one layer with several simple interrupted
sutures of 4–0 nylon or other suture of choice (Fig. 49.66). Care
must be taken to avoid any tension or scar thickening, and hyper-
trophy may occur. If wound length discrepancy is not addressed
in this or in some other manner and the wound edges are simply
gathered during closure in this area, small pockets and crypts
will typically result that can accumulate desquamated debris and
sebaceous secretions, which can be problematic for the patient.
Fig. 49.64 Incorrect insetting of the lobule. If the earlobe is inset into
the cheek so that the long axis of the earlobe (red line) sits anterior to
the long axis of the ear (black line) in the lateral view, the ear will have
an unnatural, “facelifted” appearance. (Procedure performed by an
unknown surgeon. Copyright © Timothy Marten.)
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 VIII Surgical Rejuvenation of the Face and Neck

a b

Fig. 49.65 Concealing the perilobular scar. The cheek flap should be
trimmed and the earlobe inset in such a manner that the lobule ends
up situated in a superior position with a rounded overall shape and a
modest cleft between the lobule and the cheek, even it if was more
inferiorly situated and square in shape before surgery. (a) The perilob-
ular scar is tucked up in a concealed location and is not visible, and a
cleft is present between the lobule and cheek. (Procedure performed
by Timothy Marten, MD, FACS.) (b) The perilobular scar has been made
too low, and the natural cleft between the lobule and the cheek has
been obliterated. The scar sits in a visible location, and the lobule has
a telltale “attached” and square and unnatural shape. (Procedure
performed by an unknown surgeon. Courtesy of Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)
Closure of the Submental Incision
If a submental incision has been made as part of the facelift pro-
cedure, it is typically left open but covered with a moist sponge
until all other incisions have been closed and other procedures
have been performed to allow for a final inspection of the neck
area before leaving the OR. hile ostensibly straightforward,
closing this incision must be done meticulously and with care if
an inconspicuous scar is to be obtained. Even a small irregularity
in this area can become a significant concern to the patient and
spoil an otherwise excellent result.
The submental incision is closed in two layers to ensure precise
approximation of subcutaneous fat and skin and to prevent a
depressed scar. Typically, the inferior wound edge has been sub-
ject to trauma from retractors, and often there is a discrepancy in
the amount of subcutaneous fat present on the two sides, with the
chin side thicker and the submental side thinner. This discrepancy
must be addressed and wound edges matched in thickness before
closure is begun. The first layer of closure is accomplished using
several deep dermal sutures of 5–0 Monocryl (or similar suture).
Final approximation is made with simple interrupted sutures of
6–0 nylon.
49.6.15 Completion of Concurrently
Planned Procedures
Upon completion of the face, neck, and forehead lift portions of
the procedure, attention is turned to upper blepharoplasty, lower
blepharoplasty, upper lip lift, and other planned procedures, as
Fig. 49.66 Accommodating wound length discrepancy when insetting
the lobule. If the lobule has been inset correctly, a wound length
discrepancy and skin redundancy will typically be present on the
posterior surface of the ear at the lobular-conchal junction. This is
managed by excising a triangle of skin (black dotted lines) correspond-
ing to the tissue excess in this area. Closure is made in one layer with
several simple interrupted sutures of 4–0 nylon or other suture of
choice (see also Fig. 49.57); red dotted line shows location of typical
postauricular incision plan. (Courtesy of Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)
indicated. Perioral resurfacing and buccal fat reduction, if indi-
cated, are typically performed last.
49.6.16 Dressings
After all planned procedures have been completed and all inci-
sions have been closed, the patient’s hair is washed with sham-
poo and rinsed with warm water. A final inspection of sutured
incisions is then made. If poor alignment is found in any area, it
is locally reprepped, and sutures are removed and replaced as
required.
Once the patient’s hair has been shampooed and rinsed,
conditioner is applied and the hair carefully detangled with a
wide-toothed comb. Failure to wash, condition, and detangle the
patient’s hair adequately after completion of the procedure can
result in matting and tangling that can be problematic in the post-
operative period. Once conditioned and detangled, the patient’s
hair is typically placed in a loose braid (if long).
No dressing is required or applied, as the use of closed suction
drains has supplanted their use. The traditional facelift dressing
of mineral oil–soaked cotton and rolled gauze is unnecessary if
closed suction drains are used, and a strong argument can be
made that a facelift dressing is actually counterproductive and

678
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
of potential harm to the patient. This is because these dressings
place unnecessary and potentially dangerous pressure on thin
flaps of cervicofacial tissue and can compromise already tenuous
circulation in them. In addition, they preclude inspection and
monitoring of tissue perfusion in the operative site and can dis-
guise and delay the diagnosis of serious problems such as hema-
toma, flap ischemia, and pressure necrosis. Most patients also
find the traditional facelift dressings cumbersome, confining, and
claustrophobic, and their family members are often frightened by
them.
Patients are typically discharged with a hat, scarf, and sun-
glasses. If perioral resurfacing or lip augmentation has been
performed, a rigid, disposable surgical mask ( cone mask ) that
rests off of the perioral area is also provided to patients to use
to conceal and protect that area during the healing period when
away from their homes.
49.7 Postoperative Care
Performance of the procedure itself fulfills only part of our
obligation to the patient, and the care that patients receive
postoperatively is arguably as important as the surgery itself.
Diligent postoperative care will also ensure the best result and
limit the likelihood that problems and complications will occur.
All patients are discharged to an aftercare specialist with
specific written instructions as to the care they are to receive.
e are always available to answer questions and see any patient
if needed. Patients are asked to rest quietly and apply cool (but
not icy cold or ice) compresses to their eyes and face for 15 to 20
minutes of every hour they are awake for the first 3 days after
surgery, even if they have not had eyelid surgery as part of the
procedure. For most patients, edema peaks at about this time. It
is not necessary or productive to apply cool compresses contin-
ually throughout the day, or at night. If the patient has had fat
grafting to the lips, cool compresses are applied to the perioral
area in a similar manner and on a similar schedule. If perioral or
lower eyelid resurfacing has been performed, these areas can be
covered with plastic wrap ( Saran rap ) before cool compresses
are applied.
Compresses should be cool but not ice cold. Ice, ice packs,
blue ice, and ice in plastic bags and the like should never be
applied directly to the face, as this can frostbite facial skin and
damage fat grafts. For some time, most of our patients have used
a facial cooling mask and cool water system (AqueCool Masque,
Aqueduct Medical, San Francisco, CA) that provides dry, thermo-
statically controlled, consistent cooling. This system is convenient
and comfortable for the patient and can be used by many patients
even when they sleep.
All patients are provided oral analgesics, sleeping pills, anti-
emetics, and preservative-free ophthalmic ointment and artifi-
cial tears solution, in addition to specific instructions for their
use. Patients are required to use preservative-free ophthalmic
ointment each night for the first 3 weeks after surgery or until
all signs of eye irritation have abated. Preservative-free artificial
tears are used throughout the day as needed. Patients should be
reminded that eye drops are not sufficient for nocturnal use.
Contrary to tradition, patients are instructed to sleep flat
on their backs without a pillow. A small cylindrical neck roll is
permitted if the patient requests it. This posture ensures an open
cervicomental angle and averts dangerous neck flexion, folding
of the neck skin flap, and obstruction of regional lymphatics that
inevitably occurs if the patient is allowed to “elevate the head on
a pillow as is commonly recommended. In addition, swelling
will drain to the back of the head instead of the jowl/jawline and
anterior neck when the patient lies flat in this position, where it
is not harmful, is less noticeable and is more rapidly transmitted
away from the head and neck area when the patient sits upright.
Patients are shown an elbows on knees at the coffee table
position, which ensures an open cervicomental angle while sit-
ting. This posture places the patient’s book, magazine, paperwork,
notebook computer, or meal in a position that allows reading,
writing, eating, and TV watching to be performed comfortably and
safely with the patient’s chin up and cervicomental angle open.
All patients should be examined the morning after surgery if
possible. This visit is important if incipient problems are to be
identified early in a treatable stage. All sutures should be checked,
and any appearing too tight should be cut but left in place.
Releasing potentially overtight sutures prevents skin necrosis,
alopecia, and suture marks. Leaving the cut suture in place, rather
than removing it, averts annoying bleeding from the suture site
that inevitably occurs if the suture is completely removed at that
time.
All flaps are carefully inspected as well. Whenever incipient
compromise is noted, one must be suspicious that a tight closure
has resulted in excessive tension over that area. If compromise is
suspected, offending sutures should be removed, even if wound
separation may result. Secondary healing of the separated incision
is always superior to and easier to revise than a large area of more
anteriorly situated full-thickness skin necrosis.
Patients are advised to take a soft, wet, easy-to-chew diet as tol-
erated after surgery and are encouraged to avoid dry, salty, sour,
and difficult-to-chew foods, with a primary focus on maintaining
hydration over eating ( salivary rest diet ). Patients are asked
to abstain from the intake of alcohol for 2 weeks after surgery
and until they are no longer taking pain pills (acetaminophen
included) or sleeping medication.
Patients begin a daily routine of showering and shampooing no
later than 3 days after their procedures, but they may shower the
day after their surgery if they wish ( name tag –type lanyards are
provided to patients to attach their drain reservoirs to). This helps
remove crusting about the suture lines, keeps incisions clean
and bacteria counts down, and usually improves the patient’s
general overall well-being. It also facilitates suture removal at
the patient’s follow-up visits. Patients are instructed that they
need not be as thorough as usual when washing their hair after
their procedure and that they need not attempt to remove all
dried blood and crusts. They are also assured that shower water,
shampoo, and conditioners are not harmful and will not cause
infection. Showering and shampooing are permitted even when
drains are in place.
Drains are usually left in place until the first suture removal
visit. This is because drain output often quickly falls on the first or
second day during the time the patient is mostly supine and resting
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 VIII Surgical Rejuvenation of the Face and Neck
but then picks up again when the patient begins to spend more
time upright and starts to move the head about more. Leaving the
neck drain in longer, for 4 to 5 days, will reduce the likelihood that
small collections will form and will speed the overall resolution
of edema, ecchymosis, and induration in the neck area. This is
especially the case if deep-layer neck lift maneuvers have been
performed, such as subplatysmal fat excision and submandibular
gland reduction.
Sutures are removed in two visits over a period of 7 days. 6–0
nylon sutures are removed on the first visit, 4 to 5 days after
surgery. Half-buried vertical mattress sutures and scalp sutures of
4–0 nylon are removed on the second visit, 7 days after the proce-
dure. It is usually not productive to try to remove sutures hidden
under dried blood or crusts along suture lines if present. These
are usually removed at a third visit, approximately 2 weeks after
surgery, at which time crusts are gone and remaining sutures can
be readily identified.
Patients should be warned that their scalp and parts of their
face may be partially numb after surgery and that they must be
careful when bathing that shower water is not too hot and that
hair dryers are not used on high heat settings. Patients are also
instructed not to perm, tint, dye, highlight, color, or otherwise
chemically treat their hair for 2 weeks after surgery, as these
treatments can result in hair breakage or hair loss. Hot curlers
and curling irons must be used with care for several months, as
patients can unknowingly burn their foreheads and scalps using
them.
hen patients return to work and to their social lives will
depend upon their tolerance for surgery, their capacity for healing,
the type of work they do, the activities they enjoy, and how they
feel overall about their appearance. Patients are asked to set aside
2 to 3 weeks, to recover from surgery, and additional time off is
recommended before an important business presentation, family
gathering, vacation, or like event. If the patient is doing well and
not experiencing problems, she or he is allowed to return to light
office work and casual social activity 9 to 10 days after surgery. It
is often wise that they begin with a limited workday at first and
to adjust their schedules thereafter. If a patient’s job entails more
strenuous activity or physical labor, a longer period of convales-
cence may be required. Patients are advised not to drive for the
first 10 days after surgery and until they are feeling well, their
vision is clear, and they are off pain medications.
Patients are advised to avoid all strenuous activity during
the first 2 weeks after surgery including heavy lifting, stooping,
straining, and bending forward, and they are informed that aero-
bic activities and exercise during this time can precipitate bleed-
ing and hematoma formation. Two weeks after surgery, patients
are allowed to begin light exercise and gradually work up to their
presurgical level of activity. Four to six weeks after surgery they
are allowed to engage in more vigorous activities, including most
sports, as tolerated.
Patients are informed that will often take 2 to 3 months to look
good in a photograph or to be seen at an important function or
event. They are also advised to expect some firmness in the face
and submental areas for 6 to 9 months and that numbness will
typically be present in some areas for 12 to 18 months. If patients
have had fat injections as part of their procedures, additional
680
recovery time may sometimes be required before patients feel
presentable.
49.8 Case Studies
49.8.1 Case 1
This 42-year-old woman is shown before (on the left in each
view) and 13 months after surgery (on the right in each view)
in Fig. 49.67. She had had no prior plastic surgery. On the
preoperative views, note suboptimal eyebrow position and
configuration, sagging cheeks and jowls, and atrophy in the
cheeks and infraorbital area. She has a sad and melancholic
appearance even when she is smiling. She appears tired and
unfit even though she is trim and in excellent overall health.
eck laxity and poor neckline suggest an older and unfit
appearance.
She underwent a facelift, neck lift, limited incision forehead
lift, conservative upper and lower blepharoplasties, fat transfer,
and upper lip lift. o skin resurfacing, facial implants, or other
ancillary procedures were performed, but after this surgery she
had her teeth whitened and straightened. A nevis on the neck was
also removed.
On the postoperative views, note the soft, natural facial con-
tours and the absence of a tight, pulled, or facelifted appearance.
Improved eyebrow position provides a more feminine and alert
appearance. The cheeks and jawline have been repositioned and
redundant skin removed. Atrophy in the upper cheek and infra-
orbital areas has been corrected by lifting sagging cheek tissue to
a youthful position and by fat transfer. ote restoration of cheek
fullness, improved transition from lower lid to cheek, elevation
of corners of mouth, smooth jawline, and improved neck. The lip
lift has shortened the distance from the base of the nose to the
upper lip border and improved the appearance of her mouth. Note
also that that her scars are well concealed, no distortion of the ear
is present, and the earlobe is in normal position. She appears fit,
decisive, and more attractive.
49.8.2 Case 2
This 65-year-old woman is shown before (on the left in each
view) and 13 months after surgery (on the right in each view) in
Fig. 49.68. The patient had had previous upper and lower eyelifts
performed by an unknown surgeon. On the preoperative views,
note her high forehead, asymmetric eyebrows, frown lines,
cheek and jawline laxity, neck bands, labiomandibular groove,
and atrophy of the lips, cheek, and infraorbital areas. Despite a
bright smile she has a tired and melancholic appearance. ote
also that the patient has a large submandibular salivary gland,
evident as a fullness in the upper neck area.
The patient underwent a facelift, neck lift, hairline lowering
forehead lift, upper and lower eyelifts, dermabrasion of lip lines,
and fat transfer to the cheeks and lips. o skin resurfacing, facial
implants, or other ancillary procedures were performed.
On the postoperative views, note the soft, natural facial con-
tours and the absence of a tight, pulled, or facelifted appearance.
Eyebrow asymmetry has been improved and the hairline lowered.
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.67 Case 1: a woman aged 42 years at time of treatment, who had had no prior plastic surgery. (a) Anteroposterior (AP) view. (Left) Before
surgery. Note suboptimal eyebrow position and configuration, cheek and jawline laxity, and atrophy in the cheeks and infraorbital area. (Right)
Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat transfer, and upper lip lift.
No skin resurfacing, facial implants, or other ancillary procedures were performed. Note soft, natural facial contours and the absence of a tight,
pulled, or facelifted appearance. Note also improved eyebrow position, providing a more feminine and alert appearance. The cheeks and jawline
have been repositioned and redundant skin removed. Atrophy in the upper cheek and infraorbital areas has been corrected by lifting sagging cheek
tissue to a youthful position and by fat transfer. (b) AP smiling view. (Left) Before surgery. Note that she has a sad and melancholic appearance even
when she is smiling. (Right) Same patient, 13 months after surgery. Note that the patient had her teeth whitened and straightened after the surgery
was performed. (c) Oblique view. (Left) Before surgery. (Right) Same patient, 13 months after surgery. A nevis on the neck was also removed. Note
improved position and configuration of the eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, elevation of corners
of mouth, smooth jawline, and improved neck. The lip lift has shortened the distance from the base of the nose to the upper lip border and improved
the appearance of her mouth. (d) Lateral view. (Left) Before surgery. Note that the patient appears tired and unfit even though she is trim and in
excellent overall health. (Right) Same patient, 13 months after surgery. Note that her scars are well concealed, no distortion of the ear is present,
and the earlobe is in normal position. She appears fit, decisive, and more attractive. (e) Lateral flexed view. (Left) Before surgery. Note neck laxity
and poor neckline, suggesting an older and unfit appearance. (Right) Same patient, 13 months after surgery. (All surgical procedures performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

The cheeks and jawline have been lifted and redundant skin
removed. Atrophy in the upper cheek and infraorbital areas has
been offset by fat transfer to create a more youthful appearance.
An improved neckline can also be seen even in the frontal view.
Her lips are fuller, no scars are visible, no distortion of the ear
is present, and the earlobe is in normal position. The enlarged
salivary gland has been reduced in size to obtain optimal neck
contour.
49.8.3 Case 3
This 37-year-old woman is shown before (on the left in each
view) and 1 year and 3 months after surgery (on the right in
each view) in Fig. 49.69. She had had prior upper blepharoplasty,
rhinoplasty, chin implant, and neck liposuction performed by
unknown surgeons. On the preoperative views, note cheek sag-
ging and jawline laxity. ote also upper eyelid hollowness result-
ing from her previous blepharoplasty procedure. She shows a sad
appearance, even when she is smiling. ote also neck fullness
and poor neck line, despite prior submental liposuction.
The patient underwent an early maintenance facelift, neck
lift, temple lift, lower blepharoplasty, and fat injections. She
also had cosmetic eyebrow, eye line, and lip tattooing. o skin
resurfacing, facial implants, or other ancillary procedures were
performed.
On the postoperative views, the patient has soft, natural
facial contours and does not have a tight, pulled, or facelifted
appearance. ote improved eyebrow position and configuration,
improved cheek fullness, improved jawline, and overall more
alert, fresher, and more feminine appearance. Fat injections
have reduced hollowing in the upper and lower eyelid areas,
filled the tear trough areas, blended the chin and jawline, and
subtly augmented the lips. There is no distortion or change in
appearance of her smile. The patient appears more rested and
engaged. Her face has a fresher, fitter, more athletic, and more
feminine appearance. ote also restoration of cheek fullness,
improved transition from lower eyelid to cheek, elevation of
corners of mouth, smooth jawline, and improved neck. o scars
are visible, no distortion of the ear is present, and the earlobe is
in normal position.

681
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.68 Case 2: a woman, aged 65 years at time of treatment, who had had previous upper and lower eyelifts performed by an unknown surgeon.
(a) Anteroposterior (AP) view. (Left) Before-surgery. Note high forehead, asymmetrical eyebrows, cheek and jawline laxity, neck bands, and atrophy
of the lips, cheeks, and infraorbital areas. (Right) Same patient, 13 months after facelift, neck lift, hairline-lowering forehead lift, upper and lower
eyelifts, dermabrasion of lip lines, and fat transfer to the cheeks and lips. No skin resurfacing, facial implants, or other ancillary procedures were
performed. Note soft, natural, facial contours and the absence of a tight, pulled, or facelifted appearance. Eyebrow asymmetry has been improved
and the hairline lowered. The cheeks and jawline have been lifted and redundant skin removed. Atrophy in the upper cheek and infraorbital areas
have been offset by fat transfer to create a more youthful appearance. (b) AP smiling view. (Left) Before surgery. Note that despite a bright smile she
has a tired and melancholic appearance. (Right) Same patient, 13 months after surgery. Her smile is natural. An improved neckline can also be seen
even in this front view. (c) Oblique view. (Left) Before surgery. Note eyebrow asymmetry, frown lines, and oblique neck with bands. Note also that
the patient has a large submandibular salivary gland, evident as a fullness in the upper neck area. (Right) Same patient, 13 months after surgery. Note
improved transition from lower eyelid to cheek, smooth jawline, and attractive neck line. The enlarged submandibular gland has been reduced in size
to obtain optimal neck contour. (d) Lateral view. (Left) Before surgery. Note lower eyelid fat protrusion, labiomandibular groove, and poor neckline.
(Right) Same patient, 13 months after surgery. Note elevation of corners of mouth; well-defined jawline; and attractive, youthful-appearing neckline.
Note that lips are fuller and no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. (e) Lateral flexed view.
(Left) Before surgery. Note how neck laxity and poor neckline lend an unfit and elderly appearance. (Right) Same patient, 13 months after surgery.
Note fuller lips, elevation of corners of mouth, well-defined jawline, and attractive and fit-appearing neckline. (All surgical procedures performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

49.8.4 Case 4
This 55-year-old Hispanic woman is shown before (on the left in
each view) and 1 year and 6 months after surgery (on the right
in each view) in Fig. 49.70. She had had no prior plastic surgery.
On the preoperative views, note the sagging cheeks, heavy jowls,
protruding lower eyelid fat, nasolabial lines, hollow under-eye
areas, and thin lips. Also note the tear trough, labiomandibular
groove, and weak chin. The patient has a stern and disapproving
appearance. To accentuate this, Fig. 49.70b presents a frowning
view, in contrast to the smiling views given for the previous
cases; it shows her strong frown muscles that produce deep
creases and an intense angry look.
The patient underwent a facelift, neck lift, limited incision fore-
head lift, upper and lower blepharoplasties, chin augmentation,
and fat transfer to the lips and cheeks. o skin resurfacing or other
ancillary procedures were performed.
On the postoperative views, note smooth facial contours,
more youthful facial shape, and absence of a pulled or a
facelifted appearance. The lower eyelid fullness has been
reduced, and a smooth transition is present between the lower
eyelid and cheek. ote also that her lips and cheeks are fuller
as a result of the fat injections. She is no longer able to frown
as severely because of muscle modification performed as part
of the forehead lift procedure. The chin implant has produced
a more attractive and balanced profile. o scars are visible, no
distortion of the ear is present, and the earlobe is in normal
position.
49.8.5 Case 5
This 68-year-old man is shown before (on the left in each view)
and 1 year and 9 months after surgery (on the right in each view)
in Fig. 49.71. On the preoperative views, the patient has degraded
eyebrow position and configuration; full, hooded upper eyelids;
sagging cheeks; deep cheek folds; and jowls. Loss of youthful
facial contour can be seen in the cheek and jowl areas. A protrud-
ing submandibular salivary gland can also be seen in the neck

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 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.69 Case 3: a woman, aged 37 years at time of treatment, who had had prior upper blepharoplasty, rhinoplasty, chin implant, and neck
liposuction performed by unknown surgeons. (a) Anteroposterior (AP) view. (Left) Before surgery. Note cheek sagging and jawline laxity. Note
also upper eyelid hollowness resulting from her previous blepharoplasty procedure. (Right) Same patient 1 year and 3 months after facelift, neck
lift, temple lift, lower blepharoplasty, and fat injections. She has also had cosmetic eyebrow, eye line, and lip tattooing. No skin resurfacing, facial
implants, or other ancillary procedures were performed. The patient has soft, natural facial contours and no tight, pulled, or facelifted appearance.
Note improved eyebrow position and configuration, improved cheek fullness, improved jawline, and overall more alert, fresher, more feminine
appearance. Fat injections have reduced hollowing in the upper and lower eyelid areas, filled the tear trough areas, blended the chin and jawline, and
subtly augmented the lips. (b) AP smiling view. (Left) Before surgery. Note a sad appearance, even though she is smiling. (Right) Same patient 1 year
and 3 months after surgery. Note improved facial shape, soft, natural facial contours, and the absence of distortion or a change in appearance of her
smile. The patient appears more rested and engaged. (c) Oblique view. (Left) Before surgery. Note cheek sagging and jawline laxity. Note also upper
eyelid hollowness resulting from her previous blepharoplasty procedure. (Right) Same patient 1 year and 3 months after surgery. Note improved
facial shape, restoration of cheek fullness, improved transition from lower eyelid to cheek, and smooth jawline. Note also subtle filling of lips achieved
with fat injections. The patient’s face has a fresher, fitter, more athletic, and more feminine appearance. (d) Lateral view. (Left) Before surgery. Note
hollow upper eyelid, tear trough, sagging cheek, labiomandibular groove, and poor jawline. Note also neck fullness and poor neck line, despite prior
submental liposuction. (Right) Same patient 1 year and 3 months after surgery. Note restoration of cheek fullness, improved transition from lower
eyelid to cheek, elevation of corners of mouth, smooth jawline, and improved neck. Note also that no scars are visible, no distortion of the ear is
present, and the earlobe is in normal position. (e) Lateral flexed view. (Left) Before surgery. (Right). Note elevation of corners of mouth; improved
jawline; and fit-appearing, attractive neckline. (All surgical procedures performed by Timothy Marten, MD, FACS. Cosmetic tattooing performed by
Athena Karsant, RN. Copyright © Timothy Marten.)

area. He has a tired and disinterested appearance even with a

broad smile.
The patient underwent facelift, neck lift, closed forehead lift,
upper and lower blepharoplasties, minor partial facial fat transfer,
and earlobe reduction.
On the postoperative views, note improved eyebrow position
and configuration, corrections of hooded eyelids, diminished
cheek folds, elimination of jowls, and restoration of youthful and
masculine facial shape without a tight or pulled appearance. The
protruding portion of the submandibular gland has also been
removed. The face has a natural appearance, and all scars are
well concealed despite the patient’s short haircut. Note also that
the earlobe has been subtly reduced, giving an antiaging effect.
hen smiling, he has an alert and composed appearance and fit,
masculine-appearing jawline. He looks rested, fit, decisive, and
virile.
Clinical Caveats
• It is not possible to design or use a “universal” facelift tech-
nique. Each patient will present with a unique set of problems
that require precise anatomic diagnosis and an appropriately
planned and individualized surgical repair.
• Attractive and natural-appearing rejuvenation of the face is
not possible without diverting tension away from the skin to
the SMAS and platysma, and unless other deep-layer struc-
tures and the aging midface are addressed.
• Skin was meant to serve a covering function and not a struc-
tural or supporting one. Using skin as the vehicle to support
sagging deep-layer tissue corrupts its function and results in
abnormal tension and related secondary problems including
poor scars, tragal retraction, earlobe malposition, and a tight
and unnatural appearance.
• The young, attractive face is characterized by a youthful
distribution of tissue and not tightness, and the goal in

683
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 49.70 Case 4: a Hispanic woman, aged 55 years at time of treatment, who had had no prior plastic surgery. (a) Anteroposterior (AP) view. (Left)
Before surgery. Note sagging cheeks, heavy jowls, protruding lower eyelid fat, nasolabial lines, and thin lips. The patient has a stern and disapproving
appearance. (Right) Same patient 1 year and 6 months after facelift, neck lift, limited incision forehead lift, upper and lower blepharoplasties,
chin augmentation, and fat transfer to the lips and cheeks. No skin resurfacing or other ancillary procedures were performed. Note smooth facial
contours, more youthful facial shape, and absence of a pulled or a facelifted appearance. The lower eyelid fullness has been reduced and a smooth
transition is present between the lower eyelid and cheek. Note also that her lips and cheeks are fuller as a result of the fat injections. (b) AP frowning
view. (Left) Before surgery, she has strong frown muscles that produce deep creases and an intense angry appearance. (Right) Same patient, 1 year
and 6 months after surgery. She is trying to frown in this photograph, but she is no longer able to do so to the same extent because of muscle
modification performed as part of the forehead lift procedure. (c) Oblique view. (Left) Before surgery. Note sagging cheeks, sagging jowl, and hollow
infraorbital areas. (Right) Same patient, 1 year and 6 months after surgery. Note restoration of cheek fullness, improved transition from lower eyelid
to cheek, elevation of corners of mouth, smooth jawline, and improved neck. (d) Lateral view. (Left) Before surgery. Note protruding lower eyelid fat,
tear trough, sagging cheek, sagging jowl, labiomandibular groove, poor neckline, and weak chin. (Right) Same patient, 1 year and 6 months after
surgery. Note restoration of cheek fullness; improved transition from lower eyelid to cheek; elevation of corners of mouth; well-defined jawline;
fuller lips; and attractive, youthful-appearing neckline. Note that the chin implant has produced an attractive and more balanced profile. Note also
that no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. (e) Lateral flexed view. (Left) Before surgery. Neck
laxity and poor neckline produces an older, unfit appearance. (Right) Same patient, 1 year and 6 months after surgery. Note fuller lips, restoration
of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, well-defined jawline, and attractive neckline. Her
chin appears stronger and in better balance with the rest of her face. (All surgical procedures performed by Timothy Marten, MD, FACS. Copyright ©
Timothy Marten.)

facelift surgery and related procedures is to reposition ptotic
tissues—not to tighten the face. Overtightening any layer of
the face, including the skin, SMAS, and platysma, is concep-
tually flawed and will result in unnatural appearances and
secondary deformities.
• Careful evaluation of most patients who need a midface lift
will show that they also need a facelift. It is rare to encounter a
patient with significant midface aging who does not also have
sagging in the cheek and jowl, and midface lifts are arguably
more logically performed in conjunction with a formal facelift
procedure than as isolated, stand-alone procedures.
• Using the SMAS to lift and reposition sagging facial tissues
and restore lost youthful facial contour circumvents the prob-
lems associated with skin-only facelifts, as the SMAS is an
inelastic structural layer capable of providing meaningful and
sustained support. Although skin must be excised in SMAS
procedures, only redundant tissue is sacrificed and closure
can be made under normal skin tension.
• The conventional “deep-plane” “low” cheek SMAS flap, ele-
vated below the zygomatic arch, suffers the drawback that it
cannot, by design, provide an effect on tissues of the midface,
perioral, and infraorbital regions. Planning the flap “higher,”
along the superior border of the zygomatic arch, overcomes
this problem and produces an improved result.
• “Lamellar” dissections, in which the skin and SMAS are dis-
sected as two separate layers, offer the important advantage
that skin and SMAS can be advanced different amounts,
along separate vectors, and suspended under differential
tension. This allows each layer to be addressed individually as
indicated and, in turn, results in a more comprehensive and
natural appearing improvement.
• Rarely does isolated aging occur in the lower face and neck,
and nearly all patients requesting facelift surgery are candi-
dates for forehead and eyelid surgery as well. Patients do not
always recognize this fact, however, and must be carefully
counseled in this regard.

684
 49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline

Fig. 49.71 Case 5. Man, aged 68 years at time of treatment. (a) Anteroposterior (AP) view. (Left) Before surgery. The patient has degraded
eyebrow position and configuration, full upper eyelids, sagging cheeks, deep cheek folds, and jowls. Loss of youthful facial contour can be
seen in the cheek and jowl areas. (Right) Same patient, 1 year and 9 months after facelift, neck lift, closed forehead lift, upper and lower
blepharoplasties, minor partial facial fat transfer, and earlobe reduction. Note improved eyebrow position and configuration, corrections of
hooded eyelids, diminished cheek folds, elimination of jowls, and restoration of youthful and masculine facial shape without a tight or pulled
appearance. (b) AP smiling view. (Left) Before surgery. Note tired and disinterested appearance despite broad smile. (Right) Same patient, 1
year and 9 months after surgery. Note alert and composed appearance and fit, masculine-appearing jawline. (c) Oblique view. (Left) Before
surgery. Note poor eyebrow position and configuration, hooded upper eyelid, sagging cheek, and loss of youthful jawline. (Right) Same patient,
1 year and 9 months after surgery. Note improved eyebrow position and configuration, restoration of cheek fullness, diminished nasolabial
fold, smooth masculine jawline, and improved neck contour. The patient has a rested, fit, decisive, and virile appearance. (d) Lateral view. (Left)
Before surgery. Note lower eyelid fullness, sagging cheek, poor jawline, heavy jowl, and neck laxity. A protruding submandibular salivary gland
can also be seen in the neck area. (Right) Same patient, 1 year and 9 months after surgery. The lower eyelid fullness has been reduced; the cheek
position has been improved; the earlobe reduced, and a fit, masculine-appearing jawline and neckline can be seen. The protruding portion of
the submandibular gland has also been removed. The face has a natural appearance and all scars are well concealed despite the patient’s short
haircut. Note also that the earlobe has been subtly reduced. (e) Lateral flexed view. (Left) Before surgery. Note poor neckline when looking
down. (Right) Same patient, 1 year and 9 months after surgery. Note improved neck contour in the flexed position. The face has a natural
appearance, and all scars are well concealed. Note also antiaging effect of earlobe reduction. (All surgical procedures performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)

• Proper analysis, careful planning, and the use of an incision
along the hairline, when indicated, can avert hairline notch-
ing and displacement without compromising the overall
outcome of the procedure. This is particularly true of patients
with marked skin redundancy and those presenting for sec-
ondary procedures.
• SMAS flaps should be advanced along a posterosuperior
vector, parallel to the long axis of the zygomaticus major
muscle. If a “vertical” or posterior vector is used, the func-
tion of the zygomaticus major muscle will be corrupted and
abnormal appearances during animation may result.
• Inappropriate excision of skin over the apex of the occip-
itomastoid defect in the postauricular area along a vector
parallel to the long axis of the sternocleidomastoid muscle is
the underlying cause of hypertrophic healing in the postau-
ricular region and, ultimately, of a wide postauricular scar.
Although an apparent excess of skin will appear to be present
in this area when the patient is supine on the operating table,
this skin is needed once the patient’s shoulders drop in the
upright position and is necessary for side-to-side head tilt.
• The opportunity to perform a facelift is a unique artistic
privilege granted to us by our patients, which carries a sig-
nificant responsibility. It deserves nothing less than our best
effort. The goals we set for ourselves will define the amount
of improvement we obtain. Creating beautiful things and
obtaining a quality result require more effort and take more
time. It is not how fast we can do it—it is how good we can
make it, and a few extra hours of our time in the OR benefit
our patients for the rest of their lives.
• Rejuvenation of the face is a considerable undertaking, and
its difficulty should not be underestimated. The procedure
must be carefully planned, meticulously carried out, and the
patient’s safety and well-being unfailingly ensured.
• Performance of the facelift procedure itself only fulfills part
of our obligation to the patients, and the care they receive
perioperatively is arguably as important as the surgery itself.
Diligent perioperative care will ensure the best result and
reduce the likelihood that problems and complications will
occur.

685
 VIII Surgical Rejuvenation of the Face and Neck

Suggested Reading Forceps

[1] Connell BF, Marten T . Deep layer techniques in cervico-facial rejuvenation. • Adson (carbide with fine teeth and tying platform) (Padgett
In: Psillakis M, ed. Deep Face-lifting Techniques. ew ork: Thieme Medical P-2511)
Publishers; 1994
2 Connell BF, Marten T . Facial rejuvenation: facelift. In: Cohen M, ed. Mastery • (1) Adson (carbide with medium teeth and tying platform)
of Plastic and Reconstructive Surgery. Boston, MA: Little, Brown Publishing; • (1) DeBakey (8 fine toothed jaws) (Codman 37-1011) (V
1994:1873–1902 Mueller CH5895)
3 Marten T, Elyassnia D. Short scar neck lift: neck lift using a submental incision
• (1) coagulating forceps straight (insulated) (Snowden Pencer
only. Clin Plast Surg 2018;45(4):585–600
0531)
4 Marten T, Elyassnia D. eck lift: defining anatomic problems and choosing
appropriate treatment strategies. Clin Plast Surg 2018;45(4):455–484 • (1) coagulating forceps curved tip (insulated)
5 Marten T, Elyassnia D. Management of the platysma in neck lift. Clin Plast Surg • (4) Allis forceps (Storz -5600)
2018;45(4):555–570
• (6) mosquito hemostats (Storz)
6 Marten T . Lamellar high SMAS face and midface lift: a comprehensive technique
for natural-appearing rejuvenation of the face. In: ahai F, ed. The Art of Aesthetic • (1) curved elly hemostat
Surgery: Principles & Techniques, 2nd ed. St. Louis, MO: uality Medical Publish- • (1) straight elly hemostat
ing; 2011
• (2) Snitz forceps (8.5 V Mueller MO 1700)
[7] Marten T . Facelift. Planning and technique. Clin Plast Surg 1997;24(2):269–308
[8] Marten T . Facelift with SMAS flaps. In: Guyuron B, Eriksson E, Persing A, et • (1) Mixter right angle forceps (8.5 Codman 19 5581)
al, eds. Plastic Surgery: Indications and Practice. St. Louis, MO: B Saunders;
2008:1445–1472
[9] Marten T . High SMAS facelift: combined single flap lifting of the jawline, cheek, Retractors
and midface. Clin Plast Surg 2008;35(4):569–603
10 Marten T . Lamellar high SMAS face and mid-lift: improved design of the SMAS
• malleable (small) Padgett 4206)
facelift for better results in the mid-face and infra-orbital region. In: ahai F, • (1) malleable (large) (Padgett P-4341)
ed. The Art of Aesthetic Surgery: Principles & Techniques. St. Louis, MO: uality • (1) Army- avy (Codman 50-4071)
Medical Publishing; 2005
• (1) Freeman ribbon (Padgett P-491)
[11] Marten T . Secondary facelift. In: Mathes S , ed. Plastic Surgery, Vol 2: The Head
and Neck, 2nd ed. St. Louis, MO: B Saunders; 2005 • (1) Freeman rake (four pronged) (Padgett P-509)
12 Marten T . Facelift: state of the art. Semin Plast Surg 2002;16(4):303
13 Marten, T , Maintenance facelift: early facelift for the younger patient. Semin
Plast Surg 2002;16(4):375–390 Misc
• (6) Bachus piercing towel clips (sm) (9 cm)
• (4) Bachus piercing towel clips (large) (13 cm)
Appendix 49.1 Marten Clinic of • (1) Obwegeser periosteal elevator (Padgett 7710)
Plastic Surgery Facelift Tray • (1) Bois elevator
• (1) metal ruler
Scalpels • (1) metal comb
• (4) scalpel handle (round) (Padgett P-650) • (1) Marten facelift flap marker (Medicon)
• (1) ankauer suction (metal) (Storz -7550)
• (1) Frazer suction and stylet
Skin Hooks
• (2) instrument retainer
• (2) double pronged skin hook (10 mm) (Padgett P-5379)
Misc Other
Needle Holders • (2) hair clip
• (4) needle holder long (7 Ryder narrow carbide jaw) (V • (1) ring / sponge forceps
Mueller ( CH 2492)
• (4) immer blue plastic clips
• (4) needle holder medium (6 carbide jaw) (Padgett P-2410) • (1) headlight joystick
• (4) needle holder small (5 ebster smooth jaws Titanium)
(Storz 5712)
Disposable
Scissors • Colorado cautery needle tip
• (1) cautery (flat blade) long tip
• (2) Metzenbaum medium curved (flap dissection) scissors
(Padgett P-6468) • (1) cautery (flat blade) short tip
• (1) aye Blepharoplasty (flap trimming) Scissors (Padgett
P-29065) Sutures
• (1) Metzenbaum small curved (suture scissors) (Storz 5104)
• 3-0 Vicryl
• (1) Mayo (utility) straight scissors (Pilling LL3) (V Mueller SU
1820) (Padgett PM 0460)
• 4-0 nylon
• 6-0 nylon
• 5-0 Monocryl

686

50 Simultaneous Facelift and Facial Fat Grafting
Timothy Marten and Dino Elyassnia
Abstract
Despite what we formerly thought, lifting cannot correct all
aspects of the aging change of the face, and fat grafting allows
treatment of age-associated loss of facial volume not addressed
by facelift surgery. Fat grafting constitutes the missing link
in facial rejuvenation, and it stands as the most important new
addition to facelift surgery since the introduction of the superfi-
cial musculoaponeurotic system (SMAS) technique.
Abundant clinical and scientific evidence, however, exists
confirming that fat grafting produces a persistent and worthwhile
improvement. Fat grafting works best when sagging tissues have
been repositioned and redundant skin excised, and simultaneous
facelift and fat grafting will provide a better result than either
technique performed alone.
Fat grafting is an artistically powerful adjunct to a facelift that
results in a more healthy, fit, youthful, sculptural, and sensual
appearance than facelift alone. Patient and surgeon preoccupation
with the swollen face stands as evidence that volume addition
has artistic merit. Fat grafting may be functionally important in
the facelift patient and provide support to the lower eyelid and
other facial tissues. Patients with full faces often have regional
atrophy and can benefit from fat grafting. In many instances fat
grafting can replace or preclude the need for facial implants, and
adding fat grafting to a facelift procedure essentially provides the
opportunity to perform simultaneously, and at a much reduced
cost, the equivalent of a chin implant, pre–jowl groove implant,
malar implant, submalar implant, jawline (Taylor) implant, tear
trough implant, and temple implant.
hile controversy continues as to which facelift technique is
best, incorporating fat grafting into facial rejuvenation proce-
dures is arguably more important than what facelift technique is
used. Fat grafting may result in an improvement in skin quality
mediated through a stem cell effect. Fat grafting is often more
important to rejuvenating the secondary facelift patient than the
facelift itself. These benefits may offset the drawbacks of increased
operating time, uncertainty of graft take, and a longer period of
recovery associated with the fat grafting procedure.
Keywords
fat grafting, fat injections, autologous fat grafting, fat transfer,
micro fat grafting, lipofilling, facelift, secondary facelift, stem
cell facelift
50.1 The Aging Face and the Need
for Fat Injections
Recognizing the components of the aging change of the face
and appreciating the underlying anatomic abnormalities is
essential to the recommendation of appropriate treatment and
50 Simultaneous Facelift and Facial Fat Grafting
the planning of surgical procedures. Careful analysis will reveal
that most patient problems will fall into three broad categories:
1. Aging and breakdown of the skin surface
2. Facial sagging, skin redundancy, and loss of youthful facial
contour
3. Facial hollowing, wasting, atrophy, and/or age-related lipo-
dystrophy
Proper treatment will depend upon the types of problems pres-
ent, the patient’s priorities, and the time, trouble, and expense
she or he is willing to endure to obtain the improvement desired.
Patients primarily concerned with surface aging of their face
may not require formal open surgical procedures and may achieve
the type of improvement they desire through salon care and der-
matologic surface treatments of the skin such as skin peels, laser
skin resurfacing, dermabrasion, intense pulsed light (IPL), chemo-
denervation (neurotoxin injections), hyaluronic acid (HA)-based
filler injections, and various forms of cutaneous laser and other
treatments designed to remove or reduce age spots, spider
veins, wrinkles, and other age-related skin surface imperfections.
Patients primarily concerned with facial sagging, skin excess,
and loss of facial contour will achieve little if any improvement,
however, if surface treatments of the skin only are employed.
These patients will require formal surgical lifts, in which sagging
tissue is repositioned and redundant tissue is excised, if these
problems are to be properly addressed and an attractive and
natural-appearing improvement is to be obtained. The misappli-
cation of surface treatments of the skin to the sagging face with
excess tissue that has lost youthful shape will produce little more
than a smooth saggy face with no improvement in contour. This
sort of smooth-saggy look, typically seen in the older patient
who has undergone laser resurfacing, is inconsistent with a nat-
ural appearance, as patients with loss of facial contour generally
also have concomitant skin surface aging. It is arguably more
attractive and natural-appearing to have a well-contoured face
with a few wrinkles and surface imperfections than a smooth but
saggy one.
Patients with significant facial atrophy and age-related hol-
lowing and loss of facial fat will generally achieve suboptimal
improvement from both surface treatments of facial skin and
surgical lifts. Smoothing skin will not hide a drawn appearance
due to loss of facial volume, and it is difficult to create natural
and attractive contours by lifting and repositioning tissues that
have abnormally thinned and involuted with age. Restoring lost
facial volume using fat injections is a powerful technique that is
now acknowledged by most plastic surgeons and other physicians
engaged in treating the aging face as the missing link and the
most important advance in aesthetic surgery in several decades or
more. Properly performed, the addition of fat to areas of the face
that have atrophied due to age or disease can produce a significant
and sustained improvement in appearance unobtainable by other
means.
687
 VIII Surgical Rejuvenation of the Face and Neck
50.1.1 Why Perform a Facelift and Fat
Injections?
hy perform a facelift and fat injections hy not perform
just the facelift, as we traditionally have The answer to these
questions lies in the multifactorial origin of facial aging just
discussed and in the fact that fat is predictably lost from the face
and areas of the face becomes hollow as one ages, in addition to
sagging, drooping, and other gravitational effects. The isolated
facelift procedure, even when aggressively and comprehensively
performed, addresses only tissue ptosis and redundancy and
often produces a lifted, but telltale hollow and underrejuve-
nated, look sometimes referred to as a cougar appearance in
lay media. Fat injections, however, allow the loss of facial fat to
be treated simultaneously with the facelift, and these objec-
tionable appearances to be avoided. All things being otherwise
equal, simultaneous facelift and fat injections will produce a
better result than either technique performed alone, and when
a facelift is performed in conjunction with fat injections, both
loss of contour and facial atrophy can be corrected and optimal
improvement can be obtained (Fig. 50.1).
50.1.2 Volumetric Rejuvenation, Tissue
n egr i n nd S em e e Additional confusion has been created by the term stem cell
Fat injections have other previously unavailable advantages for
the surgeon who performs facelift procedures. Fat injections
provide volumetric rejuvenation: a new and different means by
which to improve facial appearance, and a new dimension for
plastic surgeons to work in. Unlike injectable fillers, fat is autol-
ogous and actually integrates with facial tissues and becomes a
Fig. 50.1 Simultaneous facelift and fat injections. All things being
otherwise equal, simultaneous facelift and fat grafting will produce
a better result than either technique performed alone. (a) This
49-year-old patient with both tissue ptosis and redundancy and
marked facial atrophy. (b) Same patient seen 1 year and 3 months after
high–superficial musculoaponeurotic system (SMAS) facelift, neck lift,
closed forehead lift, lower blepharoplasty, and panfacial fat injections.
Combined lifting and filling of her face produced a better outcome than
either technique could have alone. (Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)
688
part of the face, promoting a more natural appearance during
facial movement and producing a sustained and long-lasting
improvement. In addition, mounting scientific evidence now
supports the often-cited clinical observation that fat injections
actually induce an improvement in facial tissue quality through
a stem cell effect and, when performed with a facelift, may
constitute, for the first time, rejuvenation in the true sense of
the word.
50.2 Nomenclature
The nomenclature for autologous fat transplantation can be
confusing because surgeons and others injecting fat into the face
have put forth various terms to best describe the procedure. In
addition, in an effort to market the procedure, many proprietary
marketing names and catch phrases have also been created, and
these can be especially confusing to patients. In essence, how-
ever, the commonly used terms fat transfer, fat grafting, microfat
grafting, autologous fat grafting, autologous fat transplantation,
fat injections, lipo fi , and lipo-injection all refer to the same
basic procedure. e typically use the terms fat injections and fat
transfer in our discussions with patients, as these are straight-
forward descriptive terms that do not include medical jargon
and are most easily understood and remembered.
facelift,” a procedure in which fat is variously injected into the
face with the purported but unproven benefit of tissue tightening
and rejuvenation mediated through a stem cell effect. In most
cases only fat is injected, but in some cases limited traditional
facelifts ( mini-lifts, S lifts, skin-only lifts) are simultaneously
performed. Currently it is a stretch of available scientific fact to
call fat injections a “facelift,” and it is medically more correct to
refer to the two procedures simply as combined but separate and
distinct surgeries.
50.3 Drawbacks of Fat Injections
Performing fat injections in conjunction with a facelift has
certain disadvantages that must be acknowledged including the
learning curve associated with any new procedure, an increase
in operating room time, increased postoperative edema, a longer
period of recovery, uncertainty of graft take, and the potential
for problems and complications such as asymmetries, lumps,
and other irregularities. In addition, certain patient (and often
surgeon) misconceptions will also be encountered and will have
to be overcome, including misguided beliefs held by some that
injected fat can migrate or fall or that fat injections will make
the face look fat.
50.4 Why Not Just Inject Fat?
Age-related loss of facial fat rarely exists as an isolated event in
the healthy patient, and thus patients troubled by it are rarely
logically or appropriately treated by fat injections alone. Isolated
fat injections are also arguably of questionable benefit to the
patient troubled by significant facial sagging and skin redun-
dancy. Although aggressive filling of the sagging face with fat (or
 50 Simultaneous Facelift and Facial Fat Grafting

filler) can produce improved contour and a smoother-appearing
skin surface, it generally results in an unusually large, overfilled
face that appears both unnatural and unfeminine. Such an over-
filled face is hard to correct in an attractive manner at a later date,
and it is both more logical and practical to perform fat injections
in conjunction with formal surgical lifts if needed, or as a second
stage after the facelift has been performed and ptotic tissue has
been repositioned and redundant tissue has been removed.
50.5 Where Should the Fat Be
Injected?
as the failure to replenish lost volume, and the areas in need of
treatment will be obvious.
Opportunities to see nonsmiling photographs of patients when
they were younger are highly valuable and are one of the best
ways to gain an appreciation of volume loss and its contribution
to changes that occur as the face ages. These photos are also very
helpful for educating patients as to how their face has changed
with age and for explaining the need for fat grafting during their
consultation.
In time, and after engaging thoughtfully in such study, one will
gain a deeper appreciation of facial atrophy and an increasing
desire to correct it (Fig. 50.2).

Areas in need of treatment will vary from patient to patient, and

planning fat injections requires looking at the face in a different
way and more as “sculptors” and less as “tailors,” as we have in
the past. Any area that is treatable with nonautologous inject-
able fillers is potentially treatable with fat injections including,
but not limited to, the temples, forehead, brow, glabella, radix,
upper orbit ( upper eyelid ), lower orbit ( lower eyelid ), cheeks,
midface, buccal recess, lips, perioral, nasolabial crease, genio-
mandibular groove, jawline, labiomental crease, submental
crease, and chin areas, and experience with fillers is a useful
point of reference for planning fat additions to the face.
Perhaps the best way to decide where fat is needed is for the
surgeon to study her or his facelift outcomes carefully and identify
areas where the procedure has fallen short. In most cases the
biggest shortcoming for the experienced surgeon will be evident
50.6 Sequencing Fat Injections with
Other Procedures
hen fat grafting is best performed during facelift surgery is
scientifically unanswered, but as a practical matter it is most
expedient to inject fat at the beginning of the procedure before
the facelift itself has been started. The reasons for this include
the fact that it is easier to harvest the fat at the beginning of the
procedure, before the face has been prepped or draped and when
the patient is typically in a deeper plane of anesthesia. Also, in
the beginning of the procedure the tissue planes of the face have
not been opened, the face is not swollen, and preoperatively
made pen marks and facial landmarks are easier to identify. In
addition, surgical principles suggest that it is likely best to inject
the fat before the start of the facelift procedure to limit the time
the graft is out of the body. Perhaps the most important reason

a b c

Fig. 50.2 Patient before and after simultaneous facelift and fat injections. (a) Patient before procedure. She has had not prior surgery. (b) Shaded
areas showing were fat was placed: 3 mL in each upper orbit, 4 mL in each temple, 1 mL in each tear trough, 3 mL in each infraorbital area, 4 mL
in each cheek, 2 mL in each nasolabial crease, 1 mL in each stomal angle, 2 mL in each geniomandibular groove, 3 mL in each lip, and 2 mL in the
glabella. (c) Same patient 2 years and 4 months after high–superficial musculoaponeurotic system (SMAS) facelift, neck lift, lower blepharoplasty,
and 50 mL of fat injections. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

689
 VIII Surgical Rejuvenation of the Face and Neck

to perform fat grafting first, however, is that the surgeon is more ecessary equipment is listed in Table 50.1.
technically and artistically energetic in the morning and will do
a better job than if it is performed at the end of a long facelift
procedure. If one waits until the end of a long facelift, fat grafting
50.7.3 Choosing a Donor Site
will likely be performed with less patience and care. Currently there is no scientific unanimity as to where the best
fat for grafting should be obtained, and our scientific literature
on the subject has claimed various areas to be the most optimal
50.7 Fat Injection Technique donor sites. As such, donor sites are typically chosen and marked
The technique for facial fat grafting has been described previ- in conjunction with the patient in such a manner as to improve
ously, and Coleman’s principles are adhered to when fat injec- her or his silhouette, although the ideal locations are arguably
tions are performed. those areas of diet- and exercise-resistant fat collections where
the fat is biologically programmed to be stubbornly persistent
throughout the patient’s life. For women these are typically the
50.7.1 Logistics of Simultaneous Facelift
and Fat Injections
Fat injections are often discussed or viewed by many surgeons
as a simple procedure that can be performed in a few minutes
time. This is rarely the case, however, and such an attitude will
lead to frustration, disruption of workflow, and suboptimal
outcomes. Fat must be harvested in a specific, atraumatic, and
time-consuming manner if viable tissue is to be obtained that
can be expected to survive and take at the facial recipient
site. It must then be processed and injected in a technically
demanding and time-consuming process that cannot be rushed.
It is also an artistically demanding activity that will require a
considerable amount of the surgeon’s intellectual, creative, and
physical energy. hen anything other than small amounts is
being injected, the entire procedure can easily encompass an
hour or more, something that can significantly tax an already
overburdened surgical team engaged in a demanding operation
consisting of multiple procedures. Time must therefore be
planned carefully and appropriately.

50.7.2 Needed Equipment

Special instruments are required to harvest and inject fat (Fig.
50.3, Fig. 50.5), in addition to other specialized equipment to
process and organize it. Poor outcomes are typically obtained
if sharp hypodermic needles are used to harvest fat, if fat is
not processed, or if the fat is injected in a manner similar to
that used to inject nonautologous facial fillers. In addition, if
sharp hypodermic needles are used to inject fat (other than
for a true intradermal injection), there is the potential for
intravascular injection, fat embolization, and other serious
problems including tissue infarction, visual impairment and
blindness, and embolic stroke, and therefore their routine use Fig. 50.3 Fat injection cannulas. Special blunt-tipped cannulas are
is not recommended. required to perform fat injections properly, and poor outcomes are
Reusable cannulas (Fig. 50.3a) have been the standard for many typically obtained if sharp hypodermic needles are used. Sharp needle
injection also poses a serious risk of fat embolization, and related
years and continue to be widely used by many surgeons. They problems. (a) Reusable fat injection cannulas. (b) Single-use disposable
suffer the drawback that they are time-consuming to clean and fat-grafting instruments and supplies. High-quality single-use
difficult to sterilize, and as such are not approved for use in some disposable cannulas and supplies make fat grafting convenient and
preclude the need for time-consuming cleaning, reprocessing and
countries. The smaller (and thus most useful) cannulas are also resterilization of reusable equipment. These are available in a variety of
very fragile and can break if not carefully used. diameters and lengths. (Not shown are single-use harvesting cannulas.)
In many practices disposable, single-use cannulas are gradually Shown from left to right are disposable syringe caps to cap the ends of
syringes during centrifuging, 0.7-mm (20-gauge) 4-cm-long single-use
supplanting traditional reusable cannulas (Fig. 50.3b). These disposable injection cannula, 0.9-mm (18-gauge) 6-cm-long single-use
cannulas come in a variety of diameters and lengths and do disposable injection cannula, single-use disposable Luer lock transfer
not need to undergo time-consuming cleaning, processing, and coupling for transferring fat from 10-mL syringes to 1-mL syringes.
(Copyright © Timothy Marten.)
resterilization.

690

Table 50.1 Fat injection instrument set
Harvesting instruments
Number Name Diameter Length
1 Multihole local anesthetic infiltrator 1.6 mm 15 cm
1 Carraway Harvester 2.4 mm 20 cm
1 Carraway Harvester 2.1 mm 15 cm
10-mL Luer lock syringes
Luer lock disposable syringe caps
Fat processing instruments
1 Luer-to-Luer transfer coupling
1 Syringe rack
1 Centrifuge
1-mL Luer lock syringes
Injection instruments, face
2 Injection cannula 0.7 mm 4 cm
2 Injection cannula 0.7 mm 5 cm
2 Injection cannula 0.9 mm 5 cm
1 Injection cannula 1.2 mm 6 cm
hip, waist, flank, and outer thigh, and for men the love handle
and “spare tire” areas.
Although the lower abdomen might appear on casual consid-
eration to be the easiest and best place to harvest fat from, our
experience has shown otherwise, and we prefer to take fat from
the hip and lateral thigh when possible and if the patient agrees.
The reasons for this are several. First, although using the abdomen
as a donor site means that the patient does not need to be turned
and that only one area need be prepped and draped, abdominal fat
is usually harder to extract, and the fat obtained seems to be more
fragile and have a higher oil content upon centrifugation. In
addition, when anything more than a small amount is needed, the
abdominal area is far less forgiving than the hip or the outer thigh
due to the thinner, less elastic skin typically present, and postop
irregularities and contour problems are far more likely to arise and
to be seen. In fact, consideration should be giving to placing the
patient in a liposuction garment or abdominal binder if anything
more than a small harvest is made from the abdominal area.
Harvesting fat from the hip and outer thigh requires that the
patient be turned and that two areas be prepped, but the fat in these
areas is much easier to extract, and the tissue obtained typically is
more durable and nearly free of blood and oil following centrifuga-
tion. These areas also have thicker, more elastic skin, and it has been
our experience that postoperative problems and contour irregular-
ities almost never occur. Finally, overall, patients are typically more
pleased with the improvement in their figures when fat is removed
from their hips and outer thighs than from their abdomens.
In thin patients small harvests from multiple areas may be
required, including the inner thighs, inner knees, upper buttocks,
and anterior axilla, and the additional time this will add to the
procedure must be factored into the surgical plan. Preoperative
assessment of the patient’s fat stores will allow proper allocation
of time for the harvesting process and appropriate pricing of the
procedure. e recommend that the harvest sites and site mark-
ings be photographed preoperatively on the day of surgery to
document what was agreed upon in the preoperative discussion
50 Simultaneous Facelift and Facial Fat Grafting
with the patient. This helps to avoid any dispute after surgery over
the preoperative condition of harvest sites.
50.7.4 Preoperative Marking of the Face
Fat injections cannot be placed arbitrarily, and a careful plan
must be marked preoperatively with the patient seated in an
upright position. It is not possible to mark the patient accurately
when supine and after anesthesia has begun. Marking requires
concentration on the surgeon’s part, will consume a significant
amount time, and is best carried out in a private area that is free
from distractions. Creating an initial plan on a life-sized laser
print of a photograph of the patient’s face in yellow highlight-
ing marker is helpful in organizing one’s thoughts and facilitates
discussions with the patient as to which areas will be treated. In
most cases marks are made in conjunction with the patient while
she or he holds a hand mirror. The goal is to create a topograph-
ical map of the deficient and atrophic areas of the face to guide
the surgeon during the procedure essentially a reverse plan of
that used when liposuction is performed.
Because the face is undergoing a process of lipodystrophy that
is, fat is deficient in some areas and excessive in others marks
are also made where fat needs to be removed when indicated.
These areas can be marked in a different color or designated
by some other means. Once markings are complete, additional
photographs of the patient’s marked face are taken and printed
up for use during the procedure. These are also made part of the
patient’s medical record.
50.7.5 Informed Consent
Some surgeons print up and have the patient sign and date a laser
print copy of the image of the fat injection plan marked on the
patient’s face to avert any postoperative controversy as to what
the patient’s preoperative requests were and what was agreed on
and consented to. A companion strategy is to include language in
the informed consent document stating that the discussions and
designations regarding where fat is to be placed are necessarily
approximate and that the patient consents to placement of fat
during the procedure in any area that the surgeon feels, in her or
his sole judgment, is necessary to obtain the desired effect.
50.7.6 Anesthesia
Most modern facelifts are time-consuming and technically
demanding. The addition of fat injections to the procedure will
test the patience and composure of almost any surgeon, and it
is highly recommended that one enlist the services of an anes-
thesiologist or competent certified registered nurse anesthetist
(CR A) when combined procedures are performed. This is
particularly important when the procedure is to be performed
upon a patient who is apprehensive or has a history of anesthetic
difficulties, hypertension, or other significant medical problems.
The majority of our facelifts are now performed under deep
sedation administered by an anesthesiologist using a laryngeal
mask airway (LMA). Use of an LMA allows the patient to be
heavily sedated without compromise of their airway, but the
patient need not receive muscle relaxants and can be allowed to
691
 VIII Surgical Rejuvenation of the Face and Neck

breathe spontaneously. The heavily sedated patient is also easier
to harvest fat from, especially when fat must be harvested from
multiple sites, and treatment of multiple areas of the face with fat
is facilitated under these conditions. Any skillfully administered
anesthetic, however, is adequate for performing the procedure.
50.7.7 Harvesting Fat
Fat is harvested the day it is needed, not preharvested and
frozen and stored. There are several reasons for this. First, it is
a questionable practice to store harvested fat in casually labeled
syringes in a small, unmonitored refrigerator/freezer intended
for home or office use. These devices typically do not provide
round-the-clock monitoring of internal temperatures or have
backup power, and most surgeons do not have the means to
properly log in tissue to be stored and guarantee that cross-con-
tamination, inadvertent thawing and refreezing, or mislabeling
has not occurred. In addition, storage of fat in this manner could
be construed as tissue banking, a practice that only licensed
tissue banks are legally allowed to do in some states.
More to the point, however, the preponderance of scientific
information currently indicates that to be viable, fat must be
flash-frozen to very low temperatures much in the way that a
human egg cell would, and it is not viable when slow-frozen in a
typical food freezer and later thawed. Research and development
in fat banking is under way, however, and at some future date it is
likely surgeons will be able to store viable patient fat at a regional
blood bank, tissue bank, or special tissue storage center created
specifically for this purpose.
Fat should be harvested in a thoughtful and artistic manner
that improves the patient’s figure, and thus it must generally be
removed bilaterally and in a symmetrical fashion unless body
contours dictate otherwise. Patients must be advised that fat har-
vest does not constitute formal liposuction, however, and that the
small instruments used to harvest fat are not capable of making
large improvements in body contour.
It is prudent to examine the patient at the time of their consul-
tation, unless it is obvious that plentiful donor fat is present. Thin
patients with limited fat stores and patients who have undergone
prior body lifts, liposuction, cryolipolysis, or noninvasive fat reduc-
tion procedures have compromised donor fat and often present
significant challenges when harvesting fat, and considerable extra
time and effort will be required to obtain fat from them. Anesthesia
and operating room times and the anesthesiologist’s, surgeon’s,
and facility’s fees must be calculated accordingly.
Fat is harvested after anesthesia is initiated but before prep of
the face. In all but the unusual case a complete prep of the torso is
not necessary. Typically a limited prep of the marked area is made,
and a sterile field is established about the prepped area with
adhesive-edged blue paper drape towels ( sticky blue towels ).
The surgeon and the surgical assistant need not gown for this part
of the procedure, as sterile gloves are adequate in maintaining
sterile technique for this part of the procedure.
If fat is to be harvested from the hip, waist, and lateral thigh (as
we usually prefer), the patient is turned into a semilateral decubi-
tus position; prep, drape, and harvest performed; and the patient
then turned to the opposite side, where the harvest procedure is
repeated. If the patient is positioned carefully, this technique can
be used to harvest fat simultaneously from multiple sites, including
the inner knee, posterior inner thigh, outer thigh, upper buttocks,
hip, waist, and flank area (Fig. 50.4). Obtaining fat in this fashion
from multiple sites is particularly important in thin patients with
minimal fat stores. ote that if only 10 mL is harvested from each
area, a total of 60 mL can be obtained for each side.

Fig. 50.4 Positioning patient for fat harvest. If the patient is positioned carefully in a semilateral decubitus position, fat can be simultaneously
harvested from multiple sites, including the inner knee, inner and outer thighs, buttocks, hip, waist, and flank. Obtaining fat from multiple sites is
particularly important in thin patients with minimal fat stores. Following harvest from one side, the patient is turned to the other side, where a similar
harvest (as appropriate for contours present) is performed. (Copyright © Timothy Marten.)

692

Areas from which fat is to be harvested are conservatively infil-
trated with 0.1 lidocaine with 1:1,000,000 epinephrine solution
using a specially designed multiholed 1.6-mm and 20-cm-long
local anesthetic infiltration cannula (Fig. 50.5), and an adequate
time is allowed for a proper anesthetic and hemostatic effect.
Approximately 1 mL of this dilute local anesthetic solution is
injected for every 3 mL of anticipated fat removal. It is not necessary
or desirable to infiltrate in a tumescent fashion, as overwetting the
donor site will result in an overdilute harvest and more time spent
in the harvesting process. Local anesthetic should be injected, even
if deep sedation or general anesthetic is used, to limit the overall
amount of inhalation anesthetic and narcotics given.
Fat is then harvested with a special 2.1- to 2.4-mm Carraway
Harvester (Tulip Medical Products, San Diego, CA), TriPort (Tulip
Fig. 50.5 Fat-harvesting cannulae. (a) Special harvesting cannulas
are attached to 10-mL Luer lock syringes and are used to extract fat
atraumatically from donor sites using gentle hand-applied suction. Fat
harvested with these cannulas easily passes through injection cannulas
as small as 0.7 mm (20-gauge). Shown from top down: 10-mL Luer
lock syringe, 1.6-mm by 20-cm local anesthetic infiltration cannula,
2.4-mm Tulip TriPort” harvesting cannula (Tulip Medical Products,
San Diego, CA), and 2.4-mm Coleman harvesting cannula (Mentor
Worldwide, Santa Barbara, CA). (b) Close-up of instrument tips. Shown
from top down: 10-mL Luer lock syringe, infiltration cannula, Tulip
harvesting cannula, and Coleman harvesting cannula. (Copyright ©
Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
Medical Products, San Diego, CA), Coleman (Mentor orldwide, Santa
Barbara, CA), or other like harvesting cannula attached to a 10-mL
syringe, using gentle, gradually applied syringe suction to avoid
vacuum barotrauma to the fat tissue. These harvesting cannulas are
available as both reusable and disposable types. Fat harvested with
these cannulas will easily pass through 0.7-mm (20-gauge) injection
cannulas; the use of a smaller harvesting cannula is not necessary and
will needlessly slow down the harvesting process. In general, a 30 to
50 overharvest is made to be sure an adequate supply of processed
(centrifuged and separated) fat will be available for use on the face,
as centrifuging typically reduces the apparent harvest by 30 to 50 .
Once fat harvest is complete, the stab incision used to obtain
the fat is closed with a simple interrupted suture of 6–0 nylon
or other suture of choice. The harvest site is then washed free of
prep solution and the sutured site dressed with a Tegaderm (3M,
St. Paul, M ) dressing.
50.7.8 Processing Harvested Fat
Harvested fat is generally not uniform in character and concen-
tration as extracted from donor sites, as each syringe will contain
a variable amount of fat, blood, local anesthetic, and ruptured fat
cells ( oil ), and some type of processing is necessary to obtain
homogeneous material (uniform number of fat cells per unit
volume) for injection. Although fat can be separated from the oil
and water fractions using a tea strainer type sieve or by rolling
on Telfa (Medtronic, Dublin, Ireland) gauze, the majority of the
stem cells, platelet-rich plasma (PRP), growth factors, cellular
messengers, and the platelet plug are likely lost when this is done.
In addition, it is now known that not all fat cells are the same, that
the high-density adipocytes are the most stem cell rich, and that
processing fat through a sieve or by rolling it on Telfa does not
provide a means of segregating and concentrating these.
Centrifugation, as advocated by Coleman, conversely allows sep-
aration of the oil (fat cells ruptured during the harvest process)
and water (blood and local anesthetic) fractions from the fat
cells while simultaneously concentrating these other potentially
important components, and it has been our favored method of fat
processing for almost three decades. In addition, centrifugation
concentrates the high-density adipocytes and allows the surgeon
to use this supercharged fat, which is thought to be superior
in quality and higher in stem cells for grafting into critical areas
(such as the orbits and lips) or even the entire face if an adequate
overharvest of fat is made. Research efforts have been under
way for some time to develop low-cost devices for use in clinical
settings to process fat in a way that concentrates stem cells and
other potentially bioactive components or even allows them to be
separated. As these become available, the outcomes of fat injec-
tion procedures could be significantly enhanced, and many new
and interesting uses of autologous fat will likely become possible.
Controversy has existed for some time as to whether the forces
applied to the fat during centrifugation are harmful and decrease
eventual graft take. Available evidence seems to indicate that the spin
speeds and resultant applied forces in most countertop laboratory
centrifuges typically sold and used for processing fat are at or below
the threshold value for fat cell injury and do not harm harvested fat.
Before centrifugation is begun, a sterile, disposable plastic Luer
lock cap is placed on the end of the syringe tip to keep harvested fat
inside it, and the syringe plunger is removed from the syringe barrel.
693
 VIII Surgical Rejuvenation of the Face and Neck
Capped syringe barrels containing unprocessed fat are then loaded
into the centrifuge rotor in a balanced fashion and spun for 1 to 3
minutes at 1,000 rpm. Most small, portable centrifuges available for
this purpose are inexpensive and have rotors that can be sterilized
so that the syringe barrels containing the fat remain sterile and can
be handled by the scrubbed surgical team on the sterile surgical field
after centrifugation is complete. Others centrifuges have sterilizable
tubes that fit into the rotor for this same purpose (Fig. 50.6).
Once centrifuged, syringe barrels containing centrifuged fat
are removed and will be seen to contain an upper oil (ruptured
fat cells), central fat (the material the surgeon seeks), and lower
water (blood and local anesthetic) components (Fig. 50.7).
The typically blood-tinged water (local anesthetic) component
is separated by simply removing the syringe tip cap and allowing it
to run out, and the cap is then replaced. Alternatively, the platelet
plug can be sequestered and mixed back with the fat, or it can be
injected separately into areas of the face, hands, and chest that have
sustained accelerated environmental damage. The oil fraction is
then poured off out of the top of the syringe. Telfa sponges can also
be placed inside the syringe barrel to wick up the small amount of
Fig. 50.6 Centrifuging fat. Harvested fat is generally not uniform in
character as extracted from donor sites as each syringe will contain a
variable amount of fat, blood, local anesthetic, and ruptured fat cells
(“oil”) and some type of processing is necessary to obtain uniform
material for injection. Centrifugation allows separation of the “oil” and
“water” fractions from the fat cells. (a) Small, portable countertop
centrifuge (Tulip Medical Products, San Diego, CA). (b) Close-up view of
centrifuge rotor being loaded with unprocessed fat in 10-mL syringes.
Note that the syringe tip has been sealed with a disposable plastic cap.
The removable and sterilizable metal sleeves shown fit into the rotor to
keep syringe barrels containing fat sterile and allow them to be handled
on the sterile field after spinning. Other centrifuges are designed to
allow the entire rotor to be sterilized. (Copyright © Timothy Marten.)
694
residual oil present after the majority of it has been poured off. If
fat overharvest is made, this wicking off of residual oil with Telfa
sponges need not be performed, and the top 1 or 2 mL of fat from
each syringe is simply discarded (or, if the patient is very thin,
injected back into the patient’s body at an appropriate site and
banked ). A test tube–type rack to hold the syringes containing fat
greatly facilitates fat processing activities (Fig. 50.8). The rack also
conveniently holds 1-mL syringes, syringe components, and other
equipment used in the fat grafting procedure as shown.
50.7.9 Fat and Platelet-Rich Plasma
A number of surgeons have variously advocated mixing har-
vested fat with PRP, asserting that this enhances graft take
and improves overall outcomes. Mounting evidence suggests
that this is not true, however, and currently fat grafting is best
thought of and regarded as an artistic endeavor and art project,
not a technical exercise and science experiment.
50.7.10 Patients with Previous Filler Use
Patients who have previously received filler injections present a
specific challenge to the surgeon performing fat grafting and are
arguably suboptimal candidates for the procedure. Often more
Fig. 50.7 Centrifuged fat. After harvested fat is centrifuged, three
layers can be seen: an upper “oil” layer (ruptured fat cells), a middle
layer of intact fat cells, and a bottom (“water”) layer of blood and local
anesthetic. Unlike straining of fat through a “tea strainer” sieve or
rolling it on Telfa (Medtronic, Dublin, Ireland) gauze, centrifugation
is believed to allow separation of the oil and water fractions from
the fat cells with minimal loss of stem cells, platelet-rich plasma
(PRP), growth factors, and cellular messengers. Centrifugation also
allows high-density fat (bottom 2 mL of fat in center of syringe) with
increased stem cell activity, to be separated and preferentially used if
desired. (Copyright © Timothy Marten.)

Fig. 50.8 Syringe rack. A “test tube” rack to hold the syringes
containing fat greatly facilitates fat processing activities. On the left,
syringes containing unprocessed fat are present. In the center, syringes
containing centrifuged fat can be seen. The rack also conveniently
holds 1-mL syringes, syringe components, and other equipment used
in the fat grafting procedure. (Copyright © Timothy Marten.)
filler is present than patients are aware of or admit to, and the
presence of filler hides the extent of the actual amount of atrophy
present. The presence of residual filler will also likely compromise
graft survival, make a uniform take less likely, and compromise
the ultimate outcome of the procedure. Experience has shown that
even fillers placed several years previously can make procedures
more difficult and the outcomes less predictable.
Filler patients constitute a moving target and are as such dif-
ficult to assess and treat. Patients who have undergone HA-based
filler treatments are more likely to have suboptimal graft survival
and uneven take, and they may require multiple staged treatments.
HA-based fillers, when present, can be dissolved with hyaluroni-
dase such as Vitrase (Bausch Lomb, Rochester, ) or Hylenex
recombinant (Halozyme Therapeutics, San Diego, CA), and it is
recommended that HA-based filler be removed a few days or more
before treatment. If filler is removed at the time of the procedure,
the patient does not have the opportunity to see what he or she
really looks like without the filler, and the extent of the problem is
not evident to the surgeon. hen HA-based filler is dissolved with
hyaluronidase, the patient will also have residual inflammation
and is still likely to be a suboptimal candidate for fat grafting.
Patients presently using or having used non-HA-based fillers
such as calcium hydroxylapatite (CaHA; Radiesse, Merz, Frankfurt,
Germany), polymethylmethacrylate (PMMA), or silicone typically
present an even more perplexing problem. Present use of poly-L-
lactic acid (PLLA) or previous PLLA filler use can be particularly
problematic because of the chronic inflammation, internal fibro-
sis, and related tissue compromise this material can cause. Past
and present filler users should be informed that they are more
likely to have suboptimal fat graft survival and uneven fat take
and that they will likely need multiple staged fat graft treatments.
50.7.11 Injecting Fat
After centrifugation and the oil and water fractions have been
discarded (and high-density fat segregated, if desired), the fat
50 Simultaneous Facelift and Facial Fat Grafting
tissue so obtained is transferred into 1-mL Luer lock syringes
using a transfer coupling (Fig. 50.9) or other method, as proper
injection in very small aliquots as required cannot be made with
a 10-mL, a 5-mL, or even a 3-mL syringe.
erve blocks are then performed on the face with 0.25 bupiv-
acaine with epinephrine 1:200,000 local anesthetic solution and
an adequate time allowed for a proper anesthetic and hemostatic
effect. It is typically not necessary to directly infiltrate areas to be
treated with local anesthetic if nerve blocks are performed cor-
rectly and sedation is administered, and fat is typically infiltrated
into “dry” recipient areas.
Once nerve blocks have been administered, 0.7-mm (20-gauge),
0.9-mm (19-gauge), and 1.2-mm (18-gauge) cannulas are used to
infiltrate fat into the face transcutaneously through small stab
incisions depending on the areas being treated.
Infiltration is made in multiple passes, in multiple planes as
appropriate for the area being treated, injecting on both the in
and the out strokes while moving the cannula rapidly back and
forth and feathering into adjacent areas. Injecting from at least
two separate injection sites allows crisscrossing of cannula
passes during graft placement and more smooth and uniform fat
infiltration, and it helps avert a row of corn effect that might
result if injection was made from only one site.
Determining How Much Fat to Inject
Unless one is willing to submit to a long process of trial and error,
deciding upon how much fat needs to be injected at a given site
requires empirical information provided by others who have
experience with the procedure, and one cannot simply rely
on what one sees in the operating room. In general, there is a
tendency to treat most areas too conservatively if amounts to
be administered are decided by intuition and observation alone,
and some overcorrection is needed, as not all the graft will
survive. It is also the case that more fat will be needed than one
would use to fill a similar defect with nonautologous filler.
A prudent strategy for determining the amount of fat needed
for a given site is to rate the severity of the atrophy for each region
of the face based on what is seen in the preoperative photos, and
then to use empirical published data to chose the amount to be
administered to each area.
As a practical matter this amounts to simply rating or categorizing
the severity of atrophy at each proposed site of treatment as “small,”
medium, or large and then using data published regarding range
of amounts typically needed as a guide for treatment of each area. If
the defect is “small,” one would choose an amount from the low end of
the recommended range. If the defect is large, one would choose an
amount from the high end, and if medium somewhere in between.
The authors’ recommended ranges for the technique described herein
appear in Table 50.2 for the regions shown in Fig. 50.10.
The insightful surgeon can see that these parameters must be
considered as guidelines and not absolutes, and that considerations
such as what equipment was used, how the fat was harvested, how it
was processed, how it was injected, and the condition of the tissues
receiving the fat will all influence amounts needed and eventual
outcomes. Patients who are smokers or previous smokers as well as
patients who have undergone previous noninvasive radiofrequency
and ultrasonic skin shrinking procedures are likely to have com-
promised subdermal microcirculation and thus be less than optimal
695
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 50.9 Transferring centrifuged fat to 1-mL syringes. Fat is transferred from 10-mL Luer lock syringes into 1-mL Luer lock syringes using a transfer
coupling after centrifugation and the oil and water fractions have been discarded. Proper injection in the very small quantities that are needed in
the face cannot be made with larger syringes. (a) 10-mL Luer lock syringe, 1-mL Luer lock syringe, and Luer-to-Luer transfer coupling. (b) Transfer
coupling in use. (Copyright © Timothy Marten.)
candidates for fat grafting and need more fat than those who do not
have such a history. Similarly, patients who are longstanding filler
users, especially if they have used inflammatory fillers such as PLLA,
are likely to have internal facial fibrosis and inflammatory changes
that render them suboptimal candidates as well for fat grafting, and
as patients, they will require larger volumes of fat to obtain an equiv-
alent result. Patients undergoing concomitant facelifts will typically
require less fat than patients undergoing isolated fat grafting, as the
size of their skin envelope is being reduced. It is also the case that the
thoughtful injector must add a compensation for a large and small
face and adjust the amounts administered accordingly.
Ultimately however, the strategy just outlined, and in particular
the range of recommended volumes to administer, serves as a
time-tested starting point that will shorten the beginning injec-
tor’s learning curve and serve as a point of reference from which
surgeons develop their own ranges with experience and over time.
It should be understood that the volume ranges recommended
are not absolutes and are not a guarantee of success. onetheless,
this strategy has proven very useful in our own practices over
several decades of combined experience and is the strategy we
currently employ today. ith it, surgeons currently seeking to
incorporate fat grafting into their facelift procedures have a signif-
icant head start over their predecessors, who had to develop these
guidelines largely through trial and error.
Technique of Injection
As the injection cannula is advanced and withdrawn, the surgeon
should feel for tissue resistance, and if resistance is felt injection
is made as the cannula is moved back and forth. Approximately
0.5 mL or less is injected per back-and-forth pass. This corre-
sponds to 20 to 40 passes for each 1-mL syringe of processed fat.
If tissue resistance is not felt as the injection cannula is advanced,
this indicates that a pass has already likely been made in that
area, and injection is not made, and the cannula is redirected to
an area where resistance is felt.
The goal is to inject the fat in a way that scatters it in the plane
and place of administration and optimizes its chance of developing
a blood supply and surviving, and the mental model should be one
of scattering tiny particles of fat into the recipient site in multiple
crisscrossing fine trails in multiple planes (as appropriate for the
area being treated) in such a way that each particle ideally sits in its
own compartment and has maximal contact with perfused tissue
696
and minimum contact with other injected fat cells to the extent pos-
sible. If fat is injected in the way in which an ordinary hypodermic
injection would be given, or if nonautologous fillers are typically
administered, fat cells will be bunched together, and only those on
the periphery of the injected area will have tissue contact and will
be likely to survive. The majority of the more centrally situated fat
particles will have contact only with each other and will be less
likely to survive, and this can lead to the formation of oil cysts and
contour irregularities. Put in more practical terms, the procedure
should be thought of as analogous to spray painting, not caulking.
At first the beginning injector will advance and withdraw the
injection cannula (back and forth movement) too slowly, but as
familiarity with the technique is acquired, the movements can and
should be made faster. Ultimately, all other things being equal, faster
movements are desirable, in that if the injection cannula is constantly
in motion, intravascular injection is less likely, and an accidental bolus
injection into one area is avoided. Rapid back and forth movements
ensure the smoothest and most uniform infiltration of fat.
How the syringe is held is also important in controlling the volume
expressed from the cannula with each pass and avoiding overinjec-
tion of a given area. If the syringe is held in the manner one would
typically use to give a filler injection, with the thumb on the end of
the syringe plunger, it is easy to inject too much fat unintentionally if
tissue resistance suddenly changes. More control can be generally be
maintained, and overinjection more easily avoided, if the syringe is
held with the end of the plunger in the palm of the hand (Fig. 50.11).
Although a bit of practice is required at first, with the syringe held
this way a slight closing of the hand results in only a small amount
of fat being expressed from the cannula, and overinjection of any one
area can more readily be avoided. Smaller cannulas now available
also help avoid bolus injection, as their small diameter physically
limits how rapidly fat can be extruded from the syringe.
Although cannula obstruction will be very uncommon if fat
is harvested and processed as described, if a cannula becomes
blocked, additional injection pressure should not be applied, as
this is the most common cause of a sudden and unintentional
bolus injection. It is better in such circumstances to simply
withdraw the blocked cannula, pass it to the surgical assistant,
and continue with a different one. The assistant can then clear the
obstruction while the surgeon continues to work. Typically, the
cause of the obstruction will be a particle of fat or subcutaneous
debris at the junction of the cannula and the inside of the cannula
 50 Simultaneous Facelift and Facial Fat Grafting

Table 50.2 Marten Clinic of Plastic Surgery facial fat grafting operating room reference guidelines
Region Area Cannula Tissue plane Amount, mL Special considerations iffi u y
in Fig. (per side
50.10 Size, Gauge Length, except as
mm cm noted)
1 Temples 0.9 19 5 Subcutaneous 3–7 Larger cannula is less likely to perforate temporal veins. Intermediate
If vein perforated, hold pressure on area for 3–5 min and
may then resume injections.
2 Supra-brow 0.7 20 5 Subcutaneous 1–3 Goal is to blend prominent brow with forehead. Intermediate
3 Glabella 0.7 20 4 Subcutaneous 1–3* (total) GF lines are not effectively treated with AFG unless Intermediate
neurotoxin also used.
4 Radix 0.7 20 4 Preperiosteal 1-3* (total) Can be continued on bridge of nose if inverted V or Intermediate
to skin rhinoplasty irregularities present (19).
5 Brow-supraorbital 0.7 20 4 Preperiosteal/ 1–3 Conceptualize as lowering the supraorbital rim, not filling Advanced
(“upper eyelid”) sub–orbicularis the eyelid. Must protect ocular globe during fat infiltration.
oculi
6 Infraorbital (“lower 0.7 20 4 Preperiosteal/ 1–3 Important to inject perpendicularly from below rather Advanced
eyelid”) sub–orbicularis than parallel to defect. Must protect ocular globe during
oculi fat infiltration.
7 Nasojugal groove 0.7 20 4 Preperiosteal/ 0.5–1.5 Important to inject perpendicularly from below rather Advanced
(tear trough) sub–orbicularis than parallel to defect.
oculi
8 Midface 0.7 20 4 Preperiosteal 1–3 Overlaps infraorbital, tear trough, and cheek areas. Beginner
to skin
9 Cheeks 0.7 20 5 Preperiosteal 3–7 Must consider shape of forehead, prominence of chin, and Beginner
to skin width of mandible. If temples are hollow and not treated,
filling cheeks will look unnatural. Some of this fat will typically
be encountered during subsequent SMAS dissection.
10 Lateral face/ 0.7 20 5 Subcutaneous 1–3 Carefully placed in preparotid sub-SMAS location, this fat will Intermediate
preauricular and sub-SMAS not be encountered during skin and SMAS flap dissections.
11 Buccal recess 0.7 20 4 or 5 Subcutaneous 1–3 Intermediate

12 Jawline 1.2 18 6 Preperiosteal/ 3–9 Approached medial to lateral from puncture near Intermediate
submasseteric corner of mouth. Injection made on face of bone, not
subcutaneously, into muscle, or into parotid.
13 Nasolabial crease 0.7 20 4 Subcutaneous 0.5–1.5 Inject superficially if treating NLC, deep if treating maxillary Intermediate
(NLC) recession. Injecting larger volumes will not improve
results and can crease bizarre appearance. Overfilling NLC
area can result in reduced dental show when smiling.
14 Piriform 0.7 20 4 Preperiosteal 1–3* (total) Project nasal tip. Overfilling can result in decreased upper Intermediate
dental show when smiling.
Columellar–labial 0.7 20 4 Preperiosteal 0.5–1.5 Improves columellar angle and projects tip of nose. Intermediate
junction to skin
Upper lip 0.7 20 5 Submucosal 0.5–1.5 Injection should be made to create a central tubercle with Intermediate
with emphasis a sulcus on each side of it. Upper lip should be distinctively
on vermilion– smaller than lower lip (golden ratio). If upper lip the same size
cutaneous as lower lip, mouth will appear contrived and unnatural.
junction
Lower lip 0.7 20 5 Submucosal 1–2.5 Injection should be made to create a central tubercle Intermediate
beneath with a sulcus on each side of it. Lower lip should be
vermilion distinctively larger than upper lip (golden ratio).
15 Labiomandibular 0.7 20 4 Mucosa to skin 0.5–2 (total) Goal is to fill and add structure to entire region, not to Intermediate
groove (“drool line”) spot-fill crease.
16 Labiomental sulcus 0.7 20 4 Mucosa to skin 1–4 (total) Adds vertical height to chin. Useful with chin implant to Intermediate
(“chin crease”) avoid “implant look.”
17 Geniomandibular 0.7 20 4 Preperiosteal 1–3 Goal is to integrate chin and jawline to create smooth, Beginner
groove (GMG) to skin continuous aesthetic line.
18 Chin 0.7 20 4 Preperiosteal 1–3 Exceeding 3 mL per side (6 mL total) can result in Intermediate
to skin excessive vertical height and globular appearance of chin.
19 Nasal dorsum 1–3* (total)
20 Forehead 0.7 20 5 Subcutaneous 2–4 Most often treating depression in midcentral area and Intermediate
not entire forehead.
Abbreviation: SMAS, superficial musculoaponeurotic system.
*Important notes regarding recommended amounts:
1. Amounts listed in table are amounts administered per side, except where noted with asterisk and “(total).”
2. Amounts listed in table are for fat harvested with a 2.1- to 2.4-mm harvesting cannula centrifuged for 1–3 min at 1,000 rpm and administered to average-sized
female head in 0.5-mL aliquots as part of a facelift procedure. Larger amounts may be required for uncentrifuged or “tea-strained” fat, larger female faces; male
patients; and patients not undergoing facelift procedures.
3. A prudent and proven strategy for determining the amount of fat needed for a given site is to rate the severity of the defect based on what is seen in the preoperative
photos and then to use empirical data (as in this table) to choose the amount to be administered. As a practical matter, this amounts to simply rating the severity of
the problem at each proposed site of treatment as “small,” “medium,” or “large” and then using data in this table to determine the amount typically needed for
treatment of each area. If the defect is “small,” one would choose an amount from the low end of the recommended range. If the defect is “large,” one would
choose an amount from the high end, and if “medium” somewhere in between.

697
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 50.10 Anatomic regions typically addressed in treating facial areas. Red areas represent areas where fat is typically not injected. Additional and
more detailed information on the range of amounts of fat, injection cannula to be used, and other details for each region are given in Table 50.2. For
lip information see Fig. 50.23 and Fig. 50.24 and corresponding text. (Copyright © Timothy Marten.)
Fig. 50.11 Method of holding syringe to control volume released
during injection. If the syringe is held in the way one would typically
use to give an injection it is easy to infiltrate too much fat if tissue
resistance suddenly changes. More control can be maintained, and
over-injection better avoided, if the syringe is held with the end of the
plunger in the palm of the hand. Held in this manner a slight closing
of the hand results in a small amount of fat only being expressed.
(Copyright © Timothy Marten.)
698
hub, which is most easily cleared by removing the cannula from
the syringe and extracting the particle of fat or fragment tissue
debris from inside the hub with a fine forceps.
50.7.12 Planes of Fat Placement
Fat injections will necessarily be made in different planes,
depending on the areas being treated and the problem present. In
many areas where multiple tissue layers are present to inject in
and overlying skin is thick, injection can be made full-thickness
at the treated site, from periosteum to the subdermal layer.
These areas typically include the geniomandibular groove (GMG,
prejowl groove), piriform, midface, cheek, and chin. In other
areas injections must necessarily be placed more specifically
if optimal results are to be obtained and if irregularities are to
be avoided, due to the anatomic characteristics of the treated
sites. These areas include the temples, which are injected sub-
cutaneously; the upper orbit, lower orbit, and tear trough, which
should be injected in a preperiosteal/sub–orbicularis oculi deep
plane; the lips, which should be injected predominantly in a
submucosal plane; and the jawline, which should be injected in
a preperiosteal/submasseteric plane. The easiest areas for the
beginning injector to treat are the areas in the full-thickness
category. In the beginning it is wise to stay deep and place the
majority of the graft in a predominantly preperiosteal plane.

Once familiarity with the technique has been obtained, areas in
the latter categories can then be treated. These areas will require
more careful and skilled placement of fat, however.
The look the surgeon is after is also germane to depth of
fat placement. In general, if one is looking to enhance the facial
skeleton in the way one would with a facial implant, injections
should arguably be made more deeply. If one is seeking more of an
appearance of softness, at least some of the fat should be placed
superficially if the characteristics of the recipient site allow it.
50.7.13 Particulars of Sites of Treatment
Geniomandibular Groove Prejowl
Grafting of the prejowl/GMG area with fat has a high aesthetic
payoff and is a good area for the beginning injector to gain
experience with the technique (Fig. 50.12). Filling the GMG cre-
ates a strong, uninterrupted aesthetic line from the chin to the
posterior mandible that cannot be achieved by lifting the jowl
alone, and results in a highly desirable improvement on both the
male and female face. The effect is similar to the placement of a
Mittleman Pre owl (Implantech Associates, Ventura, CA) implant
but is autologous and simpler to perform.
Injection of the GMG area is typically performed with a
4-cm-long, 0.7-mm (20-gauge) injection cannula from injection
sites on the mandibular border and the perioral area (Fig. 50.13),
and fat is placed in all tissue layers between the periosteum and
skin. Typically 1 to 3 mL of fat is placed in the GMG, depending
on the size of the depression and degree of atrophy present, but
occasionally more will be indicated. Another guideline for the
placement of fat in the GMG area is for the surgeon to imagine
filling the area in which one would place a pre- owl implant.
Cheek
Injecting the cheek with fat can enhance a patient’s facial shape
and proportion, increase cheek projection, and correct age-asso-
ciated loss of cheek volume. Often fat grafting can rival or even
exceed the kind of improvements obtained when Terino Malar,
Shell, and Binder Submalar (Implantech Associates, Ventura, CA)
a b
Fig. 50.12 Treatment of the geniomandibular groove (GMG) with fat injections. (a) Patient with deep GMG (prejowl sulcus) seen preoperatively. The
chin appears narrow and pointed, and there is poor continuity between the chin and jawline. (b) Same patient seen after facelift and injection of fat
to fill the GMG area. No chin implant was placed. The chin appears broader and more aesthetically integrated with the jawline. Fat was also used to
strengthen the posterior jawline, lower the mandibular angle, and fill the lips, nasolabial crease, cheeks, and infraorbital areas. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
and combined malar-submalar shell style cheek implants are
placed (Fig. 50.14). In some cases it can be argued that fat grafting
often results in a softer, more natural-appearing, integrated cheek
mass than cheek implants provide, and can produce a softer and
less harsh appearance (see case examples later in this chapter).
As the cheek atrophies, the lower eyelid fat bags become more
exposed and prominent (pseudoherniation). Removing lower
eyelid fat in such circumstances creates a hollow and elderly
appearance and a low lid–cheek junction. A better strategy for
many patients is to reconstitute the cheek with fat grafts, covering
up the pseudoherniated fat, raising the lid–cheek junction, and
creating a smooth and more youthful transition from the lower
eyelid to the cheek (Fig. 50.15).
Treatment of the cheek is usually performed using access inci-
sions on the cheek and the perioral areas (Fig. 50.16). A 5-cm-long
0.7-mm (20-gauge) cannula is used, and fat is placed in all tissue
layers between the periosteum and the skin. Typically 3 to 7 mL
of centrifuged fat is placed in the cheek area, depending on the
degree of atrophy present, but occasionally more will be indi-
cated. Often an asymmetrical placement of fat between the right
and left sides will also be required due to the common occurrence
of malar asymmetry, seen preoperatively in many patients.
Another guideline for the placement of fat in the cheek area is for
the surgeon to imagine filling the area in which one would place
a cheek implant. The cheek, like the geniomandibular groove, is a
good area for the beginning injector to treat.
Midface
The midface is a loosely defined triangular area bounded by the
infraorbital rim superiorly, the nasolabial fold medially, and the
zygomaticus major muscle laterally. For several decades the aging
change in this area has been characterized as one of descent and
referred to as “midface ptosis,” and as a result, a variety of failed
and/or largely abandoned procedures have been conceived over
the course of that time to lift what was thought to be the fallen
area. Often the early outcomes of these procedures looked satisfac-
tory, but surgeons and patients were confounded by the fact that
once healing was complete (and swelling had subsided), too often
no discernible difference from the preoperative condition was seen.
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 VIII Surgical Rejuvenation of the Face and Neck

In time, surgeons came to realize that the aging change in the

Fig. 50.13 Incision sites and plan for injecting fat into the prejowl or
geniomandibular groove (GMG) areas. Injection of these areas is per-
formed with a 4-cm-long 0.7-mm (20-gauge) cannula, and fat is placed
in all tissue layers between the periosteum and skin. Typically 1 to 3 mL
of centrifuged fat is placed on each side. Level of difficulty: beginner.
(Copyright © Timothy Marten.)
midface consisted largely of , not descent, and a rethink-
ing of how the midface should be best treated occurred. It is now
more widely recognized that one cannot lift an empty space but
instead must fill it, and fat injections have taken a starring role
in treatment of this aesthetically important area. Indeed, Tonnard
and Verpaele, who once advocated lifting the midface with a
medially placed minimal-access cranial suspension (MACS) suture,
have abandoned this suture placement and instead acknowledge
that the midface can be effectively and better rejuvenated by fat
injections alone.
Practically speaking, the midface is overlapped by the infraor-
bital region, the tear trough, and the cheek (see Fig. 50.10), and
when these adjacent areas are treated and feathered into each
other, specific filling of the midface may not be needed. Much
depends on how one defines each of these areas. Fat grafting
the midface when indicated can correct an atrophic and feeble
appearance that occurs as it shrinks with age by filling and
strengthening this aesthetically important area.

a b
Fig. 50.14 Enhancing the cheeks with fat. Injecting the cheek with fat can enhance a patient’s facial shape and proportion, increase cheek projection,
and correct age-associated loss of cheek volume. (a) Patient with atrophic cheek and face before facelift and fat injections. (b) Same patient seen 1
year and 8 months after high–superficial musculoaponeurotic system (SMAS) facelift, forehead lift, neck lift, and panfacial fat injections. Fat grafting
often results in a softer, more natural-appearing, less harsh, and better integrated cheek mass than cheek implants provide. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

Fig. 50.15 Enhancing the cheeks with fat and treating pseudoherniation of lower eyelid fat. As the cheek atrophies, the lower eyelid fat “bags”
become more exposed and prominent. Removing lower eyelid fat would create a hollow and elderly appearance. (a) Patient with atrophic cheek. The
lower lid fat is exposed and appears ostensibly as a “bag.” (b) Same patient seen after fat injections to the cheeks but no blepharoplasty. Protruding
lower eyelid fat has been disguised by building up and reconstituting the cheek. This produces a more youthful, fit, and attractive appearance than
removing lower lid fat would have. Note that the upper orbit has been replenished with fat injections as well. (Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)

700

Fig. 50.16 Incision sites and plan for injecting fat into the cheek area.
Fat grafting of the cheeks is typically performed with a 5-cm-long
0.7-mm (20-gauge) cannula, and fat is placed in all tissue layers
between the periosteum and skin in most cases. Typically 3 to 7 mL
of centrifuged fat is placed in each check. Level of difficulty: beginner.
(Copyright © Timothy Marten.)
Injection of the midface is typically performed with a 4-cm-long,
0.7-mm (20-gauge) cannula for stab incisions on the mid–inferior
medial cheek, and fat can be placed in all tissue layers between
the periosteum and skin. Typically 1 to 3 mL of centrifuged fat is
placed in each side, depending on degree of atrophy present, but
occasionally more or less will be indicated.
Chin
Injection of the chin with fat can correct age-associated loss of
chin volume, improve chin projection, and increase vertical chin
height, rivaling the kind of improvements obtained when small
chin implants are placed (Fig. 50.17).
Fig. 50.17 Using fat injections to project the chin. (a) Patient with underprojected chin seen before secondary facelift and fat injections. (b) Same
patient seen after secondary facelift with fat injections to the chin. No chin implant was placed. Injection of the chin with fat can enhance a patient’s
profile and approach the kind of improvements obtained when small chin implants are placed as shown. Fat was also placed in the upper and lower
orbits, cheeks, lips, and jawline areas. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
Fat grafting of the chin can also correct an atrophic and feeble
appearance that occurs as the chin shrinks with age by broaden-
ing and strengthening it (Fig. 50.18) and filling in the labiomental
groove and the submental crease when indicated. The ability to
modify and fill the labiomental crease is a distinct advantage of fat
grafting over a chin implant. Typically, treatment of the chin must
be undertaken in conjunction with the GMG, and the two areas
will overlap each other in most cases.
Injection of the chin is typically performed with a 4-cm long,
0.7-mm (20-gauge) injection cannula from injection sites on the
mandibular border. Occasionally a third incision is used in the
midline of the lower lip (Fig. 50.19), and fat is placed in all tissue
layers between the periosteum and skin. Typically 1 to 3 mL of
centrifuged fat is placed in each side of the chin, depending on its
size and shape and degree of atrophy, but occasionally more or
less will be indicated. Another guideline for the placement of fat in
the chin area is for the surgeon to imagine filling the area in which
one would place an “extended anatomic” chin implant.
Despite the recommendations of some surgeons to the contrary,
fat injections to the chin are best used for small augmentations
only. If large changes in chin projection are attempted, a globular
and less sculptural appearance is usually obtained, and patients
in need of larger increases in chin projection are arguably better
treated with a chin implant or, most ideally, a chin implant and fat
injections combined.
Nasolabial Injection
One of the first areas most patients inquire about when consid-
ering fat injections, and most surgeons are typically eager to
treat, is the nasolabial crease. Nonetheless, one must be aware of
several misconceptions and certain limitations of the fat grafting
technique in regard to the treatment of this area. The first is that
treatment of the nasolabial creases with fat is generally not as
effective as treatment with nonautologous fillers. Fat is softer
and typically placed more deeply than nonautologous fillers, and
fat is better used to treat a volume deficiency in a region of the
701
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 50.18 Using fat injections to strengthen the aging chin. (a) Preoperative view of patient with atrophic and feeble-appearing, deflated chin. (b)
Same patient seen after secondary facelift and fat injections to the chin, geniomandibular groove (GMG), and jawline areas. No chin implant was
placed. The atrophic and feeble appearance was corrected with fat injections by broadening and strengthening the chin. Treatment of the chin
along with the GMG and jawline areas enables strengthening of the entire lower facial contour. (Procedure performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)

face, as opposed to a more discrete line, wrinkle, or fold that is

Fig. 50.19 Incision sites and plan for injecting fat into the chin. Fat
grafting of the chin is typically performed with a 4-cm long 0.7-mm
(20-gauge) cannula, and fat is placed in all tissue layers between the
periosteum and skin. Typically 1 to 3 mL of centrifuged fat is placed
in each side of the chin. Level of difficulty: intermediate. (Copyright ©
Timothy Marten.)
subject to the repeated stress of facial muscle contraction and
facial movement. Patients undergoing fat injections solely for
treatment of their nasolabial folds will generally be disappointed
with the outcome. This is not the case, however, when a simul-
taneous facelift is performed and cheek and midface tissues
are repositioned and redundant cheek skin is excised. Fat is an
excellent adjunct in the treatment of the nasolabial fold in such
instances (Fig. 50.20). It is also not immediately and intuitively
obvious, but increasingly more widely appreciated by those
injecting nonautologous fillers into the face, that fi
f fi
fold by integrating it with the rest of the face, and that treatment
of the fold is more effective when combined filling of both these
areas (nasolabial crease and cheek) is made. If the cheek is filled
as well as the crease, less fat is needed to improve the nasolabial
crease, and an overall better result will be obtained.
It is now generally accepted that the nasolabial crease is also
due, at least in part, to age-related loss of maxillary projection, and
the goal of injecting fat in the nasolabial areas should be thought
of at least in part as augmentation and restoration of maxillary/
midface projection rather than as simple filling of the soft tissue

a b
Fig. 50.20 Combined lifting and filling of the nasolabial fold. (a) Patient with midface ptosis and heavy nasolabial fold. (b) Same patient seen after
high–superficial musculoaponeurotic system (SMAS) facelift and fat injections to the nasolabial creases. A combined lifting and filling provides a
better improvement than either procedure performed alone. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

702

crease. Accordingly, the surgeon’s effort, and how and where fat is
injected, will depend on the problem present. Injections should
be made more superficially and predominantly subcutaneously if
one is treating the nasolabial crease. Injections should be placed
more deeply and predominantly over the piriform in the upper
nasolabial area if one is treating age-associated maxillary reces-
sion. Many patients are best served by placement of fat in both
places.
A 4-cm long 0.7-mm (20-gauge) cannula is used, and fat is
placed in tissue layers between the periosteum and skin as appro-
priate for the problem present and, per the preceding discussion,
using access incisions in the perioral area (Fig. 50.21). Typically
0.5 to 1.5 mL of centrifuged fat is placed in the piriform/nasolabial
area, depending on the degree of the problem present, but occa-
sionally more or less will be indicated. Another guideline for the
placement of fat in the piriform area is for the surgeon to imagine
filling the area in which one would place a Peri-Pyriform implant.
Fig. 50.21 Incision sites and plan for injecting fat into the piriform
and nasolabial crease area. Fat grafting of the piriform and nasolabial
crease is typically performed with a 4-cm long 0.7-mm (20-gauge)
cannula. Fat is placed subcutaneously and superficially if treatment of
the nasolabial skin crease is the goal, and preperiosteally if improve-
ment in age-associated maxillary recession is desired. Fat is placed in
all tissue layers between the periosteum and skin if both problems are
present and are being treated. Typically 0.5 to 1.5 mL of centrifuged
fat is placed on each side. Level of difficulty: intermediate. (Copyright
© Timothy Marten.)
Fig. 50.22 Enhancement of lip volume with fat injections. Fat grafting the lips produces a soft, natural-appearing improvement in lip appearance
and slight undercorrection that is appropriate for the typical facelift patient in need of enhanced lip volume. Nonautologous fillers invite overcorrec-
tion and tend to produce a more stylized lip appearance. (a) Perioral area of a facelift patient seen before fat injections. Note that upper and lower
lips appear approximately the same size. (b) Same patient seen after facelift that included fat grafting of the lips. The lips are fuller and healthier-
appearing but soft and natural-looking. Note that the lower lip is distinctly larger than the upper lip and that fat has been placed to produce a natural,
sensual shape. (Copyright © Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
Overfilling the nasolabial area is a common eventual outcome
of the frustration that arises when treating the nasolabial crease
with fat in isolation and in the same way one would inject non-
autologous fillers. Higher and higher volumes will be tried in a
futile effort to efface the crease, but an improved outcome will not
be obtained from injecting these larger amounts of fat. Instead,
the result is generally an abnormally heavy and objectionable-
appearing unaesthetic fullness of the midface. In addition, over-
filling the nasolabial area can produce changes in the posture of
patients’ mouth and the shape and size of their smile, and result
in a change in their look. For these reasons it is important to
advise patients accordingly, for the surgeon to set reasonable
goals, and to limit the amount of fat placed in the nasolabial area
to a reasonable amount.
Lips
There is perhaps no better example of the precedence of shape
and contour over a simple increase in volume than the lips. The
real measure of success in treating the lips is whether the treated
area has a healthy, fit, youthful, and sensual appearance not
simply whether they are larger.
Despite the fact that patients and injectors are often erroneously
focused on the upper lip, the lower lip in the youthful mouth is
distinctly bigger than the upper lip, and in most cases the priority
in rejuvenation of the oral area is to restore lost lower lip volume.
This fact can easily be confirmed by having patients bring in
photos of themselves at a younger age, and a useful aesthetic goal
is to restore the relationship of the upper and lower lips to the
golden proportion of approximately 1:1.6. Overfilling the upper
lip, or making the upper and lower lips the same size, will result
in unnatural clown mouth, Halloween wax lips, or having
been punched in the mouth appeaerance. In the aesthetic, nat-
ural-appearing mouth the lower lip is distinctly larger and fuller
that the upper lip, and this should be the goal when augmenting
the lips with fat (Fig. 50.22).
Treating the lips with fat has distinct advantages and disadvan-
tages that will both attract and repel surgeons and patients alike.
The advantages include that fat is autologous and arguably what was
present in youth, and if the procedure is successful and graft take
is good, patients will be spared the inconvenience and discomfort
of having to undergo repeated filler treatments. Fat also produces a
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 VIII Surgical Rejuvenation of the Face and Neck
soft, natural-appearing improvement, and usually slight undercor-
rection, which we find to be most appropriate for the typical facelift
patient in need of some improvement around the mouth. In fact,
overcorrection of the lips with fat injections in our experience is
difficult unless a patient undergoes multiple treatments.
Fat injections to the lips have the distinct disadvantages that they
usually produce a monstrous amount of swelling that is slow to
resolve and that the take of the graft varies from patient to patient,
and therefore so does the eventual outcome. Take can also be uneven,
in some cases leading to lumps and asymmetries that can be disturb-
ing to patients. Patients seeking a quick recovery, a specific lip size or
shape, or a full, stylized lip appearance are not optimal candidates for
the procedure. In particular, patients must be warned that it is gen-
erally not possible to create the highly stylized cover girl or stung
by a bee lip appearance seen in fashion magazines using fat. These
appearances are better obtained using nonautologous fillers, and
patients seeking such appearances should be advised accordingly.
Patients seeking nuanced changes in lip appearance are also not
good candidates for fat injections. These include patients seeking
corrections of small asymmetries, patients seeking accentuation
of the vermilion–cutaneous junction or requesting that specific
parts of their lip be lifted, rolled out, and the like. hile fat can
be placed to achieve these appearances to some degree, it is rarely
dramatic or exact enough to satisfy most patients requesting
these sorts of improvements, and patients making these kinds of
requests are currently best treated with nonautologous fillers.
hen the lips are to be treated, the prep of the face should
include the upper and lower gingivobuccal sulci, the buccal sur-
face of the anterior teeth, and the tongue if it rests in the surgical
field anterior to the incisors. Typically, the lips are treated after
all other areas have been fat-grafted but before the facelift is
begun, since treatment will require the surgeon to insert her or
his fingers inside the patient’s mouth. After injection is complete,
the surgeon can remove and replace her or his outer gloves, and
the anterior face and mouth can then be quickly reprepped.
A 5-cm long, 0.7-mm cannula is usually used to infiltrate fat
into the lips, but a slightly larger 0.9-mm cannula may be easier
for the beginning injector, as it is harder to perforate the mucosa
or vermilion accidentally with the larger instrument. Injection is
made from access incisions in the perioral region (Fig. 50.23), and
fat is placed submucosally beneath the vermilion and subdermally
in the white roll areas.
Fig. 50.23 Incision sites and plan for injecting fat into the upper and lower lip areas. Fat grafting of the lips is performed with a 5-cm 0.7-mm
(20-gauge) cannula, and fat is placed submucosally beneath the vermilion and subdermally in the “white roll” areas. (a) Typically, a total of 0.5 to 1.5
mL of centrifuged fat is placed in each side of the upper lip, and (b) 1 to 2.5 mL is placed in each side of the lower lip. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)
704
Typically the first few passes of the cannula are used to place
fat subcutaneously/submucosally directly under the vermilion–
cutaneous junction, then under the “red roll,” and then subdermally
under the white roll. Fat is then infiltrated submucosally beneath
the wet and dry lip vermilion in a way that optimizes lip shape (Fig.
50.22; Fig. 50.24). A total of 0.5 to 1.5 mL is usually placed in each side
of the upper lip and 1 to 2.5 mL in each side of the lower lip, for a total
of 1 to 5 mL per lip. Lesser amounts generally produce suboptimal
outcomes after initial swelling has abated. Larger amounts increase
swelling but generally do not result in an improved outcome.
A common error to be avoided when injecting fat (or nonautol-
ogous filler) into the lips is to fill the lips indiscriminately in such a
manner that a large but shapeless and unnatural-appearing sau-
sage lip is produced. To some extent the fat injection technique is
not prone to this, as lips treated with fat naturally tend to assume
the shape of the patient’s given lip envelope once swelling abates
and healing is complete. An attractive lip is generally one that is
not just big but has an aesthetically pleasing shape, and fat can
and should be injected in a way that creates these appearances.
The attractive lower lip typically has two tubercles that is, two
areas of fullness laterally with a small central depression between
them. The attractive upper lip, by contrast, has three aesthetic
tubercles, one centrally and one on each side laterally, with slight
depressions between them (Fig. 50.24). Time taken to inject
fat to create these sorts of natural and aesthetic appearances is
well spent. In addition, depressions between lip tubercles can be
enhanced upon completion of injections by placing a finger and
thumb on the inside and outside of the lip and gently bidigitally
compressing areas between tubercles to enhance the sulci and to
optimize fat position and lip shape.
Perioral Area
et another important use of perioral fat injections is in the patient
with perioral wrinkles and pucker lines. Traditional resurfacing
by peel, laser, or dermabrasion typically provides an incomplete
solution for these patients in that these procedures address only
the skin itself and do nothing to replenish age-associated loss of
perioral subcutaneous fat. Patients may have smoother-appearing
skin in repose after these skin resurfacing treatments, but when
they speak or move their mouth, deep and objectionable lines
appear and perioral deflation and subcutaneous atrophy becomes
plainly evident. Typically these appearances spoil an otherwise

Fig. 50.24 Strategy for fat-grafting the lips. The natural and
attractive-appearing upper lip has one central tubercle and two lateral
tubercles with a sulcus between them. The lower lip should have a
central sulcus with a tubercle on each side of it. Fat should be injected
in a manner to duplicate these appearances and not simply to make the
mouth larger or to create “sausage-shaped” lips. To create a youthful
and sensual appearance, and to optimize treatment of perioral wrinkling,
fat must also be placed superficially under the vermilion–cutaneous
junction as shown. (Copyright © Timothy Marten.)
excellent facelift result and stand as telltale evidence that the
patient is really older than she or he otherwise appears.
Fat injections provide a means by which this can be avoided
and fat normally situated between skin and orbicularis oris can
be replaced. A second likely benefit of perioral fat injections
rests in the stem cell effect the procedure provides. Experience
with combined dermabrasion or laser resurfacing and perioral
fat injections empirically suggests that healing and the overall
outcome are better when resurfacing procedures are combined
with fat injections, above and beyond the improvement gained by
simple volume addition (Fig. 50.25).
hen injecting the perioral area, care must be taken not to
overfill the white upper lip in the name of wrinkle reduction, as
the patient’s upper lip can be lengthened, dental show can be
a b
Fig. 50.25 Combined perioral resurfacing and fat injections. (a) Patient seen preoperatively with wrinkled, atrophic perioral area that lends an elderly,
unhealthy, and objectionable appearance to the face. Note the flat, unprojected appearance of mouth area. (b) Same patient seen 2 years and 7 months
after high–superficial musculoaponeurotic system (SMAS) facelift that included combined perioral fat injections and perioral dermabrasion. Both
atrophy and wrinkling have been improved, and the mouth has a more youthful, vibrant, and healthy appearance. The combined treatment produced a
better appearance than either procedure performed alone. (Procedure performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
reduced, and an abnormal, convex, simian contour in profile can
result. A better strategy is to concentrate one’s efforts on and near
the white roll area, where the wrinkles are typically the deepest
and appear most objectionable (Fig. 50.25). Results are further
enhanced by injecting additional fat at the columellar–labial
angle, as this helps restore a youthful transition from the nose to
the lip and helps create a youthful concave upper lip shape.
Jawline
Fat grafting of the jawline area can enhance a patient’s facial shape
and produce the kind of improvements obtained when mandibular
border and Taylor -style mandibular angle implants (Implantech
Associates, Ventura, CA) are placed (Fig. 50.26; Fig. 50.27).
Fat injections along the mandible can also correct an atrophic
and feeble appearance that occurs as the mandibular border
shrinks with age by broadening and strengthening it. Typically,
treatment of the jawline must be undertaken in conjunction with
the GMG, and the two areas will overlap each other in most cases.
A 6-cm long 1.2-mm (18-gauge) cannula is usually used to
fat-graft the jawline, and fat is placed in a submasseteric/preperi-
osteal plane as appropriate for the problem present using access
incisions situated over the medial mandibular border and lateral
perioral areas (Fig. 50.28). Typically 3 to 6 mL of centrifuged fat
is placed on each side, but occasionally more or less will be indi-
cated. Another guideline for the placement of fat in the jawline
area is for the surgeon to imagine filling the area in which one
would place a Taylor lateral mandibular implant.
ote that in treating the jawline fat is injected in a submasse-
teric/preperiosteal plane and not injected subcutaneously, into the
parotid, or into the masseter muscle. Note also that the cannula is
inserted in a manner in which it does not perforate the parotid or
masseter but is instead passed under them.
Although not intuitively obvious, strengthening a jawline and
posterior mandibular border when indicated makes the patient
appear more youthful, fit, and attractive and is an artistically pow-
erful adjunct to a facelift that helps avert the scrawny, deficient, and
fragile mandibular contour typically seen in the aging and elderly
face, which is usually made worse when a facelift is performed.
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 50.26 Using fat injections to enhance mandibular contour and strengthen the jawline. (a) Patient seen before surgery with a small mandible
having a narrow intergonial distance. A previous facelift performed by an unknown surgeon has tightened soft tissues over the jawline, resulting in a
harsh mandibular contour. (b) Same patient after fat injections to the jawline, geniomandibular groove, chin, lips, buccal recess, midface, and cheeks.
No implants have been placed and no secondary facelift was performed. Strengthening the jawline and posterior mandibular border results in a
more fit and proportionate appearance and helps avert the tight and deficient mandibular contour typically seen in many patients after a facelift is
performed. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

Fig. 50.27 Using fat injections to enhance mandibular contour and strengthen the jawline. (a) Patient seen before surgery with small mandible,
narrow intergonal distance, and lower facial disproportion. (b) Same patient after high–superficial musculoaponeurotic system (SMAS) facelift
and fat injections to the posterior jawline. No implants have been placed. Strengthening the jawline and posterior mandibular border results in a
more fit and proportionate appearance and helps avert the tight and deficient mandibular contour typically seen in the elderly face after a facelift
is performed. (Note: Fat has also been injected in the chin, geniomandibular grooves, buccal recess, and lip areas. Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)

Fat-grafting the jawline is particularly useful in the secondary

facelift patient and in the patient with a long face seeking facial
rejuvenation or improvement. Typically the secondary facelift
patient has experienced significant loss of jawline volume due
to loss or inappropriate surgical removal of facial fat, and this
is typically compounded by overzealous tightening of overlying
tissues. These appearances are readily reversed with jawline fat
grafting, and fat-grafting this area constitutes an important part
of many of our treatment plans for our secondary and tertiary
facelift patients.

Fig. 50.28 Incision sites and plan for injecting fat into the posterior
jawline. Fat grafting of the jawline is usually performed with an 8-cm
1.2-mm (18-gauge) cannula, and fat is placed in a preperiosteal/sub–
masseteric muscle plane. Typically 3 to 6 mL of centrifuged fat is placed
in each side. Note that fat is not injected subcutaneously, into the
parotid, or into the masseter muscle. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)
Temple Area
Temporal hollowing is a consistent marker of the fourth decade
of life that is readily improved with fat injections (Fig. 50.29).
Even skillfully performed isolated eyelid surgery will result in
marginal improvement in overall orbital and upper facial appear-
ance if the outcomes of blepharoplasties are viewed against the
background of a hollow, elderly-appearing, atrophic, empty
temple. Fat-grafting the temple allows comprehensive improve-
ment of the entire upper orbital region, not just spot treatment

706

Fig. 50.29 Filling of the temple hollow with fat. Temporal hollowing is a consistent marker of the fourth decade of life that is readily improved with
fat injections. (a) Patient aged 45 before surgery. (b) Same patient 2 years and 4 months after high–superficial musculoaponeurotic system (SMAS)
facelift and fat injection to the temple region (Note: Fat has also been injected in the upper and lower orbital areas. Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)
of the eyelid areas. Accordingly, it constitutes an important and
essential part of contemporary “blepharoplasty” procedures.
Fat-grafting the temples is also important to facial shaping
typically sought by surgeons with a sharp aesthetic eye in their
facelift procedures. The ideal youthful and attractive female
face has an inverted oval shape that with age typically changes
to a more rectangular, bottom-heavy one as the lower face, jowl,
and jawline sag. Temporal atrophy and hollowing contributes
further to this rectangularization and, when advanced, even a
peanut -like facial shape. hile a well-performed facelift will
correct the lower facial squareness, temporal filling by way of fat
grafting provides for a wider intertemporal distance and produces
an overall more inverted oval shape. In this way, temporal filling
accomplishes much more than simple filling of the temporal
hollow, or even than a more comprehensive rejuvenation of the
eyelids and orbital area it can provide a more youthful, feminine,
and beautiful-appearing facial shape.
Fig. 50.30 Incision sites and plan for injecting fat into the temple areas.
Injection of the temples is performed with a 5-cm long 0.9-mm (19-gauge)
cannula, and fat is placed in a subcutaneous plane. Typically 3 to 7 mL of
centrifuged fat is placed on each side. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)
50 Simultaneous Facelift and Facial Fat Grafting
The temple areas are usually grafted in a subcutaneous plane
from small stab incisions just within the temporal hairline (Fig.
50.30). Typically 3 to 7 mL of centrifuged fat is placed in the temple
area, but occasionally more or less will be indicated. In most cases
a slightly bigger and blunter, 0.9-mm, 6-cm long injection cannula
is superior to sharper and smaller-diameter types preferred else-
where. Using slightly larger cannulas helps minimize perforation
of temporal veins predictably present in the temporal area, and
allows fat to be placed over and around them to conceal them.
The injection cannula is not inserted specifically above or below
the temporal veins but rather is allowed to pass into the plane of
least resistance in the temporal area. Should a temporal vein be
inadvertently penetrated during injection despite these precau-
tions and swelling from the leakage of venous blood noted, it is
a simple matter to hold pressure on the temporal area for a few
moments with a surgical sponge. Typically after applying uniform
and continuous pressure for a few minutes, bleeding stops and
treatment of the area can be completed.
Buccal Recess Area
Buccal atrophy is frequently present in the fourth decade of life
and beyond in patients and can be readily improved with fat
grafting, as can buccal hollowing due to previous overzealous
excision of buccal fat or resulting from ill-conceived facial lipo-
suction of the buccal area (Fig. 50.31).
Injection of the buccal recess is typically performed with a 4- or
5-cm-long 0.7-mm (20-gauge) injection cannula from injection
sites on the medial midcheek (Fig. 50.32), and fat is placed in
both subcutaneous and sub-SMAS planes. Typically 1 to 3 mL of
centrifuged fat is placed in each side, depending on the degree of
atrophy present, but occasionally more or less will be indicated.
Upper Orbit/“Upper Eyelid” Area
hether a hollow upper orbit is the result of illness, aging,
or an overzealous surgical procedure, filling it can produce a
remarkable rejuvenation of the upper eyelid and eliminate an
unnaturally hollow and elderly appearance, sometimes referred
to by patients as nursing home or owl eyes (Fig. 50.33).
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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 50.31 Correction of buccal atrophy and overexcision of buccal fat. Buccal fat excision is often erroneously recommended as a way of creating
a “high cheekbone” and more angular facial appearance. In reality, it often produces an ill, haggard, gaunt, and unfeminine appearance, especially
when performed aggressively. (a) Patient with buccal hollowing following buccal fat excision by an unknown surgeon. (b) Same patient 11 months
after fat injections to the buccal area. (Note: Fat has also been placed in the infraorbital, midface, cheek, preoral, and jawline areas. Procedure
performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
hat layers into which fat should be placed in the upper orbit
( upper eyelid ) is a subject of some debate, and subcutaneous,
sub–orbicularis oculi, and even subseptal (intraorbital) locations
have all been advocated and safely and effectively used by various
surgeons. For the beginning injector, it is safest to avoid the sub-
septal area due to the small but not insignificant risk of intraorbital
and retrobulbar bleeding and other possible problems. It is also
wise to avoid a purely subcutaneous injection in this area, due to
the extremely thin skin present, and to limit initial injections to a
preperiosteal/sub–orbicularis oculi location.
A common misconception in treating the hollow upper orbit is
that the fat is needed and should be injected in the preseptal portion
of the eyelid itself. The hollow upper eyelid is more properly and
practically restored by placing fat in a preorbital position along the
inferior margin of the supraorbital rim however, and the process
is best conceptualized as one of lowering the inferior margin of the
supraorbital rim and filling the upper orbital area to lower skin
that has retracted up into the orbit down onto the preseptal eyelid
Fig. 50.32 Incision sites and plan for injecting fat into the buccal
hollows. Fat grafting of the buccal hollow is typically performed
with a 4- or 5-cm 0.7-mm (20-gauge) cannula, and fat is placed
subcutaneously and in sub–superficial musculoaponeurotic system
(SMAS), or buccal space, locations in most cases. Typically 1 to 3 mL of
centrifuged fat is placed in each side. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)
708
to create a full and appropriately creased upper eyelid. Once one
accepts that improvement is obtained by injection of the orbit,
and not the eyelid itself, it becomes apparent that larger volumes
than might otherwise be expected are required. Smaller injection
cannulas now available have made injecting the upper orbit easier
and more predictable than in the past, as they can be advanced
more smoothly and accurately through tissues and allow the
deposition of very tiny aliquots of fat per pass, and it is highly
recommended that small cannulas be used to treat this area.
Currently a 4-cm long 0.7-mm (20-gauge) cannula is preferred,
and in general 1 to 3 mL of centrifuged fat must be placed in each
upper orbit to achieve the improvement typically required, but on
occasion more or less may be indicated.
hen fat-grafting the upper orbit, it should always be remem-
bered that one is working in very close proximity to the eye, and
although the injection cannulas are blunt-tipped, they are small
and easily capable of perforating the ocular globe. In light of this,
several important technical considerations should be observed.
First, injection sites should be placed in such a way that the
injection cannula will be passed parallel to the globe and the
supraorbital rim, not perpendicular to them (Fig. 50.34).
Directing the cannula toward the globe when injecting the upper
orbit is potentially dangerous and should be avoided. Second, the
index finger of the surgeon’s nondominant (noninjecting) hand
should always be held firmly on the inferior margin of the supraor-
bital rim as cannulas are passed into tissues and injection is made,
and this finger should always be kept between the tip of the can-
nula and the globe (Fig. 50.35). The idea is to position the finger
so that the cannula will hit it instead of penetrating the globe if
inadvertently misdirected. Having one’s finger in this position also
gives important feedback to the injector as to where the tip of the
cannula is and helps one place fat as accurately as possible. Finally,
a shorter, 4-cm long cannula is easier to control and keep in the
correct plane on the inferior margin of the supraorbital rim and
should be used in preference to longer instruments.
Fat-grafting the upper orbit and eyelid is advanced in dif-
ficulty, and this area should be treated only by a surgeon who
has gained experience treating more forgiving areas. Once that
experience is obtained, fat-grafting the upper orbit can be one of
the most artistically rewarding uses of autologous fat and is likely
to become a routine part of rejuvenating the upper eyelid in the
future.
 50 Simultaneous Facelift and Facial Fat Grafting

Fig. 50.33 Correcting upper orbital hollowing. (a) Patient with hollow upper eyelid, an unnaturally hollow and elderly ocular “owl eye” or “nursing
home” appearance following blepharoplasty performed by an unknown surgeon. (b) Same patient seen after fat injections to the upper orbit.
Although the upper lid has been incompletely filled and restored, a healthier, more youthful appearance can be seen. (Procedure performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

Fig. 50.34 Incision sites and plan for injecting fat into the upper orbital
(“upper eyelid”) area. Injection of the upper orbital area is performed
with a 4-cm long 0.7-mm cannula, and fat is placed in a sub–orbicularis
oculi/preperiosteal plane. Typically 1 to 3 mL of centrifuged fat is
placed in each upper orbit, but occasionally more is indicated. Level of
difficulty: advanced. (Copyright © Timothy Marten.)
Fig. 50.35 Protecting the globe when injecting fat into the upper
orbital (“upper eyelid”) area. To protect the ocular globe when
injecting fat into the upper orbit, the index finger of the surgeon’s
nondominant (noninjecting) hand should always be held firmly on
the inferior margin of the supraorbital rim as cannulas are passed into
tissues and injection is made. (Copyright © Timothy Marten.)

Lower Orbit/“Lower Eyelid” Area the lid itself. And as in the upper orbit, volumes required to obtain
corrections in the lower orbit are typically more than one might
Injecting the infraorbital ( lower eyelid ) area is in some ways
intuitively expect, and 1 to 3 mL is usually necessary to produce
analogous to injecting the upper orbit in that there are similar
the desired effect, although sometimes more or less will be
misconceptions as to where the fat should be placed, similar tech-
indicated. In contrast to the upper orbit, however, experience has
nical considerations for which tissue layers fat should be injected
shown that fat is best and most easily injected, and a “banana” or
into, and similar concerns regarding injury to the ocular globe. In
sausage roll (unaesthetic bulge) is less likely to occur, if injection
addition, and as with injecting the upper orbit, the artistic payoff
is made from injection sites on the midcheek perpendicular to the
is high if the procedure is carried out correctly (Fig. 50.36).
infra-orbital rim (Fig. 50.37a). hen fat is injected in this manner,
Injecting the infraorbital area allows correction of age-related
lumps and irregularities are also less common.
atrophy and hollowness, which lends the face and ill or haggard
Fat should not be injected parallel to the lid–cheek junction in the
appearance; shortens the apparent length of the lower eyelid;
infraorbital area (Fig. 50.37b). It is our observation that surgeons
and produces a youthful, attractive and highly desirable smooth
injecting fat parallel to the infraorbital rim have more trouble
transition from the lower eyelid to the cheek that is generally
getting fat into the proper plane and location and have more
unobtainable by traditional lower eyelid surgery, fat transpositions,
problems with irregularities, lumps and bumps, sausage- and
septal resets midface lifts, free fat grafts, and other such means.
banana-shaped bulges, and other untoward results.
As is the case in treating the upper orbit, fat need not and should
As is the case in injecting the upper orbit, when injecting the
not be injected in the pretarsal lower eyelid. Fat should be injected
lower orbit, the index finger of the surgeon’s nondominant (non-
deep in a submuscular (orbicularis oculi)/preperiosteal plane, and
injecting) hand should be placed firmly on the infraorbital rim to
the technical goal of the procedure should be thought of as raising
protect the ocular globe while injections are made, and this finger
up and anteriorly projecting the infraorbital rim rather that filling

709
 VIII Surgical Rejuvenation of the Face and Neck

should always be kept between the tip of the cannula and the globe to imagine filling the area in which one might place an infraorbital
(Fig. 50.38). The idea is to position the fingertip so that the cannula implant, as the goal of treatment is essentially the same.
hits it instead of penetrating the globe if inadvertently misdirected. It is wise to avoid any subcutaneous injection in the infraorbital
Having one’s fingertip in this position also gives important feedback area due to the extremely thin skin present and the likelihood of
to the injector as to where the tip of the cannula is and helps one creating visible lumps and irregularities, and to limit injections
place fat as accurately as possible. As is the case when injecting the to a preperiosteal/sub–orbicularis oculi plane until considerable
upper orbit, a shorter, 4–cm long cannula is easier to control and experience has been obtained.
keep in the correct plane on the infraorbital rim and should be used
in preference to longer instruments.
Tear Trough
As the injection cannula is advanced perpendicular to the orbit
here the infraorbital area ends and the tear trough and cheek
and toward the fingertip in a sub–orbicularis oculi/preperiosteal
areas begin is hard to define, and in reality the treatment of the
plane through infraorbital tissues, the origin of the zygomaticocu-
infraorbital, cheek, and tear trough areas must be undertaken
taneous and orbicularis retaining ligaments can be felt along the
concurrently and in most situations the treated areas will over-
infraorbital rim and the cannula tip allowed to penetrate them.
lap each other to a certain extent. In addition, it must always be
Typically after multiple back-and-forth cannula movements used
remembered that the ultimate goal of the procedure is creating
in the placement of fat in this manner, no resistance will be felt
youthful and attractive contour, not simply filling a specific area.
along the course of the ligaments, and it is assumed that the multi-
Fat-grafting the tear trough (Fig. 50.39) is simpler and faster
ple passes used to place the graft have effectively partially released
to perform than fat transposition and septal reset, and we have
them, further improving the overall outcome. Another guideline
largely abandoned the latter procedures. Unlike septal reset and fat
for the placement of fat in the infraorbital area is for the surgeon
transpositioning, fat grafting allows comprehensive rejuvenation

Fig. 50.36 Filling the hollow lower orbit with fat. (a) Patient with hollow lower eyelid, an unnaturally hollow and elderly infraorbital appearance. The
lower eyelid appears long, and there is a distinct line of demarcation between the lower eyelid and the cheek. (b) Same patient seen after facelift and
fat injections to the infraorbital area. There is a smooth transition from the lower eyelid to the cheek, and the patient has a more healthy, youthful,
and attractive appearance. (Note: The upper orbit, radix, cheek, and nasolabial crease have also been treated with fat injections, and the patient has
undergone ptosis correction. Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

a b
Fig. 50.37 Correct (a) and incorrect (b) plan for injecting fat into infraorbital (“lower eyelid”) area. Fat grafting of the infra-orbital area is typically
performed with a 4-cm long 0.7-mm (20-gauge) cannula, and fat is placed deep in a sub–orbicularis oculi/preperisoteal plane. More superficial
injections should be avoided. Typically 1 to 3 mL of centrifuged fat is placed on each side, but occasionally more or less is indicated. A smoother
effect is obtained, and a “banana” or “sausage” (unaesthetic bulge) is less likely, when fat is injected perpendicular (a) rather than parallel (b) to the
infraorbital rim. Level of difficulty: advanced. (Copyright © Timothy Marten.)

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 50 Simultaneous Facelift and Facial Fat Grafting

of the entire orbital region, not just spot-filling of the tear trough.
hen fat grafting is performed, one can fill not only the tear
trough but also the infraorbital region, the cheek and midface,
the upper orbit, the temple, and the radix and glabella while also
comprehensively rejuvenating the entire orbital region. This is
aesthetically far superior to the limited fill of the tear trough only.
Fat grafting of the tear trough area is performed through
perialar stab incisions on the medial midface with a 4-cm 0.7-mm
(20-gauge) injection cannula, and fat is placed deep in a preperi-
osteal/sub–orbicularis oculi plane, as it is when the infraorbital
area is treated. Typically 0.5 to 1.5 mL of centrifuged fat is placed
on each side, depending on how far inferiorly and laterally the tear
trough extends onto the cheek. A smoother effect is obtained, and
an unaesthetic sausage roll or banana bulge is less likely, when
fat is injected perpendicular rather than parallel to the defect
(Fig. 50.40). Another guideline for the placement of fat in the tear Fig. 50.38 Protecting the globe when injecting fat into the lower
orbital (“lower eyelid”) area. To protect the ocular globe when
trough area is for the surgeon to imagine filling the area in which injecting fat into the lower orbit, the index finger of the surgeon’s
one might place a tear trough implant, as the goal of treatment is nondominant (noninjecting) hand should always be held firmly on
essentially the same. the inferior margin of the infraorbital rim as cannulas are passed into
tissues and injection is made. (Copyright © Timothy Marten.)

50.7.14 Secondary Facelift Patient

Secondary facelift patients who have not had facial fat lost with age
replaced at their primary procedure(s), or who have had cervicofa-
cial fat inappropriately removed during their previous procedures,
typically present cases in which all sites previous discussed likely
need and warrant treatment. For these patients the fat injections
are often more important than the secondary facelift itself, which
is performed largely to improve scars and hairline displacement,
earlobe irregularities, and the like. In the majority of secondary
facelift cases, fat grafting typically provides the lion’s share of the
improvement and is capable of truly transforming the patient in a
way that traditional lifting alone cannot (Fig. 50.41).
The secondary facelift patient stands as compelling evidence that
correction of facial atrophy requires the addition of volume to the
face, not a subtraction, lifting, or tightening, and thus requires a
rethinking of the traditionally taught approach to rejuvenation of
the face. Unlike problems corrected by a lift of the face, correction
of atrophy requires the surgeon to employ techniques that fill and
sculpt the face and to think in three, instead of just two, dimen-
sions. Fat grafting, when properly performed in these patients,
produces soft and natural contours and affords the opportunity to
correct problems traditional surgery cannot (Table 50.2).
50.8 Final Touches
Fat injections are continued until the preoperatively determined
volume of fat has been added to each target area. Typically a
one- to threefold “overcorrection” must be made, as compared
with volumes one would use if nonautologous fillers are used,
but typically the patient does not look overfilled on the operating
table and before swelling sets in. In all, the process is time-
consuming and technically and artistically demanding, and its
difficulty should not be underestimated. That said, because of

Fig. 50.39 Filling the “tear trough” with fat. (a) Patient with hollow nasojugal groove (“tear trough”), an unnaturally hollow and elderly infraorbital
appearance. (b) Same patient seen after fat injections. (Procedure performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)

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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 50.40 (a) Correct and (b) incorrect plans for injecting fat into the nasojugal (tear trough) areas. Fat grafting of the nasojugal tear trough area
is typically performed with a 4-cm 0.7-mm (20-gauge) injection cannula, and fat is placed deep in a preperiosteal/sub–orbicularis oculi plane.
Typically 0.5 to 1.5 mL of centrifuged fat is placed on each side, depending on how far inferiorly and laterally the tear trough extends onto the cheek.
A smoother effect is obtained, and a sausage roll (unaesthetic bulge) less likely, when fat is injected perpendicular (a) rather than parallel (b) to the
defect. Level of difficulty: advanced. (Copyright © Timothy Marten.)

Fig. 50.41 Secondary facelift and simultaneous fat injections. (a) Preoperative view of patient who has had a previous facelift and related procedures
performed by an unknown surgeon. Although her facelift was ostensibly well performed, untreated panfacial atrophy can be seen. A secondary
facelift alone would likely result only in an unnatural tight and windswept appearance. (b) Same patient 13 months after combined secondary facelift
and fat injections. Although the facelift allowed scars to be moved to more concealed locations and for correction of earlobe irregularities, the
replenishment of lost facial volume with fat injections was far more important to the overall outcome of the procedure. Note panfacial filling of the
temples, upper and lower orbits, cheeks, midface, buccal recess, lips and perioral area, labiomandibular creases (“drool lines”), chin, geniomandibular
grooves, and over and along the jawline. A soft, healthy, youthful, and sensual appearance can be seen, unobtainable with facelift alone. (Procedure
performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)

its aesthetic importance and because it provides comprehensive 50.8.1 Microliposuction

treatment of the aging change of the face, it is likely to also
become an enjoyable one for the surgeon who adopts it, and one
that will yield great benefits to patients so treated.
After fat has been infiltrated, treated areas are palpated to
ensure that the fat has been distributed smoothly in the target
tissue and that any lumps or irregularities are gently pressed
out. The lip and cheek areas can be bidigitally palpated, and if
the orbits have been treated, the ocular globe should be gently
depressed and irregularities checked for in the infraorbital area.
hen indicated, fat is extracted from areas where excess
fat is present with a blunt-tipped 0.9- or 1.2-mm infiltration
cannula attached to a 3-mL Luer lock syringe using a syringe
microliposuction technique (Fig. 50.42).
The amount of fat extracted can be gauged by expressing the
contents of the syringe onto a gauze sponge and allowing the
blood and fluid to separate from the fat that has been removed
(Fig. 50.42b).

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 50 Simultaneous Facelift and Facial Fat Grafting

Fig. 50.42 Microliposuction technique. The face undergoes a process of lipodystrophy over time and the aging change consists of not only atrophy
but also lipodystrophy and excess fat accumulation in some areas. Fat can be extracted from areas where excess is present using a “microliposuction”
technique, applying suction to an infiltration cannula with a 3-mL syringe. (a) Fat being extracted from the jowl using a 1.2-mm injection cannula
attached to a 3-mL syringe. This technique provides a simple way for removing small quantities of fat in a precision fashion. (b) The amount of fat
extracted can be determined by emptying the contents of the syringe onto a gauze sponge and allowing the fat to separate. On the right is the fat
extracted from the patient’s jowl area. On the left is fat extracted from the nasolabial fold. (Copyright © Timothy Marten.)

50.8.2 Documenting What Was Done
A nonscrubbed member of the operating room team should keep
a detailed record of areas treated and amounts of fat injected
in each, and a fat injection data sheet is useful for this purpose
(Fig. 50.43).
Typically a mark is entered on the record by the circulator for
each 1-mL syringe injected. In the absence of a circulating nurse,
a copy of this record can also be sterilized and a temporary tally of
the fat injected kept by a scrubbed member of the operating room
team using a sterile surgical marker. The information recorded can
later then be transcribed to the patient’s official fat injection treat-
ment record after the procedure has been completed. Alternatively,
amounts injected can be recorded by a nonscrubbed team member
on a life-sized laser print of a photograph of the patient’s face.
50.8.3 Learning the Procedure
The first step in learning the fat injection technique and adding it
to one’s facelift procedure is appreciating atrophy as a significant
part of the aging process and learning to recognize it. This is more
easily said than done and will take some time to master. Then
one needs to learn the basics of the fat injection technique and
obtain the needed equipment to perform the procedure prop-
erly. Once problems have been identified, needed equipment to
perform the procedure obtained, and the basics of the technique
mastered, one must analyze the patient’s problems carefully and
budget the appropriate amount of time needed to carry out the
procedure in a technically and artistically appropriate fashion. It
is wise to make small additions of fat at first to safe areas such
as the GMG and the cheeks so as to gain familiarity with the tech-
nique. Less forgiving areas such as the upper and lower eyelids
(orbits) and tear troughs should initially be avoided. Starting out
conservatively in this manner will mean that problems, should
they occur, will be minor and easily managed. Finally, treated
patients should be followed up carefully, outcomes critically
evaluated, and ways sought of improving one’s technique and
making the next case better (Table 50.3).
50.8.4 Completion of Concurrently
Planned Procedures
Upon completion of the fat injections, face, neck, and forehead
lifts, upper blepharoplasty, lower blepharoplasty, perioral resur-
facing, and other planned procedures are performed, as indi-
cated. Because the majority of fat is needed and will be injected
in the anterior face and other areas that do not overlap the areas
dissected in these other procedures, performing them after fat is
injected does not interfere with their execution or compromise
the final outcome of the procedure. Fat placed in areas that are
dissected as part of the facelift will be seen to stick where it has
been injected and not be disrupted, partly because if properly
infiltrated, the tissue has been saturated with fat and has not
been injected in boluses of clumps, and partly due to “tissue
glue naturally secreted in response to the infiltration process.
50.8.5 Dressings
After all planned procedures have been completed and all inci-
sions closed, the patient’s hair is washed with shampoo, rinsed,
and conditioned. o dressing is required or applied. Patients are
typically discharged with a hat, scarf, and sunglasses. Drain res-
ervoirs are attached to a lanyard placed around the patient’s neck.
50.9 Postoperative Care
Most patients having combined face lifts and fat grafting are dis-
charged to aftercare specialists the first night after surgery with spe-
cific written instructions as to how they are to care for the patients.

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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 50.43 Fat injection data sheet. Using a fat injection data sheet simplifies the documentation of what was done and provides a clear and easily
accessible record of the patient’s treatment. (Copyright © Timothy Marten.)

714

Table 50.3 Learning the fat injection procedure
• Acknowledge atrophy as part of the aging deformity.
• Learn the basics of the fat injection technique and obtain the needed
equipment to perform the procedure properly.
• Make the needed commitment of time to perform the procedure.
• Don’t underestimate the technical and artistic difficulty of the
procedure.
• Make small additions at first to gain familiarity with the technique.
• Critically analyze outcomes.
• Improve.
Patients are asked to rest quietly and apply cool compresses to their
eyes and other treated areas for 15 to 20 minutes of every hour they
are awake for the first 3 days after surgery, or use a commercially
available thermostatically regulated water-cooled mask. For most
patients, edema peaks at about this time. Patients are advised not to
place ice or ice-cold compresses on their face, as this is likely to be
injurious to grafted fat and to compromise outcomes.
All patients are provided oral analgesics, sleeping pills, and
antiemetics and are instructed to sleep flat on their backs without
a pillow. A small cylindrical neck roll is permitted if the patient
requests it. This posture assures an open cervicomental angle and
averts neck flexion, dangerous folding of the neck skin flap, and
obstruction of regional lymphatics that inevitably occurs if the
patient is allowed to “elevate their head on pillows” as is commonly
recommended. In addition, swelling will drain to the back of the
head instead of the anterior neck and submental region in this posi-
tion, where it is not harmful, is less noticeable, and is more rapidly
transmitted away from the head and neck area to the torso when the
patient sits upright.
Patients are advised to take a soft, easy chew and digest diet
after surgery and encouraged to feed frequently on liquid and
light-carbohydrates foodstuffs for 2 weeks. Poor dietary intake,
or intentional dieting after fat grafting procedures, is likely to put
metabolic strain on grafted fat and compromise outcomes. Patients
are asked to abstain from the intake of alcohol for 2 weeks after sur-
gery and until they are no longer taking pain pills (acetaminophen
included) or sleeping medication. Showering and shampooing are
not harmful and are permitted even when drains are in place.
50.10 Recovery and Healing
hen patients return to work and their social lives will depend
upon how aggressively their procedure was performed (how
much fat was injected and where), their tolerance for surgery, their
capacity for healing, the type of work they do, the activities they
enjoy, and how they feel overall about their appearance. Patients
are asked to set aside 2 to 3 weeks to recover from surgery, and
additional time off is recommended before an important business
presentation, family gathering, vacation, or like event.
If patients are doing well and not experiencing problems, they
are allowed to travel and return to light office work and casual
social activity 9 to 10 days after surgery. It is often wise that they
begin with a limited workday at first and adjust their schedules
thereafter. If a patient’s job entails more strenuous activity or
physical labor, a longer period of convalescence will likely be
required. Patients are advised not to drive for the first 10 days
50 Simultaneous Facelift and Facial Fat Grafting
after surgery and until they are feeling well, their vision is clear,
and they are off pain medications.
Patients are advised to avoid all strenuous activity during the
first 2 weeks after surgery, including heavy lifting, stooping, strain-
ing, and bending forward, and are informed that aerobic activities
and exercise can result in internal bleeding and hematoma forma-
tion. Two weeks after surgery, patients are allowed to begin light
exercise and gradually work up to their presurgical level of activity.
Four to six weeks after surgery they are allowed to engage in more
vigorous activities, including most sports, as tolerated.
Patients are informed that they will often take 2 to 3 months
to have a natural appearance in a photograph or to be seen at an
important function. They are also advised to expect some firm-
ness in the face and submental areas for 6 to 9 months.
Patients will often mistakenly interpret the resolution of swell-
ing and the return of some facial wrinkles as poor graft survival
and will often comment once healing is complete that the fat went
away. Such comments arise out of the joy most patients experience
when they first see their faces surreally full and smooth after the
procedure, the fact that volume addition to the face often produces
subtle three-dimensional changes, and because most patients
simply forget the extent to which a lack of volume was present in
treated areas on their preoperative faces. The treating physician
can also sometimes initially experience similar disappointment for
similar reasons, and it can take time to train one’s eye to recognize
improvements made. The key to assessing outcomes is to take well-
matched photographs in multiple views and to learn to recognize
improvements made. Reviewing preoperative photographs with
the patient after surgery is an excellent way to assure them that a
beneficial improvement has been obtained and that the procedure
was productive and worthwhile. Ultimately the surgeon with a
well-developed aesthetic eye seeks a nuanced improvement over
multiple areas, not an overly stylized and immediately recogniz-
able filling of one or two regions. Indeed, many of the patient
examples included in this chapter are arguably overfilled and
somewhat stylized outcomes, but these typically need to be shown
to the surgeon learning the procedure to see and appreciate what
is possible. Once the effects of treating each area are understood,
a more nuanced approach to treating one’s patients can be taken.
50.11 Retreatment
Most of the change in facial contour seen on the patient’s face 4 to
6 months after the procedure is likely to consist of living fat and
constitute a persistent improvement, and patients can be informed
that what they see is what they get at that point, as swelling and
induration have largely resolved at that time. Four to six months
after surgery is also the time at which most surgeons performing
fat injections feel that facial edema, induration, and inflammation
have resolved sufficiently to the point where retreatment can be
considered should it be indicated and the patient request it. Since
there is a limit to the amount of fat that can be properly infiltrated
into the thin, atrophic face, the need for secondary fat grafting
should not be viewed as a failure of the primary procedure; it is
simply an inherent limitation of the technique. If the patient has
achieved improvement with the primary treatment, a secondary
procedure will typically be equally or more beneficial and often
can be far less comprehensive than the first.
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 VIII Surgical Rejuvenation of the Face and Neck
50.12 Complications
e have seen no major complications attributable to fat injec-
tions while performing the procedure simultaneously with
facelifts over the past 25 years, including infection and emboliza-
tion, tissue infarction, or blindness. These devastating problems
have been reported, however, and are known to occur when fat
injections are performed. Clinical experience has shown that
embolization is extremely uncommon when fat is injected with
a blunt cannula and in accord with currently recommended
technique, but more cases might be seen as more surgeons
perform the procedure. Embolization and the majority of related
complications, including blindness, have been reported with
sharp needle injection, and these and other complications of fat
injections have been discussed in detail by Coleman and others.
Complications of simultaneous facelift and fat injections
attributable to the fat injection procedure fall largely under the
heading of aesthetic problems and include lumps, oil cysts,
asymmetries, undercorrection, overcorrection, and donor site
irregularities. These are more accurately considered inherent
risks of the procedure, however, in that even if the procedure is
technically performed properly and with care, variations in take
that can occur with any graft, which are beyond the surgeon’s
control, can cause them. This is particularly true in the case of a
fat graft, as fat has shown itself to be comparatively fragile tissue.
Certain patients seem to be at higher risk for problems and com-
plications as a result of compromised condition of fat donor and
recipient sites. These patients include smokers and former smokers,
patients who have undergone previous radiotherapy, and patients
who have undergone radiofrequency or ultrasound skin-shrinking
treatments. Unlike laser resurfacing procedures, where energy
is dispersed on the skin surface, these latter procedures disperse
energy in the deep dermis and subcutaneous areas, which can
cause damage to tissue microcirculation, which appears to com-
promise graft take. Compromise of a similar sort seems to also be
present in patients who have had large volumes of inflammatory
fillers, such as poly-L-lactic acid (PLLA) or calcium hydroxylapatite
(CaHA) microspheres, and in patients who have had hyaluronic
acid–based fillers present for a long time. Simply dissolving
hyaluronic acid–based fillers enzymatically with hyaluronidase
when present does not seem to eliminate this problem, as residual
inflammation seems to be present still, which in turn can result in
suboptimal graft take. All such patients should be approached with
caution, and it is prudent that they be informed that they are likely
to be at an increased risk of problems and complications.
Patients who have undergone previous liposuction, especially
laser or ultrasound procedures, will typically be more difficult to
harvest from. In addition, the fat harvested will typically have an
increased oil (ruptured fat cell) fraction and will be more likely to
have fibrotic tissue fragments that clog injection cannulas.
Most complications will be small and easily managed if fat
injections are performed properly and conservative additions are
made. “Oil cysts” can usually be simply aspirated or unroofed.
Lumps have been exceedingly rare in our own practices but are
now being increasingly seen in patients who have been treated by
other physicians. These can usually be treated by microliposuc-
tion, direct excision, or overgrafting with more fat. Asymmetries
and undercorrections are generally treatable by additional fat
injections, and donor site irregularities are generally treatable
with touch-up liposuction and/or fat grafts.
716
Overcorrection is uncommon in single-stage treatments and is
typically seen only when patients undergo multiple fat injection
procedures. In fact, when a patient returns after a single-session
fat-grafting procedure with an overfilled appearance, one should
be suspicious that the patient has received filler injections from
another physician or other injector. This is particularly the case if a
Tyndall effect (fullness and bluish discoloration in the tear trough
and infraorbital area) is present, if ridges are seen in the nasolabial
creases, or if excess fullness seems to be present in untreated or
lightly fat-grafted areas. In such cases, it is prudent to consider
hyaluronidase administration even if the patient denies having
filler recently placed before the problem is treated as one due to
excess fat, as our experience has frequently shown that in many
cases this will resolve the problem. It should be remembered,
however, that fullness due to PLLA, calcium hydroxylapatite
(CaHA), polymethyl methacrylate (PMMA), silicone, or permanent
filler injections will not respond to hyaluronidase treatment.
hen overcorrection occurs, improvement can usually be obtained
by judicious extraction of fat from overcorrected areas. Other than in
the orbital area, when overcorrection occurs, improvement can be
made by judicious removal of fat from overcorrected areas using a
microliposuction technique (see Fig. 50.42) using a 0.9- or 1.2-mm
injection cannula attached to a 3-mL syringe. Irregularities or
overfilling of the orbital areas often require opening the eyelid and
removing the offending fat under direct vision, however, and small
lumps and bumps on the lips are readily treated by direct excision
using a radially situated incision made in a vermilion wrinkle.
The best way to treat complications is to avoid them altogether,
and the surgeons with the fewest are likely to be the ones who
take the time to learn to perform the procedure properly, obtain
the needed equipment necessary to do so, and introduce it into
their practice gradually and in a conservative manner.
50.13 Some Concerns and Questions
50.13.1 Doesn’t the Fat Go Away?
Although many surgeons recognize volume loss as part of the
aging process, they cling to the excuse that the fat doesn’t last
as a way of not having to learn and perform the fat injection pro-
cedure. This assertion has now been proved to be meritless and
is no longer a valid justification for denying the patient the many
important benefits fat grafting has to offer (Fig. 50.1, Fig. 50.2,
Fig. 50.41, Fig. 50.44, and case examples). Unlike temporary fillers,
fat is living autologous tissue that neovascularizes and establishes
itself as part of the face. It is analogous to hair transplantation and
other grafts performed by plastic surgeons. Furthermore, if the
grafts did not persist, there would not be overcorrected patients.
50.13.2 Isn’t the Fat Lumpy?
Asserting that fat grafts are lumpy has also been a common
excuse surgeons have used not to learn or perform the procedure,
and this too has now been proven to be false and no longer remains
a valid excuse to deny the patient the many important benefits of
fat grafting. If proper technique and equipment are used, lumps
and irregularities will be far less common than problems and
complications seen after almost every other aesthetic surgery
procedure we perform. Unlike fillers, fat actually integrates with
the tissues it is infiltrated into, and there is a natural smoothing
 50 Simultaneous Facelift and Facial Fat Grafting

effect, since fat must be scattered in the tissue to survive. If fat is
injected in clumps, the central fat typically undergoes necrosis
and does not survive. Fat grafting has been our secret weapon for
obtaining faces smoother than can ever be obtained by facelifting
alone (Fig. 50.1, Fig. 50.45). That is not to say that irregularities
are not possible. Fat must be injected with meticulous care in the
appropriate planes for the areas treated if contour irregularities are
to be avoided. Simply put, this means injecting deep in any thin-
skinned area until considerable experience has been obtained.
50.13.3 e e eig
Gain or Loss?
A large weight gain will compromise almost any plastic surgery
procedure, and that is arguably the case with fat grafting as
well. Despite this, a number of anecdotal case reports have been
endlessly recycled at meetings and conferences and among plas-
tic surgeons regarding patients with large lips, overfull cheeks,
and so on as a result of large weight gains after fat grafting. The
reality is that such large weight gains would spoil the result of
almost any aesthetic surgery procedure, and thus any argument
to this effect constitutes false logic and a hypocritical double
standard.
Fat grafting in a child or younger patient does hold the potential
for a change in graft volume with age and weight gain, but most
patients in the typical facelift age group have reached a stable
weight that fluctuates only modestly during the rest of their lives.
Therefore the concern about areas treated with fat becoming
objectionably large with weight gain is essentially overwrought
and again falls into the category of excuse-making by surgeons

a b
Fig. 50.44 Does the fat last? This patient is seen (a) before and (b) 3 years and 7 months after a facelift and fat grafting in which 58 mL of fat was placed.
It can be easily seen that the infraorbital, cheek, midface, buccal recess, nasolabial fold, lips, stomal angle, chin, geniomandibular groove, and jawline
areas are all distinctly fuller almost 4 years after these procedures and that the fat has persisted in each area treated. (Copyright © Timothy Marten.)

a b
Fig. 50.45 Is the fat lumpy? (a) A 55-year-old patient seen before facelift and fat grafting. She has tissue ptosis, skin redundancy, and facial atrophy.
(b) Same patient seen 1 year and 4 months after high–superficial musculoaponeurotic system (SMAS) facelift, neck lift, forehead lift, lower blepharo-
canthoplasty, and panfacial fat injections. If proper technique is used, lumps and irregularities will be far less common than complications seen after
almost every other aesthetic surgery procedure. Practically speaking, fat grafting is the surgeon’s “secret weapon” for obtaining faces smoother than
can ever be obtained by facelifting alone. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

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 VIII Surgical Rejuvenation of the Face and Neck

not interested in learning or taking the time to perform the pro-

cedure. eight gain may actually afford the facelift patient some
benefits in that if weight is gained and the grafts are seen to grow,
growth is experienced in areas where the increase in volume
maintains facial proportion. ithout fat grafts, weight gain tends
to occur in areas that create a disproportionate, unattractive, and
objectionable appearance, such as the jowl and the neck. After
fat grafting, weight gain occurs in all areas, and the face remains
proportionate and appears more attractive. The face may become
bigger, but it remains proportionate and attractive.
50.14 Results/Case Examples
50.14.1 Patient Example 1
The woman in Fig. 50.46 presented at age 45 with overall facial
laxity and panfacial atrophy. She had not had any previous plastic
surgery. She underwent a high-SMAS facelift, neck lift, closed fore-
head lift, and lower eyelid lift combined with transfer of 50 mL of fat
to the temples, cheeks, lips, nasolabial fold, GMG, stomal angles, and
upper and lower orbital areas (Fig. 50.2). Two years and 4 months

Fig. 50.46 Patient Example 1. (a,b,c) Before-surgery views of a woman, aged 45. Note overall facial laxity and panfacial atrophy. The patient has had
no previous plastic surgery. (d,e,f) Same patient, 2 years and 4 months after high–SMAS facelift, neck lift, closed forehead lift, lower eyelid lift, and
fat transfer to the temples, cheeks, lips, nasolabial, geniomandibular groove, stomal angles, and upper and lower areas (see Fig. 50.2 for a diagram
of fat placement). A total of 50 mL of fat has been placed. Note soft, natural facial contours and the absence of a tight, pulled, or “facelifted” appear-
ance. Facial atrophy has also been simultaneously corrected and the patient has a healthier, more youthful, and more feminine appearance. The
combined facelift and fat injection procedures have produced a result that could not be obtained by either procedure alone. (All surgical procedures
performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

718
 50 Simultaneous Facelift and Facial Fat Grafting

postoperatively, she shows soft, natural facial contours without a eyelid lifts, and earlobe reduction, and he received a total of 28
telltale tight or pulled appearance. She looks healthier, younger, and mL of facial fat injections. He is shown 1 year and 9 months after
more feminine thanks to the correction of her facial atrophy. his procedure. These combined procedures restored a younger,
healthier, and more virile appearance.

50.14.2 Patient Example 2

The 68-year-old man in Fig. 50.47 presented with sagging
cheeks, cheek folds, and jowls and loss of volume in the cheeks,
infraorbital, perioral, and GMG areas. He underwent a high-
SMAS facelift, neck lift, closed forehead lift, upper and lower
50.14.3 Patient Example 3
Although the face of the 53-year-old woman in Fig. 50.48 might
appear full at first glance, she shows regional atrophy in her tem-
ples, cheeks, infraorbital and perioral regions, GMG, chin, and

Fig. 50.47 Patient Example 2. (a,b,c) Before-surgery view of a man, aged 68. The patient has sagging cheeks, deep cheek folds, and jowls. Loss of
facial volume is also evident in the cheeks, infraorbital, perioral, and geniomandibular groove areas. (d,e,f) Same patient, 1 year and 9 months after
high–SMAS facelift, neck lift, closed forehead lift, upper and lower eyelid lifts, partial facial fat injections, and earlobe reduction. A total of 28 mL of
fat was placed. Note restoration of youthful and masculine facial shape without a tight or pulled appearance. Facial atrophy has also been simultane-
ously corrected and the patient has a healthier, more youthful, and masculine appearance. The combined facelift and fat injection procedures have
produced a result that could arguably not have been obtained by either procedure alone. (All surgical procedures performed by Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)

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 VIII Surgical Rejuvenation of the Face and Neck

jawline with sagging jowls. Previous upper and lower eyelifts
have been performed by an unknown surgeon. She underwent
a high-SMAS facelift, neck lift, temple lift, canthopexy, and mole
removal, combined with 66 mL of fat placed in her temples,
cheeks, infraorbital, nasolabial, perioral, GMG, chin, and jawline.
She is shown 1 year and 5 months after her procedure. The addi-
tion of fat to her face made it younger and more fit and attractive.
50.14.4 Patient Example 4
This 62-year-old woman had undergone facelift, neck lift,
blepharoplasties, and other procedures performed by
unknown surgeons, but her face still showed sagging in the
neck and jowls as well as atrophy in the cheeks, temples, chin,
and jawline along with the orbital, perioral, and GMG areas.

Fig. 50.48 Patient Example 3. (a,b,c) Before-surgery view of a woman, aged 53. Although the patient’s face appears full at first glance, a careful
examination shows regional atrophy to be present in the temples, cheeks, infraorbital, perioral, geniomandibular groove, chin, and jawline areas.
The patient has had prior upper and lower eyelifts performed by an unknown surgeon. (d,e,f) Same patient, 1 year and 5 months after high–SMAS
facelift, neck lift, temple lift, canthopexy, and fat transfer to the temples, cheeks, infraorbital, nasolabial, perioral, geniomandibular groove, chin,
and jawline areas. A total of 66 mL of fat was placed simultaneously with the facelift and related procedures. Note soft, natural facial contours and
the absence of a tight, pulled, or “facelifted” appearance. Facial shape has been significantly improved, and the patient now has a more youthful
appearance. Although fat has been added to the patient’s face, it has a more trim, fit, and feminine appearance. Note also that lips are fuller but
natural-appearing. The combined facelift and fat injection procedures have produced a result that could arguably not have been obtained by either
procedure alone. An unwanted mole has been removed from the left upper lip. (All surgical procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)

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 50 Simultaneous Facelift and Facial Fat Grafting

She underwent a high-SMAS facelift, neck lift, small-inci- lower orbital regions, cheeks, midface, lips, stomal angle,
sion forehead lift, and earlobe reduction; she received 70 chin, and jawlines as well as the orbital, perioral, and GMG
mL of fat placed in the temples, glabella, radix, upper and regions; and she also underwent trichloroacetic acid (TCA)

Fig. 50.49 Patient Example 4. (a,b,c) Before-surgery view of a woman, aged 62, who had had previous facelift, neck lift, blepharoplasties,
and other procedures performed by an unknown surgeon. Note residual facial sagging and neck and jowl fullness. Although the patient’s face
appears full at first glance, a careful examination shows atrophy to be present in the temples, cheeks, and orbital, perioral, geniomandibular
groove, chin, and jawline areas. (d,e,f) Same patient, 12 months after high–SMAS facelift, neck lift, small-incision forehead lift, trichloroacetic
acid lower eyelid peel, earlobe reduction, perioral dermabrasion, and fat grafting of the temples, glabella, radix, upper orbital, lower orbital,
cheek, midface, nasolabial, perioral, lip, geniomandibular groove, stomal angle, chin, and jawline areas. A total of 70 mL of fat was placed
simultaneously with the facelift and related procedures. Note restoration of youthful and feminine facial shape without a tight or pulled
appearance. Facial atrophy has also been simultaneously improved. Temple hollowing has been corrected, orbital atrophy corrected, an
improved transition from the lower eyelid to the cheek is evident, the cheek and midface can be seen to be fuller, and the chin flows smoothly
and aesthetically into a smooth jawline. Although fat has been added to the patient’s face, it has a more trim, fit, feminine, and photogenic
appearance. Note also that lips are fuller but natural-appearing. The combined facelift and fat grafting procedures have produced a result that
arguably could not have been obtained by either procedure alone. (All surgical procedures performed by Timothy Marten, MD, FACS. Copyright
© Timothy Marten.)

721
 VIII Surgical Rejuvenation of the Face and Neck

peel in the lower eyelid and dermabrasion in the perioral
regions. She is shown 12 months following her procedure.
These combined procedures restored a younger, healthier,
and more youthful appearance with a smooth aesthetic tran-
sition from the lower eyelid to the cheek and from the chin
to the jawline.
50.14.5 Patient Example 5
The 75-year-old woman in Fig. 50.50 had previously undergone
multiple facelifts and other cosmetic procedures, including laser
resurfacing that was performed by unknown plastic surgeons,
yet cheek laxity and uncorrected panfacial atrophy left her with a

Fig. 50.50 Patient Example 5. (a,b,c) Preoperative views of a woman, aged 75, who had had multiple prior facelifts and related procedures, including
previous laser resurfacing, performed by unknown plastic surgeons. Note marked cheek laxity despite prior surgeries, and fragile, elderly appearance
due to uncorrected panfacial atrophy. Another facelift would predictably produce a gaunt, haggard, or even ill appearance. (d,e,f) Same patient,
1 year 7 months after high–SMAS facelift, neck lift, forehead lift, upper and lower eyelid lifts, canthopexy, and fat transfer to the temples, cheeks,
midface, upper and lower eyelids, lips, nasolabial creases, stomal angles, geniomandibular grooves, chin, and jawline. A total of 90 mL of fat was
placed simultaneously with the facelift and related procedures. No skin resurfacing, facial implants, or other ancillary procedures were performed.
In these situations fat injections are arguably more important to the overall outcome than the facelift itself. Facial contour has been significantly
enhanced and facial volume restored. The patient has a healthy, fit, and feminine appearance that could not have been obtained by either procedure
performed alone. (Previous procedures performed by an unknown surgeon. Secondary surgical procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)

722

fragile, elderly appearance. She underwent a high-SMAS facelift,
neck lift, forehead lift, upper and lower eyelid lifts, and cantho-
pexy along with transfer of 90 mL of fat to her temples, cheeks,
midface, eyelids, lips, nasolabial creases, stomal angles, GMGs,
chin, and jawline. She is shown 1 year and 7 months after her
procedure. These combined procedures resulted in a healthy, fit,
younger, and more feminine appearance that could not have been
achieved by the surgical procedures or the fat grafting alone.
Clinical Caveats
• Patients with significant facial atrophy will generally achieve
suboptimal improvement from both surface treatments of
facial skin and surgical lifts. The addition of fat to areas of the
face that have atrophied due to age or disease can produce a
significant and sustained improvement in appearance unob-
tainable by other means.
• Performing fat injections in conjunction with a facelift has
certain disadvantages that must be acknowledged, including
the learning curve associated with any new procedure, an
increase in operating room time, increased postoperative
edema, a longer period of recovery, and uncertainty of graft
take.
• Fat contains adult stem cells that have been shown to
produce growth factors and other as yet not clearly defined
cellular mediators that have a regenerating effect on adjacent
tissues, and injecting fat into the face as part of a facelift has
a rejuvenating and regenerative effect on the facial skin not
obtainable with “lifting” or resurfacing.
• Isolated fat injections are of questionable benefit to the
patient troubled by significant facial sagging and skin
redundancy. Although aggressive filling of the sagging face
with fat can produce improved contour and a smoother-ap-
pearing skin surface, it generally results in an unusually
large, overfilled face that appears both unnatural and
unfeminine.
• Areas in need of treatment with fat will vary from patient, and
planning fat injections requires looking at the face more as a
“sculptor” and less as a “tailor” than we have done in the past.
• Poor outcomes are typically obtained if sharp hypodermic
needles are used to harvest and inject fat and if fat is injected
in a manner similar to that used to inject nonautologous
facial fillers. Sharp needle injection can also result in fat
embolization and serious related problems and thus is not
recommended.
• Donor sites are typically chosen in conjunction with patients
in such a manner as to improve their silhouette, although
ideal locations are arguably those areas of diet- and exercise-
resistant fat collections where the fat is biologically pro-
grammed to be persistent throughout the patient’s life.
• It is recommended that the donor sites and site markings be
preoperatively photographed to document what was agreed
upon and to avoid any dispute over the patient’s preoperative
condition after surgery.
• Fat should be harvested in a thoughtful and artistic manner
that improves the patient’s figure, and thus it must generally
be removed bilaterally and in a symmetric fashion unless
body contours dictate otherwise.
50 Simultaneous Facelift and Facial Fat Grafting
• Harvested fat is generally not uniform in character, as each
syringe will contain a variable amount of fat, blood, local
anesthetic, and ruptured fat cells, and some type of process-
ing is necessary to obtain uniform material for injection.
• Not all fat cells are the same, and available scientific evidence
suggests that higher-density fat cells have higher stem cell
activity. Accordingly, centrifugation, which concentrates
high-density fat, is arguably a better way to process fat after
harvesting than simply letting it settle or by washing it in a
“tea strainer”-type sieve, as the latter methods do not allow
high-density fat to be segregated.
• A common misconception in treating the hollow upper orbit
is that the fat should be injected to the preseptal portion of
the eyelid itself. Volume is more properly restored by placing
fat in a preorbital position along the inferior margin of the
supraorbital rim, and the goal in treating the upper orbit
should be thought of as lowering the inferior margin of the
supraorbital rim.
• It should always be remembered that when injecting the
upper orbit, one is working in close proximity to the eye, and
although the injection cannulae are blunt-tipped, they are
capable of perforating the ocular globe. Technical measures
described herein must be taken to protect the patient’s eye.
• Filling the upper cheek produces a profoundly beneficial effect
on the nasolabial crease, and that treatment of the crease is
more effective when combined filling of both these areas is
made. If the cheek is filled, less fat is needed to improve the
nasolabial crease.
• A common error to be avoided when injecting fat into the lips
is to fill the lips in such a manner that a large but shapeless
and unnatural-appearing “sausage lip” is produced. The
attractive lower lip typically has two areas of fullness laterally
with a small central depression between them. The attractive
upper lip, on the other hand, has three areas of fullness,
one centrally and one on each side with a slight depression
between them. Time taken to inject fat to create these sorts
of appearances is well spent.
• Injection of the geniomandibular groove (GMG) with fat has
a high aesthetic payoff and is a good area for the beginning
injector to gain experience with the technique. Filling the
GMG creates a strong, uninterrupted aesthetic line from the
chin to the mandible and is a highly desirable improvement
on both the male and the female face.
• Although not intuitively obvious, strengthening the jawline
and posterior mandibular border makes patients appear
more youthful, fit, and attractive and is an artistically pow-
erful adjunct to a facelift that helps avert the deficient and
fragile mandibular contour typically seen in the aging and
elderly face.
• It is wise to make small additions of fat to “safe” areas at first
to gain familiarity with the technique. Less forgiving areas
should initially be avoided. Starting out conservatively in this
manner will mean that problems, should they occur, will be
minor and easily managed.
• Treated patients should be followed up carefully, outcomes
critically evaluated, and ways to improve one’s technique
continually sought.
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 VIII Surgical Rejuvenation of the Face and Neck
50.15 Acknowledgment
All figures, illustrations, tables, and descriptions of concepts,
methods, and technique included in this chapter are courtesy of
the Marten Clinic of Plastic Surgery and are used with permission.
Opinions expressed in this writing are those of the authors and
are not intended to be construed as, or used to define, a standard
of care.
Suggested Reading
[1] Marten T, Elyassnia D. Fat injection: a systemic review of injection volumes by
facial subunit discussion article. Aesthetic Plast Surg 2018;2018(42):5
2 Marten T, Elyassnia D. Facial fat grafting: why, where, how, and how much.
Aesthetic Plast Surg 2018;42(5):1278–1297
724
3 Marten T, Elyassnia D. Simultaneous facelift and fat grafting: combined lifting
and filling for rejuvenation of the aging face. In: Coleman S, Mazzola R, Pu L,
eds. Fat Injection from Filling to Regeneration, 2nd ed. ew ork, : Thieme;
2018
4 Marten T, Elyassnia D. Simultaneous facelift and fat grafting. In: Connell BF, Sun-
dine M , eds. Aesthetic Rejuvenation of the Face and Neck. ew ork, : Thieme;
2016:160–187
5 Marten TJ. Secondary deformities and the secondary facelift. In: eligan P, Rubin
P, eds. Plastic Surgery. Vol. 2: Aesthetic, 4th ed. London, U : Elsevier; 2018
6 Marten T, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg
2015;42(2):219–252
[7] Marten T . High SMAS facelift: combined single flap lifting of the jawline, cheek,
and midface. Clin Plast Surg 2008;35(4):569–603
[8] Marten T . Facelift. Planning and technique. Clin Plast Surg
1997;24(2):269–308
[9] Marten T . Maintenance facelift: early facelift for younger patients. Semin Plast
Surg 2002; 16(4):375–390

51 Facial Implant Augmentation
Imran Ratanshi and Michael J. Yaremchuk
Abstract
Alloplastic implant augmentation offers an accurate and pre-
dictable strategy to address facial skeletal deficiency. Silicone or
porous polyethylene implants are most common owing to their
predictable implant behavior and capacity for fine-tuning with
scalpel or contouring bur. Facial implants are commonly used to
augment the mandible, malar eminence, piriform aperture, and
infraorbital rim. Most deficiencies can be managed with ready-
made or off-the-shelf implants. However, three-dimensional
irregularities, such as postorthognathic contour imbalances,
are best addressed with custom computer-assisted designed/
manufactured (CAD/CAM) implants. This chapter will describe
principles underlying implant selection, indications for treat-
ment, and operative technique to optimize aesthetic outcome.
Keywords
facial augmentation, alloplastic implant, silicone, porous poly-
ethylene, mandible, malar, infraorbital, piriform, CAD/CAM
51.1 Indications
Since the skeletal infrastructure is fundamental to facial
appearance, patients with normal, deficient, or surgically altered
anatomy may all benefit from augmentation of their craniofacial
skeleton.
Conceptually, autogenous bone would be the best material to
restore or augment the craniofacial skeleton, because it has the
potential to be vascularized and subsequently incorporated into
the facial skeleton. However, donor site morbidity as well as the
time and operative costs associated with autogenous bone can
be significant. In addition, the inevitable resorption and the
poor handling characteristics of autogenous bone grafts limit
a b
Fig. 51.1 A 52-year-old woman underwent posterior mandible and chin augmentation to increase angularity at the time of rhytidectomy.
(a) Preoperative lateral view. (b) Diagrammatic representation of implant augmentation. (c) Postoperative lateral view.
51 Facial Implant Augmentation
the quality and predictability of the aesthetic result. For these
reasons, the majority of facial skeleton augmentation is done with
alloplastic implants.
51.1.1 n e nd e ni i n
Facial skeletal augmentation is most often done to enhance
facial appearance in patients whose skeletal relationships are
considered within the normal range. Definition, angularity and
balance of their facial dimensions is desired (Fig. 51.1).
51.1.2 e ien y
Skeletal osteotomies and rearrangement are usually required to
treat facial deformities that are disfiguring and are of functional
consequence to vision, breathing, and mastication. Mild midface
and mandibular hypoplasia are common in patients with normal
or orthodontically compensated occlusion. The appearance
of skeletal osteotomies and rearrangements can be simulated
through the use of facial implants in these patients. Fig. 51.2
and Fig. 51.3 demonstrate how implant surgery can mimic the
appearance of skeletal osteotomies in this group of patients.
Because the Le Fort I maxillary osteotomy and advancement is
performed beneath the infraorbital foramen, the midface skeleton
above the foramen remains deficient in its sagittal projection. The
midface skeleton is now more prominent in its lower half after Le
Fort I advancement surgery and as a result, the cheeks appear low.
Sagittal split osteotomy of the deficient mandible with advance-
ment in the sagittal plane may result in ramus asymmetry. Gaps
at the osteotomy sites after sagittal osteotomy of the mandible, or
horizontal osteotomies of the chin with advancement, can leave
visible depressions along the mandible border. Implants designed
to augment the infraorbital rim can correct the upper midface
deficiency after Le Fort I advancement. Implants designed to
c
725
 VIII Surgical Rejuvenation of the Face and Neck

a b

c d
Fig. 51.2 (a) Illustration of midface concavity and Class III malocclusion. The dotted line shows potential lines of osteotomy, and the arrow shows
anticipated advancement. (b) Osteotomy and advancement at the Le Fort III level provides midface projection and Class I occlusion. Note change
in soft tissue profile. (c) Illustration of midface concavity and corrected Class I occlusion. (d) Multiple midface implants provide a soft tissue profile
mimicking the effect of Le Fort III osteotomy and advancement but do not alter occlusion.

a b

c d
Fig. 51.3 (a) Mandibular deficiency with Class II malocclusion. Dotted line shows potential lines of osteotomy. Arrows show anticipated advance-
ment. (b) After sagittal split osteotomy with horizontal osteotomy advancement of the chin to increase chin projection. Note that the occlusion has
been corrected from Class II to Class I. Note change in soft tissue profile. (c) Mandibular deficiency with corrected Class I occlusion. (d) The visual
effect of sagittal split osteotomy and horizontal osteotomy of the chin with advancement has been simulated with mandible and chin implants.
Note that the Class I occlusion is unchanged. Note the change in soft tissue profile. Notice also that the border regularities inherent with skeletal
osteotomies are avoided when implants are used. Patients who have had orthognathic surgery to correct occlusal disharmony are often left with
contour imbalances and irregularities. Both the midface and lower face can manifest characteristic postorthognathic contour irregularities, which are
amenable to alloplastic implant improvement.

726
 51 Facial Implant Augmentation

augment the mandible angle can camouflage angle asymmetries.
Implants can bridge the gap at sagittal and horizontal osteotomy
sites to create a regular contour of the mandible border (Fig. 51.4;
Fig. 51.5). The gap implants are routinely placed secondarily but
can also be placed at the time of primary surgery.
Because postorthognathic contour imbalances and irregular-
ities are three-dimensional (3D), computer-assisted designed/
manufactured (CAD/CAM) implants are invaluable in improving
appearance in this group of patients. Fig. 51.6 shows a 3D
computed tomography (CT) image of a patient after mandibular
osteotomies and the implants designed to create symmetry.
Computer technology has recently been introduced to plan and
guide orthognathic osteotomies as well as to design and manu-
facture custom fixation devices. ith preoperative anticipation
and prediction of the intraoperative surgical outcome, implants
potentially can be designed to correct anticipated imbalances at
the time of the orthognathic procedure.
51.1.3 Rejuvenation
The soft tissue changes associated with facial aging occur in
concert with remodeling processes of the craniofacial skeleton.
Pessa and colleagues, as well as Shaw and ahn, analyzed
changes in shape to the orbital rims in different age subgroups
(see Suggested Reading). Findings included curve distortions of
the superior medial upper orbit and inferolateral lower orbit.
There was also retrusion of the infraorbital rim, as illustrated
in Fig. 51.7. Alloplastic augmentation of the infraorbital rim can
restore youthful contour in an aged skeleton.
Shaw and han also showed that retrusion of the midface
skeleton with age as demonstrated by the difference in glabella,
maxilla, and piriform angles. Morphologic changes with age were
also documented in the mandible. Alloplastic augmentation can
restore youthful skeletal contours while providing support for the
soft tissue envelope as shown earlier in Fig. 51.1.
51.2 Evaluation and Planning
Physical examination is the most important element of preoper-
ative assessment and planning. Reviewing photographic images
with the patient can be helpful when discussing aesthetic con-
cerns and goals. All faces are asymmetric. This recognition pre-
operatively is important to both the surgeon and the patient. The
patient’s asymmetry should be pointed out during the preoper-
ative consultation so that the patient can anticipate asymmetry
in the postoperative result. Preoperatively, the asymmetries
belong to the patient. Postoperatively, if not identified before the
surgery, they are attributed to the surgeon.

a b c d
Fig. 51.4 Typical facial contour sequelae after orthognathic surgery and subsequent implant correction. (a) Lateral appearance of patient after Le
Fort I advancement, sagittal split, and horizontal chin osteotomies. (b) Illustration showing skeletal movements responsible for facial contour dishar-
monies and irregularities. (c) Infraorbital rim, mandible angle, and chin implants to correct imbalances and irregularities. (d) Postop appearance after
implant correction.

a b
Fig. 51.5 Implants are available that span short gaps in inferior border contour after horizontal or sagittal ostotomy (Matrix Surgical, Atlanta, GA).
These implants may be placed at the time of osteotomy surgery or during secondary surgery. (a) Model with osteotomy gap. (b) Implant spans
osteotomy gap resulting in regular mandibular border.

727
 VIII Surgical Rejuvenation of the Face and Neck

a b

Fig. 51.6 Three-dimensional computed tomography (CT) images used to plan correction of mandible asymmetry after mandibular osteotomies.
(a) Image after osteotomies. (b) Image of implants designed to create symmetry.

Fig. 51.7 Pessa et al showed that in the youthful face, the cheek fat lies anterior to the cornea and the orbital fat lies slightly anterior to the orbital
rim. With aging, the cheek mass tends to lie posterior to the anterior surface of the cornea, the orbital fat moves slightly anterior, and the infraorbital
rim has a significant movement posteriorly. Hence, retrusion of the infraorbital rim with aging will make the eyes appear more prominent by changing
globe–rim relations, and it will significantly impact the appearance of the lower lid bags, particularly in those who tend toward maxillary hypoplasia.

51.2.1 Radiologic Examination 51.2.2 Facial Measurements

Most aesthetic procedures are done without preoperative radio-
logic assessment. In general, the size and position of the implant
are largely aesthetic judgments. Cephalometric X-ray images are
most often used for planning chin augmentation surgery.
CT scans provide the ability to view the skeleton in different
planes and, through computer manipulation, in three dimen-
sions. CT imaging provides digitized information that can be
transferred to CAD/CAM design software. CAD/CAM implants
provide an increased level of refinement in both reconstructive
and aesthetic applications. Full-scale (1:1) models can also be
fabricated using CAD/CAM methods for surgical planning, and
implants can be customized for the needs of the patient. The
design process can also be conducted virtually, as demonstrated
in Fig. 51.8.
Because implant augmentation of the facial skeleton results in
measurable changes in facial dimensions and proportions, it
is intuitively attractive and appropriate to use facial measure-
ments to evaluate the face and to guide surgery. hile they are
commonly referenced in texts discussing facial skeletal augmen-
tation, neoclassical canons have a limited role in surgical evalu-
ation and planning. Similar to Leonardo da Vinci’s observations,
they are based on idealizations.
Medical anthropology is the accumulation of large numbers
of precise, reproducible surface measurements of various popu-
lation groups of both sexes. These data define normative values
as well as gender and ethnic differences in facial measurements
and proportions. Anthropometric landmarks, measurements, and
inclinations are useful for planning implant and other craniofacial

728

Fig. 51.8 Virtually planned custom midface, chin, and mandible implants. Native anatomy is shown in relief. (a) Anteroposterior craniofacial view.
(b) Lateral craniofacial view.
surgery. Frontal views of female and male faces drawn from
average anthropometric measurements for 21-year-old orth
American Caucasians are shown in Fig. 51.9.
51.2.3 Sexual Dimorphism
On average, all facial measurements are greater in men than in
women. In addition, the relations between measurements differ
in men and women. For example, the lower third of women’s
faces tends to be absolutely and relatively narrower than that
of men. Sex-related differences have implications for surgical
planning. Fig. 51.10 shows typical male and female skulls.
51 Facial Implant Augmentation
51.3 Autogenous Implant Materials
51.3.1 Bone
Autogenous bone has the potential to be revascularized and
then assimilated into the facial skeleton. For that reason, it is the
only material available to reconstruct segmental load-bearing
defects of the facial skeleton reliably. hen used as an onlay
graft, these attributes can lead to graft resorption and unreliable
augmentation of the facial skeleton. The morbidity, time, and
cost associated with autogenous graft harvest also makes it an
unattractive material for aesthetic facial skeletal augmentation.
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 51.9 Frontal view of female and male faces drawn from average anthropometric measurements for 21-year-old North American Caucasians.

a b
Fig. 51.10 (a) Male and (b) female skull images. (Courtesy of the Atkinson Skull Collection, University of the Pacific School of Dentistry, Webster
Street, San Francisco, CA.)

51.3.2 Fat
Autogenous fat grafting has become a valuable addition to the
facial aesthetic procedural armamentarium. A small augmenta-
tion of either the underlying skeleton or the overlying soft tissue
envelope may result in almost clinically imperceptible facial con-
tour. However, the resultant facial contours diverge between these
modalities as the degree of augmentation increases. A progressive
increase in the projection of the facial skeleton by osteotomy
and advancement, or with alloplastic augmentation using rigid
implant materials, results in a facial contour that is increasingly
skeletal and defined. On the other hand, a progressive increase in
the volume of the overlying soft tissue envelope results in a facial
contour that is increasingly less defined. In many clinical instances,
fat grafting can complement the result of skeletal augmentation.
area morbidity while vastly simplifying the procedure in terms
of time and complexity. Implant materials used for facial skeletal
augmentation are biocompatible; that is, they have an acceptable
reaction between the material and the host. In general, the host
has little or no enzymatic ability to degrade the implant, with the
result that the implant tends to maintain its volume and shape.
Likewise, the implant has a minimal and predictable effect
on the host tissue that surrounds it. The alloplastic implants
presently used for facial reconstruction have not been shown to
have any toxic effects on the host. The host response to these
materials involves forming a fibrous capsule around the implant,
which is the body’s way of isolating the implant from the host.
The most important implant characteristic that determines the
nature of the encapsulation is the implant’s surface characteris-
tics. Smooth implants result in the formation of smooth-walled
capsules. Porous implants allow varying degrees of soft tissue

51.4 Alloplastic Implant Materials ingrowth, which results in a less dense capsule).
Solid silicone, porous polyethylene, polytetrafluoroethylene
Virtually all aesthetic facial skeletal augmentation is done with (PTFE), and hydroxyapatite (HA) are the materials most often used
alloplastic materials. The use of synthetic material avoids donor for aesthetic facial augmentation.

730
 51 Facial Implant Augmentation

51.4.1 Polysiloxane (Silicone) 51.5 Morbidity and Complications

Solid silicone (Implantech, Ventura, CA) or the silicone rubber Associated with Alloplastic
used for facial implants is a vulcanized form of polysilox-
ane. It has the following advantages: it can be (i) sterilized Implants
by steam or irradiation, (ii) carved with either a scissors
The facial implants just described are biocompatible. Extensive
or scalpel, and (iii) stabilized with a screw or a suture.
review of the literature discounts any association of these
Because of its smooth surface, it can be removed quite easily.
implants with carcinogenicity, systemic disease, or hypersen-
Disadvantages include the tendency to cause resorption of
sitivity. Complications tend to be technique-related rather than
bone underlying it, particularly when used to augment the
due to material selection. The senior author’s personal experi-
chin; the potential to migrate if not fixed; and the potential
ence with porous polyethylene implants placed over a 10-year
for its fibrous capsule to be visible when placed under a thin
period in 661 patients demonstrated a 1.6 overall complication
soft tissue cover.
rate.

51.4.2 yer u r e y ene 51.5.1 Bone Erosion

Polytetrafluoroethylene (PTFE; Gore-Tex, Implantech,
Bone erosion, which is inevitable beneath smooth implants and
Ventura, CA) has a carbon–ethylene backbone to which are
visible on X-ray images, often raises concern, but it is never clini-
attached four fluorine atoms. It is very chemically stable, has
cally apparent. Receded bone may complicate secondary surgery
a nonadherent surface, and because it is not cross-linked, it
by creating an irregular skeletal surface. Rarely, an implant
is very flexible. Preformed implants are made with a pore
positioned over a tooth root can result in bone erosion, which
size between 10 and 30 m, which allows for some soft tissue
may lead to dental symptoms requiring root canal surgery.
ingrowth. However, it is smooth enough to be maneuvered
easily through soft tissues. This material can be fixed to
underlying structures with sutures or screws. It is easily 51.5.2 Infection
sterilized.
Implants are susceptible to bacterial colonization and infection.
If microorganisms are not eliminated rapidly from an implant
51.4.3 Polyethylene surface, they will adhere to the implant initially by nonspecific
physical forces and then by the formation of biofilms character-
Polyethylene is a simple carbon chain of ethylene monomer.
ized by clustering together in an extracellular matrix attached
The high-density, porous variety (Omnipore, Matrix Surgical,
to the implant. Biofilms protect bacteria from host defenses
Atlanta, GA; Medpor, Stryker, alamazoo, MI) is used for
and antibiotics. Since antibiotic treatment alone is usually not
facial implants because of its higher tensile strength. The
successful, facial implant–related infections are best treated by
porosity of Omnipore or Medpor has both advantages and
implant removal and appropriate wound care. Implants may be
disadvantages. The advantages include its tendency to allow
replaced in 6 to 12 months.
extensive soft tissue ingrowth, thereby lessening its tendency
to migrate and to erode underlying bone. Its firm consistency
allows it to be easily fixed with screws and contoured with 51.5.3 Implant Malposition
a scalpel or electrically powered bur without fragmenting.
The limited skeletal exposure afforded by remote incisions,
However, its porosity causes soft tissue to adhere to it,
a complex 3D skeletal topography, and potential mismatch
making placement more difficult and requiring larger pock-
between the posterior surface of an implant and the facial
ets to be made than with smooth-surfaced implants. The soft
skeleton can lead to less than ideal implant placement. Implant
tissue ingrowth also makes implant removal more difficult
malposition is best avoided by wide subperiosteal exposure of
than with smooth-surfaced implants. Despite these intrinsic
the area to be augmented, thus providing landmarks to guide
shortcomings, porous polyethylene remains the authors’
positioning. Once the desired location is determined, screw
implant material of choice.
fixation guarantees that the implant cannot be displaced in the
postoperative period. Screw fixation also obliterates any gaps
51.4.4 Hydroxyapatite between the posterior surface of the implant and the skeleton.
Gaps translate into unanticipated increases in implant projec-
Hydroxyapatite is a calcium phosphate salt found as a major
tion. The exact fit of CAD/CAM implants to the desired area of
component of bone matrix. Dense hydroxyapatite can be
augmentation make malposition less likely.
produced synthetically. Porous hydroxyapatite can be entirely
synthetic or formed by chemically converting the naturally
porous calcium carbonate skeleton of marine coral. Porous 51.6 Operative Technique
hydroxyapatite is also available as granules for injection.
Hydroxyapatite has the theoretical advantage of being oste- 51.6.1 Preparation
oinductive and osteoconductive. These attributes have been
shown experimentally but have yet to demonstrate clinical To facilitate intraoperative hemostasis, patients are instructed
relevance. to discontinue any medications, foods, or supplements that can

731
 VIII Surgical Rejuvenation of the Face and Neck
compromise the blood clotting cascade. To optimize intraoral
hygiene, professional dental examination and cleaning may be
indicated. Patients are always prescribed chlorhexidine mouth-
wash for 48 to 72 hours prior to the anticipated surgery.
ith the exception of chin augmentation, operations are per-
formed with the patient under general anesthesia, preferably with
nasotracheal intubation. Since most operations employ intraoral
incisions, this approach optimizes access and allows optimum
preparation of the operative site as well as control of the airway
(Fig. 51.11). The operative field is infiltrated with a solution con-
taining epinephrine (1:200,000) to minimize bleeding. A throat
pack is placed, and both the skin and the oral mucosa are prepared
with a povidone–iodine solution. Antibiotics, usually cephalospo-
rins, are administered intravenously prior to the onset of surgery
and redosed intraoperatively depending on the length of surgery.
Oral antibiotics are administered for the 5 days following surgery
only if intraoral access for implant placement was employed.
51.6.2 Incisions
Incisions are always planned remote from implant placement
and never obtained through open wounds. Implants positioned
directly beneath surgical incisions are at risk for exposure,
contamination, and then loss. These operative approaches are
borrowed from craniofacial and aesthetic surgery.
Coronal incisions are used to place implants in the frontal and
temporal areas. Transconjunctival retroseptal incisions (often with
Fig. 51.11 General anesthesia using nasotracheal intubation is ideal
for midface and mandible augmentation. Endoscopy draping of the
endotracheal tube and circuit allows it to be in the operative field and
mobile. The airway is protected and controlled. A panoramic view of
the operative area is provided.
732
a lateral canthotomy for increased exposure) are used to access
the infraorbital rim, malar area, and internal orbit. The lateral
extent of the lower lid blepharoplasty incision provides access to
the lateral orbit and zygomatic arch. This small cutaneous incision
leaves an inconspicuous scar. It is used with the transconjunctival
approach when a lateral canthotomy is avoided. Blepharoplasty
skin–muscle flaps provide alternative access to this area.
Intraoral incisions are used to augment the midface as well as
the mandibular body and ramus. Intraoral incisions are made
with a generous labial cuff to allow watertight, reliable mucosal
closure (Fig. 51.12).
Chin area augmentation is preferably performed through a
submental incision. This approach to the chin provides optimal
exposure of the skeletal anatomy and the mental nerves. Unlike
the intraoral approach, which avoids a cutaneous scar, the sub-
mental approach does not violate the mentalis muscle. Mentalis
dysfunction can result in lower lip descent, excessive lower tooth
show, and chin pad ptosis.
51.6.3 Implant Selection
The majority of aesthetic facial skeletal augmentation is done
with silicone (Implantech, Ventura, CA) or porous polyethylene
(Omnipore, Matrix Surgical, Atlanta, GA; Medpor, Stryker,
alamazoo, MI), implants; the latter is the senior author’s
preference. It is important to note that manufacturers provide
multiple implant shapes and sizes intended for specific anatom-
ical areas. It is unusual for the senior author to use an implant
without changing its contour (reducing it) to meet the needs of
the specific situation. Implants can be trimmed with a scalpel or
bur for precise contouring.
51.6.4 Screw Fixation
Screw fixation prevents movement of the implant, which adds
precision as well as early and late predictability to the result. By
Fig. 51.12 Surgical access to expose the posterior mandible. An intra-
oral mucosal incision is made along the ramus and posterior body of
the mandible approximately 1 cm above the sulcus on its buccal side.
Intraoral incisions to expose the midface are also made approximately
1 cm above the sulcus on the labial side.

applying the implant to the skeleton, screw fixation eliminates
any gaps between the implant and the recipient bed. Gaps are
potential sites for hematoma or seroma accumulation. Gaps
provide an unanticipated increase in implant projection, thereby
resulting in an effective increase in augmentation and risk for
migration and malposition. Screw immobilization of the implant
allows in-place contouring of the implant at the recipient site,
which can enable creation of a clinically imperceptible transition
between the implant and the recipient skeleton.
51.6.5 Hemostasis
Several maneuvers are employed to minimize bleeding and its
sequelae. These include infiltration of the operative field with
epinephrine-containing solution prior to the onset of surgery.
Dissection is performed in the subperiosteal plane. The majority
of dissection is done with the needle-tipped electrocautery.
euro Pattie sponges (Medtronic, Minneapolis, M ) soaked in
epinephrine are placed in one area of the dissection while the
surgeon moves to another area. ounds are never closed until
hemostasis is achieved. Suction drains are always used when the
posterior mandible is stripped of its overlying masseter muscle
These drains are placed below the mandible in the most depen-
dent position to maximize efficacy. Mildly compressive dressings
are applied over the area of surgical dissection. Prophylactic
anticoagulation is not used in conjunction with facial implant
surgery by the senior author.
51.7 Midface Implants
51.7.1 Piriform Aperture
Augmentation of the piriform aperture area is usually performed
to move the lower midface profile from one of concavity to relative
convexity, mimicking the visual effect of Le Fort I advancement
a b
Fig. 51.13 Influence of a paranasal implant on position of the nasal base, nasolabial angle, and vertical plane of the lip. (a) Profile view of patient with
lower midface concavity and acute nasolabial angle. (b) Profile view shows that augmentation of the piriform aperture area creates a convex profile
and opens the nasolabial angle.
51 Facial Implant Augmentation
(Fig. 51.13). A deficiency in lower midface projection is common
in patients with surgically corrected clefts. Retrusion of the
lower midface may occur when upper and lower jaw fractures
are reduced with respect to occlusion only and not to preinjury
3D skeletal anatomy above the occlusal level. It may also occur
after comminuted maxillary fracture reduction and fixation if
the surgery is inadequate to resist soft tissue deformity forces
accompanying massive edema. Paranasal augmentation can help
restore the preinjury lower face convexity. Augmentation of the
alveolus and lower lateral paranasal area will improve lip and
nasal relationships and overall facial balance. It is often a useful
adjunct during the rhinoplasty procedure. Augmenting the skel-
eton in this area can alter the projection of the nasal base, the
nasolabial angle, and the vertical plane of the lip.
Operative Technique
Piriform aperture (or paranasal) implants are designed as right and
left crescents. An upper gingivobuccal sulcus incision is made just
lateral to the piriform aperture to avoid placing incisions directly
over the implant. The incision is made at least 1 cm above the
sulcus to provide an adequate cuff of mucosa inferiorly to allow
layered closure (Fig. 51.14). The lip elevators can be seen after
the mucosa is incised. These muscles are not divided but rather
are retracted during the exposure of the maxilla. Subperiosteal
dissection exposes the area to be augmented. The borders of
the piriform aperture, the infraorbital nerve, and the root of the
canine tooth should be identified during surgery. Defining the
bony edges of the piriform aperture provides bony landmarks
that help facilitate precise and symmetric implant placement.
The implant may compromise the nasal airway if positioned
beyond the medial bony edge of the aperture. Identification of
the nerve avoids inadvertent retractor or implant damage to the
structure. The root of the canine tooth will be visible as a distinct
bulge just lateral to the piriform aperture. The implant will, in
part, lie directly over it. The surgeon must avoid damaging these
733
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 51.14 Diagrammatic overview of paranasal implant surgery. The
incision is made on the labial side of the buccal sulcus and lateral to the
area to be augmented. The gold area indicates the area of subperios-
teal dissection. Note proximity of infraorbital nerve. Note that the root
of the canine tooth lies below the area to be augmented. It must be
avoided during screw immobilization of the implant.
b
Fig. 51.15 This 20-year-old woman underwent rhinoplasty and paranasal augmentation. (a) Preoperative frontal, lateral, and oblique views.
(b) Postoperative frontal, lateral, and oblique views.
734
structures if screw fixation is used to immobilize the implant.
The incision is closed in layers. Because of the relatively small
area of dissection, no drains are used.
Clinical Example
A 20-year-old woman underwent rhinoplasty and paranasal
augmentation. Increasing midface convexity visually decreased
the projection of the nose (Fig. 51.15).
51.7.2 Cheek (Malar Eminence)
Prominent malar bones are considered attractive. The lack of
anthropometric and cephalometric landmarks makes analysis
and augmentation of the malar area largely subjective. Malar
deficiency is often part of a generalized midface deficiency for
which malar augmentation alone may be inadequate or, even,
inappropriate. Clinical experience has shown that when malar
projection is deemed inadequate, malar augmentation is most
effective when it re-creates the contours of a normal skeleton
with prominent anterior projection. The availability of 3D CT
scans has enabled the senior author to correlate the underlying
skeletal topography with the overlying soft tissue envelope.
ith this information, the senior author places the point of max-
imum projection just at, or slightly lateral to, the intersection of a
vertical line placed through the lateral canthus and a horizontal
line traversing the infraorbital foramen.

Implant Design
Malar implants should reproduce the normal contours of the
facial skeleton. Myriad implant designs of both porous polyeth-
ylene (Matrix Surgical USA, Atlanta, GA; Stryker, alamazoo,
MI) and silicone (Implantech, Ventura, CA) are available. An
intraoperative photograph in Fig. 51.16 shows a typical shape
and placement of a malar implant.
Implant projection varies from 3 to 5 mm. The thickness of the
overlying soft tissue envelope will influence selection of implant
projection. The silhouettes of large implants can become visible
as the overlying cheek tissues atrophy and sag with time. The
capsule formation that accompanies smooth-surfaced implants
further exaggerates the tendency toward implant visibility.
Asymmetric implant placement is not uncommon after malar
implant surgery. This reflects limited exposure of a complex
surface topography and the impossibility of seeing both operative
sites simultaneously for comparison.
Certain implant designs do not mimic the contours of the
midface skeleton. For example, submalar implants are designed
to be placed over and below the origin of the masseter muscle a
location where there is no midface skeleton in an attempt to
provide cheek fullness. The lower midface fullness result is an
unnatural midface: one with too much lower midface fullness,
which actually detracts from malar definition and projection.
Operative Technique
Exposure of the area to be augmented is key. To that end, both
eyelid and intraoral approaches are employed. A transcon-
junctival retroseptal incision with lateral canthotomy is
the senior author’s preferred eyelid approach. An upper
gingivobuccal sulcus incision is made over the premolars. The
incision is made at least 1 cm above the sulcus to provide an
adequate inferior cuff of mucosa for closure. The lip elevators
can be seen after the mucosa is incised. These muscles are
not divided but rather are separated in their longitudinal
Fig. 51.16 Typical shape and position of a malar implant. Implants
are carved to meet the needs of the patient. Most often, its length is
adjusted so that it extends from the zygomaticotemporal suture to just
beneath the infraorbital foramen.
51 Facial Implant Augmentation
orientation and retracted during the exposure of the zygoma
and lower maxilla.
Subperiosteal dissection exposes the area to be augmented.
Laterally, the dissection extends just beyond the zygomaticotem-
poral suture. Medially, at this level, it extends to the infraorbital
foramen, where the infraorbital nerve is visualized. This requires
elevation of the zygomaticus major and zygomaticus minor muscles
from their origins and the sacrifice of the zygomaticofacial nerve.
The levator anguli oris (caninus) lies deep to the zygomatic muscles.
Its origins are usually separated from the canine fossa of the maxilla
immediately inferior to the infraorbital foramen. The lip elevators
and the infraorbital nerve are retracted to provide exposure.
After skeletal exposure, the implants are modified to meet the
specific needs of the reconstruction. As noted previously, sym-
metric implant placement is challenging. Implants are available
with registration features that aid in implant positioning (Matrix
Surgical USA, Atlanta, GA).
As with placement in other craniofacial skeletal locations, the
implant is fixed to the skeleton with screws for several reasons.
Doing so allows precise, stable positioning of the implant and
adapts the posterior surface of the implant to the anterior surface
of the malar bone, thereby obliterating gaps between the implant
and the malar bone (gaps between the implant and the bone will
result in an undesirable increase in augmentation in the gap area).
Immobilizing the implant with screws allows final in-place con-
touring of the implant to ensure proper implant projection and an
imperceptible transition between the implant and the bone.
Before the incisions are closed, the infraorbital nerve is iden-
tified to be confident that any early postoperative complaints of
decreased sensation in the distribution of the infraorbital nerve
can be attributed to the trauma of soft tissue retraction and not
implant compression.
51.7.3 Infraorbital Rim
The relationship between the globe and the orbital rims will
determine whether the eyes appear prominent or deep-set.
Because the infraorbital rim and upper midface skeleton support
the lower eyelids and the cheek soft tissues, their projection has
an impact on lid and cheek position. Patients with deficient skel-
etons are more likely to undergo premature lower lid and cheek
descent with aging. This lack of skeletal support predisposes to
lower lid malposition after blepharoplasty and limits the efficacy
and longevity of midface lift procedures.
Globe–Rim Relations
The relationship of the globe to the orbital rims is a primary
determinant of the appearance of the upper third of the face.
elks and elks categorized globe–orbital rim relationships and
the tendency for the development of lower lid malposition after
blepharoplasty (Fig. 51.17). On sagittal view, they placed a line or
vector between the most anterior projection of the globe and
the malar eminence and lid margin. A positive vector relationship
exists when the most anterior projection of the globe lies behind
the soft tissues overlying the midface skeleton in the parasagittal
plane. A negative vector relationship exists when the most ante-
rior projection of the globe lies ahead of the soft tissues overlying
the midface skeleton in the parasagittal plane. This relation
735
 VIII Surgical Rejuvenation of the Face and Neck

a b c

Fig. 51.17 Jelks and Jelks categorized globe–orbital rim relationships by placing a line or “vector” between the most anterior projection of the
globe and the soft tissues overlying the midface skeleton in the parasagittal plane. (a) Positive vector relationship. (b) Negative vector relationship.
(c) “Reversed” negative vector relationship resulting from increasing the sagittal projection of the infraorbital rim with an implant.

reflects a deficiency in midface projection. They warned, similar
to Rees and LaTrenta, that patients whose orbital morphology
has a negative vector relationship are morphologically prone
to lid malposition after lower blepharoplasty. Augmentation of
the infraorbital rim with an alloplastic implant in patients with
midface deficiency can bring it into a better relationship with the
globe, thereby reversing the negative vector.
Indications for Reversing the Negative Vector
Infraorbital rim augmentation is part of the strategy for
normalizing the appearance in patients with midface skeletal
deficiency. It can be adapted for negative vector patients who
are first seeking improvement in their periorbital appearance or
for those whose lid malposition and round eye appearance have
been exaggerated by previous lower blepharoplasty.
Eye prominence results from a deficiency in skeletal projection
and correlates with a more inferior position of the lower lid
(resulting in scleral show) and a more medial position of the lateral
canthus. Descent of the lower lid increases the height of the palpe-
bral fissure, while the more medial position of the lateral canthus
decreases its width. Hence, patients with poorly projecting upper
midface skeletons have round eyes, as compared with the long
narrow eyes characteristic of young people with a normal perior-
bital morphology. Furthermore, in the skeletally deficient, the lack
of infraorbital rim projection and cheek prominence often allows
their lower lid fat compartments to be visible, giving them early
bags. Patients with this morphology can benefit from reversing
their negative vector at the time of their blepharoplasty together
with resuspension of their midface soft tissue envelope (Fig. 51.18).
egative vector patients who develop lid malposition after con-
ventional blepharoplasty can have their lid position and palpebral

a b
Fig. 51.18 (a) Frontal and (b) lateral views of a woman with midface skeletal morphology (negative vector) predisposing to lower lid and cheek
descent, resulting in a “round eye” appearance with prominent bags. On lateral view, the artist has drawn in the underlying deficient facial skeleton.

736

fissure shape improved by increasing their skeletal support with
alloplastic augmentation of the infraorbital rim together with
midface soft tissue elevation and lateral canthopexy.
In addition to a deficiency in sagittal skeletal projection, eye
prominence may also result from excess of orbital soft tissue
volume, as seen in thyroid-induced Graves’ ophthalmopathy.
Infraorbital rim augmentation together with midface soft tissue
elevation can be a useful adjunct to orbital decompression in
patients with Graves’ disease.
Preoperative Evaluation
A disproportion in sagittal globe–rim relations is usually obvi-
ous, and correction is made by clinical judgment.
Implant Design
Implants are designed to augment the sagittal projection of the
infraorbital rim. Implants can provide up to 5 mm of anterior
projection. They have malar components of various surface areas
and can be segmented for easier placement and conformation to
the underlying skeleton (Matrix Surgical, Atlanta, GA). They are
fixed with screws to eliminate movement and apply the implant
to the skeleton. Implants are trimmed to meet the specific needs
of the patient (Fig. 51.19).
Operative Technique
Infraorbital rim augmentation requires exposure of the entire
midface skeleton and concomitant elevation of the midface soft
tissue envelope in the subperiosteal plane (Fig. 51.20).
The infraorbital rim and adjacent anatomy must be exposed
sufficiently to ensure ideal implant placement, smooth implant
facial skeleton transition, and screw fixation. A lower lid blepha-
roplasty incision of the surgeon’s preference exposes the infraor-
bital rim. It is important to identify the infraorbital nerve, which
exits from the infraorbital foramen about 8 mm below the margin
of the orbit. This may be 3 to 6 mm in patients with significant
maxillary hypoplasia, who are the most common candidates for
this surgery. The orbicularis oculi and the origins of the lip eleva-
tors are separated from the underlying skeleton in a subperiosteal
plane to expose the infraorbital rim.
a b
Fig. 51.19 Implants designed specifically for infraorbital rim sagittal augmentation (Matrix Surgical, Atlanta, GA). (a) Oblique view. (b) Overhead
view.
51 Facial Implant Augmentation
Together with the lid incision, an intraoral sulcus incision is
used to free the midface soft tissue envelope in a subperiosteal
plane. Adequate elevation of the soft tissue envelope requires its
separation from the masseter tendon.
The implant is carved to fit the specific needs of the patient.
Segmenting the implant may facilitate placement of the implant
through limited skeletal access. The implant is fixed to the skeleton
with titanium screws to allow precise application of the implant
to the surface of the skeleton.
After the implant is positioned, sutures are used to elevate
and secure the malar midface and lid soft tissues. Through
the intraoral incision, two figure-of-eight sutures are used to
purchase the midface soft tissues. These sutures incorporate
the incised periosteum, the origins of the released lip elevators,
and cheek subcutaneous tissue. A suture placed at the midpupil
level approximately 3 cm beneath the pupil is passed through
the lower lid incision and secured to the rim implant. Another
suture is placed in the lateral aspect of the malar fat pad (placed
approximately 3 cm beneath the lateral canthus) and is tied to
a drill hole placed in the lateral orbital rim. The elevated sub–
orbicularis oculi fat (SOOF) and adjacent musculature now rest
on the augmented skeleton and help to support the freed and
elevated lid margin. A negative vector patient who underwent
infraorbital rim augmentation for periorbital rejuvenation is
shown in Fig. 51.21.
In negative vector patients with postblepharoplasty lid
retraction, lateral canthopexy is added to rim augmentation with
midface lift. A bridge of bone lateral canthopexy is performed
to narrow the palpebral fissure and to provide additional support
for the elevated lower lid margin. Through the lateral extent of
an upper lid blepharoplasty incision, both limbs of the lateral
canthus are purchased with a figure-of-eight suture. If scarring
limits the upward mobility of the lateral canthus, the lateral thirds
of the middle lamellae are incised with the needle tip electrocau-
tery. Two drill holes are placed in the lateral orbital rim just above
and 1 to 2 mm below the zygomaticofrontal suture. Each end of
the suture is then passed from within the orbit through the drill
holes in the lateral orbital rim. The sutures are tied over the bridge
of bone between the two holes. The inferior drill hole placement
determines the lateral canthal position, which should be 2 to 3
mm above the plane of the medial canthi.
737
 VIII Surgical Rejuvenation of the Face and Neck

The bridge of bone canthopexy is preferred for several reasons.

Drill holes placed in the lateral orbital rim can be placed after
precise measurement, allowing for predictable and symmetric
lateral canthus positioning. The bridge of bone provides a secure
fixation point. The passing of the canthopexy stitch from inside
the orbit to outside applies the lid to the globe. This maneuver
avoids the lid–globe dysjunction in the lateral commissure that is
common when canthopexy sutures are tied to the outer surface
of the lateral orbit.
A patient who underwent infraorbital rim augmentation, mid-
face elevation, and lateral canthopexy is presented in Fig. 51.22.

51.8 Lower Face

Fig. 51.20 Overview of operation to increase projection of infraorbital
rim and “reverse the negative vector” in patients with upper midface
skeletal deficiency. A transconjunctival retroseptal incision (broken
blue line) with the lateral extent of a lower lid blepharoplasty incision
(solid red line) to expose the infraorbital rim is illustrated. This approach
preserves the integrity of the lateral canthus and, hence, the palpebral
fissure. A lateral canthotomy would increase exposure but is accom-
panied by a greater risk of palpebral fissure distortion. An intraoral
incision is used to access the lower midface skeleton and to identify
and protect the infraorbital nerve. The lower lid and midface soft
tissues are freed by subperiosteal dissection in the area shown in gold.
51.8.1 Chin
Chin augmentation with implants is the most frequently per-
formed facial implant surgery. Although it is often considered a
relatively trivial surgical procedure, asymmetry, lip dysfunction,
and poor transition between implant and native mandible are not
uncommon. Effective preoperative planning requires an under-
standing of the patient’s desires, recognition of the impact of
previous facial surgery or orthodontic treatment on the patient’s
appearance, and careful facial examination. This careful preopera-
tive analysis, together with refinements in surgical technique and
implant design, will help optimize the surgical outcome. hen
chin augmentation is considered as an adjunct to rhinoplasty or
neck rejuvenation, preoperative analysis should be as rigorous as
it is when chin deficiency alone is the presenting complaint.

a b

c d
Fig. 51.21 The woman shown in Fig. 51.18 who underwent infraorbital rim augmentation and midface lift. No fat was removed from the lower lids.
(a) Preoperative frontal view. (b) One year postoperative frontal view. Note that without direct manipulation of lower lid fat, the “early bags” are
meliorated but not eliminated. (c) Preoperative lateral with artist rendition of underlying facial skeleton. (d) One-year postoperative lateral view with
artist’s rendition of augmented facial skeleton.

738
 51 Facial Implant Augmentation

a b

c d
Fig. 51.22 A 52-year-old woman had undergone previous browlift, rhytidectomy, and upper and lower lid blepharoplasty. Lower lid retraction was
treated by multiple canthopexies, spacer grafts, and full-thickness skin grafts. Dry eye symptoms persisted. Infraorbital rim augmentation, midface
lift, and lateral canthopexy resolved her symptoms. Her brows and hairline were repositioned. (a) Preoperative frontal view. (b) Postoperative frontal
view. (c) Preoperative lateral view. (d) Postoperative lateral view.

Physical Examination S gi r e i n r e Vie

Physical examination must include analysis of both the skeleton
and its soft tissue envelope. The lower third of the face must
relate appropriately to the upper two-thirds. ithin the lower
third, the position of the lips and depth of the labiomental sulcus
are affected by the projection of the chin.
Imaging
In contrast to orthognathic surgery, where cephalometric X-ray
studies are intrinsic to the preoperative planning, preoperative
X-ray images can be helpful but are not mandatory for implant
surgery. Plain X-ray images may be helpful during revision sur-
gery after previous osteotomies.
Three-dimensional CT scans and the models that can be gener-
ated from their data are the gold standard for planning surgery to
ameliorate facial skeletal asymmetries. Custom implants can be
made using these data.
Anthropometric Assessment
ormative data are helpful in analyzing the chin and planning its
augmentation, not only in its sagittal but also in its vertical and
horizontal projections.
The anthropometric studies of Farkas showed that the mean
inclination of the facial profile as defined by a line from the
glabella to the pogonion was 3 3.4 in men and 4.1 3.0 in
women (Fig. 51.23).
These data show that men’s chins project more than women’s and
that “normal” chin projection is considerably less than that deter-
mined ideal by subjective criteria. This does not mean that aug-
mentation beyond one standard deviation would be unattractive in
any given individual, but it may look too large, especially in a woman.
Subjective criteria for an ideal profile are at variance from those
obtained by objective analyses. Ignoring sexual dimorphism,
artists usually portray a larger chin than normally exists in reality.
Lip–Chin Relations
There is a consensus among authors that the chin should rest
slightly posterior to the lower lip and the lower lip posterior to
the upper lip.
Labiomental Angle
The inclination of labiomental angle must be evaluated when
considering an increase in the sagittal projection of the chin.

739
 VIII Surgical Rejuvenation of the Face and Neck

a b
Fig. 51.23 The inclination of the facial profile as defined by a line from the glabella (g) to the pogonion (pg). The broken line is drawn perpendicular
to the Frankfort horizontal line (Porion, Po, to Orbitale, Or) at an inclination of 0°. The solid red line represents the mean inclination of the study
group. The shaded area encompasses one standard deviation (SD). (a) The mean inclination in 100 young North American white men was −3
3.4°. (b) The mean inclination in 100 young North American white women was −4.1 3°. In both men and women, note that the chin rests slightly
posterior to the lower lip and the lower lip lies slightly posterior to the upper lip. These data show that men’s chins project more than women’s and
that “normal” chin projection is considerably less than that determined “ideal” by subjective criteria. This does not mean that augmentation beyond
one standard deviation would be unattractive in any given individual, but that it may look too large, especially in a woman.

There is a considerable variability in this inclination. In general, Surgical Anatomy

the inclination is more acute in men than it is in women. hen
Structures susceptible to iatrogenic injury during chin augmen-
the angle is already acute, chin augmentation will make it more
tation include the mental nerve as well as the lower lip retractors
acute, thereby deepening the labiomental angle. Such deepening
and elevators. Their anatomy is depicted in Fig. 51.25.
is usually dysaesthetic.

Mental Nerve
Vertical Projection (Height)
The inferior alveolar nerve, a branch of the mandibular nerve,
On average, the distance from the base of the nose (subnasion) to
enters the mandibular canal with the inferior alveolar vessels
the mouth opening (stomion) is half the distance from subnasion
to gnathion. In order words, the height of the mandible in the
midline should account for approximately two-thirds of the
lower face height, or subnasion to gnathion (Fig. 51.24).
The vertical height of the chin can be increased with implants
in three ways. (1) An illusion of increased length can be obtained
by moving the most projecting part of the chin inferiorly by
implant positioning. Real increases in vertical projection require
(2) CAD/CAM implants or (3) horizontal osteotomy with a spacer
of desired height between the proximal and distal chin segments.

Horizontal Projection (Chin Width)

The width of the chin should be appropriate for the vertical pro-
jection. This is the rationale for extended chin implants, which
allow a transition between the augmented chin point and the
anterior mandibular body.

Predicting the Soft Tissue Response to Skeletal

Augmentation
The soft tissue–to–hard tissue change in patients undergoing
alloplastic augmentation of the chin averages between 77.7 and
90 . This reflects the variability in the thickness of the chin soft Fig. 51.24 In both male and female faces, the height of the mandible
tissue envelope. The thicker the overlying soft tissue envelope, the in the midline, from stomion to gnathion (sto–gn), should account for
two-thirds of the lower face height, from subnasion to gnathion (sn–gn).
less its surface response to the underlying skeletal augmentation.

740

a b
Fig. 51.25 Shows the anatomy of the lower lip elevators and retractors as well as the path of the mental nerve. These structures are susceptible to
injury during chin augmentation. (a) Frontal view. (b) Lateral view.
through the mandibular foramen, which is located in the inner
aspect of the ramus of the mandible. The nerve and vessels course
obliquely from the ramus to the body, where it exits as the mental
nerve through the mental foramen, which is located at the level of
the first or second premolar. Vertically, the mental foramen was
located almost halfway from the tip of the alveolar process to the
lower border of the mandible. The potential location of this nerve
is important to recognize when placing screws or performing hor-
izontal osteotomies of the mandible. After exiting the foramen,
the mental nerve divides into two or three branches to supply
sensation to the mucosa and the skin of the lower lip and chin.
Mentalis Muscle
The mentalis muscle is an elevator of the central lower lip. It
arises from the mandible at the level of the root of the lower
lateral incisor and therefore defines the inferior limits of the
sulcus intraorally. It fans inferiorly as a truncated cone whose
base inserts on the skin and therefore dimples the skin when
elevating and protruding the lower lip. It is the most frequently
damaged muscle during chin surgery. If it is divided and improp-
erly repaired or stripped from its origin and allowed to descend
to a more inferior position, the result is inferior malposition of
the lower lip, with increased lower incisor show and deepening
of the sulcus as well as inferior displacement of the chin pad.
Lip Depressor Muscles
The depressor anguli oris (triangularis), the depressor labii inferio-
ris (quadratus), and platysma are all depressors of the lower lip. The
depressor labii inferioris and depressor anguli oris arise from the
oblique line of the mandible to merge with orbicularis oris and skin
51 Facial Implant Augmentation
of the lower lip. The platysma muscle sends fibers that originate
from the mandible beneath the oblique line and merge with the lip
depressors. Subperiosteal dissection separates these muscles as a
continuum from the bone. Failure to stay in the subperiosteal plane
may cause damage, usually short-lived, to these muscles. Clinically
this injury mimics that of marginal mandibular branch palsy, since
the marginal branch innervates the lower lip depressors.
Implant Selection
The goal of surgery is to create an anatomically correct, gender-
appropriate, stable mandible contour that satisfies the aesthetic
goals of the patient. The design and composition of the implant
should help accomplish this. Myriad designs of various materials
are available. In general, female chins tend to be narrower and
tapered while male chins are wider and square (see Fig. 51.10).
Porous polyethylene implants come in two pieces: a right half
and a left half. Segmentation facilitates placement of the relatively
long and stiff implant. The two-piece design also provides flexibil-
ity in positioning the lateral extensions of the implant, ensuring
that it mimics the inclination of the patient’s mandibular body.
A tab insert joins the right and left halves of the chin implant.
Registration tabs are meant to align with the inferior border of the
mandible to ensure symmetric placement (Fig. 51.26).
Silicone rubber implants are designed as one piece. The material’s
flexibility allows it to be inserted through relatively small access inci-
sions. A one-piece implant, particularly one with lateral extensions,
is unlikely to have an arc, projection, and inclination appropriate
for every mandible (Fig. 51.27). These implants can be divided into
three pieces for greater ease of insertion. Use of a stair-step, rather
than a straight line, can help better align the implants correctly.
741
 VIII Surgical Rejuvenation of the Face and Neck

a b
Fig. 51.26 The two-piece design and registration tabs allows the implant to mimic inclination of mandible. (a) Registration tab guides alignment
with inferior border of mandible. (b) Central connecting tab acts as a hinge between implant segments, allowing border alignment.

Fig. 51.28 Screw fixation of the implant to the mandible prevents

implant movement and obliterates gaps between the implant and
Fig. 51.27 The arc, the inclination of the limbs, and the contour of anterior surface of the mandible. Screw fixation also allows in-place
the posterior surface of an extended one-piece implant may all be contouring of the implant to ensure desired contour and an impercep-
inappropriate for the shape of a mandible. This three-dimensional tible implant-to-skeleton transition.
computed tomography image demonstrates a clinical example. Note
how the inferior borders of the lateral extensions of the one piece
extended implant fail to align with the inferior border of the mandible.
A two-piece design allows adaptation of each of these parameters
for a given mandible. When placed through the submental approach, Submental Approach
the two-piece implant limits asymmetry in the horizontal plane. With
one-piece implants, asymmetry in horizontal positioning increases as The chin and the anterior mandible are accessed through a sub-
one proceeds laterally.
mental incision. ide subperiosteal dissection is performed. The
upper limits of the dissection is the origin of the mentalis muscle.
Laterally, the mental foramen with its exiting nerve and the infe-
rior border of the mandible body are exposed. Lateral dissection
Operative Technique
extends approximately 1 cm beyond the area of augmentation.
The technique presented here employs porous polyethylene
The submental approach and extended dissection avoid damage
implants (Fig. 51.28). They employ right and left components
to the mentalis muscle, allow visualization of the mental nerve,
joined by a midline connecting feature. The design demon-
and provide a panoramic view of the complex and varying
strated here also has registration features, which aid in implant
contours of the mandible to enable precise implant placement.
alignment. The fundamentals of the technique are applicable for
The technique of intraoral placement of chin implants avoids
implants of any material or design.
a cutaneous scar but provides limited exposure to the menton
while compromising the mentalis muscle. As a result, the intra-
Anesthesia oral approach is often associated with implant malposition and
lower lip dysfunction resulting from mentalis muscle division or
Chin augmentation with implants may be performed under local
detachment.
or general anesthesia.

742

Implant Positioning
Marking the midline of the pogonion aids in symmetric implant
placement. The midline can be marked with a marker, drill hole,
or temporary screw. This is useful for implants of any design or
material. It may be beneficial to contour prominences on the
native mandible to allow better congruence between the poste-
rior surface of the implant and the mandible surface. The senior
author’s preference is a two-piece porous polyethylene implant
with registration tabs incorporated at the inferior border of the
implant. Right and left portions of the implant are placed and
then positioned. The registration tab dictates lateral positioning.
The connecting tab joins the two implant segments in the mid-
line and also acts as a hinge to allow the implant to adjust to
the unique inclination of the mandible border. The connecting
bar also allows the width of the implant to be varied as dictated
by the space between implant right and left segments. In most
instances, there will be a gap between the medial aspects of the
implant halves.
Screw Fixation and Closure
The implant is fixed to the skeleton with screws. The wound is
closed in layers. A mildly compressive dressing is placed imme-
diately once the operation is complete and is removed in 48 to
72 hours.
a b
c d
Fig. 51.29 A 50-year-old woman underwent chin augmentation with a 3-mm two-piece porous polyethylene implant combined with rhytidectomy.
It was placed to lower the most projecting point of the chin. (a) Preoperative frontal and (b) lateral views. Postoperative (c) frontal, (d) lateral, and (e)
oblique views.
51 Facial Implant Augmentation
Clinical Examples
Patients who have undergone primary chin augmentation using
the techniques just described are shown in Fig. 51.29 and Fig.
51.30.
51.8.2 Mandible Angle
Indications
Patients with normal, deficient, or surgically altered anatomy
may all benefit from implant augmentation of the mandibular
body, angle, and ramus.
Most patients who desire mandible augmentation have lower
face horizontal dimensions that relate to the upper and middle
thirds of the face within a normal range. These patients, usually
men, perceive a wider lower face as desirable. Mandibular body
and ramus augmentation in women with normal-dimensioned
mandibles should be done conservatively, with the intention of
providing definition.
Another group of patients who benefit from mandible augmen-
tation are those with skeletal mandibular deficiency who have had
their dental relationships normalized through orthodontic tooth
movement. The anatomy associated with mandibular deficiency
can be camouflaged with implants. The addition of an extended
chin implant will camouflage the poorly projecting chin.
A third group of patients who may benefit from alloplastic aug-
mentation of the mandible are patients who have had their Class
II dental malocclusion due to mandibular deficiency corrected by
sagittal split osteotomy with advancement of the distal segment.
e
743
 VIII Surgical Rejuvenation of the Face and Neck

a b

c d e
Fig. 51.30 A 31-year old man underwent chin augmentation with a 7-mm projection two-piece porous polyethylene implant. A submental lipectomy was
also performed. (a) Preoperative frontal and (b) lateral views. (c) Postoperative frontal, (d) lateral, and (e) oblique views.

This skeletal rearrangement often results in asymmetries and
border irregularities. Mandible implants, particularly those that
are computer-designed to fit the particular needs of the patient,
can improve contour and symmetry in these circumstances.
Physical Examination
Physical examination is the most important element in preop-
erative assessment and planning. Reviewing life-size anterior
and lateral photographs with the patient can be helpful when
discussing aesthetic concerns and goals.
Imaging
Posteroanterior (PA) and lateral cephalograms provide data that
can help the surgeon determine how the dimension of the implant
might be altered to best suit the patient. However, 3D CT scans
and the models obtained from their data can be invaluable when
attempting to correct asymmetries associated with congenital,
posttraumatic, or postsurgical deformities. In general, the size
and position of the implant are largely aesthetic judgments.
Surgical Anatomy
Skeleton
The mandible consists of the tooth-bearing body and the ramus,
which extends upward from the angle. The ramus, including the
angle (gonion), is covered on its external surface by the masseter
muscle. The oblique line runs forward and downward from
the anterior border of the ramus. It affords attachment for the
depressor labii inferioris and depressor anguli oris. The platysma
is attached near the inferior border of the mandible. The bucci-
nator muscle is attached to the outer lip of the superior border of
the mandible as far forward as the first molar tooth (Fig. 51.31).
Musculature
Only the masseter and, indirectly, the medial pterygoid, as part
of the mandibular sling, are encountered during mandibular
augmentation. The masseter and the medial pterygoid muscle
are so positioned that they form a sling around the inferior
border of the mandible and therefore suspend the angle of
the mandible. hen placing a mandibular angle implant, it is
necessary to separate the superficial portion of the masseter
and its sling component from the mandible in a subperiosteal
plane. Tearing the periosteum at the inferior border may disrupt
the sling mechanism and allow the freed masseter to ride up,
causing a depression in the soft tissues overlying the angle. This
depression is exaggerated when the muscle is contracted.
The buccinator is another muscle that is encountered during
exposure of the mandible during mandibular augmentation. The
buccinator is the principal muscle of the cheek. It forms the lateral
wall of the oral cavity and is incised when exposing the posterior
mandible (Fig. 51.31).

744
 51 Facial Implant Augmentation

a b
Fig. 51.31 Mandible anatomy. (a) Surface topography. (b) Muscle origins and insertions.

Inferior Alveolar Nerve

The inferior alveolar nerve is a branch of the mandibular nerve
(cranial nerve V3). It enters the mandibular canal with the infe-
rior alveolar vessels through the mandibular foramen, which is
located in the inner aspect of the ramus of the mandible approx-
imately halfway between its anterior and posterior borders. It
is important to visualize the path of the inferior alveolar nerve
when placing screws to immobilize mandibular implants.

Implant Design
Ramus and body implants are capable of changing the shape of
the mandible in three dimensions: bigonial width (go–go), ramus
height from gonion to condylar process (go–cdl), and body length
from gonion to gnathion (go–gn). Fig. 51.32 demonstrates basic
implant designs for the mandible angle. The implant usually
extends from the posterior vertical border of the mandible to the
oblique line. The flange at the implant’s inferior border allows
the implant to register to the mandible border (Fig. 51.33).
Fig. 51.32 Mandible angle implants of increasing lateral projection
(Matrix Surgical, Atlanta, GA) used to increase lower facial width.

Fig. 51.33 Illustration of mandibular body and angle implant used in combination with a chin implant. This combination is often used for patients
with Class II mandibular deficiency.

745
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 51.34 Intraoral mucosal incision is made along ramus and
posterior body of mandible. It is made approximately 1 cm above the
sulcus on its buccal side.
Operative Technique
In anticipation of implant surgery, the patient is instructed to
optimize oral–dental hygiene. Chlorhexidine mouthwashes are
prescribed for 72 hours preoperatively.
Anesthesia
It is the senior author’s preference to perform mandibular aug-
mentation under general anesthesia (nasotracheal intubation
is ideal). This provides a panoramic view of the operative field.
The airway is protected while the oral cavity can be optimally
prepared. The face and oral cavity are prepared with an iodine
solution after placement of a throat pack. The operative site
is infiltrated with 1:200,000 epinephrine solution to provide
hemostasis.
Incisions
A generous intraoral mucosal incision is made to expose the
ramus and body of the mandible. It is made at least 1 cm above
the sulcus on its buccal side (Fig. 51.34). The anterior ramus
and body of the mandible are freed from their soft tissues. It
is important to free both the inferior and posterior borders of
the mandible of soft tissue attachments so as to allow implant
placement.
Freeing of the inferior border inevitably violates the pterygo-
masseteric sling. Care should be taken not to divide the sling,
which results in postoperative elevation of the muscle and
midramus bulging with masseter muscle contraction. As deter-
mined by preoperative assessment, the implant is trimmed
with a scalpel or mechanical bur before its placement on the
mandible.
746
Fig. 51.35 Screw fixation of the implant to the mandible through an
intraoral approach.
Implant Positioning and Fixation
To ensure the desired placement, certain implants are
designed with registration tabs that align with the inferior
border of the mandible (Matrix Surgical USA, Atlanta, GA). To
ensure its desired position and to apply it to the surface of the
mandible without gaps, the implant is fixed to the mandible
with titanium screws. A long, guarded drill facilitates screw
hole drilling. ith vigorous retraction, implant fixation can
be done through the intraoral incision (Fig. 51.35). Clamping
the implant to the mandible maintains implant position during
screw fixation.
Screws are placed to avoid the anticipated path of the inferior
alveolar nerve before its exit from the mental foramen. Screws
immobilize the implant and eliminate any gaps resulting from the
lack of congruence between the posterior surface of the implant
and the anterior surface of the mandible. Reduction of promi-
nences on the surface of the mandible minimizes gaps between
the implant and the skeleton. It is crucial to soften any transitions
between the implant and the mandible, particularly where the
implant extends beyond the anterior mandibular border’s inferior
edge. Any step-offs between the implant and the mandible in
this area may be visible in thin patients. Screw fixation of the
implants allows scalpel or mechanical bur final contouring with
the implants in place.
After hemostasis is appropriate, the wound is irrigated (anti-
biotic irrigation is a rational adjunct to decrease bacterial con-
tamination in this operation performed through intraoral access).
The incision is closed in two layers with absorbable sutures. Care
is taken to evert the mucosal edges. A small suction drain is left
in until the next morning. I prefer one with a trocar that allows
the skin exit site to be located behind the ear lobule. An elastic

a b
d e
Fig. 51.36 A 30-year-old man with Class I dental occlusion and mandibular deficiency desired improvement in jaw angle width and lower border
definition, as well as chin projection. A mandible ramus and posterior body augmentation with the implants was performed with a chin augmentation.
(a) Preoperative anterior, (b) oblique, and (c) lateral views. (d) Postoperative anterior, (e) oblique, and (f) lateral views.
tape external dressing is used to help apply the soft tissues to the
implant and avoid hematoma formation.
Patients are administered broad-spectrum antibiotics (ordi-
narily cephalosporins) intravenously immediately before the pro-
cedure. Oral antibiotics are administered for 5 days postoperatively.
A liquid diet is prescribed for the first 3 days postoperatively
and a soft diet for the next 5 days. Frequent mouthwashes are
advised, as well as very careful tooth brushing.
Suggested Reading
Clinical Example
A clinical example is shown in Fig. 51.36.
51.9 Concluding Thoughts
Alloplastic augmentation of the facial skeleton provides a pre-
dictable alteration of skeletal contours. The use of computer
planning and manufacture brings added sophistication to this
modality.
Clinical Caveats
• Access incisions are always made remotely from planned or
previous underlying implants.
• For chin augmentation, an extraoral, submental approach is
preferred to an intraoral incision, as it optimizes exposure and
avoids injury to the mentalis muscle.
• Screw fixation of the implant is essential to avoid implant
migration. It obliterates gaps between the implant and skel-
eton, thereby making implant projection more predictable.
51 Facial Implant Augmentation
c
f
• Drains are frequently placed to minimize dead space and
assist with fluid egress.
• Custom CAD/CAM implants should be considered in circum-
stances of 3D deformities, particularly if bilateral or from
previous orthognathic surgery
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 VIII Surgical Rejuvenation of the Face and Neck
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52 Neck Lift
Foad Nahai
Abstract
Options for rejuvenation and contouring the neck range from
liposuction to extensive procedures including subplatysmal
resection of fat, digastric muscle reduction, and excision of the
superficial lobe of the submandibular gland.
Keywords
neck lift, submental lift, digastric muscle excision, submandibu-
lar gland excision
52.1 Introduction
My thinking and current approach to treatment of the neck
have been influenced by the work of my close friends. Courtiss’s
submental liposuction, Feldman’s corset platysmaplasty, and
Connell’s modification of the subplatysmal structures, combined
with the experience ohn Bostwick and I have had with endo-
scopic face- and neck lifting, have all shaped my approach to the
neck. Equally important has been the experience gained through
secondary neck lifts.
Courtiss demonstrated that removal of submental fat
resulted in redraping and recontouring of the submental skin
without any redundancy. ormal skin quality and elasticity are
prerequisites. Feldman’s corset platysmaplasty improved the
submental contour and jawline and eliminated platysma bands.
Connell’s subplatysmal approach further improved neck con-
tour through the elimination of bulging fat, digastric muscles,
and submandibular glands. Our experience with endoscopic
face- and neck lifts clearly established that all of the compo-
nents of a neck lift could be performed through minimal-access
incisions, and if skin excision was not needed, the standard
retroauricular facelift incision, serving only for access, could be
totally eliminated.
Almost all facelift procedures, especially those involving the
superficial musculoaponeurotic system (SMAS), will have some
effect on the neck, particularly the jawline. For a small group
of patients this may be all that they need, whereas others will
need more extensive procedures involving a submental incision. I
have found the vertical simulation test very useful in my decision
making concerning the need for a submental incision and central
neck procedures. Other factors I take into account in deciding
whether to make a submental incision include modifications of
the platysma in the midline and subplatysmal procedures. eck
lifts are performed not only in conjunction with facelifts but also
as separate procedures without a concomitant facelift.
ot all patients’ necks have the same morphology, nor do their
necks age at the same rate or in the same way. The approach to
each neck is individualized to maximize the result. eck lifting
involves a combination of rejuvenation or reversal of the aging
52 Neck Lift
process and recontouring. Volume management superficial and
deep to the platysma are integral parts of neck contouring. The
spectrum of procedures available to us ranges from liposuction
only to a full open neck lift, and through multiple incisions with
intervention in each of the three planes superficial, intermedi-
ate, and deep. After careful evaluation, the surgeon selects the
appropriate procedure and plans the incisions, vectors, and planes
of intervention (Fig. 52.1).
Surgical Options
• Liposuction only
Suction-assisted liposuction (SAL)
Ultrasound-assisted liposuction (UAL)
Power-assisted liposuction (PAL)
Laser-assisted liposuction (LAL)
• Submental lift
• Endoscopic neck lift
• Short-scar facelift, with or without submental incision
• Full-scar facelift, with or without submental incision
The components of a neck lift include fat contouring, muscle
and fascia plication, subplatysmal procedures, skin redraping and
redistribution, and skin excision. Fat may be removed from under
the skin, between the platysma muscles, and below the muscle. In
the superficial plane the fat may be removed through liposuction
or direct excision. The fat between and deep to the platysma
muscles is removed by direct excision, since liposuction deep to
the platysma is risky and inappropriate. Muscle and fascia pli-
cation involves the platysma muscle and its investing fascia. The
procedures deep to the platysma include fat removal, tangential
excision of the anterior belly of the digastric muscles, intracap-
sular removal of the superficial lobe of the submandibular gland,
and release of the suprahyoid fascia.
Components of a Neck Lift
• Fat contouring
Superficial
Deep
• Muscle and fascia plication
• Subplatysmal procedures (deep plane)
• Skin undermining
Skin redraping and redistribution
Skin excision
Skin resurfacing
Management of skin in the neck differs from management of
facial skin. To obtain optimal results in the neck, it is not always
necessary to remove excess skin. The neck affords more options
for skin redraping and redistribution, and excellent results are
749
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 52.1 Different morphologies of the aging neck demand an
individualized approach to neck rejuvenation.
possible without skin excision. The key is to assess the skin of the
neck and establish whether the excess, if any, is real or apparent.
In patients with deeply etched transverse lines, undermining of
Fig. 52.2 (a) Anatomy of the neck. (b) Distribution of fat within the neck.
750
the skin is necessary to improve those lines. Rarely, peels and/or
fillers and fat may improve these lines.
52.2 Pertinent Anatomy
52.2.1 Fat
ithin the neck, fat is found in the subcutaneous tissue between
the skin and platysma muscle. The thickness of this fat pad will
vary according to the patient’s morphology, weight, and genetics.
It is usually more abundant in the submental area, extending in
between the platysma muscles if they are separated at this level.
There is also a collection of fat deep to the platysma muscles and
superficial to the digastric muscle and the submandibular gland.
Dramatic neck recontouring can be achieved through removal of
neck fat in these different levels (Fig. 52.2).
The operative view shown in Fig. 52.3 demonstrates en bloc
resection of preplatysmal–submental fat and separate en bloc
resection of interplatysmal and subplatysmal fat.
Although the jowls or the jowl fat pads extend into the neck,
it is facial fat that should be returned to the lower face, where
it belongs, or be excised as needed. It is not part of the fat in the
neck.
 52 Neck Lift

52.2.2 Muscle
Platysma
The platysma muscles separate the neck into superficial and
deep compartments. These muscles are large, thin sheets that
extend from the face across the neck and down to the clavicle.
ithin the submental area, the anatomy of the muscle varies
greatly from individual to individual. Cardoso de Castro’s
anatomic studies led him to classify the relationship of the two
platysma muscles and their interdigitations or decussation in the
submental area into three types (Fig. 52.4).
This confirms our clinical impression that in the majority of
patients there is very limited interdigitation of the muscles medi-
ally, as evidenced by the two visible platysma bands in the aging
neck. Stuzin discussed retaining ligaments that hold the platysma
against the deep cervical fascia; he described them as a series of
fibrous bands extending from the mandibular symphysis distally Fig. 52.3 Intraoperative view of en bloc resection of preplatysmal and
to the thyroid. ith aging, attenuation of this retaining ligament submental fat and separate resection of interplatysmal fat.
system allows platysmal descent, which accounts not only for
platysma bands but also for the increasingly oblique cervical
angle, both of which are hallmarks of the aging neck. hile these
anatomical descriptions are useful additions to our knowledge Digastric Muscle
of the intricate anatomy, treatment of platysma bands remains a The anterior belly and posterior belly of the digastric muscle form
challenging problem with much debate as how best to eliminate two sides of the submental triangle. The third side is the ramus of
the bands. eurotoxins also offer an alternative to surgical modi- the mandible. ithin this triangle lie the submandibular gland,
fication of the platysma. the facial artery and vein, the lingual nerve, and the marginal
mandibular branch of the facial nerve (Fig. 52.5).

Fig. 52.4 Classification of platysma anatomy, as defined by the relationship of the two muscles in the submental area. Type I: In 75% of cases (most
common), there is a limited decussation of the platysma muscles, extending 1 to 2 cm below the mandibular symphysis. Type II: In 15% of cases,
decussation of the platysma extends from the mandibular symphysis to the thyroid cartilage. Type III: In 10% of cases, there is no decussation or
interdigitations.

751
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 52.5 Anatomy of the submental triangle.

52.2.3 Submandibular Gland
Submandibular glands lie within the submental triangle.
hether clinically visible glands are ptotic or simply enlarged
is currently a matter of debate. The submandibular gland lies in
close proximity to the facial artery, which crosses superficial to
the posterior portions of the gland. The marginal mandibular
branch of the facial nerve crosses the gland superficially. The
safest approach to resection of the gland is intracapsular, because
all of these structures lie outside of the capsule of the gland (Fig.
52.6).
52.2.4 Clinical Correlations
The platysma divides the neck into a superficial and a deep
compartment. My clinical approach to the neck, the layered

Fig. 52.6 The submandibular gland and surrounding structures.

752

approach, includes intervention in three planes: superficial,
intermediate, and deep (Fig. 52.7):
• The superficial plane includes only the subcutaneous fat, and
intervention in this plane is limited to fat contouring.
• The intermediate plane includes the platysma muscles, any
fat lying between them, and the occasional lymph node.
Intervention in this plane includes resection of the fat and
plication of the platysma muscle medially and laterally.
• The deep plane includes the subplatysmal fat, the digastric
muscles, and the submandibular gland. The resection of the
subplatysmal fat is relatively safe; however, the anterior veins
of the neck may course within the fat.
Tangential excision of the anterior belly of the digastric muscle
is also relatively safe and bloodless. The dissection of the sub-
mandibular gland has to be performed cautiously and within the
capsule. Resection of the superficial lobe is relatively safe, because
this portion of the gland is well away from the facial vessels, facial
nerve, and lingual nerve. Dissections beyond this superficial lobe,
or extracapsular dissection of the gland, are more likely to lead to
vascular injury with profuse bleeding and nerve injuries. The sup-
rahyoid fascia also lies in the deep plane. This fascia is occasionally
released to improve further on the cervical angle in patients with
a high hyoid.
52.3 Preoperative Assessment
Careful evaluation of the neck and its relationship to the lower
third of the face will lead to selection of the appropriate proce-
dure with which to meet the patient’s goals. This evaluation also
a b
Fig. 52.7 (a) The superficial, (b) intermediate, and (c) deep planes of the neck.
52 Neck Lift
help determine incisions, vectors, and planes of intervention.
In order of importance in neck recontouring and rejuvenation,
I assess the fat, muscles, submandibular gland, and finally, the
skin for skin excess and skin elasticity. The jowls and the jawline,
the interface of the neck and face, are also evaluated.
Focus of Neck Evaluation
• Fat
• Muscles
• Submandibular gland
• Skin
• Neck–face interface
• Jawline and jowls
52.3.1 Fat
Fat removal has the most dramatic effect on neck contouring.
Therefore it is important to determine the accurate location of
fat in the neck, whether it is only under the skin or also between
and below the platysma muscles.
To differentiate between subcutaneous and subplatysmal fat,
the surgeon pinches the submental area with the patient at rest
and then after contraction of the platysma muscle (Fig. 52.8). If
the amount of fat within the pinch diminishes on contraction of
the muscle, a significant amount of fat lies deep to the muscle,
indicating that subcutaneous fat removal alone may not result in
an ideal contour. If there is subplatysmal fat, an open procedure
for defatting below the platysma is indicated, and subcutaneous
fat removal or liposuction will yield a suboptimal result.
c
753
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 52.8 The location of submental neck fat is assessed by pinching
the fat at rest and observing its movement with contraction of the
platysma.
52.3.2 Muscle and Submandibular Gland
The platysma and digastric muscles are evaluated. The pla-
tysma bands may be visible at rest or on animation only. The
location of the bands and the distance between them is noted.
Transcutaneous evaluation of the digastrics may not always be
possible, especially in a heavy neck. The digastric muscles are
best evaluated during the procedure, after the subcutaneous fat
is removed (Fig. 52.9).
If flexion of the neck results in a bulge, it may be appropriate
to consider digastric muscle excision. Occasionally the digastric
muscle may be visible transcutaneously, especially in candidates
for a secondary neck lift. The submandibular gland is often visible
transcutaneously, presenting as a bulge within the submental
triangle. In a heavy neck it may not be visible, and intraoperative
evaluation may be necessary before the surgeon decides about the
gland.
52.3.3 Skin
The length of the skin incision in neck lifting reflects the location
of the excess skin to be removed and whether deeply etched
transverse neck lines need to be addressed surgically through
undermining. If there is no excess, the entire neck procedure
is performed through minimal incisions. I evaluate whether
the skin excess is real or apparent and, if it is real, where that
excess lies. The success of short-scar procedures relies not only
on assessment of the location of skin excess but also on the
quality and elasticity of the skin. The vertical simulation test is
invaluable in evaluating skin quality and skin excess. ormal
skin elasticity is essential for all short-scar procedures. Patients
who have inelastic, sun-damaged skin must have the full retro-
auricular incision for a good result.
Apparent excess skin will redrape after recontouring below the
skin, such as submental skin following fat removal in all three
planes, as well as digastric and submandibular gland excisions.
The skin must have sufficient elasticity to redrape. It is the long
side of the triangle redraping into the two shorter sides, thus
eliminating the apparent skin excess.
Fig. 52.10 shows skin redraping after fat removal and platysma
plication through a submental incision in a patient with apparent
excess skin. A short preauricular incision was made to tighten the
754
a
b
Fig. 52.9 Evaluation of excess skin of the neck and platysma bands
(a) with the patient at rest and (b) on animation.
SMAS so as to improve on the jowls and the jawline. o neck skin
was excised.
Real excess skin usually extends below the thyroid cartilage and
posteriorly beyond the sternocleidomastoid muscle. If there is real
excess skin or if skin quality is poor, a full retroauricular incision
is essential.
The patient shown in Fig. 52.11 demonstrates skin excess
beyond the thyroid cartilage and behind the sternocleidomastoid
muscle, as well as poor skin elasticity, as evidenced by the sun-
damaged appearance. A full facelift incision, including a retroau-
ricular extension, is required for an optimal result.
52.3.4 Vectors
Skin evaluation influences my choice of vectors. The vertical
vector applied to the neck in combination with a facelift, through
SMAS and skin elevation, will define and improve the jawline.
The more diagonal vector required for skin resection in the
retroauricular area will define and improve the lower and lateral
neck.
52.3.5 Neck–Face Interface
If there is significant jowling and descent of the neck–face
interface with blunting of the jawline, an isolated neck lift
procedure will not address those problems and will lead to a
suboptimal result. In such patients a lower face and neck lift
is a more appropriate operation. In selected patients, judicious
liposuction of the jowl fat will improve the jawline. I feel that a
better option is to reposition the jowls through a facelift incision
and SMAS elevation.

a b
c d
Fig. 52.10 (a,c) Preop and (b,d) postop photos (top) and diagrams
(bottom) following fat removal and platysma plication through a
submental incision. The superficial musculoaponeurotic system was
tightened through a short preauricular incision to contour the jawline.
No neck skin was excised, but the effect of skin redraping is significant.
52.3.6 Planes of Intervention
Through clinical evaluation of the neck I determine the planes
of intervention. If only subcutaneous fat excision is needed,
liposuction in the superficial plane is the procedure of choice.
If platysma bands have to be dealt with, an intermediate plane
intervention is planned. If subplatysmal fat removal, modifica-
tion of the digastric muscles, or submandibular gland excision is
required, intervention in the deep plane is planned. It is not rare
to perform procedures in all three planes.
52.4 Preoperative Planning and
Decision Making
I currently have five options for neck recontouring or rejuvena-
tion, ranging from liposuction to a full-scar face- and neck lift:
1. Liposuction
2. Submental neck lift
3. Endoscopic or limited-incision neck lift
4. Short-scar face- and neck lift
5. Full-scar face- and neck lift
52 Neck Lift
Fig. 52.11 Patient with skin excess beyond the thyroid cartilage and
behind the sternocleidomastoid muscle, as well as generally poor skin
elasticity.
In the superficial plane, liposuction alone results in significant
contour improvement and relies on normal skin quality for
redraping. The other four options enable intervention in the
intermediate or platysmal plane as well as access to the plane
below the platysma. In combination with a facelift, the face–neck
interface, jawline, and jowls are rejuvenated. The full-scar face-
and neck lift is the only option that includes retroauricular skin
excision.
Table 52.1 represents surgical options, along with each of the
components of the neck lift that apply to that approach.
52.5 Operative Technique
52.5.1 Liposuction
The best candidates for liposuction recontouring of the neck are
usually younger patients with normal-quality skin and localized
excess submental fat. Clinical evaluation of the platysma muscles
and subplatysmal fat is the key to patient selection. In addition
to the pinch test described earlier, the patient’s neck is examined
at rest and on animation for the presence of platysma bands (Fig.
52.12).
If platysma bands are present at rest, the patient would be
best served by a submental lift. If bands are visible on animation
but not at rest, removal of the subcutaneous fat will expose the
bands, and these patients are also best served by an alternative
approach that would eliminate the platysma bands. Liposuction
will unmask underlying platysma bands or deep plane fullness.
The best way to avoid this is a complete and detailed evaluation
of the neck before selecting liposuction as the procedure of choice
for neck contouring.
Technique
Liposuction of the neck may be performed with the patient
under local or general anesthesia. I prefer general anesthesia if
additional procedures are planned. The patient is placed supine
on the operating table with the neck in full extension. Through
an access incision in the submental area and optional incisions
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 VIII Surgical Rejuvenation of the Face and Neck

Table 52.1 Choosing the best option for neck lift

Neck lift options: components of neck lift
Fat Muscles Skin
Planes or layers Subcutaneous Interplatysmal Subplatysmal Platysma Digastric Submandibular No Real Excess Poor Aged neck–
of the neck gland Excess quality face interface
Liposuction
only
Submental
neck lift
Endoscopic
limited incision
neck lift
Short-scar face
and neck lift
Full-scar face
and neck lift

a b c
Fig. 52.12 A detailed and dynamic evaluation of the neck is necessary to identify the best operative approach. (a) Platysma bands visible at rest,
(b) no visible platysma bands at rest, (c) platysma bands visible on animation.

behind each earlobe, the neck is infiltrated with a wetting
solution. My preference is Ringer’s lactate solution with 250 mg
of lidocaine and 1 mg of epinephrine added to each liter. I find
that 100 mL of this solution is more than adequate for anesthesia,
vasoconstriction, and sufficient wetting of the tissues for UAL.
I usually wait 12 to 15 minutes following infiltration for full
anesthetic effect and vasoconstriction.
Ultrasound-Assisted Liposuction
For UAL of the neck, I use a short 2- or 3-mL solid probe with a
power setting of 5 and either continuous or pulse mode with the
LySonix UAL device (Mentor Corp., Santa Barbara, CA). The UAL
phase is usually no longer than 2 to 3 minutes. This is followed by
aspiration with a flat 2- or 3-mL cannula. I prefer UAL over SAL in
the neck because in my hands it yields a smoother result.
Suction-Assisted Liposuction
My choice of cannula for suction-assisted liposuction of the neck
is a flat 2- or 3-mL single-hole cannula. The suction is started
through the submental incision with the hole always toward
the deep tissue, never toward the skin. It is important to leave at
least 3 to 5 mL of fat on the deep surface of the skin so as to avoid
postoperative irregularities. Removal of an excessive amount of
fat or oversuctioning under the dermis will lead to adherence of
the skin to the underlying platysma, resulting in tethering and
banding.
Excessive fat removal in the subcutaneous plane to mask or
correct problems deep to the platysma is a common error that is
often difficult to reverse, as seen in the woman shown in Fig. 52.13.
Overaggressive fat removal from her neck and submental area has
unmasked platysma bands and prominent digastric muscles.

756
 52 Neck Lift

Fig. 52.13 Overaggressive fat removal from the neck and submental
area has unmasked platysma bands and prominent digastric muscles.

Fig. 52.14 The liposuction cannula is passed through separate tunnels

fanning out from the submental incision.
In SAL of the neck the cannula is passed slowly through sepa-
rate tunnels, fanning out from the submental incision (Fig. 52.14).
I make it a point never to make more than one or two passes in
each tunnel, because repeated passes within a tunnel will lead to Results
oversuction and irregularities. If suction of the jawline and lateral
The patient shown in Fig. 52.15 underwent liposuction of her
neck is also indicated, a separate incision behind each earlobe is
neck and is shown preoperatively and 4 years postoperatively.
made for access. This also allows a crisscrossing of the tunnels in
The redraping of her excess neck skin in the submental area is
the submental area. It is best to err on the side of leaving too much
apparent. o skin excision was performed.
fat behind rather than oversuctioning. The endpoint is judged by
The young woman shown in Fig. 52.16 underwent UAL of the
direct observation of the recontouring effect and by pinching the
submental area and neck; she still has some persistence of her
skin and subcutaneous tissues. I also roll my fingers along the skin
jowls, but the jawline and submental area have been improved.
with gentle pressure to look for irregularities to ensure that the fat
The patient shown in Fig. 52.17 underwent liposuction of the
removal has been uniform.
submental area and transoral chin augmentation with a solid sili-
o drains are required for liposuction of the neck, but compres-
cone implant. Improvement of facial proportions is demonstrated,
sion is applied with either foam tape or an elastic garment.
with a more pleasing jawline and neck–jaw angle.

a b c d
Fig. 52.15 (a,c) Preop and (b,d) 4-year postop photos following liposuction of the neck without skin excision.

757
 VIII Surgical Rejuvenation of the Face and Neck

a b c d
Fig. 52.16 (a,c) Preop and (b,d) postop photos following liposuction of the submental area and neck. The submental and jawline contours are
improved.

Liposuction of the submental area and neck unmasked platysma

bands, more noticeable on the right than on the left, in the patient
shown in Fig. 52.18. A better result would have been achieved
through a submental neck lift, including platysma plication.

52.5.2 Submental Neck Lift

The submental neck lift includes an incision in the submental
area, variable undermining of the neck, and intervention in
each plane of the neck as indicated. The submental neck lift
may be performed as an isolated procedure for recontouring of
the submental area and neck or in combination with a short- or
full-scar facelift. The degree of skin undermining will vary from
individual to individual, depending on the clinical appearance of
the neck, skin quality, and skin excess.
a b
Technique
An isolated submental neck lift is not a common procedure in
my practice. The submental approach described here is usually
performed in combination with a facelift.
The procedure is performed with the patient under general
anesthesia; the patient is placed supine with the neck extended.
The neck is infiltrated with a dilute lidocaine and epinephrine
solution, usually 0.25 lidocaine with epinephrine 1:400,000.
The incision is made just posterior to the submental crease.
The dissection is then continued anteriorly under the crease to
release it from the underlying tissues. If indicated, this dissection
progresses forward and laterally to release the mandibular liga-
ments. Subcutaneous defatting is then performed. I prefer to do
this directly rather than through liposuction. ith the scissors, I
elevate the skin with a 3- to 5-mm layer of fat.
The skin is undermined in this plane toward the thyroid carti- c d
lage and laterally as needed. Then this submental fat is resected
from the superficial surface of the platysma. In thin individuals Fig. 52.17 (a,c) Preop and (b,d) postop photos following
liposuction of the submental area and transoral alloplastic chin
in whom no fat removal is planned, the dissection starts directly augmentation.

758

a b
Fig. 52.18 (a,c) Preop and (b,d) postop photos following liposuction of the submental area and neck. The procedure has unmasked platysma
bands.
over the platysma, leaving all the fat on the deep surface of the
skin (Fig. 52.19).
If procedures are planned deep to the platysma, the platysma
on each side is elevated, and any fat in between layers of or deep
to the platysma is directly excised as needed. If interplatysmal
or subplatysmal fat excision is planned or performed, it is very
important to leave an adequate subcutaneous layer of fat to avoid
a submental depression. There is often a very small lymph node or
two in the fatty layer, between layers of or deep to the platysma,
which is usually included in this resection.
Once the platysma has been elevated and the fat deep to it
removed, the anterior belly of the digastric muscle on each side
Fig. 52.19 Undermining performed in a submental neck lift.
52 Neck Lift
c d
can easily be visualized (Fig. 52.20). The anterior bellies of the
digastric muscles may be tangentially excised, totally excised, or
the two plicated in the midline.
Most commonly I do a tangential excision. This starts anteriorly
at the origin of the muscle. A hemostat is passed halfway through
the thickness of the muscle (Fig. 52.21). The tips are then spread,
and with electrocautery the muscle fibers are transversely divided
so that at least half the thickness of the muscle is tangentially
excised by dissecting posteriorly along the muscle to its tendinous
junction. On the rare occasions when I resect the entire anterior
belly, the origin is divided first with electrocautery and then the
tendinous junction (Fig. 52.22).
Once the anterior belly of the digastric muscle has been dealt
with, an enlarged submandibular gland is easily visualized. Even
if a decision has already been made to dissect the gland, the neck
Fig. 52.20 The platysma muscle is elevated to expose fat and digastric
muscle.
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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 52.21 (Left) The digastric muscle is tangentially excised. (Right)
A hemostat passed halfway through the digastric muscle guides the
extent of resection.
is flexed and the contour assessed before proceeding with partial
gland excision. The most important step in resecting the gland
is to incise the capsule and to perform the resection piecemeal.
This will greatly decrease the risk of bleeding and damage to the
surrounding nerves.
Once the gland is visualized, I grasp it with an Allis forceps or
place a 3–0 suture through the gland and pull the gland into view.
The capsule is incised with needle-tip cautery; then the gland is
resected piecemeal (Fig. 52.23; Fig. 52.24). If there is any bleed-
ing, the vessels are easily cauterized. Occasionally the small artery
feeding the gland is encountered and must be suture ligated. Once
the gland has been suitably reduced in size, the neck is again
flexed and the effect on neck contour assessed. Gland excision
proceeds in this manner until the desired contour is achieved.
After these deeper procedures are completed, the platysma
muscles are plicated in the midline. I prefer interrupted sutures
Fig. 52.23 Exposure and partial resection of the submandibular gland.
760
Fig. 52.22 At least half the thickness of the digastric muscle is
excised by transverse myotomies at the muscle’s origin and tendinous
insertion.
with permanent material. The tail end of a suction drain is left
deep to the platysma before completing the midline plication.
Occasionally I plicate the platysma in two layers. The second layer
is sutured with an absorbable material.
For an isolated submental lift, the procedure at this stage is
almost complete. eck undermining extends laterally on either
side until effective skin draping is seen. If there is any skin
redundancy, the undermining is extended until this excess is
eliminated. Any remaining contour irregularities are dealt with
through direct fat excision, if possible. Otherwise, liposuction is
done with a small, flat 2- or 3-mm cannula. A suction drain is
routinely placed in the neck. The skin is closed in two layers: 4–0
poliglecaprone (Monocryl, Ethicon, Somerville, ) for the dermis
and intracuticular 5–0 Monocryl for the skin. Tapes and dressings
are applied.
Fig. 52.24 Piecemeal excision of superficial lobe of submandibular
gland.

Postoperative Care
Patients undergoing an isolated submental lift may be allowed to
go home on the same day as surgery. Those undergoing a facelift
in combination will remain overnight in our facility. A compres-
sion tape or garment is worn for several days postoperatively.
The drain is removed the next day after surgery.
Result
Preoperative evaluation of the man shown in Fig. 52.25 demon-
strated platysma bands on animation, with fat superficial and
deep to the platysma muscle. He had an indistinct neck–jaw angle.
He underwent a submental neck lift, including subplatysmal fat
excision and digastric excision. o subcutaneous fat was removed,
so that a smooth contour remained. He also had chin augmenta-
tion with an anatomic solid silicone implant. Postoperative views
demonstrate improved contour without skin irregularities.
52.5.3 Endoscopic or Limited-Incision
Neck Lift
Technique
The submental neck lift described earlier has almost entirely
replaced our original endoscopic neck lift procedure. This pro-
cedure was essentially the same through the submental incision.
Additional incisions were then made behind each earlobe, and
the endoscope aided in the wide undermining of the neck skin
from one sternocleidomastoid muscle to the other. Endoscopic
visualization also facilitated hemostasis. A headlight and a
Deaver or lighted retractor through the submental incision have
now replaced the endoscope.
Results
The patient shown in Fig. 52.26 underwent an endoscopic neck
lift, including platysma plication and neck suspension sutures
through a 4-cm submental incision and a 1-cm retroauricular
incision on each side. There was no skin excision.
a b
Fig. 52.25 (a,c) Preop and (b,d) postop photos following submental neck lift, including subplatysmal fat and digastric excision, and chin augmentation.
52 Neck Lift
A similar procedure was performed on the patient shown in
Fig. 52.27, who exhibited platysma bands and apparent excess
skin in the submental area.
52.5.4 Short-Scar Face- and Neck Lift
The ideal candidate for a short-scar face- and neck lift is a patient
who has no excess neck skin but has jowls and aging of the neck-
face interface. The short-scar approach, with a vertical upward
vector on the SMAS and slight diagonal vector on the skin, will
improve the jawline (Fig. 52.28). If needed, neck recontouring
through liposuction or through a submental approach may be
performed at the same time. ith the submental approach,
I connect the face and neck dissections in the subcutaneous
plane. The technical aspects of the procedure for the neck were
described earlier.
Technique
A prehairline incision is made below the sideburn, and a pre-
auricular intratragal incision is made down to and around the
earlobe (Fig. 52.29a).
The skin flap is elevated and the dissection connected with the
neck dissection, which usually extends to the posterior border of
the sternocleidomastoid (Fig. 52.29b,c).
The sub-SMAS dissection is then initiated at the junction of
the adherent and mobile SMAS. A diagonal incision is made in
the SMAS, extending from the zygomatic prominence toward the
angle of the mandible. The dissection then continues along the
lateral border of the platysma (Fig. 52.30a–c).
The SMAS-platysma flap is mobilized by blunt dissection and
then pulled upward in the face and posteriorly in the neck (Fig.
52.30d). Usually in a heavy face, a portion of the elevated SMAS
and platysma is resected; in thin faces, it is plicated with perma-
nent or absorbable suture material (Fig. 52.30e). My preference is
3–0 PDS. The lateral plication of the platysma will further define
the neck. This lateral plication is always performed regardless of
whether a submental approach and medial platysmal plication is
performed. I place a drain in all facelifts. The drain is brought out
behind the earlobe.
c d
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 VIII Surgical Rejuvenation of the Face and Neck

a b c d
Fig. 52.26 (a,c) Preop and (b,d) postop photos following endoscopic neck lift, including platysma plication and neck suspension sutures.

a b c d
Fig. 52.27 (a,c) Preop and (b,d) postop photos following endoscopic neck lift with platysma plication.

The facial skin is redraped directly upward with a slight diagonal The ideal candidate shown in Fig. 52.34 underwent a short-scar
vector posteriorly. The excess skin is resected and an anchoring facelift through a submental incision with subplatysmal interven-
suture of 3–0 polydioxanone is placed at the base of the concha. tion, including partial excision of the submandibular gland. A lower
The excess skin is then trimmed, tailored around the tragus, and lid blepharoplasty was also performed. The postoperative result
inset (Fig. 52.31). A two-layer closure of 4–0 Monocryl to the demonstrates improvement of the submental area and jawline.
dermis and running 6–0 rapid-absorbing catgut to the epidermis
completes the procedure. Dressings are applied, and the patient
remains overnight in our facility.
52.5.5 Full-Scar Face- and Neck Lift
The best candidates for a full-scar face- and neck lift are indi-
Results viduals with aging changes of the face and neck, especially the
neck–face interface, with inelastic skin and excess lower and
The woman shown in Fig. 52.32 underwent a short-scar facelift
posterior neck skin. The vertical simulation test is most useful
that included a submental incision with platysma plication. She
for selecting short or long scar. The procedure is similar to the
is seen 4 years postoperatively.
operation described previously, with the exception that the skin
The preoperative views of the patient shown in Fig. 52.33a
incision is continued around the earlobe up to the level of the
demonstrate jowls and apparent excess skin in the submental area;
tragus or higher and then across into the occipital hair.
she also exhibited platysma bands on animation. She underwent a
The patient shown in Fig. 52.35 demonstrates jowls, a visible
short-scar face- and neck lift, including a submental incision with
submandibular gland, platysma bands, and excess skin below
submental fat removal and platysma plication. The postoperative
the thyroid. The vertical vector on the SMAS will improve her
view demonstrates neck recontouring, improvement of jowling,
jowls, and the redraping of the apparent submental skin excess
and no retroauricular scars (Fig. 52.33b).

762
 52 Neck Lift

b c
Fig. 52.28 (a) The ideal candidate for a short-scar face- and neck lift
has no excess neck skin but exhibits jowls and aging of the neck-face
interface. (b) The short-scar approach imparts a vertical vector of Fig. 52.29 (a) Markings for prehairline and preauricular intratragal inci-
elevation on the superficial musculoaponeurotic system and a slight sions. (b) The superficial musculoaponeurotic system (SMAS)-platysma
diagonal vector on the skin. (c) The short-scar facelift incision. flap is elevated upward in the face and (c) posteriorly in the neck.

Fig. 52.30 (a) The sub–superficial musculoaponeurotic system (SMAS) dissection is initiated at the junction of the adherent and mobile SMAS. (b)
A diagonal incision is made in the SMAS, extending from the zygomatic prominence toward the angle of the mandible. (c) The dissection continues
along the lateral border of the platysma. (d) The SMAS–platysma flap is mobilized and then pulled upward in the face and posteriorly in the neck. (e)
A portion of the flap is resected in heavy faces and plicated in thinner faces.

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 VIII Surgical Rejuvenation of the Face and Neck

a b
Fig. 52.31 (a) The facial skin is pulled directly upward with a slight
diagonal vector posteriorly. (b) Excess skin is resected and the flap
inset.

will improve the submental area (Fig. 52.36a). ith rather long
sideburns, this patient is a candidate for the classic facelift inci-
sion, extending from the temporal area into the occipital hair (Fig.
52.36b). The postoperative view, compared with the preoperative
view, demonstrates neck recontouring (Fig. 52.36c,d).
a b
Fig. 52.32 (a) Preop and (b) 4-year postop photos of patient who
underwent a short-scar facelift that included a submental incision with
platysma plication.

Technique more extensive skin undermining with this incision, extending

Occasionally, in individuals with unusually lax skin with signif-
icant excess skin in the lower neck, this incision is modified so
that at the level of the tragus or just below, it will cross to the
hairline and follow the occipital hairline downward and poste-
riorly (Fig. 52.37). This modification allows resection of more
of the neck skin without altering the occipital hairline. There is
beyond the posterior border of the sternocleidomastoid muscle
and behind the ear. Management of the SMAS and platysma was
described previously, as was the anterior closure of the wounds.
A second anchoring suture of 3–0 PDS is placed through the
skin flap and into the mastoid fascia at the level of the earlobe.
The excess skin behind the ear is resected in stages, aligning the

a b c d

e f
Fig. 52.33 (a,c,e) Preop and (b,d,f) postop photos of patient who underwent a short-scar face- and neck lift, including a submental incision with
submental fat removal and platysma plication. (e,f) Photos demonstrate no retroauricular scars.

764
 52 Neck Lift

a b c d
Fig. 52.34 (a,c) Preop and (b,d) postop photos of patient who underwent a short-scar facelift through a submental incision with subplatysmal
intervention, including partial excision of the submandibular gland.

Fig. 52.35 This patient demonstrates jowls, a visible submandibular

gland, platysma bands, and excess skin below the thyroid, making her
a good candidate for a full-scar face- and neck lift.

hairline first and then resecting the skin. I close the hair-bearing
scalp with staples and two layers of Monocryl, including a final
intracuticular layer behind the ear. hen closing behind the ear, it
is important to include the deep fascia in the retroauricular sulcus
within the closure; this will prevent outward migration of the
retroauricular scar. Dressings and postoperative management are
the same as described for the short-scar face- and neck lift.
Fig. 52.36 (a) The vertical vector on the superficial musculoaponeu-
rotic system will improve her jowls, and the redraping of the apparent
submental skin excess will improve the submental area. (b) With
Results rather long sideburns, this patient is a candidate for the classic face-lift
The middle-aged woman shown in Fig. 52.38, seen preopera- incision, extending from the temporal area into the occipital hair. (c)
tively and 5 years postoperatively, underwent an endoscopic Preoperative view. (d) The postoperative view demonstrates neck
recontouring.
brow lift, upper and lower lid blepharoplasty, face and neck lift
with platysma plication, and CO2 laser resurfacing of the fore-
head and perioral area. The split-face view demonstrates that
brow position has been maintained and platysma bands have The middle-aged patient shown in Fig. 52.39 underwent a
been eliminated. face- and neck lift, with upper and lower lid blepharoplasty. o

765
 VIII Surgical Rejuvenation of the Face and Neck
Fig. 52.37 Incision for a full-scar facelift continues around the ear up
to about the level of the tragus or just below, crosses to the hairline,
and follows the occipital hairline inferiorly and posteriorly.
subcutaneous fat was removed from her neck. Her improved con-
tour is the result of subplatysmal procedures, including digastric
and submandibular gland excision.
The woman shown in Fig. 52.40 had a lower lid blepharoplasty,
face and neck lift, including a submental incision, subplatysmal
fat removal, and platysma plication. Her postoperative result
demonstrates smooth recontouring of the neck.
a b
Fig. 52.39 (a,c) Preop and (b,d) postop photos of patient who underwent face- and neck lift including digastric and submandibular gland excision
and upper and lower lid blepharoplasty.
766
a b c
d e
Fig. 52.38 (a,d) Preop and (b,e) 5-year postop photos of patient
who underwent endoscopic brow lift, upper and lower lid
blepharoplasty, face- and neck lift with platysma plication, and CO2
laser resurfacing of the forehead and perioral area. Split-face view
(c) demonstrates appropriate brow position and elimination of
platysma bands.
The patient in her 60s in Fig. 52.41 is shown before and 3 years
after a full-scar facelift, a neck lift with no fat removal, a temporal
brow lift, an upper lid blepharoplasty, a lower lid blepharoplasty
including fat preservation, orbicularis redraping, and canthopexy.
An oblique view of her in her 20s is included. The only flaws in an
otherwise good result at 3 years are the wrinkles around her lat-
eral brow and central neck. These are related more to skin quality
than to the effectiveness of her face and neck lift. A resurfacing
procedure at this stage would be beneficial.
c d
 52 Neck Lift

a b c d
Fig. 52.40 (a,c) Preop and (b,d) postop photos of patient who underwent lower lid blepharoplasty, face- and neck lift, including a submental
incision, subplatysmal fat removal, and platysma plication.

a b c d

e f
Fig. 52.41 (a,c) Preop and (b,d) 3-year postop photos of patient in her 60s who underwent full-scar facelift, neck lift with no fat removal, temporal
brow lift, and upper and lower lid blepharoplasty. (e,f) Patient is shown in her 20s for comparison.

767
 VIII Surgical Rejuvenation of the Face and Neck

The middle-aged patient shown in Fig. 52.42 underwent a face

and neck lift, including subplatysmal fat removal and platysma
plication. o subcutaneous fat was removed to maintain a 5-mm
layer of fat over the platysma. The improved neck contour is the
result of subplatysmal procedures and platysma plication.

52.6 Problems and Complications

The most common error I see in neck recontouring is overoperat-
ing in the superficial plane to mask or improve intermediate- or
deep-plane problems. The tendency is to overdo the removal
of subcutaneous fat rather than deal with problems related to
interplatysmal or subplatysmal fat, the digastric muscle, and
submandibular gland. Reluctance to address the deeper layers in
the neck leads to suboptimal contouring. The excessive removal a b
of subcutaneous fat leads to adherence of the denuded dermis
Fig. 52.42 (a) Preop and (b) postop photos of patient who received a
directly onto the platysma muscle, producing contraction bands
face- and neck lift, including subplatysmal fat removal and platysma
and unusual skin tethering that is most obvious on movements plication.
involving the platysma. Although correction of untreated
subplatysmal contour problems is relatively straightforward,
improvement of skin–platysma adhesions is very difficult.
Preoperatively, the patient shown in Fig. 52.43 demonstrated
neck irregularities, reflecting overzealous subcutaneous fat
removal in a previous surgery rather than a subplatysmal proce-
dure to recontour the neck. The problem was further compounded
by skin dyschromias resulting from CO2 laser resurfacing. Excision
of digastric muscles and submandibular glands improved her
contour; however, the problem of adhesions of skin directly to the
platysma is extremely difficult to overcome.
I have found that full mobilization of the skin off the platysma
with secondary redraping offers some improvement. Autologous
fat, dermis grafts, and acellular dermal matrix are suitable options
for improvement of such problems.
Another common error with neck lifts is related to vectors.
The preferred vectors include an upward vector in the face and a a b
diagonal posterior vector. Excessive posterior traction on the neck
Fig. 52.43 (a) Preop view of patient with neck irregularities from
without adequate vectors of elevation anteriorly along the jawline
overzealous fat removal during a prior surgery and skin dyschromias
will lead to a banding or a hammock effect, whereby the lower from CO2 laser resurfacing. (b) Postop view following excision of
and posterior neck are effectively tightened, but laxity remains in digastric muscles and submandibular glands demonstrates improved
the submental area, jowls, and neckline. neck contour. Skin adhesions to the platysma limit the final result.
The patient shown in Fig. 52.44, who had undergone two previ-
ous facelifts, demonstrates the inappropriate vectors and planes of
intervention employed during her previous facelifts. She is shown undermining or poor skin quality. Most often, however, the cause
1 and 2 years after a tertiary face- and neck lift, with redirection of is undercorrection or failure to correct the jowls, jawline, and the
SMAS and skin vectors and subplatysmal recontouring. neck–face interface. Correction requires a facelift with appropriate
Secondary problem areas include the following: management of the facial skin.
Fat problems are related to overexcision or underexcision.
• Skin
Overexcision is most often performed in the subcutaneous plane;
• Fat
this can be avoided through the use of smaller cannulas, turning
• Platysma the hole away from the skin, limiting the passes in each tunnel,
• Digastric muscles and striving to leave a uniform 3- to 5-mm thickness of fat deep to
• Submandibular glands the skin. Underremoval of fat is most often seen deep to the pla-
• Inappropriate vectors tysma and adjacent to the submental incision itself. These can be
avoided through proper planning and appropriate management of
each plane or layer of the neck.
Skin problems following neck lifts are usually related to
The most frequently encountered problem with the platysma
failure of adequate redraping as a consequence of insufficient
is the persistence of platysma bands. These occur when the bands

768
 52 Neck Lift

a b c

d e f
Fig. 52.44 (a,d) Preop view of a patient with a suboptimal result from two prior facelifts. (b,e) 1-year and (c,f) 2-year postop views following tertiary
face and neck lift with redirection of superficial musculoaponeurotic system and skin vectors and subplatysmal recontouring.

are not dealt with primarily or when the plication sutures fail.
Solutions include reoperation to plicate or resect as indicated and
temporary treatment with botulinum toxin injections. Alternative
approaches such as transcutaneous division of platysma bands, as
advocated by Gonzalez, and stairstep division of the platysma, as
described by Saylan, are appropriate options.
A persistent bulge following neck contouring in the submental
area most often is the anterior belly of the digastric muscle, which
may have been unmasked when subcutaneous fat was removed.
Correction is relatively straightforward, entailing digastric exci-
sion through a submental incision.
Bulging in the submental triangle results from an enlarged sub-
mandibular gland. Most often this was present preoperatively and
was not dealt with or was unmasked by subcutaneous defatting.
Correction entails a submental approach and partial excision.
Appropriate vectors in the neck include an upward vector in the
submental area where the skin redrapes, an upward vector along
the jawline, and a diagonally posterior vector behind the ear. For
an optimal result, a balance must be struck among these vectors.
Excessive traction in any one of these vectors without appropriate
countertraction in the others will result in banding or a hammock
effect. Correction includes reoperation and remobilization with
more balanced traction.

769
 VIII Surgical Rejuvenation of the Face and Neck
52.7 Concluding Thoughts
The neck does not always have to be opened in order to be
recontoured and rejuvenated, nor is it necessary to operate deep
to the platysma in every patient. A full preoperative assessment
of the three planes, together with intraoperative evaluation, will
indicate the procedure or procedures that will most effectively
recontour the neck.
Clinical Caveats
• The surgeon should avoid overoperating in the subcutaneous
plane to overcome deeper problems.
• For optimal results, the deeper planes must be approached
and modified directly.
• For liposuction, cannulas 3 mm or smaller in diameter should
be used.
• Patients must be evaluated for platysma bands and subpla-
tysmal fat before liposuction.
• Liposuction may unmask preexisting platysma bands.
• Liposuction should be avoided in patients who have fat super-
ficial and deep to the platysma, because results will likely be
suboptimal.
• The number of liposuction passes should be limited to one or
two in each tunnel.
• The cannula hole should be turned away from the dermis.
• Undermining widely is recommended to achieve adequate
skin redraping.
• Stretched, inelastic skin will not redrape and must be resected.
• Recontouring the neck without addressing the lower third of
the face will yield suboptimal results.
• At least 3 to 5 mm of subcutaneous fat should be left on the
skin flap.
• Subplatysmal fat should be removed rather than overresec-
tion of subcutaneous fat.
• The need for digastric or submandibular gland excision should
be evaluated intraoperatively.
• Submandibular gland excision is performed within the cap-
sule of the gland.
• Submandibular gland excision is approached in a piecemeal
fashion.
• The surgeon must maintain harmony between the lower third
of the face and the jawline.
• Resurfacing (such as a peel with 20% trichloroacetic acid)
should be considered to improve skin quality in the neck.
Suggested Reading
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53 Secondary Neck Lift
Timothy Marten and Dino Elyassnia
Abstract
The increased number of patients seeking neck improvement
at a younger age, coupled with the typically disappointing out-
comes of “noninvasive” and “minimally invasive” treatments,
has resulted in a significant increase in requests for secondary
neck lift procedures. In the evaluation and treatment of the
patient presenting for secondary neck lift, one must identify
and treat not only new problems due to age and time but
those that have resulted from prior procedures as well. Often,
these secondary irregularities present the biggest challenge to
the surgeon in terms of creativity, planning, preparation, and
technique.
Merely performing submental liposuction and tightening the
skin ignores a number of anatomic problems and produces medi-
ocre outcomes and secondary neck irregularities, particularly in
the secondary neck lift patient. Submental liposuction can result
in the inappropriate removal of subcutaneous fat essential to a
natural and youthful appearance.
Subplatysmal fat excision, submandibular gland reduction, and
superficial digastric myectomy can all contribute to creating the
best neck contour possible, and the skilled neck surgeon must
master treatment of all three of these “deep layer” problems and
use them in conjunction with each other as indicated in both
primary and secondary procedures if optimal results are to be
obtained.
Platysma bands comprise a heterogeneous group of distinct
problems. Platysmaplasty and platysmamyotomy address two
different problems. The key to successful treatment will rest in
understanding the origins of platysma problems, identifying the
type of problem present in a given patient, and employing logical
solutions to address those problems.
Keywords
secondary neck lift, submental liposuction, double chin, witches’
chin, submandibular gland reduction, digastic myectomy,
cervical lipectomy, subplatysmal fat, subplatysmal lipectomy,
interdigastric fat, platysmaplasty, platysmamyotomy, platys-
mapexy, platysma bands, anterior platysma bands, platysma
hyperfunction, full width platysma transection, postauricular
transposition flap
53.1 Introduction
The increased number of patients seeking neck improvement
at a younger age, coupled with the typically disappointing out-
comes obtained with the myriad of “noninvasive” treatments
patients and surgeons must navigate, has resulted in a signif-
icant increase in requests for secondary neck lift procedures.
Although many aspects of planning and performing secondary
surgery are similar to those of a well-conceived and planned
53 Secondary Neck Lift
primary procedure, additional considerations must be taken
into account in the evaluation and treatment of the patient pre-
senting for secondary neck lift, as one must identify and treat
not only new problems that are the product of age and time but
those that have resulted from any prior procedure as well. Often
these secondary irregularities present the biggest challenge to
the surgeon in terms of creativity, planning, preparation, and
technique.
Consideration must also be given to possible underlying ana-
tomical damage that may have resulted from previous procedures
but is not evident as a visible deformity. This includes possible
damage to skin, subcutaneous fat, superficial musculoaponeurotic
system (SMAS), platysma, and deeper structures. Injury to these
tissues at the time of the primary procedure can preclude certain
maneuvers and limit the overall amount of improvement possible
at the time secondary surgery is performed. Red flag procedures
in this regard include ultrasonic liposuction (damage to and
overreduction of subcutaneous fat), radiofrequency and ultra-
sonic skin-tightening treatments (damage to and overreduction
of subcutaneous fat, damage to skin microcirculation, and damage
to microlymphatics), chemolipolysis (subcutaneous fibrosis),
cryolipolysis (damage to subcutaneous fat, damage to skin micro-
circulation, and damage to microlymphatics), prior suture lifts,
and prolonged large-volume use of facial fillers (granulomas and
filler fibrosis ).
As in primary procedures, recognizing the problems in the
secondary neck lift patient and appreciating their underlying ana-
tomic abnormalities is fundamental to planning and performance
of any repair. Although not all problems can always be completely
corrected, any surgeon able to recognize their anatomic basis
can, through the application of logic and careful planning, select
techniques that are safe and effective.
It is unlikely there will ever be a consensus on how a neck lift
should be performed, and it is a fact that no one procedure will
be best for all patients. The technique used cannot be arbitrary,
must depend on the problems present, and must necessarily vary
from patient to patient. Success or failure in treating the neck in
both primary and secondary cases, as is the case with the nose,
breast, and body, lies in the diagnosis of underlying problems and
the application of a logical surgical plan. Any surgeon capable of
identifying the anatomic basis of patient problems and forming a
sound plan for their correction can potentially achieve excellent
outcomes.
The best treatment of secondary problems is to avoid them
in the primary procedure, and as a result, the question arises
of how one should perform a neck lift and what steps can be
taken to avoid common problems and complications. Perhaps
it is easiest to start by recognizing what not to do. Although it
is a commonly advocated practice, it is not enough to perform
submental liposuction and tighten the skin in most patients,
as such an approach ignores a number of anatomic problems
present in many patients seeking neck improvement including
771
 VIII Surgical Rejuvenation of the Face and Neck
platysmal laxity, platysma bands, excess subplatysmal fat, large
submandibular glands, digastric muscle hypertrophy, and
developmental factors such as the size and shape of the bony
jaw and chin. Removing subcutaneous fat and/or tightening skin
over these problems does not correct them, and the presence
or absence of each must be looked for in order to create and
apply an appropriate surgical plan (Fig. 53.1). Once this fact is
acknowledged, it becomes clear that any procedure that targets
subcutaneous fat (cryolipolysis, chemolipolysis, liposuction,
etc.) or the skin (postauricular skin excision, radiofrequency or
ultrasound skin-shrinking treatment, etc.) is destined to fail
and result in secondary problems. Any surgeon who regards the
problem present in the neck as consisting solely of excess sub-
cutaneous fat and lose skin that can be treated with procedures
that target only that tissue layer and try to remove or shrink skin
is destined to produce mediocre outcomes at best and, more
likely, secondary neck deformities.
It is also conceptually flawed and ultimately clinically inef-
fective to try to force contour in the neck by suspending tissue
(suture lifts, thread lifts, suspension sutures, barbed sutures)
or corset tightening of the platysma. A young, attractive neck
is not tight and does not have a tight platysma but rather a
youthful distribution of tissue on it. Tightness is an aberration
created by surgeons employing conceptually flawed techniques,
and once that fact is recognized, it becomes clear that common
neck problems are not appropriately treated by platysma tight-
ening ( corset platysmaplasty, ultrasound radiofrequency tissue
tightening, tissue heating, etc.) and that our goal in neck lift is to
modify tissues that have changed or hypertrophied with age in
a way to create youthful, attractive neck contour not to tighten
the neck.
53.2 Strategies for Primary and
Secondary Neck Lifts
Patients seeking secondary neck lift will present with a variety
of irregularities and have a range of options available to them
depending on the problems present, the degree of improvement
they seek, and the time, trouble, and expense they are willing
to undergo to obtain the improvement they desire. hile it is
a b
Fig. 53.1 Patient seen before and after neck lift. It is not enough to perform submental liposuction and tighten the skin in most patients. Such
an approach ignores anatomic problems present in many patients seeking neck improvement. (a,c) A careful evaluation shows patient preopera-
tively to be troubled by platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands, and digastric muscle hypertrophy.
Little or no excess subcutaneous fat is present, however. (b,d) Removing subcutaneous fat and tightening skin over these problems would not
correct them or produce the type of improvement shown. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of
Plastic Surgery.)
772
essential to discuss these options and the advantages and dis-
advantages of each, patients are also seeking our guidance as to
what is possible, what is practical, and what is really best. It is not
enough to steer patients to procedures we are most comfortable
with performing. e are professionally bound and ethically
obliged to refer patients for the care they need and desire if we
are not able to provide it ourselves.
53.2.1 Submental Liposuction
Submental liposuction (and arguably other noninvasive
treatments, including cryolipolysis, deoxycholic acid injec-
tions, and radiofrequency and ultrasound skin shrinking
and tissue shrinking treatments that primarily exert their
effect through subcutaneous fat destruction) is the simplest
and likely the most commonly performed surgical procedure
to improve neck contour in the range of options available to
patients. It does not constitute a true neck lift, however, and
only occasionally produces optimal outcomes. Patients and
surgeons are predictably drawn into a sense of denial of this,
however, by the fact that submental liposuction will occasion-
ally produce worthwhile improvement in select cases, and it is
these atypical good outcomes that are displayed in surgeons’
offices, placed in advertisements, shown on TV, published in the
beauty press and on websites, and even included in presenta-
tions at plastic surgery meetings and symposia. Adding to the
deception is that fact that these photographs are usually taken
in the early postoperative period, when swelling is still present
that obscures irregularities and underlying but untreated deep
layer problems.
In reality, submental liposuction (along with the afore-
mentioned noninvasive procedures that target subcutaneous
neck fat) is an incomplete solution to neck problems for most
patients. As a standalone treatment it suffers the significant
drawback that it falsely assumes poor neck contour to be
solely the result of the accumulation of subcutaneous fat, and
it is conceptually flawed in that it does not address platysma
laxity and other deep-layer problems that together typically
play a much larger and more important role in the aging
neck and neck contour deformities. As such, the majority of
patients undergoing this procedure achieve arguably marginal
c d

improvement, but not comprehensive correction of their neck
problems, and ultimately relying on this technique as the only
method to obtain improved neck contour will seldom be suc-
cessful (Fig. 53.2).
Submental liposuction is also a frequent cause of many vexing
patient problems and complications, as it often leads to unin-
tended but inappropriate removal of subcutaneous fat essential
to a natural and youthful appearance, and this can in turn expose
underlying problems of deep layer origin. Misapplied and over-
used, or when aggressive ultrasonic, laser, or other power tools
are overenthusiastically applied, submental liposuction all too
commonly can also result in overresection of precious subcuta-
neous fat and unnatural and objectionable appearances. These
problems are typically not evident in the operating room or in the
early postop period, when cervicosubmental tissues are swollen;
however, they appear later and once present, are very difficult to
correct (Fig. 53.3).
a b
Fig. 53.2 Typical outcome seen with submental liposuction.
(a) Patient presenting for forehead and eyelid surgery who is also
requesting liposuction of her neck, seen preoperatively. A careful
examination of this patient’s neck shows little excess subcutaneous
fat to be present, and a large submandibular salivary gland and
platysma bands are evident. (b) Same patient after forehead and
eyelid surgery and submental liposuction. Overall neck contour has not
been significantly improved. The large submandibular salivary gland
is still present, platysma laxity has not been corrected, and aggressive
subcutaneous fat removal has made platysma bands more obvious.
(Courtesy of Marten Clinic of Plastic Surgery.)
a b
Fig. 53.3 Overexcision of subcutaneous fat with liposuction. (a) The
patient has had aggressive “small cannula microliposculpture” by an
unknown surgeon, which resulted in too much fat being removed. The
neck and submental region are irregular, unnatural, and unattractive.
(b) A different patient has had “laser liposuction” performed by an
unknown surgeon. Inappropriate overresection of fat has resulted
in harsh and unnatural contours along with unattractive exposure
of platysmal bands. (Courtesy of Marten Clinic of Plastic Surgery.
Procedures performed by unknown surgeons.)
53 Secondary Neck Lift
Liposuction, in combination with ill-conceived overtightening
of neck skin, can add the additional problems of hairline displace-
ment and wide and hypertrophic postauricular scars, compound-
ing the overall deformity (Fig. 53.4).
Despite its many drawbacks and propensity to precipitate
troublesome and difficult to correct problems, the conceptual
and comparative technical simplicity of submental liposuction is
nonetheless appealing to less experienced surgeons and nonsur-
geons seeking to improve the neck. Indeed, these aspects of the
technique almost guarantee that, appropriate or not, it will con-
tinue to be overused and misapplied to patients who are not good
candidates for the procedure, and more experienced surgeons will
be called on to correct the resulting problems.
53.2.2 “Short-Scar” Neck Lift (Neck Lift
with Submental Incision Only)
Although submental liposuction alone will rarely produce
optimal neck improvement in both primary and secondary
procedures, a neck lift performed through a submental incision
without any removal of skin can create attractive cervical
contour in many patients (Fig. 53.5), and the improvement that
can be obtained with a short-scar neck lift in which no skin is
removed stands as a testament to the relative unimportance of
skin excision and tightening in improving neck contour. This is
particularly true if a facelift and aggressive skin resection were
performed as part of the patient’s primary procedure. In such
cases skin excision, when performed, is typically undertaken as
simply a means to correct wide or misplaced scars or earlobe and
tragal irregularities.
The short-scar neck lift is effective because, in contrast to
liposuction, a neck lift performed through a submental incision
allows deep-layer problems (subplatysmal fat excess and sub-
mandibular gland enlargement) and platysmal laxity typically
present in the majority of patients seeking neck improvement
to be addressed. This, however, raises the questions of how good
a b
Fig. 53.4 (a,b) Overexcision of postauricular skin. It is a common
error to attempt to lift the neck by tightening neck skin. It is not
possible to create a sustained improvement in neck contour in this
manner, and ill-conceived overtightening of neck skin will result in
wide postauricular scars and, if the incision is planned poorly, hairline
displacement. Neck contour is properly created by modification of
deep-layer structures, and only skin that is truly redundant should be
removed. In some cases, no skin at all need be removed (see Fig. 53.5).
(Courtesy of Marten Clinic of Plastic Surgery. Procedures performed by
unknown surgeons.)
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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 53.5 Neck lifts with a submental incision only. Although submental liposuction alone will rarely produce optimal neck improvement, a neck lift
performed through a submental incision without any removal of skin can create attractive cervical contour in many patients. These patients had their
procedures performed through submental incisions only. No incisions were made in the periauricular areas, no periauricular scars are present, no skin
was removed, and no lateral platysmal suspension was performed. (a) Procedure performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic
of Plastic Surgery. (b) Procedure performed by Dino Elyassnia, MD, FACS. Courtesy of Dino Elyassnia, MD. (c) Procedure performed by Timothy Marten,
MD, FACS. Courtesy of Marten Clinic of Plastic Surgery. (d) Procedure performed by Dino Elyassnia, MD, FACS. Courtesy of Dino Elyassnia, MD.

neck contour can be created without removing and tightening the
skin, and what happens to the excess skin if only the deeper-
layer treatment is done and no skin is excised. The answer to this
question is twofold.
First is the simple (but often difficult to accept) concept that in a
properly performed neck lift, contour is created by modification of
deep layers of the neck, not by tightening the skin. Skin is intended
to be a covering layer and serve a covering function, and it was
meant to stretch and give as we move and express ourselves. It
was not intended to be a structural supporting layer or to hold
up sagging muscle and fat or lift hypertrophied structures lying
beneath it.

774

The second part of the answer lies in the increase in neck surface
area that occurs when neck contour is improved using deep-layer
neck maneuvers. Improving neck contour by excising redundant
subplatysmal fat and performing other deep-layer maneuvers as
indicated, followed by reconstituting a lax platysma (but not cre-
ating a tight corset ) will result in a deeper cervicomental angle, a
longer curvilinear distance from the mentum to the sternal notch,
Fig. 53.6 (a) Redistribution of “excess” skin in short scar neck lift. In
the preoperative condition (left), subplatysmal fullness (subplatysmal
fat and large submandibular glands) has resulted in an oblique neck,
and the neck skin is distributed over a straight surface between the
chin and the sternum. This straight line spans the shortest distance
between the two points, and to the eye excess skin appears to be
present. Postoperatively (right), subplatysmal fullness has been
eliminated, creating a deeper, more concave, and geometrically larger
and longer neck surface. The skin is redistributed over a curved line
that takes a longer path between the two points. (Surgical procedure
performed by Timothy J Marten, MD, FACS. Illustration courtesy of the
Marten Clinic of Plastic Surgery.) (b) Improper excision of skin from
the submental incision and “bowstring effect.” Once it is recognized
that treatment of subplatysmal neck problems increases neck surface
area and deepens the cervicomental angle, it becomes clear why it is
counterproductive to excise any skin from the submental incision, as
this can create a “bowstring” effect and actually blunt the cervicomen-
tal angle. This maneuver will also result in objectionable “dog ears” at
each end of the incision that spoil cervicosubmental contour. If skin
excision is necessary, it is more practically, effectively, and logically
removed from the postauricular area. (Illustration courtesy of the
Marten Clinic of Plastic Surgery.)
53 Secondary Neck Lift
and a more concave and geometrically larger and longer neck
surface. hen neck skin is redraped and redistributed over the
deeper, more concave surface, excess skin is absorbed and none
need be removed (Fig. 53.6a). These simple but not necessarily
intuitive or immediately obvious facts explain why skin excision
need not be performed in patients with good skin quality and mild
to moderate apparent skin excess to obtain a good result in both
primary and secondary neck lift procedures. In female patients,
good results can be obtained from short-scar neck lifts in patients
up to their late 30s. In male patients, satisfactory outcomes can be
achieved in patients up to their late 50s.
Once the fact that increased neck surface area is produced by
deepening the cervicomental angle is acknowledged and accepted,
it becomes clear why it is counterproductive to excise any skin
from the submental incision: this can create a bowstring effect
and actually blunt the cervicomental angle. Skin removal along
this vector is not helpful in most patients. The submental skin
incision is used only for access to the neck in a properly performed
neck lift, and if skin excision is necessary, it is more practically,
effectively, and logically removed from the postauricular area
(extended neck lift or a facelift procedure) along a more appropri-
ately directed lateral vector (see Fig. 53.6b).
The results that can be obtained with a short-scar neck lift
stand as compelling confirmation of the supremacy of the deep-
layer approach over more traditional procedures that mistakenly
focused on skin excision, subcutaneous fat removal, and platysmal
tightening.
53.2.3 Why Not Perform a Short-Scar
Neck Lift on Everybody?
There is a limit to the amount of neck skin that can be absorbed
and managed in this manner, however, and an isolated neck lift
performed through a submental incision only is typically best as
a primary procedure for male patients and younger women with
mild to moderate skin excess, good skin elasticity, and minimal
or modest aging in the midface, cheek, and jowl. In patients pre-
senting for secondary procedures in which skin was aggressively
excised at the primary procedure, a submental incision only
may be needed to perform needed deep-layer maneuvers and to
achieve the desired improvement in neck contour.
53.2.4 Inappropriate Placement
of Chin Implants
The difference between the presence of poor neck contour and
microgenia is frequently misunderstood, and it is a common
misconception that placement of a chin implant improves neck
contour. A chin implant is a treatment for a small chin, not for
a poor neckline, and the presence or absence of microgenia and
the need for a chin implant is a cephalometric determination
that is independent of the condition of the neck. Placement of a
chin implant when microgenia is not present is a conceptual and
artistic error that will create unnatural appearances, and in some
secondary neck procedures it may be necessary to remove an
overly large chin implant and replace it with a smaller one. Much
depends on the type of implant that was placed at the primary
procedure, however. Silicone implants are soft and flexible, do
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 VIII Surgical Rejuvenation of the Face and Neck

not integrate with adjacent tissue, and are typically surrounded
with a smooth, nonadherent capsule that makes removal and
replacement relatively easy. Porous polyethylene implants, how-
ever, are naturally brittle and typically incite tissue ingrowth
that can make removal and replacement or exchange very
difficult. In many cases, porous polyethylene implants have been
divided into pieces at the primary procedure and reassembled
in situ with multiple screws and miniplates. In these situations,
removal and replacement can be very difficult and time con-
suming and require special instrumentation. If a chin implant
is removed completely and not replaced with a smaller one, the
chin pad must be carefully resuspended to avoid chin pad ptosis.
Fat grafting is also typically helpful in reestablishing a full and
supple appearance in such situations.
hen true microgenia is present, however, placing a chin
implant in combination with a neck lift will produce a more har-
monious and balanced profile and a more aesthetic and attractive
cervicofacial profile (Fig. 53.7). hen a well-performed, compre-
hensive neck lift is performed, it is often the case that a slightly
smaller implant than the surgeon’s intuition suggests may be
more appropriate.
53.2.5 Residual Skin Excess and
Inappropriate Skin Shifts Due
to Primary Short-Scar Facelift
Surgery Plans
If a significant amount of redundant skin is present, it must be
excised to obtain the best result, and in such situations it is most
logically and effectively excised in the postauricular areas using
periauricular skin incisions extending across the mastoid and
down along the occipital hairline. Skin excision from the submen-
tal incision is conceptually flawed and will actually degrade neck
contour rather than improve it (see Fig. 53.6b), and skin excision
using large midline -plasties will result in a poorly concealed,
odd-appearing geometric scar and bizarre changes in beard hair
inclination in men (Fig. 53.8). Skin excision from the neck is not

Fig. 53.7 (a–c) Neck lift with a chin implant. The difference between the presence of poor neck contour and microgenia is commonly misunderstood,
and it is a common misconception that placement of a chin implant improves neck contour. When true microgenia is present, however, placing a
chin implant in combination with a neck lift will produce a more harmonious and balanced profile and a more aesthetic and attractive cervicofacial
contour. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

776
 53 Secondary Neck Lift

as it is unusual to encounter patients with excess skin in the neck

a b
Fig. 53.8 Unaesthetic scarring from submental and anterior neck skin
excision using a -plasty. If a significant amount of redundant skin is
present on the anterior neck and submental area, it is most logically,
effectively, and aesthetically excised from the postauricular areas
along the occipital hairline rather than on the anterior neck using a
Z-plasty. (a) A large midline Z-plasty used on this man has resulted in a
poorly concealed, odd-appearing geometric scar and bizarre changes
in beard hair inclination. (b) A different patient has had skin excised
from the anterior neck using a similar Z-plasty technique. The obvious
and objectionable-appearing scar is inconsistent with a well-performed
aesthetic surgery procedure. (Courtesy of Marten Clinic of Plastic
Surgery. Procedures performed by unknown surgeons.)
possible using a short-scar facelift incision (Fig. 53.9). A significant
excision of skin from the anterior neck and submental region is not
possible when a short postauricular incision plan and a “vertical”
shift of facial skin are used as is advocated in a minimal-access
cranial suspension (MACS) lift or like procedures (Fig. 53.10).
Skin excision can be combined with treatment of the submental
neck and subplatysmal neck problems as an extended or long-scar
neck lift or as part of a facelift procedure (Fig. 53.11; Fig. 53.12;
Fig. 53.13).
53.2.6 Neck Lift with a Facelift
Practically speaking, most patients in need of a neck lift with skin
excision presenting for primary procedures also need a facelift,
but not elsewhere on the face. This is particularly true in women,
and it is aesthetically inappropriate to perform an isolated neck
lift in most women who present for facial rejuvenation. Lifting
only the neck but not the cheeks, jowls, and jawline at a primary
procedure can create an unnatural and unfeminine appearance.
Combining a facelift with a neck lift is almost always the best
approach in a primary procedure to obtain a balanced, natural,
and harmonious rejuvenation of the female face, although not
all patients will recognize or accept this (Fig. 53.13). Performing
a facelift in combination with a neck lift at primary procedures
also allows for more complete and comprehensive removal of
neck skin. In addition, whereas many men will be put off by the
idea of a facelift, they will readily agree to undergo the more
palatable-sounding extended neck lift, which in essence can be
performed as a low-SMAS procedure.
53.3 Surgical Planning in Neck Lift
53.3.1 Planning the Submental Incision
and Correcting Residual and
Uncorrected “Witch’s’ Chin” and
“Double Chin” Appearances
hether performing a neck lift alone or in combination with a
facelift, optimal improvement in neck contour generally cannot
be obtained in most patients unless a submental incision is
made, despite the long list of historical but conceptually flawed
and failed attempts to avoid doing so.
Traditionally this incision is placed directly in and along the
submental crease in a well-intended but counterproductive
attempt to conceal the resulting scar (Fig. 53.14). This incision
plan should be avoided if possible, however, as it will surgically
reinforce the crease and accentuate a “double chin” or “witch’s
chin deformity. Exposure of the submental region will also be
compromised, and difficulty will be encountered when suturing
or dissecting low in the neck. A more posterior placement of

a b c
Fig. 53.9 Incorrect incision plan for skin removal in neck lift. If a significant amount of redundant skin is present on the neck, a short-scar facelift
incision plan does not allow skin to be shifted along an optimal vector and is not helpful in reducing loose skin on the anterior neck and in the submen-
tal area. (a) Preoperative plan for a short-scar facelift (red dotted line) resulting from a well-intended but misguided attempt to shorten the incision in
the postauricular area. When skin is shifted along a proper posterior vector parallel to the mandibular border (blue arrow), a dog-ear is produced in the
postlobular area. (b) In some cases the dog-ear is “modest” as shown, but it typically exists as a telltale sign that surgery has been performed and as a
source of embarrassment to the patient. Little or no skin is eliminated from the anterior neck and submental area when such a plan is used. (c) Often
the dog-ear is far from modest, and objectionable puckering and gathering occurs even though little or no improvement is gained in the anterior neck
and submental regions. Planning the incision along the occipital hairline prevents this problem, allows skin to be excised along an optimal vector, and
provides for a well-tailored scar without objectionable bunching or gathering. (Illustration courtesy of Marten Clinic of Plastic Surgery.)

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 VIII Surgical Rejuvenation of the Face and Neck

Fig. 53.10 Incorrect incision plan for skin removal in neck lift has
resulted in an inappropriate skin shift. The patient underwent a previ-
ous facelift in which a short postauricular incision plan was used and
a vertical shift of preauricular skin was made to minimize the amount
of puckering and gathering in the postauricular area. The use of this
vertical skin vector has resulted in wrinkled neck skin being overshifted
up onto the lower face, creating an objectionable and unnatural appear-
ance, and little or no skin has been advanced out of the submental area,
where skin reduction is needed most. Neck contour remains oblique
because a submental incision was not made and deep-layer problems
(subplatysmal fat accumulation, submandibular gland enlargement,
and digastric muscle hypertrophy) all remain untreated.
Fig. 53.11 Correct incision plan for a long-scar or “extended” neck
lift. If a significant amount of redundant skin is present on the neck, it
must be excised to obtain the best result, and in such situations it is
most logically and effectively excised in the postauricular areas, using
a periauricular skin incision that extends down the occipital hairline
rather than under the chin. This incision plan avoids a temporal inci-
sion, which is of concern to some patients, but provides for significant
skin removal from the neck and some improvement in the lower face
and along the jawline. (Illustration courtesy of Marten Clinic of Plastic
Surgery.)

Fig. 53.12 (a,b) Extended neck lift. Skin excision can be combined with treatment of the neck through the submental incision as an “extended” or
“long-scar” neck lift or as part of a facelift procedure. Both of these patients had skin excised as part of their procedures, and an incision was made in
the periauricular area. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

this incision will preclude these problems but still result in an
inconspicuous and better-concealed scar (Fig. 53.15, Fig. 53.16,
Fig. 53.17).
The submental incision should be placed well within the man-
dibular shadow and well posterior but parallel to the submental
crease at a point lying roughly one-half the distance between the
mentum and the hyoid. This usually corresponds to a site situated
1 to 1.5 cm posterior to the crease (Fig. 53.18).
Regrettably, in many secondary neck lifts an incision will have
been previously made in the submental crease at the primary

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 53 Secondary Neck Lift

Fig. 53.13 Comprehensive rejuvenation of the face. Combining a neck lift with a facelift and related procedures is almost always the best approach
to obtain a balanced, natural, and harmonious rejuvenation of the female face, although not all patients will recognize or accept this. (a,b,c,d,e) This
62-year-old woman had previously undergone a facelift, neck lift, and blepharoplasties performed by an unknown surgeon. She is seen before and
12 months after a secondary facelift, secondary necklift, limited incision forehead lift, and panfacial fat transfer. Preoperatively in the lateral view
(d) it can be seen that subcutaneous fat has been overresected, and in the lateral (d) and lateral flexed (e) views it can be seen that the traditional
neck lift consisting of submental liposuction, platysmaplasty, and skin excision has failed to produce an attractive neck contour. The secondary neck
lift consisted of excision of residual subplatysmal fat, reduction of prominent submandibular salivary glands, partial digastric myectomy, and pla-
tysmaplasty. No subcutaneous fat was removed, and only a modest amount of skin was removed as part of correcting earlobe irregularities. A more
youthful, fit, feminine, and attractive neck contour can be seen. Addressing all regions of the face has produced a natural, balanced, and harmonious
result, and a far better outcome than a neck lift alone. (Primary procedure performed by an unknown surgeon. Secondary procedures performed by
Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

779
 VIII Surgical Rejuvenation of the Face and Neck

procedure, and this will have exacerbated a double chin or witch’s
chin appearance. In such cases the patient and surgeon must con-
sider the advantages and disadvantages of using the same site for
the submental incision or making a new one in a more appropriate
location. If the scar in the submental crease is well healed and the
patient is in an older age group, it may be best to make the incision
for the secondary procedure in a more appropriate posterior posi-
tion to obtain optimal access to the deep neck. If the scar in the
submental crease is poorly healed, or if the patient is in a younger
age group or is concerned about having a second scar in the sub-
mental area, it may be best to excise the existing scar, lengthen it
to the extent possible, and use it as access to the deep neck in the
secondary procedure. Ultimately, it is wise to leave the decision to
the patient after appropriate discussion has been made.
The submental incision, when optimally sited in primary pro-
cedures, should be approximately 3 to 3.5 cm in length, but it may
be made longer as long as neither end will be advanced up onto
a visible portion of the face when skin flaps are shifted. Healing

Fig. 53.14 Traditional but incorrect plan for the submental incision.
The incision should not be placed directly along the submental crease
(arrow), as this will reinforce the submental retaining ligaments and
accentuate the “double chin” appearance. Note that the typical plan
of skin undermining (yellow area) also promotes a double chin appear-
ance because the crease is not undermined, the retaining ligaments
are not released, and the fat of the chin and the neck cannot be readily
blended to create a smooth transition between them. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.15 Correct location for the submental incision. Placing the
submental incision 1.5 cm posterior to the submental crease prevents
accentuation of the double chin and witch’s chin deformities and
provides for easier dissection and suturing in the anterior neck (com-
pare with Fig. 53.14). Note that this incision plan allows the submental
crease to be undermined and submental retaining ligaments to be
released and the fat of the chin pad and submental neck to be blended
to create a smooth and aesthetically pleasing transition between
them. (Illustration courtesy of Marten Clinic of Plastic Surgery.)

Fig. 53.16 Correction of the “double chin” deformity. (a) Patient with double chin seen preoperatively. (b) Same patient seen after face- and neck
lift. The submental incision was made posterior to the submental crease to allow undermining and release on the submental retaining ligaments
and blending of chin and neck fat to create a smooth and aesthetically pleasing transition between them. The subplatysmal neck was treated with
subplatysmal fat excision and by excision of protruding parts of the submandibular gland and digastric muscle. (Procedures performed by Timothy
Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

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 53 Secondary Neck Lift

a b c d
Fig. 53.17 (a,c) Correction of the “witch’s chin” appearance. (b,d) Patient who has undergone previous “neck lift” consisting of submental
liposuction and platysmaplasty performed by an unknown surgeon, with “witch’s’ chin” appearance seen preoperatively before secondary neck lift.
Same patient seen after facelift, secondary neck lift, fat grafting, and related procedures. The chin pad has been undermined and fat of the chin has
been blended with remaining fat in the submental area to create a smooth and aesthetically pleasing transition between the two areas. (Procedures
performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

a b
Fig. 53.19 Healed submental incisions. Placement of the submental
incision posterior to the submental crease will still result in an incon-
spicuous, well-concealed scar while simultaneously providing better
access and exposure when working in the deep layers of the neck. (a)
Healed submental scar in a female patient. (b) Healed submental scar
in a male patient. (Procedures performed by Timothy Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)

will be best, and the scar will be best concealed, if it is made as a

straight, not a curved, line (Fig. 53.19).

53.3.2 Planning Treatment of

Fig. 53.18 Plan for optimal submental Incision placement marked
on a patient. The submental portion of the facelift incision (solid line)
should be placed posterior to the submental crease (dotted line),
approximately one-half the distance between the mentum and hyoid
(black arrows) in primary procedures. Usually this corresponds to a
point about 1.5 cm posterior to the submental crease. In secondary
procedures where an incision has already been made and a scar exists
in the submental crease, a decision must be made as to whether the
surgeon should excise the existing scar and use the same incision,
or make an incision in a more appropriate location that gives better
access and exposure to the deep neck. Dotted lines along jawline
and in inferior neck represent approximate extent of subcutaneous
skin undermining. Parallel solid lines on anteroinferior neck represent
approximate location of cricoid cartilage. (Courtesy of Marten Clinic of
Plastic Surgery.)
the Platysma
Fundamental Concepts in Treatment of
Platysma Irregularities
As surgeons have pursued improved outcomes in treating the
neck, our understanding of the origin of platysma muscle irregu-
larities has improved and platysma muscle treatment techniques
have evolved. Experience has shown that the traditional notion
that horizontal platysma tightening ( corset platysmaplasty)
will correct deep-layer neck problems, including accumulations
of subplatysmal fat and the presence of large submandibular
glands and protruding digastric muscles, was misguided and
that proper treatment of these problems will require procedures
that address the actual anatomic problems present. Over time,
thoughtful surgeons have come to understand and accept that
a sustained improvement in neck contour is created not by

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 VIII Surgical Rejuvenation of the Face and Neck
platysma tightening but rather by the deep-layer maneuvers that
specifically target these problems (subplatysmal fat excision,
submandibular gland reduction, and partial digastric myectomy).
Experience has also confirmed that traditional platysma-
tightening procedures will not universally correct platysma bands
and that our traditional view that all platysma bands are a homoge-
neous problem and simply a product of age-associated horizontal
platysmal laxity was conceptually flawed and the underlying cause
of many decades of failed treatments. In reality, platysma bands
comprise a heterogeneous group of distinct problems, and for
many patients platysma bands can be seen to be the product of not
only horizontal laxity but longitudinal platysmal hyperfunction and,
as such, refractory to traditional horizontal lifting and tightening
procedures. Proper treatment of these problems requires horizon-
tal platysma transection or partial platysma excision (or treatment
by other like means) to disrupt longitudinal hyperfunction.
Assessing Platysma Deformity
The cervico-submental region of each patient must be care-
fully examined both at rest and during platysmal activation if
complete assessment of platysmal deformity is to be made, as
secondary neck lift patients almost universally have residual
platysma abnormalities. This is best accomplished by asking
the patient to push your jaw forward and tighten your neck
or show me your bottom teeth and tighten your neck. It is
often helpful if the surgeon demonstrates this maneuver first for
the patient to be sure it is correctly performed. Frequently an
insignificant-appearing deformity at rest will be obvious upon
muscle activation (Fig. 53.20). Failure to recognize and appro-
priately correct these “dynamic deformities” is the reason too
many neck lift patients appear improved in repose but unnatural
or bizarre in conversation, animation, and other activities that
result in platysma muscle activation.
Examination of the cervico-submental region with and with-
out platysmal activation allows one to distinguish whether the
residual bands are “hard” dynamic or “soft” adynamic bands.
Soft, adynamic bands change little during platysma activation
a b
Fig. 53.20 Dynamic assessment of the cervico-submental region and
platysma muscle. (a) The neck is examined in repose and (b) with the
platysma contracted. In repose a modest platysma problem appears
to be present, and horizontal platysma laxity can be seen to be modest
in the patient shown. Upon platysma activation, however, pronounced
longitudinal platysma hyperfunction and objectionable platysma
bands can be seen. (Courtesy of Marten Clinic of Plastic Surgery.)
782
and are predominantly a problem of loose skin or horizontal
platysmal laxity (Fig. 53.21a). Hard, dynamic bands become tight
or exaggerated upon platysmal activation and indicate a problem
of longitudinal platysmal hyperfunction (Fig. 53.21b).
Plan for Treatment of Horizontal Platysma
Laxity and “Soft” Bands
If submental support is poor due to horizontal platysmal laxity or
platysmal diastasis and optimal improvement in the anterior neck
is desired, anterior platysmaplasty is planned (Fig. 53.22). Anterior
platysmaplasty is the procedure in which the medial borders of
the platysma muscle are sutured together to help consolidate
the neck, reduce horizontal platysmal laxity, and improve neck
appearance when the patient flexes the neck and looks down (Fig.
53.23). It is not, however, adequate or effective in the treatment of
excess subplatysmal fat, prominent submandibular glands, hyper-
trophy of the anterior bellies of the digastric muscles, or hard
dynamic platysmal bands. ot recognizing and acknowledging
this fact, and well-intended but misguided attempts to treat these
problems by medial or lateral platysmal pulling and tightening,
have led to frustration for many surgeons treating the aging neck.
Treatment of these problems will require that other maneuvers,
discussed elsewhere in this chapter, be performed.
Plan for Treatment of Platysma Hyperfunction
and Dynamic “Hard” Bands
It is important to distinguish between soft, adynamic pla-
tysmal bands and “hard,” dynamic bands in both primary and
secondary neck lift patients, as treatment will vary depending on
the type present. Patients with soft bands are usually adequately
treated with skin excision or skin excision and platysmaplasty
a b
Fig. 53.21 “Soft” and “hard” platysma bands. Examination of the
cervico-submental region during platysma activation allows one to
distinguish between “hard” dynamic and “soft” adynamic cervical
bands. Treatment will vary fundamentally depending on the type of
band present. (a) A patient’s neck seen during platysma activation.
Soft, adynamic bands change little during platysma activation and are
predominantly a problem of loose skin or horizontal platysmal laxity.
(b) A different patient’s neck seen during platysma activation. Hard,
dynamic bands become tight or exaggerated upon platysma activation
and indicate a problem of longitudinal platysma hyperfunction.
Differentiating between hard and soft platysma bands is important
because treatment varies depending on the type of band present.
(Courtesy of Marten Clinic of Plastic Surgery.)
 53 Secondary Neck Lift

a b
Fig. 53.22 Anterior platysmaplasty. Anterior platysmaplasty reduces
horizontal platysma laxity, improves submental support, consolidates
the neck, and is the primary treatment of “soft” platysma bands.
Despite wishful thinking by some surgeons, it is not adequate or
effective treatment of dynamic “hard” platysma bands, nor of excess
subplatysmal fat, prominent submandibular glands, and protrusion of
the anterior bellies of the digastric muscles. (Illustration courtesy of
Marten Clinic of Plastic Surgery.)
Fig. 53.23 Anterior platysmaplasty. Platysmaplasty improves
submental support and enhances neck appearance when the patient
looks down. (a) Patient seen preoperatively with horizontal platysma
laxity. Simply tightening the skin will not correct this appearance in a
sustained fashion. (b) The same patient after extended neck lift and
ancillary procedures that included anterior platysmaplasty. The skin can
be seen to lie smoothly over the deeper, concave, and geometrically
longer anterior neck surface. The procedure included subplatysmal fat
excision and excision of protruding portions of the submandibular gland
and digastric muscle. Fat grafting has also been performed to enhance
the chin and jawline. (Procedures performed by Timothy J Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)

laterally on the platysma muscle borders as commonly advocated

does not address the origin of dynamic platysma bands and is
alone. Patients with hard bands, however, require transverse
f Likewise, attempts
platysma myotomy or some other procedure that disrupts longi-
to excise dynamic platysma bands vertically along the length of
tudinal platysma muscle hyperfunction and prevents the muscle
the muscle fibers is not a logical or effective treatment, as the
from contracting upon itself. Much as when a dancer with a
band is not fixed in location and any such maneuver does not
ruptured Achilles’ tendon cannot point the toe, dividing the pla-
address overall longitudinal muscle hyperfunction in a complete
tysma transversely prevents it from pulling upon itself and away
and comprehensive way.
from the anterior surface of the neck. The result of platysma
Platysmal bands are generally seen to lie in medial and lateral
myotomy when properly performed is dramatic, long-lasting,
locations and are often referred to as anterior and lateral platysma
and superior to any suture, suture suspension, lateral suspen-
bands (Fig. 53.25). Each band is situated near the medial or lateral
sion of the platysmal border, or corset platysmal tightening
technique (Fig. 53.24). The length of transection required can
be varied depending on the location and configuration of bands
present and may thus differ from patient to patient. The key to
success in treating hard, dynamic bands is to acknowledge that
they are the product of longitudinal platysma muscle hyper-
function, not one of horizontal platysma laxity, and employing
a plan of treatment that recognizes this fact. Pulling medially or

Fig. 53.24 Platysma myotomy. (a) Patient seen with objectionable-

appearing “hard,” dynamic platysma bands before platysma myotomy.
(b) Same patient after platysma myotomy. The result of platysma
myotomy is typically dramatic, long-lasting, and superior to any
suture, suture suspension, lateral suspension of the lateral platysmal
border, or “corset” platysma tightening technique. Note that the goal
of the procedure is a reduction in platysma hyperfunction, however,
and not a complete absence of muscle movement. (Courtesy of Marten
Clinic of Plastic Surgery.)
Fig. 53.25 “Anterior” and “lateral” platysmal bands. Platysma bands
are generally seen to lie in medial and lateral locations and are often
referred to as anterior and lateral platysma bands. Each band is situated
near the medial and lateral platysma muscle borders but does not
usually correlate precisely with them. (Illustration courtesy of Marten
Clinic of Plastic Surgery.)

783
 VIII Surgical Rejuvenation of the Face and Neck

platysma muscle border but does not usually correlate precisely

with it, and they are not specifically fixed in location. Patients
with only anterior platysmal bands can be treated with a partial
transverse platysma myotomy by dividing the muscle medially
and subtotally through and beyond the section of it in which the
band is present low in the neck at the level of the cricoid cartilage
(Fig. 53.26). The platysma muscles arguably need not be com-
pletely transected when only an anterior band is present, just the
region where the platysmal band is located.
If lateral as well as anterior bands are present, the myotomy
is carried more laterally to include them as well (Fig. 53.27). If
Fig. 53.26 Plan for treatment of “anterior” dynamic “hard” platysmal
poor definition is present over the lateral mandibular border in bands. Transverse platysma myotomy is performed in the region of
addition to anterior and lateral neck bands, or if comprehensive the platysma muscle where the platysmal band is present. (a) Anterior
improvement is desired, platysmal myotomy is planned to con- neck after platysmaplasty but before anterior platysma myotomy. (b)
After anterior platysma myotomy. (Note: Myotomy is most easily and
tinue “full-width” superolaterally up to the anterior border of effectively performed after platysmaplasty has been completed.) Note
the sternocleidomastoid muscle (Fig. 53.28). A similar full-width that because uninterrupted muscle is present laterally, the potential
myotomy of this type is also indicated in a firm obtuse neck with for new band formation in that area is possible when this plan is used.
(Illustration courtesy of Marten Clinic of Plastic Surgery.)
a short platysma and poor definition over the mandibular angle
but no bands.
In theory and principle, in many necks, only a subtotal myotomy
is indicated and need be performed. As a practical matter, how-
ever, complete transection of the platysma is typically performed
in most of our patients when any form of myotomy is indicated, to
limit the possibility that bands will recur in areas of muscle that
were not divided, or that residual platysma bands will be present.
Despite assertions to the contrary, full-width platysma myotomy
will not result in an overly thin-appearing neck ( lollipop neck )
or in reduced support of the submandibular glands when
properly performed. These are merely false assertions put forth
by surgeons who do not perform the procedure and do not want
to go to the time and trouble of learning and performing it. Fig. 53.27 Plan for treatment of “anterior” and “lateral” platysmal
Medial wedge resections of platysma at the hyoid and vertical bands. If lateral bands are present, the myotomy is carried more later-
ally to include them as well. (a) Anterior neck after platysmaplasty but
excisions of platysma bands, while shown in many textbooks, are
before anterolateral platysmal myotomy. (b) After anterolateral myot-
not typically effective in treating dynamic platysma bands, in that omy. (Note: Myotomy is most easily and effectively performed after
a large segment of adjacent and more laterally situated muscle platysmaplasty has been completed.) Note that because uninterrupted
remains untreated. Vertical excision of platysma bands, while still muscle is still present laterally, the potential for new band formation
in that area is possible when this plan is used. (Illustration courtesy of
advocated by some, has proven to be an ineffective treatment that Marten Clinic of Plastic Surgery.)
has been abandoned by experienced surgeons. Trying to isolate
and specifically excise the responsible muscle segment is difficult
at best, since the band is not specifically fixed in its location, and a
partial excision along a vertical axis typically allows or incites new
bands to form in an adjacent untreated area. Similarly, attempts
to place rigid support across the cervicomental angle, in the
form of a mastoid-to-mastoid “noose” of suture or commercially
available synthetic straps to lift platysmal bands, are conceptually
flawed and practically problematic. Experience has shown that
these maneuvers do not work and are the source of many patient
problems.

Treatment of “Radiofrequency Neck”
and “Ultrasound Neck”
Medial wedge resections of platysma at the hyoid can result in
unaesthetic exposure of underlying cervical anatomy, a harsh
transition from the submental region to the neck, and lower lip
dysfunction and asymmetric smile. These procedures are not
recommended in routine treatment of platysma bands, although
they are useful in certain secondary cases and in situations
a b
Fig. 53.28 Plan for “full-width” platysmal transection. Full-width
myotomy not only corrects anterior and lateral bands but provides
improved definition over the lateral mandibular border. (a) Anterior
neck after platysmaplasty but before full-width platysmal myotomy.
(b) After full-width platysmal myotomy. (Note: Myotomy is most easily
and effectively performed after platysmaplasty has been completed.)
A full-width division of this sort minimizes the chance that new bands
will form at a future date in areas where the muscle was not fully
transected. (Illustration courtesy of Marten Clinic of Plastic Surgery.)

784

where there has been fibrosis and scarring of subcutaneous
tissues and the platysma in that area. These problems can result
from noninvasive treatment of the neck with radiofrequency,
ultrasound, internal tissue heating, cryolipolysis, chemolipolysis,
laser liposuction (see Fig. 53.3, right), or use of inflammatory fill-
ers in the neck area. hen these noninvasive neck deformities
are present, a high myotomy (division at the level of the thyroid
cartilage rather than the cricoid), or even a partial myectomy
(excising damaged platysma muscle from the anterior neck at
the level of the thyroid cartilage), may be indicated (Fig. 53.29).
53.3.3 Evaluation and Assessment of
the Submental Region
Traditional neck lift techniques do not adequately address many
aspects of aging in the submental region, and it is not enough
in most situations to limit treatment of the neck to preplatysmal
lipectomy alone or with postauricular skin excision. For many
patients, subplatysmal fat accumulation, submandibular
salivary gland ptosis (enlargement), and digastric muscle
hypertrophy will contribute significantly to the neck contour
problems present and will necessitate additional treatment if
a b
Fig. 53.29 Plan for partial platysma myectomy for treatment of “non-
invasive,” “radiofrequency” and “ultrasound” neck deformity. When
marked fibrosis of the platysma muscle is present, traditional platysma
myotomy (transverse division of the platysma at the level of the cricoid
cartilage) will typically be inadequate, and effective treatment usually
requires partial platysma myectomy and removal of a major section
of the damaged muscle present on the anterior neck. (a) Preoperative
patient with platysma muscle hyperfunction (“dynamic hard bands”)
but uninjured muscle, showing surface expression of hyoid, thyroid,
and cricoid cartilages. This patient would be effectively treated with
simple platysma myotomy performed at the level of the cricoid
cartilage (see Fig. 53.26, Fig. 53.27, Fig. 53.28). (b) Schematic of the
segment of platysma muscle removed in partial platysma myectomy
(area shaded in red) when fibrotic, scarred platysma is present in cases
of “radiofrequency” and “ultrasound” neck. Typically the procedure is
begun by dividing the platysma transversely full-width at the level of
the midthyroid cartilage with electrocautery, working through both
the submental and postauricular incisions, taking care to avoid dividing
the underlying fascia if possible. The superior and inferior cut edges
of the muscle are then undermined using electrocautery on top of the
underlying fascia for a distance of 5 to 10 mm. The undermined seg-
ments of muscle are then excised and beveled flat using Metzenbaum
scissors or cautery. Note that a 1.5- to 2-cm cuff of platysma muscle
is left in place and undisturbed below the cervicomental angle (below
the level of the hyoid), especially laterally, to protect the cervical
and marginal mandibular branches of the facial nerves. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
53 Secondary Neck Lift
optimal improvement is to be obtained (Fig. 53.30). It must be
acknowledged and accepted that simply tightening the platysma
and creating a tight platysma corset over these problems will
not correct them and will not produce a sustained improvement
in neck contour if underlying deep-layer problems are not
addressed.
Identifying the Neck with Excess Subplatysmal
Volume
The presence of abnormal fullness in the submental space can be
demonstrated preoperatively by taking and examining a lateral
looking-down view photograph (Connell’s view) of the patient’s
neck (Fig. 53.31). Often a neck that looks reasonably good in the
straight lateral view will be revealed to be unexpectedly full
when the patient looks down, as if looking at items on a desk,
a menu at a restaurant, a program at the theater, or images on a
phone screen. Failure to appreciate subplatysmal fullness preop-
eratively and treat it appropriately intraoperatively will result in
compromised outcomes.
Fullness in the subplatysmal space and the need to explore and
treat the deep neck is indicated when the neck is full in Connell’s
view, and this picture should be taken and examined by any sur-
geon performing neck surgery. If this view is not taken before and
after surgery, the analysis of the patient’s neck was incomplete
and the documentation that the procedure was well performed
is inadequate.
Understanding the Distribution of Fat in
The Neck
A key element to obtaining good outcomes in the neck lies in
understanding the distribution of fat in the cervico-submental
region and choosing a treatment plan accordingly. Cervical fat is
present in three distinct anatomic layers: (1) preplatysmal (sub-
cutaneous), (2) subplatysmal, and (3) deep cervico-submuscular
( interdigastric ). hile our traditional focus has been the pre-
platysmal layer (which all too often has ended up overresected),
the secret to good outcomes in the neck is aggressively treating
the subplatysmal layer to create contour (typically in conjunc-
tion with prominent submandibular glands and digastric muscle
hypertrophy the deep neck triad ) and fighting to preserve
subcutaneous fat so as to maintain a youthful, healthy, and soft
appearance. Accordingly, contemporary neck lift requires many
surgeons to rethink what they have been taught and the tech-
niques that they are using. In all cases it should be the aim of the
surgeon to produce a youthful, attractive, and healthy-appearing
neck, not simply one devoid of fat.
Assessing the Location of Fat in the Neck
In all but the unusual or young patient, the majority of cervical
fat accumulation in patients seeking neck lifts and facelifts will
be present in a subplatysmal location, and little if any will need
to be removed from the preplatysmal layer. Indeed, as patients
age, fat stores generally shift from a preplatysmal location to a
subplatysmal one, and the small amount of subcutaneous fat
seen in the typical patient presenting for a facelift or neck lift
is necessary and must be preserved if a soft, youthful, natural,
785
 VIII Surgical Rejuvenation of the Face and Neck

a b
Fig. 53.30 Recognizing the origin of neck problems in the submental region. For many patients requesting secondary necklift, subplatysmal fat
accumulation, submandibular salivary gland “ptosis” (enlargement), and digastric muscle hypertrophy will contribute significantly to the neck
deformity present and necessitate specific treatment. Simply tightening the platysma over these problems will not correct them. Specific additional
treatment is necessary if these problems are to be improved. Note that the presence of submandibular gland and digastric muscle problems can be
diagnosed simply by looking at this patient. (a) Surface expression of common problems seen in secondary necklift patients. (b) Cadaver view of
corresponding problems show in (a). (Illustration courtesy of Marten Clinic of Plastic Surgery.)

a b c
Fig. 53.31 Assessing the presence of excess volume in the subplatysmal space. (a) Patient seen following traditional neck lift procedure in the
standard lateral view. The result appears ostensibly good. (Procedure performed by an unknown surgeon.) (b) Same patient seen after traditional
neck lift procedure in lateral flex view (Connell’s view). Inadequate treatment of the subplatysmal space is evident and the resulting objectionable
submental fullness can be seen. (Procedure performed by an unknown surgeon.) (c) Same patient after secondary face- and neck lift that included
treatment of irregularities in the subplatysmal space (subplatysmal fat, large submandibular salivary glands, and protruding anterior belly of the
digastric muscle). Proper treatment of the deep neck has provided an improved outcome. (Procedure performed by Timothy Marten, MD, FACS.
Courtesy of Marten Clinic of Plastic Surgery.)

non- surgical, and attractive appearance is to be obtained. display an unnatural and unaesthetic overresected or gutted
Although the necks of patients undergoing liposuction (or like appearance. Once one acknowledges these facts, the futility and
procedures that target subcutaneous fat) may look good ini- undesirability of cervicosubmental liposuction in most patients
tially when swelling is present, once it resolves, they typically becomes obvious.

786

Assessing the Amount of Preplatysmal Fat
Present
Often just taking a moment to look carefully at the oblique neck
of a patient presenting for neck lift surgery will reveal that,
despite the oblique contour, a paucity of subcutaneous fat is
actually present. In many circumstances the majority of deeper
anatomy can be easily seen beneath the skin, lending an old
appearance to the neck. This is in stark contrast to the plushly
padded necks of young people, where a thick layer of subcuta-
neous fat is present and where little if any deep neck anatomy
can be seen.
The presence or absence of preplatysmal fat can also be assessed
by examining the neck with and without platysma activation. In
necks where little preplatysmal fat is present, the bands will be
clearly visible along their entire course, and a skin on muscle
appearance will be seen (see Fig. 53.20; Fig. 53.21b; Fig. 53.24a;
and Fig. 53.25). hen preplatysmal fat is present, however, the
bands will be partially obscured, usually predominantly in the sub-
mental area, and the presence of subcutaneous fat overlying them,
lying between the skin and the platysma, can be seen (Fig. 53.32).
Assessing the Presence of Subplatysmal Fat
Abnormal collections of subplatysmal fat can be identified by
preoperative palpation of the neck wattle with and without
platysmal activation. Fat lying predominantly in a preplatysmal
position will generally feel soft and remain in the examiner’s
grasp upon platysmal muscle activation. Fat lying in a subpla-
tysmal position, however will have a firmer feel and will tend
to be pulled superiorly out of the examiner’s grasp when the
platysma is contracted (Fig. 53.33). This test can be performed
a b
Fig. 53.32 (a,b) Recognizing the presence of preplatysmal fat. The
presence of preplatysmal fat can be identified by examining the neck
with the platysma contracted. When preplatysmal fat is present the
platysmal bands will be partially obscured, usually predominantly
in the submental area, and the subcutaneous fat overlying them,
lying between the skin and the platysma, can be seen. In this patient
platysma bands can be seen clearly in the inferior neck, where little
subcutaneous fat is present, but are hidden and lost more superiorly in
the submental region, where preplatysmal fat is present. It should be
noted that it is relatively rare to find excess preplatysmal fat in most
patients in this age group and presenting for facelift or secondary neck
lift surgery, as the majority of it was aggressively stripped out with
liposuction or by other means at the primary procedure. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
53 Secondary Neck Lift
by the patients on themselves under the surgeon’s supervision
as means of helping them understand why liposuction will not
properly address their problem and why a submental incision
must be made and subplatysmal fat removed.
These problems are in forefront of the treatment of the neck
in secondary procedures, as typically the superficial neck (skin,
subcutaneous fat, and platysma) has been aggressively (over)
treated in primary procedures, whereas the deep-neck problems
have been typically unrecognized and ignored.
Two typical scenarios where subplatysmal fat is likely to be
present are in patients undergoing primary procedures who
have firm, obtuse necks and who have been troubled by lifelong
cervicomental fullness and in patients presenting for secondary
surgery who have poor cervical contour. In these individuals,
subplatysmal lipectomy will predictably be required (Fig. 53.34).
ot all fat should arbitrarily be removed from the deep neck
however, and deep cervical fat (interdigastric fat) should not be
removed. hen deep cervical interdigastic fat is erroneously
excised, an objectionable depression in the submental region
will result, often referred to as the dug-out neck or cobra neck
deformity (Fig. 53.35). Typically this depression is more evident
when the neck is flexed somewhat or when the patient swallows
and when prominent submandibular glands and anterior belly of
the digastric muscles have not been concomitantly reduced. hen
a dug-out neck or cobra neck deformity is present in a patient
presenting for secondary neck lift, significant improvement can
generally be obtained by properly treating residual fullness situ-
ated laterally due to untreated submandibular gland fullness and
digastric muscle hypertrophy.
53.3.4 Planning Treatment of the
Large Submandibular Gland
Preoperative assessment of the submandibular glands must be
made in patients seeking secondary improvement in neck con-
tour, as prominent glands are commonly overlooked or ignored
a b
Fig. 53.33 Assessing the location of cervicosubmental fat.
(a) Submental “wattle” is grasped with the face and neck in repose and
the platysma muscle relaxed. (b) The patient is then asked to activate
the platysma muscle. In this patient, fat is pulled superiorly from the
examiner’s grasp, indicating a predominantly subplatysmal position.
Fat lying predominantly in a subcutaneous, preplatysmal position
would tend to remain within the examiner’s grasp when the platysma
is activated. (Courtesy of Marten Clinic of Plastic Surgery.)
787
 VIII Surgical Rejuvenation of the Face and Neck

a b
Fig. 53.34 Patients likely to have subplatysmal fat accumulation.
(a) oung patient with firm, obtuse neck who has been troubled by
lifelong cervicomental fullness. These patients typically have large
collections of subplatysmal fat and are suboptimal candidates for
submental liposuction. (b) Patient presenting for secondary surgery
who has poor cervical contour. It can be seen that superficial subcuta-
neous fat has been stripped out of her neck at the primary procedure
and the remaining fat is almost completely in a subplatysmal location.
Note soft, plushly padded face but “skin on muscle” appearance in the
submental region. Note also failure to sculpt and blend the fat of the
inferior chin and the submental region and the resulting mild “witch’s
chin” appearance. (Courtesy of Marten Clinic of Plastic Surgery.)
a b
Fig. 53.35 (a,b) The “dug-out neck” or “cobra neck” deformity. “Dug-out
neck” and “cobra neck” are pejorative terms used to describe situations
in which too much deep cervical fat has been erroneously overexcised
or when subplatysmal fat has been aggressively excised but protruding
submandibular salivary glands and anterior bellies of the digastric muscles
have not been concomitantly reduced, resulting in an objectionable
depression in the submental region. (Procedures performed by
unknown surgeons. Courtesy of Marten Clinic of Plastic Surgery.)

at the primary procedure and typically contribute to the appear-

ance of a full, obtuse, and lumpy neck in the secondary sur-
gery patient. Large submandibular glands are most easily seen in
the upper lateral neck in the secondary facelift patient who has
had prior aggressive cervicosubmental lipectomy (Fig. 53.36).
However, they may be partially hidden by residual submental fat
or lax platysma muscle in the patient who was timidly treated
at the primary procedure, and this emphasizes the importance
of palpating the necks of such patients as part of their evalua-
tion. Failure to diagnose the presence of a large submandibular
gland will lead to disappointing and unexpected bulges in the
lateral submental regions postoperatively no matter what
other maneuvers might be undertaken (skin tightening, lateral a b
platysmal suspension, corset platysmaplasty, suspension suture
placement, etc.).
Submandibular glands are usually palpable as firm, smooth,
discrete, mobile masses in the lateral submental triangle, lateral
to the anterior belly of the digastric muscle and medial to the
inner aspect of the ipsilateral mandibular border. Submandibular
glands lying superior to the plane tangent to the inferior border
of the mandible and the ipsilateral anterior belly of the digastric
muscle do not disrupt neck contour and will usually not require
treatment. Glands protruding inferior to this plane are likely to c d
be problematic, however, especially if subplatysmal fat has been
removed or partially removed, even if the platysma muscle is Fig. 53.36 Prominent submandibular glands. Large submandib-
ular glands are usually evident as protruding masses in the lateral
tightened and redundant skin is excised. These glands demand submental triangle, lateral to the anterior belly of the ipsilateral
treatment if optimal improvement in neck contour is to be digastric muscle and medial to the mandibular border. (a) Patient with
obtained. residual prominent submandibular gland after facelift and submental
liposuction. His prior procedure has made the prominent glands more
obvious. (b) Patient with residual prominent submandibular gland after
Understanding the Etiology of the “weekend neck lift.” Aggressive resection of subcutaneous fat has
exposed the prominent gland, which was not treated. (c) Patient with
Prominent Submandibular Gland residual submandibular glands after “platysma placation.” (d) Patient
with residual submandibular glands after “corset platysmaplasty.”
Despite various claims to the contrary, experience has shown (Procedures performed by unknown surgeons. Courtesy of Marten
that prominent submandibular glands are actually large, not Clinic of Plastic Surgery.)
ptotic, and that the platysma contributes little to their position or
support. Attempts at tightening the platysma when a prominent

788

gland is present usually result in modest, short-lived improve-
ment. The same is true with the various conceptually flawed
suture suspension methods that have been historically tried and
now largely abandoned. Careful preservation and sculpting of
the periglandular fat will sometimes allow small prominent
glands to remain relatively disguised, but large, prominent
glands will require that the protruding portion be resected if
optimal improvement is to be obtained (Fig. 53.37).
Discussing Submandibular Gland Reduction
with the Patient
hile a routine part of a neck lift procedure in many surgeon’s
practices and not something for which most surgeons obtain
specific written consent, the decision to perform submandibular
gland reduction is arguably best made in conjunction with the
patient after appropriate discussion of the advantages and dis-
advantages of the procedure have been made. Often a prominent
submandibular gland and the disturbing appearance of the
resulting lump in the anterior neck is one of the primary con-
cerns of the patient presenting for secondary surgery. Patients’
desire to obtain correction usually outstrips their concerns over
possible problems and complications.
Consideration should be given to informing the patient that
the procedure may prolong submental induration and edema
and carries a small increased risk of temporary submental
discomfort, bleeding, sialoma, salivary fistula, and dry mouth
symptoms, although in our combined 40 years of practice per-
forming submandibular gland reduction, we have seen no major
complications and only the occasional fluid collection requiring
percutaneous aspiration. Patients should be informed when these
problems are discussed that, while uncommon, they can occur. It
is also helpful if they understand that only the protruding portion
a b
Fig. 53.37 Correction of the prominent submandibular salivary gland.
Despite claims to the contrary, experience has shown that prominent
submandibular glands are actually large, not ptotic, and proper treat-
ment will require that the protruding portion be resected if meaningful
improvement in neck contour is to be obtained. (a) Patient with prom-
inent submandibular gland that contributes significantly to poor neck
contour and an elderly, unmasculine appearance. (b) Same patient seen
after neck lift that included submandibular gland reduction. Submental
liposuction and skin tightening would have made the prominent gland
more visible. Platysmal tightening would have produced a short-term
improvement at best, because the prominent gland is large and sits in a
solid fossa of tissue formed by the anterior belly of the digastric muscle,
the inselateral mandibular border, and the mylohyoid muscle. Trying to
“lift” it by tightening the platysma is like trying to put 2 liters of water
in a 1-liter bottle. (Procedures performed by Timothy Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)
53 Secondary Neck Lift
of the gland is excised and that the majority of the gland is left in
place and not removed.
53.3.5 Planning Treatment of Prominent
Anterior Belly of the Digastric
Muscle
A subgroup of patients seeking both primary and secondary
surgery will present with large, bulky anterior bellies of their
digastric muscles that are commonly seen in secondary neck lift
patients as linear paramedian submental fullness (Fig. 53.38).
Large anterior bellies of the digastric muscles are most easily
seen in the secondary surgery patient whom has had prior
aggressive cervicosubmental lipectomy. However, in patients
presenting for primary procedures large muscles are frequently
hidden by excess submental fat, large submandibular glands, or
lax platysma muscle, and a surgeon’s failure to identify them in
these patients will predictably result in unexpected and objec-
tionable submental fullness postoperatively regardless of what
other maneuvers might be undertaken (skin tightening, lateral
platysmal suspension, “corset” platysmaplasty, suspension suture
placement, etc.).
hen large, prominent digastric muscles are present, subtotal
fi (excising the protruding portion of
the muscle) is indicated and can provide for significant improve-
ment in neck contour. In unclear cases the final decision as to
whether partial digastric myectomy should be performed is often
best deferred until the day of surgery, after the improvement
produced by other modifications of the deep neck (subplatysmal
fat excision and submandibular gland reduction) can be assessed,
and digastric muscle reduction is usually performed as the third
step in treatment of these three structures ( deep neck triad ).
Fig. 53.38 Prominent anterior belly of the digastric muscle in patient
who has had a prior neck lift. The anterior belly of the digastric
muscle can be seen as objectionable linear paramedian fullness in the
submental region. Prominent digastric muscles often go unnoticed at
the time of the primary procedure, because they are frequently hidden
by cervical fat and lax platysma muscle. Postoperatively they are often
erroneously regarded as a “low hyoid.” (Previous procedure performed
by unknown surgeon. Courtesy of Marten Clinic of Plastic Surgery.)
789
 VIII Surgical Rejuvenation of the Face and Neck
hile a routine part of a neck lift procedure in many sur-
geon’s practices and not something for which most surgeons
obtain specific written consent, the decision to perform partial
digastric myectomy (muscle reduction) is arguably best made in
conjunction with the patient after appropriate discussion of the
advantages and disadvantages of the procedure have been made.
Typically patients’ desire to obtain optimal improvement in neck
contour outstrips their concerns over possible problems and
complications of the procedure.
Consideration should be given to informing the patient in whom
digastric muscle reduction may be needed that it may prolong
submental discomfort, induration, and edema and carries a small
increased risk of bleeding and a theoretical risk of vocal distur-
bance in voice professionals, although in our combined 40 years of
practice performing digastric muscle reduction, we have seen no
major complications and only one hematoma attributable to the
procedure. Patients should be informed when these problems are
discussed that, while uncommon, they can occur. It is also helpful
if the patient understands that only the protruding portion of the
muscle is excised and that the majority of the muscle is left in
place and not removed.
53.3.6 Preoperative Preparations
and Care
All patients undergo a preoperative physical evaluation, and all
those over 50 years old and any with significant medical prob-
lems must be cleared by their internist or personal physician
before their procedure is performed. Each patient is required to
avoid agents known to cause platelet dysfunction for 2 weeks
prior to surgery, and a list of products that contain aspirin and
other medications and products that have antiplatelet activity
is provided.
Smokers and Former Smokers
All patients who smoke are asked to quit 4 weeks before their
procedure and are required to avoid smoking and all secondhand
smoke for 2 weeks after. Patients who smoke, or who have a sig-
nificant history of smoking but have quit, are advised in writing
that their risk of serious complications, including poor healing,
flap necrosis, skin slough, and thromboembolic phenomena, is
significantly higher than in nonsmokers. It is generally assumed,
however, that most patients will not cease smoking, and extra
care should be taken to be sure informed consent is complete in
this regard.
Fortunately, flap viability is dependent upon a variety of factors
other than smoking that are under the surgeon’s control. These
factors include the amount of tissue trauma during dissection,
the extent of skin undermining, and the amount of tension on
the skin flap. Because deep neck lifting procedures create contour
by modifying deep neck structures and not by placing tension
on cervicofacial skin flaps, a careful surgeon employing proper
technique can operate with acceptable risk on smokers. It is also
often the case that a patient presenting for secondary surgery
has a more robust and durable skin flap with enhanced axial
blood flow ( delayed flap ) that is less prone to compromise and
slough than a patient presenting for a primary procedure. Smokers
should always be approached with caution, however, and it should
790
be recognized that these patients are suboptimal candidates for
surgery and are at increased risk for serious local and systemic
complications.
Ultrasonic and Radiofrequency
“Skin-Shrinking” Treatments
Patients should be questioned carefully about previous noninva-
sive radiofrequency and ultrasonic skin-shrinking procedures
(Ultherapy, Ulthera, Inc., Mesa, A ; Thermage, Solta Medical,
Bothell, A; or Thermi, Solta Medical, Bothell, A), as experience
strongly suggests that these treatments injure subcutaneous
fat, damage skin subdermal microcirculation, and compromise
superficial microlymphatic vessels. Patients who have undergone
these treatments seem to be suboptimal candidates for both
primary and secondary facelift and neck lift procedures.
The patient who has previously undergone facial ultrasonic and
radiofrequency skin shrinking treatments is part of a growing
body of patients who seem to sustain clinically significant com-
promise of their skin microcirculation as a result of these and like
procedures, putting them at greater risk of slough and healing-
related problems following facelift and neck lift procedures.
Typically, the neck has been subjected to more aggressive treat-
ment. Unlike laser resurfacing, skin-shrinking procedures direct
and dissipate energy under the skin, rather than on its surface, and
energy meant to tighten the face appears to damage both sub-
dermal microcirculation and adjacent superficial microlymphatic
vessels. The incidence of problems seems to parallel the number
and intensity of treatments the patient has undergone, which
one would expect to parallel the degree of compromise of their
tissues. These patients also seem to experience prolonged edema
and a longer period of recovery following facelift and neck lift
surgery when they have previously undergone these procedures.
Consideration should be given to advising patients who have
undergone previous ultrasonic or radiofrequency “skin-shrinking”
treatments in writing that their risk of serious complications,
, , , fi
higher than in patients who have not undergone these procedures,
especially if they have undergone multiple previous treatments. From
the surgeon’s standpoint, experience has shown that these patients
should be regarded, approached, and treated as similar to smokers.
Allocating Operating Room Time
It is important that adequate operating room time be allotted
for secondary neck lift procedures, as they are deceptively time-
consuming compared with primary procedures. A secondary neck
lift, when performed in conjunction with facelift revision, forehead
plasty, eyelid surgery, fat injections, skin resurfacing, and other
procedures often needed when secondary neck lift is performed,
will often encompass 6 hours or more, even when performed by
a fast surgeon working with a well-organized and experienced
OR team. Most surgeons we know who perform these complicated
combined procedures on a regular basis have resigned themselves
to this fact and have made appropriate adjustments in their sur-
gery schedules. Usually this means allotting an entire day for the
procedure. For difficult procedures, or when additional surgery is
requested (e.g., rhinoplasty), it is recommended that the proce-
dures be staged over two separate days.
 53 Secondary Neck Lift

53.4 Anesthesia Technique
53.4.1 Anesthesia Considerations for
Neck Lift Procedures
hile it is possible to perform a limited procedure that one can
technically call a neck lift under local anesthesia, any such
procedure necessarily encompasses significant compromises in
the treatment of the deep neck and platysma that form the foun-
dation of the modern neck lift procedure and will typically not
allow the performance of important related and ancillary pro-
cedures, including comprehensive fat grafting, SMAS facelifting,
and often-needed forehead surgery, due to limits on the amount
of local anesthetic that can be administered and the patient’s
and surgeon’s tolerance for the procedures’ complexity and
length. Adding oral and/or intravenous (IV) sedation ( conscious
sedation”) to procedures performed under local anesthesia can
improve the patient’s experience and facilitate the performance
of more comprehensive operations, but doing so negates many
of the purported advantages of a local technique. It also places
the surgeon in the role of anesthesiologist and in charge of mon-
itoring the patient and managing and treating intraoperative
problems (hypertension, arrhythmias, etc).
Secondary neck lift procedures are typically time-consuming
and technically demanding and arguably will test the patience
and composure of almost any surgeon. It is highly recommended
that any surgeon new to these techniques consider enlisting the
services of an anesthesiologist as part of a team approach to
patient care. This is particularly important when the procedure
is to be performed upon a patient who is apprehensive or has a
history of anesthetic difficulties, hypertension, sleep apnea, gas-
troesophageal reflex disorder (GERD), or other significant medical
problems. This will avert the frustration and aggravation of trying
to perform a technically demanding procedure while simulta-
neously being shouldered with the responsibility of supervising
the administration of an anesthetic, monitoring the patient, and
managing intraoperative problems.
Traditionally the cuff of the LMA is inflated to create a seal so that
a ventilator can be used, positive pressure ventilation applied, and
vapor anesthetics administered. This is not necessary, however,
when patients are not paralyzed and only heavily sedated, when
intravenous sedation is used rather than inhalation anesthetics,
or when the patient is allowed to breathe spontaneously. In such
cases the cuff of the LMA can be left uninflated or be minimally
inflated and the LMA left to function as simply a large oral airway.
ot inflating the cuff limits pressure in the hypopharynx and
reduces the likelihood of related postoperative discomfort in the
throat.
The LMA (LMA device with a flexible shaft) is partic-
ularly useful in neck surgery (Fig. 53.39). hen this device is
used and the breathing circuit is separately draped, the breathing
circuit can be moved from side to side as required during the
procedure to obtain unobstructed access the cervicosubmental
region as needed.
Most surgeons initially considering using an LMA are under-
standably fearful that the bladder on the device, when inflated,
will distort the cervical region and interfere with neck assess-
ment and treatment. e have found this not to be the case, and
although a bulge is often evident if the LMA cuff is inflated, the
surgeon can simply ignore it and carry out all neck maneuvers as
usual and as indicated. The bulge created by the inflated cuff will
not affect gauging the extent to which deep-layer neck maneuvers
are carried out (submandibular gland reduction, subplatysmal fat
resection, and digastric muscle reduction) or interfere otherwise

53.4.2 Our Preferred Neck Lift Anesthesia

Technique
ot using local anesthesia does not automatically equate to
a need for general anesthesia, however, and formal general
anesthesia, in which patients are paralyzed, endotracheally
intubated, and placed on a ventilator, is not necessary and is
arguably not optimal for the performance of most facelift and
neck lift procedures, including secondary ones.
The majority of our primary and secondary neck lifts are now
performed under deep sedation administered by an anesthesi-
ologist using a laryngeal mask airway (LMA). The use of a LMA
allows the patient to be heavily sedated without compromise of
the airway, but the patient need not receive muscle relaxants and
can be allowed to breathe spontaneously. An LMA is also less likely
to become dislodged during the procedure than an endotracheal Fig. 53.39 Flexible laryngeal mask airway (LMA). The use of a laryngeal
mask allows the patient to be heavily sedated without compromise of
tube, and it will not trigger coughing and bucking when the the airway, but the patient need not receive muscle relaxants and can
patient emerges from the anesthetic. be allowed to breathe spontaneously. An LMA with a flexible shaft is
It is useful to modify the way in which the laryngeal mask is tra- particularly useful in neck surgery, as it allows the breathing circuit to
be easily moved when working in the submental area.
ditionally used when performing neck lift and related procedures.

791
 VIII Surgical Rejuvenation of the Face and Neck
with the neck lift procedure (platysmaplasty, platysmamyotomy,
lateral platysma suspension using a postauricular transposition
flap, drain placement, etc).
53.4.3 Preop Anesthesia Medications
Most patients receive preoperative medication tailored and
adjusted to their age, weight, height, personality, specific cir-
cumstances, and general health, and this regimen is modified
depending upon the type of anesthetic used. Typical preop
medications currently used for patients in good health without
contraindications and as appropriate for their weight and gen-
eral conditions include clonidine (0.1–0.3 mg orally), atenolol
(12.5–25 mg orally), and midazolam 3 to 5 mg intramuscularly,
typically administered in the deltoid muscle. These medications
should be administered after all preop discussions have been
made, patient questions answered, and preoperative consents
and other related paperwork signed. Oral narcotics should not
be given as part of the premedication, as they commonly result
in nausea and vomiting. Cocaine, anticholinergics, and parasym-
pathomimetics are also avoided in our practices.
Antiemetics are given routinely in a preemptive fashion at the
beginning of each procedure and typically include ondansetron
(10 mg IV) and dexamethasone (3–5 mg IV). It should be noted that
dexamethasone is administered for its antiemetic properties, not
as a means to reduce swelling. Patients with a history of motion
sickness, perioperative nausea and vomiting, or other risk factors
are given medications to block the emetic reflex at multiple levels,
typically including aprepitant (Emend) (40–80 mg orally) and/or a
scopolamine patch (placed on the upper inner thigh).
53.4.4 Patient Monitoring During
Anesthesia
All patients are fully monitored with electrocardiography,
automatic sphygmomanometry, transcutaneous pulse oximetry,
and mainstream capnography. Perioperative blood pressure is
closely monitored and aggressively treated should it become
significantly elevated, especially in patients with existing hyper-
tension or a borderline condition. The latter group of patients
should be watched closely and treated preemptively, as they
typically become hypertensive once the surgery and anesthesia
is begun.
53.4.5 Method of Intraoperative
Sedation
The current mainstay of patient sedation during our face- and neck
lift procedures is achieved through the use of propofol. Typically
a bolus (1–2 mg/kg) is administered by the anesthesiologist prior
to LMA insertion, followed by a drip infusion administered via
an infusion pump depending on the patient’s circumstances and
titrated to the patient’s needs (75–200 g/kg/min).
In most cases the IV anesthetic infusion is titrated to a deeper
level for a brief period once the patient has been prepped and
draped to give the surgeon a few minutes of deep sedation in
which to perform local anesthetic nerve blocks and infiltrate all
proposed sites for incision with local anesthetic solution.
792
53.5 Surgical Technique
53.5.1 Patient Positioning, Urinary
Catheter Insertion, and Patient
Marking
The patient is placed supine on a warmed and well-padded,
slightly flexed operating table, and a special effort is made to
ensure and document that the elbows, heels, and other potential
pressure points are well protected. The patient’s lower extrem-
ities are then elevated and antiembolic pedal compression
devices applied. If the procedure is anticipated to take longer
than 4 hours, an indwelling balloon-tipped urinary catheter
(Foley catheter) is placed after sedation is begun or general
anesthesia administered. During this time the incision plan
is marked with a fine-tipped surgical marker after skin to be
marked is degreased with isopropyl alcohol. If fat grafting is to
be performed, fat is harvested at this time, before the face is
prepped and draped, which typically entails turning the patient
into right and left lateral decubitus positions. A temperature
probe is then taped in the axilla or groin, and the patient is suf-
ficiently covered or a patient warming device applied to allow
the room to be cooled for the comfort of the scrubbed team
members.
53.5.2 Patient Prepping and Draping
After anesthesia is begun, fat has been harvested, the patient
has been positioned on the table, the urinary catheter placed
(if indicated), and the incision plan marked on the patient, a
sterile prep drape is placed beneath the patient’s head and bland
ophthalmic ointments instilled into each eye. Each patient then
receives a full surgical scrub of the entire scalp, face, ears, nose,
neck, shoulders and upper chest with full strength (1:750) ben-
zalkonium chloride (BA ; e.g., ephiran, Sanofi, Paris, France)
solution. The patient’s head is then placed through the opening
of a split sheet, or split adhesive-backed disposable transverse
laparotomy sheet (tails facing the patient’s feet), leaving the
entire head and neck region unobscured from the clavicles up.
o turban or head drape is used if facelift, extended neck
lift, or foreheadplasty is to be performed. This allows unim-
paired examination of the cervicofacial profile in its entirety
throughout the procedure and provides complete access to the
periauricular areas when required.
The breathing circuit is subsequently draped separately from
the patient by wrapping it with a sterile paper drape sheet and
securing it with 1-inch (2.5-cm) Steri-Strips (3M, St. Paul, M )
or by covering it with a sterile stockingette. This allows it to be
moved during the procedure as the patient’s head is turned from
side to side and away from the submental area when working
in the neck through the submental incision. hen drapes are
applied in this manner, it is not necessary to secure the LMA
with tape or by other means as long as the anesthesiologist
and/or other members of the operating room team present are
watching its position. If an endotracheal tube is used, it can be
conveniently and effectively secured to the upper lip skin with a
TegaDerm (3M, St. Paul, M ) or similar sterile, adhesive-backed
dressing.
 53 Secondary Neck Lift

53.5.3 Administering Local Anesthesia

Local anesthetic is administered even if deep sedation or general
anesthesia is used. This limits stimulation of the patient and the
overall amount of anesthetic needed and significantly reduces
or often eliminates the need for intraoperative narcotics. A
significant and helpful hemostatic effect is also obtained when
epinephrine/tranexamic acid–containing solutions are used.
Sensory nerve blocks are performed using 0.25 bupivacaine
(Marcaine) with epinephrine 1:200,000 injected with a 25-gauge
needle attached to a 10-mL ring control syringe. This allows the
rest of the neck or face to be injected with a reduced degree of
stimulation. Skin marked for incision is then infiltrated with
the same solution. Areas where subcutaneous dissection will
be made are infiltrated with 0.1 lidocaine (Xylocaine) with
epinephrine (1:1,000,000) and tranexamic acid (1,000 mg per
500 mL of local anesthetic solution), taking care to ensure that
the total dose of lidocaine does not exceed 7 mg per kilogram
per 4 hours (Fig. 53.40). Using this dilute local anesthetic solu-
tion, the subcutaneous neck can be generously infiltrated, and
typically 100 mL or more is infiltrated per side. A generous infil-
tration provides several important advantages, including hydro-
predissection, expansion of the subcutaneous space to be dis-
sected, and improved hemostasis.
Infiltration of the preauricular cheek (if indicated) and postau-
ricular areas is carried out using a 22-gauge spinal needle, as skin
in these areas is typically adherent and resistant to injection with
a blunt cannula, especially if previously dissected at a primary
procedure. Infiltration of the neck and submental regions is
carried out with a 1.6-mm 20-cm-long multihole, blunt-tipped
infiltration cannula. If subcutaneous fat was aggressively resected
at the primary procedure, subcutaneous infiltration can be a dif- Fig. 53.40 (a,b) Local anesthetic solutions. (Courtesy of Timothy
ficult and time-consuming activity that must be undertaken with Marten, MD, FACS, and the Marten Clinic of Plastic Surgery. Used with
care. o direct infiltration beneath the platysma is necessary if the permission.)
overlying subcutaneous tissues are infiltrated generously at the
beginning of the procedure as just described.
Generous infiltration of dilute local anesthetic solution with a has been previously overresected at the primary procedure in
1.6-mm (or like) infiltration cannula is particularly helpful if tissue the misguided belief that the poor neck contour present was
conditions allow it, as the blunt tip tends to keep the infiltration the due to excess subcutaneous fat, and additional fat removal
in the proper plane and the multiple back-and-forth passes compounds the hard and aged appearance that is usually pres-
needed to infiltrate the large volume of local anesthetic effectively ent. A careful examination made by a thoughtful and observant
predissect and preestablish the plane to be subsequently sharply surgeon of patients presenting for secondary neck lift will often
dissected with Metzenbaum scissors. In many cases, additional show them to typically have a relatively soft, plushly padded face
back-and-forth injection cannula movements above and beyond with a skeletonized skin on muscle appearance in the neck (see
what is needed to infiltrate the local anesthetic solution are made Fig. 53.2; Fig. 53.3). Once this occurrence is acknowledged and
to maximize this predissection effect. the resulting appearance recognized, it becomes apparent that in
most cases the surgeon must fight to preserve as much subcuta-

53.6 Operative Sequence for Skin neous fat as possible and sacrifice only subcutaneous fat that is
found to be truly redundant after all deep-layer maneuvers have
Flap Elevation been performed.

53.6.1 Preservation of Existing 53.6.2 Submental Incision Placement

Subcutaneous Fat
Many surgeons begin neck lift surgery by performing submental
liposuction, but in almost all cases in secondary procedures
a conscious and concerted effort must be made to preserve all
subcutaneous fat that is present. Typically subcutaneous fat
If a submental incision was not made at the primary procedure, it
should be made in the secondary operation, 1.5 cm or more pos-
terior to the submental crease, approximately halfway between
the mentum and hyoid (Fig. 53.18). Making the incision in this
location helps conceal it in the shadow of the mandible, avoids

793
 VIII Surgical Rejuvenation of the Face and Neck
surgical reinforcement of the crease and accentuation of the
double chin and witch’s chin irregularities, and provides better
exposure of and facilitates dissection of the deep neck (see Fig.
53.13; Fig. 53.14; Fig. 53.15; Fig. 53.16; Fig. 53.17).
If an existing scar is present in the submental crease where a
submental incision was made previously at the primary procedure,
one must decide whether this should be excised and reused or a
new incision in the submental region made (and thus a new scar
created) in the more advantageous location just described. Factors
to be considered are the quality of the existing submental scar, the
patient’s age, and the patient’s skin type and quality. If the scar is
inconspicuous and mobile, if the patient is older, and if the patient
is fair-skinned, these factors favor making a new incision in a more
appropriate and advantageous position. In such cases the existing
scar can be undermined and released from the relocated one and
then intradermally fat grafted (if necessary), and the new scar can
be expected to be inconspicuous once healed. Moving the incision
in this way also allows it to be made longer and will provide better
exposure than if it is made a second time in the submental crease.
If the scar is irregular and/or tethered, if the patient is younger,
or if the patient has a darker skin type, it may be preferable to
excise the existing scar and release the adjacent tethered areas,
even though this will make exposure and dissection in the deep
neck more difficult. It is wise in such circumstances to leave the
final decision to the patient after appropriate discussion of the
advantages and disadvantages of relocating the scar.
53.6.3 Skin Flap Elevation
Once the submental incision has been made, the surgeon should
stand at the head of the table during dissection of the submental
region while the assistant retracts the edges of the incision with
a pair of 10-mm double-pronged skin hooks. Having the assistant
retract frees up the surgeon’s nondominant hand to apply coun-
tertraction to the skin being elevated and to assess flap thickness
and provides for optimal teamwork. Skin undermining should be
made using a medium curved Metzenbaum scissors, and the dis-
section should be made subcutaneously, leaving the majority of
the subcutaneous/preplatysmal fat on the platysma surface. This
makes fat excision and sculpting easier later in the procedure if
required, and it precludes the need for more tedious and demand-
ing excision of fat from the undersurface of the cervical skin flap.
Unlike the dissection of the facelift skin flap, in which a con-
scious effort must be made to prevent the flap from becoming too
thick and the SMAS from being compromised, a slightly deeper
dissection should be made in the neck to preserve a slightly
thicker layer of subcutaneous fat. Preservation of a thicker layer
of fat helps avoid a hard or overresected appearance in the cervi-
cosubmental area and objectionable overexposure of underlying
neck anatomy postoperatively. Many necks of secondary facelift
patients will have been previously aggressively stripped of sub-
cutaneous fat, and only subplatysmal fat will need to be or should
be removed. Raising a cervical skin flap in these patients can be
tedious and time-consuming and should be undertaken with care.
Submental dissection is continued inferiorly and laterally. If a
short-scar neck lift is being performed, the dissection is extended
laterally to the anterior border of the sternocleidomastoid muscle
and up into the postlobular area (Fig. 53.41).
794
If an extended (long-scar) neck lift or concomitant facelift is
being performed, this dissection will join the upper lateral neck
dissection made previously through postauricular and perilobular
incisions (Fig. 53.42).
Cervical skin flap elevation can be technically challenging in
the secondary neck lift patient, especially in the submental and
postauricular areas, where subcutaneous fat excision by liposuc-
tion or other means is typically more aggressive. In these areas
one frequently encounters thick patches of fibrotic subcutaneous
tissue and dermomuscular adhesions that must be carefully dis-
sected and released. Careful infiltration of local anesthetic with a
blunt infiltration cannula in the proper plane (hydrodissection) in
combination with repeated back and forth movements of the infil-
tration cannula in that plane (blunt dissection or predissection)
as mentioned previously will greatly facilitate subsequent sharp
dissections in such circumstances.
Upon completion of subcutaneous undermining of the anterior
neck and submental regions, a retrograde dissection should be
made subcutaneously up onto the inferior chin. This will ensure
that the submental restraining ligaments present under and
responsible for the submental crease have been divided and that
the submental crease has been released from its bony attachments,
and this maneuver provides for subsequent blending of chin and
submental fat after other neck maneuvers have been completed to
obtain a visually smooth and optimally seamless, aesthetic tran-
sition from chin to submental region. This has typically not been
done at the primary procedure, and failure to do so contributes
significantly to the presence of a double chin. Some bleeding is
usually encountered from perforating vessels that accompany
ligaments in this region during this maneuver, but this should not
prevent the surgeon from carrying out this important step. Care
should be taken when using cautery in this area to avoid cautery
injury to the overlying skin.
If a facelift or extended neck lift is being performed and the
upper lateral neck is being approached from a postauricular
incision, care must be taken to avoid injury to the great auricular
nerve. This nerve provides sensation to the lower two-thirds of
the ear and travels superficially superiorly in the upper lateral
neck over the sternocleidomastoid muscle fascia. The most
superficial portion of the nerve is anatomically constant and lies
approximately 6.5 cm inferior to the auditory meatus, midway
between the anterior and posterior borders of the sternocleido-
mastoid muscle, and it is helpful to mark this spot preoperatively
on the neck skin surface to guide dissection. If the dissection
is performed in the correct plane, however, the nerve will lie
deep to the plane of skin flap elevation and will be covered by
a thin layer of subcutaneous fat, at least in the primary surgery
patient. It is prudent that all dissection made through the great
auricular corridor (over the course of the great auricular nerve),
in both secondary and primary cases, be made with great care
under direct vision and not blindly or using a scissors pushing
technique.
Patients with thin faces, or those undergoing secondary facelifts,
will not uncommonly have little subcutaneous fat between the
superficially situated portion of the great auricular nerve and
the skin, however. For this reason, extra caution must be taken
in these patients in elevating the skin flap in this area, and a clear
knowledge of nerve anatomy is required.

Fig. 53.41 Extent of skin undermining in short-scar neck lift. Skin
undermining is carried inferiorly below the level of the cricoid cartilage
(double solid lines), laterally to the anterior border of the sternocleido-
mastoid muscle, and superiorly beneath the submental crease (dotted
line) and through the submental and mandibular retaining ligaments.
Undermining and releasing the submental crease and carrying the
dissection retrograde up onto the chin allow the fat of the chin and
submental area to be seamlessly blended. The solid line shown poste-
rior to the submental crease is the site for the submental skin incision.
(Illustration courtesy of the Marten Clinic of Plastic Surgery.)
53.6.4 Cervical Lipectomy
The key to obtaining good outcomes in the neck in both primary
and secondary cases is in understanding the distribution of fat
in the cervico-submental region and choosing a treatment plan
accordingly. Cervical fat is present in three distinct anatomic
layers: preplatysmal (subcutaneous), subplatysmal, and deep
cervico-submental (interdigastric), and the thoughtful surgeon
must learn how to recognize and treat each layer appropriately
for the conditions present.
hile our traditional focus has misguidedly and mistakenly
been on the preplatysmal layer (submental liposuction and
related surgical and nonsurgical procedures that reduce subcuta-
neous fat), most patients presenting with poor neck contour will
be troubled instead by fat excess predominantly in the subplatys-
mal layer. This is even more so the case in the patient presenting
for secondary neck lift, as typically the surgeon performing the
primary procedure mistakenly targeted the superficial layer only.
Understanding and accepting this anatomic reality, and learning
to treat subplatysmal fat appropriately, is a key part of obtaining
consistently good outcomes in both primary and secondary neck
lift procedures.
53 Secondary Neck Lift
Fig. 53.42 Subcutaneous skin undermining for an extended neck
lift or when a necklift is performed with a facelift. Orange-lit area
shows subcutaneous skin undermining that is performed through the
periauricular incisions when a neck lift is performed with a facelift (or
during an extended neck lift procedure). Submental skin undermining
(yellow-lit area) is then completed through the submental incision (solid
line in submental area). Double horizontal lines on the inferior anterior
neck show the location of the cricoid cartilage. (Illustration courtesy of
Marten Clinic of Plastic Surgery.)
Cervical lipectomy is a technically demanding maneuver that
requires patience, perseverance, and artistic sensitivity, and the aim
of the surgeon should be to produce an attractive neck, not simply one
devoid of fat. Contrary to what is traditionally practiced, if a facelift
is being performed in conjunction with the neck lift, subcutaneous
lipectomy (including liposuction), if indicated, should be performed
after deep-neck maneuvers and shifting and suturing of the SMAS
and platysma, not at the beginning of the procedure. If subcutaneous
submental liposuction and/or lipectomy is performed at the begin-
ning of the procedure, fat will be mistakenly excised from regions
of the neck that will be raised onto the face when SMAS flaps are
advanced and suspended, and this can result in inadvertent creation
of harsh or irregular mandibular contours (Fig. 53.43). In almost all
cases, but especially in secondary procedures where subcutaneous
fat has typically been previously overresected, it is best to leave the
subcutaneous fat layer untouched until all other maneuvers are com-
pleted and improvements obtained with them assessed. Only then
should the surgeon consider removing fat from the subcutaneous
layer. Typically what appeared to be excess fat initially will be seen
not to be so after deep-layer maneuvers have been completed.
Exploration of the subplatysmal space is indicated if pre-
operative assessment suggests that a significant collection of
795
 VIII Surgical Rejuvenation of the Face and Neck
subplatysmal fat is present, large submandibular glands are
identified, or large digastric muscles are detected or if uncertainty
exists as to any aspect of the condition of the subplatysmal
space. The presence of excess volume in the submental space
can be demonstrated preoperatively by examining a lateral look-
ing-down view photograph (Connell’s view) of the patient’s neck
(see Fig. 53.31). Significant accumulations of subplatysmal fat,
and the presence of abnormal fullness in the subplatysmal space
can also be demonstrated intraoperatively by Connell’s Test. This
consists of placing gentle superior traction on the cheek flaps (if
face lift) or cheeks (if isolated neck lift) and flexing the neck. If the
neck appears full upon this maneuver, consideration should be
given to exploration of the subplatysmal space and the removal of
redundant subplatysmal fat and/or protruding portions of other
enlarged structures.
Subplatysmal exploration is performed through the submental
skin incision. The subplatysmal space is entered by incising the
superficially situated fascia between the medial platysma muscle
borders using a Metzenbaum scissors or electrocautery. In many
patients, varying degrees of decussation of the right and left pla-
tysma muscles will be present in the submental region, and this
area is divided. A combination of blunt and sharp scissors tech-
niques is used to isolate and elevate the medial muscle edges. This is
greatly facilitated by grasping and retracting the muscle edge near
the chin by the assistant using a 10-mm double-prong skin hook or
an Allys forceps. The surgeon can then place countertraction more
inferiorly on the muscle edge with a DeBakey or similar forceps.
The dissection is subsequently carried laterally, over the anterior
belly of the digastric muscle hugging the underside of the platysma.
Typically the subplatysmal space will be found to have been
untouched or timidly dissected at the primary procedure in
secondary cases, and if this dissection is carefully made, a well-
defined and relatively avascular plane can usually be identified.
Small communicating vessels are not infrequently encountered,
however, especially near the medial muscle borders. These should
a b
Fig. 53.43 Sequencing excision of preplatysmal fat when simultaneous
facelift and neck lift are performed. If submental liposuction is
performed before the superficial musculoaponeurotic system (SMAS)
is elevated, denuded areas will be subsequently advanced onto the
lower face. This can result in a harsh mandibular contour. To avoid
this problem, preplatysmal fat should be removed, if indicated, after
the SMAS flap has been raised. (a) Incorrect plan for preplatysmal fat
excision (gray shaded area indicated by arrow). Submental liposuction
is performed at the beginning of the procedure before SMAS flap is
raised. (b) After SMAS elevation, areas stripped of fat (gray shaded
area indicated by black arrow) are moved up onto the lower face.
(Illustration courtesy of Marten Clinic of Plastic Surgery.)
796
be carefully divided and fulgurated as required. Subplatysmal
fat should be left on the deep surface of the neck and not raised
with the platysma flap. This will facilitate subplatysmal fat pad
removal, as it is technically more difficult to resect fat from the
undersurface of the muscle than en bloc from the deep surface of
the neck. As the dissection proceeds laterally, the assistant places
a small Harrington or similar retractor in the subplatysmal space
to retract the platysma and expose the submandibular gland.
The plane tangent to the anterior bellies of the digastric muscles
with the neck in neutral or slightly flexed position should be used
as the landmark for subplatysmal fat removal. Fat deep (superior) to
this plane is deep cervico-submental fat (interdigastric fat), which
should not be removed if a dug out or cobra neck deformity is
to be avoided (see Fig. 53.35). All fat present in the subplatysmal
space lying superficial (inferior) to this plane consists of subplatys-
mal fat and should theoretically be removed if optimal contour is
to be obtained. If subplatysmal fat excision is made with the neck
flexed, inadvertent overexcision of intradigastric fat can occur.
As a practical matter, overall neck contour must be considered,
as it is the curvilinear plane across the submental region tangent
to the borders of the mandible and the anterior bellies of the
digastric muscles that ultimately determines attractive neck
contour (Fig. 53.44).
If large submandibular glands or anterior bellies of the
digastric muscles are present and it is elected that they not be
treated, subplatysmal fat removal should be more conservative
if accentuation of these problems is to be avoided. Fibrous fat
in the prehyoid region should also not be arbitrarily removed,
especially in women, as accentuation and masculinization of the
Fig. 53.44 Anatomy of optimal neck contour. The curvilinear plane
across the submental region tangent to the borders of the mandible (near
black line), to the ipsilateral anterior belly of the digastric muscle (near red
line), to the contralateral digastric (far red line), to the contralateral man-
dibular border (far black line) ultimately defines optimal attractive neck
contour. Between the border of the mandible and the ipsilateral digastric,
poor contour is due to protruding submandibular glands (excised
specimen shown). Between the digastric muscle bellies the problem is the
subplatysmal fat (excised specimen shown). After subplatysmal fat removal
and submandibular salivary gland reduction, additional improvement can
be obtained by reducing the anterior digastric muscle bellies themselves
(area beneath near and far red lines). (Procedure performed by Timothy
Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)
 53 Secondary Neck Lift

larynx can occur. If prominent submandibular glands and digastric
muscles are appropriately treated, however, more aggressive and
near-complete resection of subplatysmal fat can typically be made.
Subplatysmal fat will be evident as a centrally situated, trian-
gular fat pad with its base lying at the hyoid and its tip near the
mentum (Fig. 53.45). It should be removed as appropriate, and as
determined by the position and size of the digastric muscles and
the size of the submandibular glands. Fat removal should not be
arbitrary, and close attention must be paid to the new contours
created. Subplatysmal fat excision often results in division of

c d
Fig. 53.45 Subplatysmal fat. (a) Illustration showing the position of the triangular subplatysmal fat pad located in the submental part of the subpla-
tysmal space with its tip near the mentum and base at the hyoid bone. (c) Cadaver view of the submental region and subplatysmal fat similar to that
shown in the illustration above but closer up. The arrow is pointing to the subplatysmal fat, which has been outlined with a broken line. The right and
left borders of the platysma have been elevated, showing the contents of the submental space. The subplatysmal fat pad can be seen overlying the
digastric muscles to the upper right and left of the triangle. The hyoid bone is at the base of the triangle. (b) Cadaver demonstration of subplatysmal fat.
The head is slightly turned to the viewer’s right and the chin is at the upper right-hand corner of the photo. The two upper arrows point to the anterior
bellies of the right and left digastric muscles, and the lower arrow to the subplatysmal fat pad. In this photo, the subplatysmal fat pad has been reflected
inferiorly but is still attached at its base just inferior to the hyoid. The hyoid is now visible along with the interdigastric space. There is a small amount of
deep cervical fat (interdigastric fat) visible between the two upper arrows that has been reflected to the viewer’s right. (d) Intraoperative demonstration
of the subplatysmal fat specimen lying over the submental part of the subplatysmal space from which it was removed. The patient’s chin is pointing
superiorly and is in the upper left corner of the photo. The neck is in the lower right corner of the photo. (Courtesy of Marten Clinic of Plastic Surgery.)

797
 VIII Surgical Rejuvenation of the Face and Neck

tributaries of small pretracheal and submental vessels, and a long
shielded cautery forceps and good suction should be available to
obtain adequate hemostasis when required.
Fat situated deep to the plane tangent to the anterior bellies of
the digastric muscles and beneath the deep cervical fascia (deep
cervical or “interdigastric” fat) should not be removed, and the over-
whelming temptation to “clean out” the deep cervical space must be
resisted. Platysmaplasty, invaginating platysma in a corset fash-
ion, suturing the anterior bellies of the digastric muscles together,
and other like maneuvers that have been tried and failed cannot
compensate for overzealous excision of deep fat, and in time, once
submental swelling has subsided, an objectionable dug-out or
cobra neck submental depression will appear in the necks of
patients so treated (see Fig. 53.35).
Operative Sequence for Subplatysmal Fat
Excision
Once the platysma muscles have been raised and the prominent
submandibular glands identified (see discussion that follows),
the subplatysmal fat pad is most easily isolated by identifying
each anterior belly of the digastric muscle near its insertion
at the chin after making a small incision with scissors in the
overlying fat and fascia. Once the muscle is identified in that
location, the dissection is carried down inferiorly and laterally
on the digastric muscle’s anterior (inferior) surface to its inser-
tion at the lateral hyoid. If the submandibular glands have been
previously mobilized inside their capsules, the dissection along
the surface of each anterior digastric muscle belly can be taken
into the submandibular capsule, and this dissection along the
anterior surface of each digastric defines the lateral border of
the subplatysmal fat pad. Fat overlaying each anterior digastric
muscle belly is then divided with electrocautery because of
the predictable presence of a branch vein in this area. Once the
lateral borders of the fat pad have been dissected, the right and
left inferior corners are dissected up off the underlying muscle
fascia toward the midline. The plane tangent to each digastric
muscle anterior belly is then imagined, and all fat lying inferior
(superficial) to that plane is removed using electrocautery, leav-
ing the interdigastric fat between the anterior digastric muscle
bellies intact and in place. Typically a vein will be encountered
and require cautery in the prehyoid region.
53.6.5 Submandibular Gland Reduction
If large submandibular glands are present, they can usually be
seen and palpated lateral to the ipsilateral belly of the anterior
digastric muscle on each side within its respective subman-
dibular triangle, protruding inferiorly to a plane tangent to the
digastric muscle belly and the mandibular border (Fig. 53.46; see
also Fig. 53.36, Fig. 53.37).
The protruding portion can be resected through the submen-
tal incision before submental platysmaplasty is performed to
improve neck contour, if indicated (Fig. 53.47). hile excising
subplatysmal fat predominantly improves neck contour under the
chin and in the lateral view, reducing protruding submandibular
salivary glands improves contour under the mandible and in the
oblique view and accentuates the shadow under the jawline. As
such, simply removing subplatysmal fat is incomplete treatment
of the neck and fails to rejuvenate the cervico-submental area
comprehensively.
Prominent submandibular glands will be encountered as
subplatysmal dissection is carried over the anterior belly of the
ipsilateral digastric muscle. The prominent gland will appear as a
smooth pink to tan mass covered by a smooth capsule. Reduction
is begun once the ipsilateral platysma muscle has been elevated
by incising the capsule overlying the gland inferomedially just
lateral to the anterior belly of the digastric muscle. The subman-
dibular gland will be evident once exposed in this manner due
to its distinctive lobulated appearance. Its inferior portion is then
gently grasped and easily separated from its capsule using a gentle
blunt scissors spreading technique. Although all vital structures
are outside the glandular capsule, care should be taken when
mobilizing the gland superolaterally, as both the retromandibular
vein and the marginal mandibular branch of the facial nerve are
in proximity in that area.

a b c
Fig. 53.46 (a,b,c) Surface expression of large submandibular salivary gland. Typically large submandibular glands will be seen in the lateral submen-
tal triangle as a round protrusion situated lateral to the more medially situated anterior bellies of the digastric muscles, which appear as a more linear
paramedian fullness, and the difference in appearance of the two problems is a reflection of their differing anatomic origins. In many instances, and
especially in many patients seeking secondary neck surgery, the diagnosis of both problems can be made by simply looking at the patient’s neck, as
in this case. This patient has had a prior face- and neck lift. (Illustration courtesy of Marten Clinic of Plastic Surgery.)

798

a
b
c and cannot be accessed or resected from the superficial submental
d e
Fig. 53.47 Surgical approach to submandibular gland reduction. (a)
Cadaveric demonstration of submandibular triangle. Chin is in the upper
right corner of the photo. The excessive portion of the submandibular
gland (SMG) is found protruding inferiorly to a plane tangent to the
digastric (lower arrow) and the mandibular border (small upper arrow).
(b) Intraoperative photo demonstrating exposure of the submandibular
gland. The patient’s head is in similar position to the cadaver head shown
in (a) with the chin in the upper right corner. A submental incision has
been made approximately 1.5 cm posterior to the submental crease and
the neck subcutaneously undermined. The right platysma muscle has
been elevated and is retracted with a double-pronged skin hook and a
malleable retractor. The gland will be seen as a distinct bulge just lateral
to the ipsilateral anterior belly of the digastric (scissors tips rest on digas-
tric). The capsule has been incised inferomedially and the submandibular
gland isolated using blunt dissection. (c) Intraoperative photo prior to
resection of the excess portion of the gland with head in similar position
to (a) and (b). The gland has been mobilized and gently pulled inferiorly.
The dotted line represents the level at which the inferior portion of the
gland will be excised. (d) Intraoperative photo just prior to excision of the
protruding part of the gland with head in a similar position to (a) and (c),
but close-up. Gland reduction should be performed incrementally with
electrocautery in such a manner that the portion protruding inferior to
the plane tangent to the ipsilateral anterior belly of the digastric muscle
and the ipsilateral mandibular border will be resected. (e) Patient seen
immediately after necklift that included partial submandibular gland
reduction but no skin resection. The photo shows the excellent contour
created without skin tightening. The excised portions of the subman-
dibular glands are also demonstrated on both the right and left sides
(subplatysmal fat was also excised and the anterior bellies of the digastric
muscles reduced; however, these specimens are not shown).
53 Secondary Neck Lift
An examination of the gland once mobilized inside its capsule
will show it to be large, not merely ptotic, and this observation
forms the basis of the recommendation that resection of the
protruding portion be performed. Examination of the exposed
gland will also clearly demonstrate that attempts to reposition it
more superiorly by suture suspension or by tightening overlying
platysma muscle will ultimately be fruitless.
A key step in the safe performance of the procedure is adequate
mobilization of the gland, and a modest overmobilization will
make both gland resection and the control of any intraglandular
bleeding that might be encountered much easier.
Once adequately mobilized inside its capsule, the inferior portion
of the gland is grasped, and pulled gently inferiorly and medially
out of its fossa and away from adjacent structures. The redundant
portion is subsequently gauged and excised under direct vision in a
medial-to-lateral direction along the planned line of resection with
monopolar coagulating current cautery. Excision of the excess part
of the gland should be performed in such a manner that the portion
protruding inferior to a plane tangent to the ipsilateral anterior
belly of the digastric muscle and the ipsilateral mandibular border
will be resected. It is usually best that initial resection be conser-
vative and that the gland be incrementally reduced thereafter as
required. ever is it necessary or appropriate to remove an entire
gland (and in fact the majority of the submandibular salivary gland
sits cephalad to the mylohyoid muscle in the floor of the mouth
approach described herein). This could result in a depression or
other contour abnormality and could precipitate an objectionable
depression or “dry mouth” condition.
Excision of the redundant and protruding portion of the
submandibular gland should be performed using an extended
flat-tipped cautery and a long, high-quality atraumatic (DeBakey
or similar) forceps. A flat-tipped, extended cautery is superior
for controlling bleeding of an intraglandular vessel, should it be
encountered, than is a needlepoint cautery tip, and monopolar
current is superior for this purpose to bipolar cautery. A long,
high-quality, insulated coagulation forceps is also required.
As in all surgery of the neck and submental region, a fiber-optic
headlight or retractor is mandatory, as are a competent assistant
and a second scrubbed team member to pass instruments and
sutures as needed. One person cannot effectively or safely per-
form both these roles. A suction cannula ( ankauer) or smoke-
evacuating retractor should also be placed, and the position of the
cautery tip relative to vital adjacent structures must be known
at all times during the resection. If a smoke-evacuating retractor
is used, a second suction setup for a ankauer suction should be
available in the event that bleeding is encountered during the
resection and suction is needed to obtain hemostasis.
Anatomy of Submandibular Gland Blood Supply
The submandibular artery enters the submandibular gland
superolaterally and will not be directly and specifically encoun-
tered when performing conservative resections typically made
for aesthetic purposes; only its terminal branches, extending into
the gland itself, will be encountered. Dissection should always be
made carefully in this area, however, and as one becomes more
practiced in the procedure and makes more comprehensive
resections as a result, this vessel will often be seen as a discrete
799
 VIII Surgical Rejuvenation of the Face and Neck
branch of the much larger submental artery. In many cases, if
care is exercised, resection of the most superolateral portion
of the protruding portion of the gland can be made without
dividing this vessel, and it can be isolated and grasped with a
hemostatic (Schnidt) forceps and ligated.
Algorithm for Management of Bleeding
Encountered During Submandibular Gland
Reduction
Submandibular gland reduction must not be performed without
good light, proper instruments, requisite exposure, adequate
suction, sufficient personnel, and considered caution, as intra-
glandular vessels may be encountered. These vessels are more
commonly encountered when larger resections are necessary
and are most easily managed by immediate and thorough fulgu-
ration before further dissection is made. Typically, bleeding will
occur from both the gland (patient) side and the specimen side,
and this is usually best controlled by quickly moving the cautery
back and forth between the two ends of the cut vessel. If only the
gland (patient) side is cauterized, bleeding will often continue
from the specimen side, obscuring the surgical field. In most
cases, pulling inferiorly on the specimen side will slow bleeding
from the cut vessel edges and facilitate controlling them.
If bleeding cannot be readily controlled by direct cauterization
of each side of the cut vessel, suction should be applied, an insu-
lated cautery forceps used to grasp the bleeding point directly, and
the point subsequently cauterized by application of coagulating
cautery current to the instrument.
If bleeding is brisk and not easily controlled by the cauterization
methods described above, the gland should be pulled inferiorly
and its entire cut edge compressed proximally with a second
DeBakey or long insulated coagulation forceps. Once bleeding is
controlled in this manner, the wound can be irrigated and suc-
tioned to clear the field and the offending vessel then carefully
identified by gently intermittently releasing the compression
across the cut edge of the gland. Once identified, it can then be
grasped with a second instrument and cautery applied.
In the unlikely event that bleeding cannot be controlled by the
preceding three maneuvers, the submandibular fossa should be
packed with a gauze sponge and digital pressure firmly applied
by the surgeon’s finger for several minutes, pressing the gland
against the inner aspect of the mandible and the floor of the
mouth. In most cases, when the gauze is carefully removed, the
bleeding will be seen to have stopped, the subplatysmal space can
be irrigated and suctioned to clear the operative field of any blood,
and a search for the bleeding point can be made and any suspi-
cious areas cauterized or ligated. In the unlikely circumstance that
direct pressure applied in this manner is not effective (and this
has never been the case in our combined 30 years of performing
the procedure), the surgeon can place a finger or fingers from the
opposite hand inside the patient’s mouth and bimanually com-
press the gland to halt the bleeding.
Treatment of the Cut Submandibular
Gland Edge
Once excision of the protruding portion of the gland is complete,
the submental region is irrigated and a check for hemostasis
800
along the gland’s cut edge is made. Experience has shown that it
is not necessary or productive to attempt to oversew the cut edge
of the gland or close the glandular capsule. These maneuvers not
only are technically difficult but also could result in injury to
nearby neurovascular structures. It is also not necessary or pro-
ductive to overcauterize the cut edge of the gland in an attempt
to seal or shrink it. This typically results in more postoperative
pain and swelling and prolonged submental induration.
Submandibular Gland Reduction and
Major Complications
Subtotal submandibular gland reduction to date has not resulted
in any cases of hematoma, airway compromise, salivary fistula,
or gustatory sweating in our practices and our combined 30-year
experience.
Limits of the Submandibular Gland
Reduction Procedure
It must be understood and acknowledged that submandibular
gland reduction, although important in the rejuvenation of most
necks, will not in and of itself result in attractive neck contour.
Other problems must be identified and addressed if optimal
results are to be obtained.
Submandibular reduction should be regarded as an advanced
technique. It should be undertaken by surgeons well versed in
cervical anatomy and experienced in more basic maneuvers used
to rejuvenate the neck, and the operating surgeon must at all
times have the specific algorithm for managing bleeding clearly
in mind. It is highly recommended that any surgeon uncertain of
the anatomy of the submental triangle or the exact relationships
of important structures in this area review them carefully before
undertaking this dissection.
53.6.6 Partial Digastric Myectomy
After subplatysmal lipectomy and submandibular gland reduc-
tion have been performed, assessment should be made of the
anterior bellies of the digastric muscles and whether partial
digastric myectomy would produce further improvement in neck
contour. In most cases, additional improvement in neck contour
can be obtained by performing this procedure.
Typically, large digastric muscles will appear as a linear para-
median fullness lying medial to the rounder and more laterally
situated submandibular gland fullness and the difference in
appearance of the two problems is a reflection of their differing
anatomic origins: the anterior belly of the digastric muscles is a
linear paramedian structure and the submandibular gland is a
rounder more laterally situated structure (Fig. 53.48).
Usually digastric muscle excess is most evident after subpla-
tysmal lipectomy and submandibular gland reduction has been
performed, but in some cases it may be evident preoperatively in
patients seeking secondary or, less commonly, primary surgery.
In these situations additional improvement in neck contour may
be obtained by performing superficial, subtotal anterior digastric
myectomy (excising the protruding portion of the muscle).
Superficial, subtotal anterior digastric myectomy is performed
under direct vision, through the submental incision after the

subplatysmal space has been opened, the platysma muscle
mobilized, and subplatysmal fat and protruding portions of the
submandibular gland resected, if indicated. The redundant por-
tion of muscle can be excised either by a tangential strip excision
technique or by a partial division and excision technique. hile
both are reliable and effective, in most cases tangential strip exci-
sion provides the simplest and most intuitive and straightforward
means of removing the protruding portion of the muscle belly.
Tangential strip excision is performed by visually gauging
the muscle redundancy, grasping the redundant portion with a
DeBakey or similar forceps, and tangentially excising a strip of
muscle longitudinally from the muscle belly with a Metzenbaum
scissors or, more commonly, with monopolar electrocautery using
coagulating current. Typically tangential excision will result in
modest bleeding from the excised area that is easily controlled
with cautery once muscle reduction is complete if Metzenbaum
scissors are used.
Excision is begun near the muscle origin at the mentum and
continuing to the muscle belly insertion at the lateral hyoid.
The muscle is then reassessed and the action repeated until the
protruding portion is fully removed and optimal contour has been
established. Approximately 50 of the muscle is removed in the
typical case, with the most muscle removed near the hyoid and
the least near the chin (Fig. 53.49).
In the partial division and excision technique of digastric muscle
reduction, the excess muscle present is gauged and isolated on a
Fig. 53.48 Surface expression of large digastric muscle. Typically large
digastric muscles will appear as a linear paramedian fullness lying
medial to the rounder and more laterally situated submandibular gland
fullness, and the difference in appearance of the two problems is a
reflection of their differing anatomic origins. In many cases the diag-
nosis of both problems can be made by simply looking at the patient’s
neck, as in this case. This patient has had a prior face- and neck lift (see
also Fig. 53.30 and Fig. 53.46). (Illustration courtesy of Marten Clinic
of Plastic Surgery.)
53 Secondary Neck Lift
tonsil forceps by pushing the tips of the instrument through the
midmuscle belly at the level of optimal contour and spreading to
split the muscle along the length of its fibers. The isolated muscle
segment resting on the instrument, consisting of the superficial,
protruding portion of the muscle, is then excised with scissors or
cautery by dividing it near the mandible and the hyoid (Fig. 53.50).
The neck is re-examined and the maneuver repeated again if nec-
essary until an improved contour is obtained. Usually this entails
the excision of the most superficial half or less of each muscle, with
more muscle excised near the hyoid and less near the chin, as is the
case when the tangential excision technique is used.
It should be noted that the myectomy, regardless of how it is
performed, is a partial and subtotal reduction of the protruding
portion of the digastric muscle only, not an arbitrary exentera-
tion of the entire muscle belly. It should also be understood that
optimal contour is achieved when more muscle is resected near
the hyoid and less near the chin. In addition, partial, superficial
digastric myectomy, although an important maneuver in the
rejuvenation of many necks, will not in and of itself result in
attractive neck contour. Other problems must be identified and
treated if optimal results are to be obtained. Finally, although
a b
Fig. 53.49 Digastric muscle reduction strategy. (a) Typical appearance
of a large anterior belly of the digastric muscle. (b) Digastric muscle
fullness is treated in a manner that optimizes submental contour.
Approximately 50% of the muscle is removed in the typical case with
more muscle removed near the hyoid and less near the chin (shaded
gray area). (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a b
Fig. 53.50 Partial division and excision technique of digastric muscle
reduction. (a) Excess muscle present is gauged and isolated on a
tonsil forceps by pushing the tips of the instrument through the
midmuscle belly at the level of optimal contour and spreading to split
the muscle along the length of its fibers. (View from patient’s right of
right digastric muscle through submental incision. Patient’s chin is at
the left upper corner of the photo, and the neck is on right.) (b) The
isolated muscle segment resting on the instrument, consisting of the
superficial, protruding portion of it, is then excised with scissors or
cautery by dividing it near the mandible and the hyoid. The neck is
re-examined and the maneuver repeated again if necessary until an
improved contour is obtained. (Illustration courtesy of Marten Clinic
of Plastic Surgery.)
801
 VIII Surgical Rejuvenation of the Face and Neck

partial, superficial digastric myectomy is conceptually simple and Platysmaplasty is usually performed using multiple simple
technically straightforward, it should be regarded as an advanced interrupted sutures of 3–0 polyglactin (Vicryl), or suture of choice,
technique. It should be undertaken by surgeons familiar with on a medium to large (FS-1) needle. Long instruments are needed,
cervical anatomy and experienced in more basic maneuvers used and patience will be required. The platysmaplasty repair should
to rejuvenate the neck. be snug but should not be tight. A tight corset and permanent
sutures are not necessary, and a tight corset will not result in
a sustained improvement in cervical contour if deep-layer prob-
53.6.7 Anterior Platysmaplasty lems are not addressed.
Once subplatysmal fat excision, submandibular gland reduction, Optimal improvement generally cannot be obtained if repair
and partial digastric myectomy have been performed as indicated is performed using a running suture, as some gathering and a
and treatment of the subplatysmal space is complete, anterior purse string effect can occur. This will result in shortening along
platysmaplasty is performed. Anterior platysmaplasty (perhaps the line of repair and can cause bowstringing and postoperative
more properly referred to as anterior platysmorrhaphy, but midline band formation. If the initial approximation is made using
most commonly referred to in our literature as platysmaplasty) interrupted sutures, this problem is averted and the platysma is
is the procedure in which the medial borders of the platysma distributed over and into the concave surface created by deep-
muscle are sutured together to help consolidate the neck, reduce layer neck maneuvers (removal of subplatysmal fat, subman-
horizontal platysma laxity, and improve neck appearance when dibular gland reduction, and partial digastic myectomy). If only
patients flex their neck and look down (see Fig. 53.22 and Fig. partial suturing to the hyoid is performed in the submental area,
53.23). It is performed in the majority of patients and provides irregularities may result at the cervicomental angle.
an improved result in most necks. It is not, however, adequate or Once initial approximation has been made with interrupted
effective treatment of excess subplatysmal fat, prominent sub- sutures, the line of repair can be oversewn and reinforced with a
mandibular glands, protruding anterior bellies of the digastric simple running or running inverting suture without a purse string
muscles, or the treatment of platysma hyperfunction and “hard” and shortening effect, although this is typically not done in our
dynamic platysma bands. Treatment of these problems will patients. If a permanent suture is used, care should be taken to
require that other deep-layer maneuvers previously discussed saturate each suture with antibiotic solution prior to placement
(and subsequently discussed) be performed. and to bury all knots.
Anterior platysmaplasty is performed by suturing the medial
muscle borders of the platysma muscles together from mentum
to thyroid cartilage (Fig. 53.51). If redundant muscle is present
medially, it is excised and discarded before suturing is performed
so that a smooth, edge-to-edge approximation of the medial
muscle borders can be made without inversion, invagination, or
imbrication (Fig. 53.52). Experience has shown that this produces
a better and more consistent outcome and makes it less likely
that objectionable midline fullness or central neck bands will
result after healing and relaxation of tissues has occurred than
when excess muscle is invaginated and a multilayer plication or
“corset” is performed.
Typically, platysmaplasty is performed by suturing the
trimmed medial muscle borders together edge to edge, without
invagination, with interrupted sutures, beginning at the mentum
and proceeding inferiorly to the hyoid and then down to the level
of the midthyroid cartilage. Alternatively, approximation can be
started at the hyoid and then extended superiorly to the mentum
and then from hyoid to midthyroid level. The approach is not as
important as is creating a smooth, well-tailored approximation
and reconstitution of the platysmal layer.
hen a facelift and a neck lift are performed together, platys-
maplasty should be performed after cheek SMAS flap dissection
and suspension to prevent an accentuation of the effects of
aging and gravity and compromised improvement on the face
(Fig. 53.53). Although raising and suspending cheek SMAS flaps
first makes platysmaplasty suture placement more difficult by
superiorly shifting the skin, it allows optimal repositioning of the Fig. 53.51 Anterior platysmaplasty. Repair of platysmal diastasis from
mentum to thyroid cartilage (arrows) improves submental support and
cheek and jowl and provides for the best overall improvement.
helps consolidate the neck. It is not adequate or effective treatment for
f f fi , “hard,” dynamic platysmal bands, however. If dynamic platysma bands
f , f are present, proper treatment will require that platysmamyotomy be
fi (Fig. 53.54). performed (Fig. 53.26, Fig. 53.27, Fig. 53.28). (Illustration courtesy of
Marten Clinic of Plastic Surgery.)

802

a b
Fig. 53.52 Anterior platysmaplasty. (a) If redundant muscle is present
medially (dashed red line), it is gauged and excised before suturing is
performed (b) so that a smooth, edge-to-edge approximation of the
medial muscle borders can be made (right). This produces a better
outcome and reduces the likelihood that objectionable midline fullness
or bands will result after healing has occurred, compared with when
excess muscle is invaginated and a multilayer “plication” or “corset” is
performed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a b
Fig. 53.53 (a,b) SMAS flaps should be raised before platysmaplasty
is performed. If the neck lift is done with a facelift, the cheek SMAS
should be suspended (green arrows) before platysmaplasty is per-
formed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a b
Fig. 53.54 SMAS flaps should be raised before platysmaplasty is
performed. (a) If platysmaplasty is performed before cheek SMAS
suspension (black arrows), (b) elevation of the cheek SMAS flaps and
improvement in the face will be compromised (red arrows). (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
53 Secondary Neck Lift
Platysmaplasty should be performed with the neck in a neutral
position. If the closure is made with the neck extended, excessive
tightness may result when the patient looks down after surgery.
This is particularly the case if platysmaplasty is performed in
conjunction with some form of lateral platysmal suspension,
discussed in the following section.
53.6.8 Management of the
Lateral Platysmal Border
If a short-scar neck lift is performed, there is no access to, or
option for, lateral platysma suspension. If a neck lift is performed
in conjunction with a facelift, or if an extended neck lift is being
performed, lateral platysmapexy (Fig 53–55) can be performed,
or more typically a post-auricular transposition flap is created
and used (Fig 53.56, Fig. 53.57).
hen mild horizontal platysma muscle redundancy is present
in the neck, lateral platysmapexy is performed (Fig. 53.55). Lateral
platysmapexy ensures that the platysma is draped smoothly and
snugly along the cervicomental angle and helps to consolidate the
neck further, especially when the patient looks down. It is usually
effective only when suturing is performed over the upper one-
fourth of the sternocleidomastoid muscle, where its fascia is less
mobile. In thin necks the cut muscle edges can be overlapped. In
fuller necks, redundant muscle can be trimmed and the muscle
segments sutured edge to edge. Due to the overall mobility of
sternocleidomastoid fascia, however, limited support can be
obtained by these maneuvers.
hen horizontal platysma muscle redundancy is large, or
optimal improvement is cervicomental contour is desired,
a postauricular transposition flap (PATF) of cheek SMAS is
planned (Fig. 53.56, Fig. 53.57). The PATF is created by splitting
off redundant tissue from the posterior margin of the cheek
SMAS flap, but leaving it attached inferiorly to the cervico-sub-
mental platysma. If properly constructed and secured, this flap
will provide for optimal reduction in horizontal platysma laxity
a b
Fig. 53.55 Lateral platysmapexy. When mild horizontal platysma
muscle redundancy is present in the neck, lateral platysmapexy may
suffice. (a) Before lateral platysmapexy. (b) After lateral platysmapexy.
The inferior border of the posterior margin of the superficial muscu-
loaponeurotic system (SMAS) flap is advanced laterally and posteriorly
and sutured to the upper sternocleidomastoid fascia in a manner
that tightens the platysma under the mandibular border and along
the cervicomental angle. Lateral platysmapexy should be performed
after anterior platysmaplasty (see Fig. 53.22, Fig. 53.53). (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
803
 VIII Surgical Rejuvenation of the Face and Neck

and dynamic reinforcement of the upper neck and submental
areas when the patient looks down. hen used in conjunction
with an anterior platysmaplasty, PATFs result in a continuous
mastoid-to-mastoid sling of muscle across the upper neck
along the cervicomental angle and optimal improvement in
neck contour.
If an extended neck lift is performed, a limited periauricular
incision will be present, but a PATF can still be created and a low
SMAS flap can be used to effect improvement in the lower face
and along the jawline that otherwise would not be obtained if pla-
tysmaplasty alone, or platysmaplasty and lateral platysmapexy,
were performed (Fig. 53.56).

Fig. 53.56 Postauricular transposition flap (PATF) when an extended neck lift is performed. If an extended neck lift is performed, a limited preauricular
incision will be present, but a PATF can still be created, and a “low” superficial musculoaponeurotic system (SMAS) flap can be used to effect improve-
ment in the lower face and along the jawline that otherwise would not be obtained. (a) Plan for PATF with low SMAS flap. (b) After flap creation and
transposition to the postauricular area. (c) After elevation and suturing of low SMAS flap and suturing of PATF to the mastoid fascia. In combination
with anterior platysmaplasty (broken line), a mastoid-to-mastoid sling of autologous tissue that defines the cervicomental angle is created. The low
SMAS flap provides improvement in the lower face and along the jawline that would not be otherwise obtained if platysmaplasty alone or platysma-
plasty and lateral platysmapexy were performed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)

Fig. 53.57 Postauricular transposition flap (PATF) when a facelift is performed. If a facelift is performed, a PATF can be created from the posterior
margin of a “high” superficial musculoaponeurotic system (SMAS) flap, and the high SMAS flap can be used to effect improvement in the cheek and
midface region. (a) Plan for PATF with high SMAS flap (superior margin of SMAS flap planned at level of zygomatic arch). (b) After flap creation and
transposition to the postauricular area. (c) After elevation and suturing of high SMAS flap and suturing of PATF to the mastoid fascia (typically some
shortening of the flap is performed). In combination with anterior platysmaplasty (broken line), a mastoid-to-mastoid sling of autologous tissue that
defines the cervicomental angle is created. The high SMAS flap provides improvement in the upper face and midface that would not be otherwise
obtained if platysmaplasty alone, or platysmaplasty and lateral platysmapexy, or platysmaplasty and low SMAS lift, were performed. (d) Partially
completed PATF seen in a facelift patient. High SMAS flap has been elevated and its superior margin anchored over the zygomatic arch. Because
the SMAS flap is properly advanced along a vector parallel to the long axis of the zygomaticus major muscle some redundancy is present along the
posterior margin of the flap. This is excised in a manner such that when the posterior margin of the flap is sutured to the pre-auricular SMAS remnant
it is closed under no tension, but it is left attached to the cervical platysma below the mandibular border. This allows suspension of the lateral
platysma border to the fixed mastoid fascia.

804

f , f uniformly distributed over the anterior neck and under slight
be performed after anterior platysmaplasty has been performed. If
the transposition flaps are suspended first, the platysma muscles
can be shifted laterally and it may be difficult to join them in the
midline (Fig. 53.58).
Suspension to the mastoid is performed with interrupted
sutures of 3–0 polyglactin (Vicryl) on FS-1 needle (or other suture
of choice). A permanent suture is not necessary, and if used, the
knots may be palpable by the patient in the postauricular area.
The more proximal portions of the flap are secured to the under-
lying fascia with a simple running suture of the same material
along its upper border. This consolidates the deep layer repair in
the perilobular area and prevents the flap from bunching up or
rolling up upon itself.
For a PATF to be effective, it must be properly designed and
constructed and its intended purpose kept in mind. A common
error is for the surgeon to construct it too timidly and superiorly
and in such a manner that its pull is placed over and along the
mandibular border (Fig. 53.59a). Such a design pulls on the
lateral face and does not improve the neck and cervicomental
angle. Properly constructed, the flap should exert its pull below
and inferior to the mandible and along the cervicomental angle
(Fig. 53.59b).
53.6.9 Transverse Platysma Myotomy
Although anterior platysmaplasty will often result in an
attractive neck at rest and on the operating table, objection-
able-appearing dynamic platysma bands and muscle striations
will often still be evident in conversation and during animation
after surgery if additional steps are not taken. These problems
can be minimized by performing transverse platysma myotomy
(see Fig. 53.24, Fig. 53.26, Fig. 53.27, and Fig. 53.28). The extent
of platysma transection will arguably depend upon the muscle
irregularities present and thus can be varied from patient to
patient.
Platysma myotomy should be performed after anterior platys-
maplasty and lateral platysmal suspension (lateral platysmapexy
or PATF) have been completed, as the platysma muscle will be
a b
Fig. 53.58 (a) If suspension of the lateral platysmal borders (lateral
platysmapexy or postauricular transposition flap) is performed before
anterior platysmaplasty (black arrows), (b) the plastysma muscles
may be laterally displaced and approximation of the medial plastysmal
borders (platysmaplasty) may not be possible (red arrows).
53 Secondary Neck Lift
tension. Myotomy should be performed low in the neck at the
level of the cricoid cartilage when the platysma muscle is in
good condition and has not been compromised in the previous
procedure or by noninvasive treatments, and extended slightly
superiorly as it is extended laterally (Fig. 53.60, Fig. 53.61). At
this level the muscle is thin and will bleed less, and the cut edges
are less likely to be visible postoperatively, but muscle action
will nonetheless be interrupted. In addition, a smooth transition
across the cervicomental angle is maintained and the risk of
lower lip dysfunction is minimized. If transection is made higher,
these benefits can be lost (Fig. 53.60b). This is particularly true
when myotomy is performed at the level of the hyoid along the
cervicomental angle or when wedges of platysma muscle are
removed at that location as is shown in many plastic surgery
textbooks. The platysma muscle is much thicker at that level, and
the cut edges are more likely to bleed and/or be visible after sur-
gery. In addition, a high transection or resection of this sort can
result in a severe and unaesthetic transition for the submental
region to the neck and adversely affect platysma action, resulting
in asymmetric movement of the lower lip during speaking and
expression or a change in lower lip posture. Transecting the
platysma high along the cervicomental angle laterally also puts
both the cervical and marginal mandibular branches of the facial
nerve at risk.
Anterior platysma myotomy is best begun working through
the submental incision just inferior to the most inferior platys-
maplasty suture (Fig. 53.26a). The medial platysmal border is
identified over the cricothyroid area and grasped and lifted away
from the deep cervical fascia with a long DeBakey-type forceps.
Myotomy is then made by nibbling through the muscle in small
increments with a Metzenbaum scissors or with electrocautery.
As the muscle is divided, it usually separates a centimeter or
more, exposing the fascia beneath it.
a b
Fig. 53.59 Improper and proper construction of the postauricular
transposition flap (PATF). (a) Improper design and construction of
the PATF. The flap has been designed and constructed too superiorly
and pulls along the lower face and lateral mandibular border. Such a
construction does little to improve the neck. (b) Correct design and
construction of the PATF. The flap has been designed and constructed
more inferiorly so that its resultant pull is below the mandible and
along the cervicomental angle. Such a design optimizes cervico-
submental contour.
805
 VIII Surgical Rejuvenation of the Face and Neck
a b
Fig. 53.60 Correct and incorrect level for platysma myotomy.
(a) Correct level (level of cricoid cartilage) for platysma myotomy.
Myotomy should be performed low in the neck at the level of the
cricoid cartilage and extended slightly superiorly as it is extended
laterally. At this level the muscle is thin and will bleed less, and the cut
edges are less likely to be visible postoperatively. In addition, a smooth
transition across the cervicomental angle is maintained, and lower
lip dysfunction is avoided. (b) Incorrect level (level of hyoid bone) for
platysma myotomy. The platysma muscle is much thicker, and the cut
edges are more likely to bleed and be visible after surgery. In addition,
a high transection or resection can result in an unaesthetic transition
from the submental region to the neck and result in asymmetrical
movement of the lower lip. (An exception is “noninvasive neck defor-
mity,” in which patients will need partial myectomy.) (See Fig. 53.29.)
Serrated or supersharp scissors should not be used, as they
tend to pick up and cut adjacent tissue and posterior fascia and can
result in injury to the anterior jugular vein. Unintended injury to
the anterior jugular vein will result in annoying bleeding that can
be difficult to control. Gentle spreading with scissors tips before
each cut is made helps separate the platysma from underlying
cervical fascia and facilitates dissection when scissors are used. In
most cases, however, cautery is used.
Myotomy is continued laterally and slightly superiorly accord-
ing to the preoperative plan depending on whether anterior
or both anterior and lateral bands are present. If a full-width
division of the platysma is planned, the most lateral portion of
the transection (most lateral portion of the muscle) is completed
through the postauricular incisions by identifying the lateral
muscle border, incising it, and incrementally extending the inci-
sion until it is brought into continuity with the incision made in
the muscle anteriorly through the submental incision, using one
of the methods (Metzenbaum scissors or electrocautery) previ-
ously described (Fig. 53.61b).
Patients should be counseled that the goal of platysma myot-
omy is a reduction in platysma hyperfunction and decrease in
the prominence of hard, dynamic platysma bands. It should not
be their expectation that the procedure will result in a complete
absence of platysmal movement or a complete elimination of
hard dynamic bands. Patients desiring and expecting a complete
absence of platysmal movement are not good candidates for the
procedure and are likely to be disappointed with the outcome.
They should instead be steered toward neuromodulators or some
other form of treatment. Patients desiring a reduction in platysma
hyperfunction and decrease in the prominence of hard, dynamic
platysma bands will, however, almost always be pleased with the
outcome of the procedure.
806
a b
Fig. 53.61 Sequence for performing platysma myotomy. (a) Anterior
platysma myotomy is begun working through the submental incision
just inferior to the most inferior suture placed when platysmaplasty
was performed. The medial platysma border is identified over the
cricothyroid area and grasped and lifted away from the deep cervical
fascia. Myotomy is then made by nibbling through the muscle in small
increments with a Metzenbaum scissors or using electrocautery. (b) If
a “full-width” division of the platysma is planned, the most lateral
portion of the transection is completed through the postauricular
incisions by identifying the midlateral muscle border, incising it, and
incrementally extending the incision until it is brought into continuity
with the incision made in the muscle anteriorly through the submental
incision.
53.6.10 Partial Platysma Myectomy
Despite the historic effectiveness of platysma myotomy in
treating dynamic platysma bands, a growing number of
patients are now being encountered who have been over-
treated with radiofrequency or ultrasound skin-shrinking
treatments and are as a result troubled by dense subcutaneous
fibrosis and thermal damage to their platysma, manifested
as objectionable muscle fibrosis, evident as both resting
and dynamic dense platysma thickenings that are largely
refractory to traditional platysma muscle transection an
occurrence that some surgeons refer to as noninvasive neck
deformity (Fig. 53.62). In these patients a more aggressive
strategy must be undertaken if meaningful improvement is to
be obtained.
Patients with thermal damage to their platysma as a result
of radiofrequency or ultrasound skin-shrinking treatments
(or application of other forms of energy to the subcutane-
ous neck and face) can be significantly improved by partial
platysma myectomy (excising part of the platysma muscle).
Partial platysma myectomy is performed by making a high
myotomy full-width at the level of the midthyroid (instead of
the cricoid) cartilage. The superior cut edge and the inferior
cut edge of the divided muscle are then undermined modestly
and as appropriate for the problem present on the deep fascia,
and each elevated muscle edge is then resected by beveling it
with Metzenbaum scissors or electrocautery. Typically, this will
result in the equivalent of resecting the platysma present on the
majority of the interior neck from the superior border of the
thyroid cartilage to the cricoid cartilage or occasionally lower.
hen performed correctly, a significant improvement in neck
contour and a marked reduction in neck irregularities can be
obtained.

Fig. 53.62 Noninvasive neck deformity. This patient has undergone
multiple previous noninvasive neck “skin-tightening” procedures,
performed by unknown surgeons, that have degraded the appearance
of her neck and have resulted in difficult-to-treat secondary irregu-
larities. Note the contrast between the plushly padded lower face
and supraclavicular area with marked destruction of subcutaneous
fat in the submental and anterior neck areas where treatments were
administered. Almost no subcutaneous fat remains in the treated
areas, and the patient has an elderly “skin-on-muscle” appearance.
Note also fibrosis and objectionable thickening and banding of pla-
tysma muscle, even though the patient’s face is in repose, as a result of
energy application beneath the skin. Simple platysmaplasty and even
platysma myotomy are ineffective in treating these patients. These
patients typically require partial platysma myectomy (see Fig. 53.29)
and may be candidates for second-stage fat grafting.
It should be noted that platysma myectomy must maintain a
cuff of muscle along the cervicomental angle posteriorly if the
marginal mandibular and cervical branches are to remain unin-
jured, and that submental platysma must be left intact and simply
contoured if lower lip dysfunction is to be avoided. In some but
not all cases, platysma myectomy will result in a (typically posi-
tive) change in the posture of the lower lip and less lower dental
show during speaking and smiling.
53.6.11 Final Contouring of
Cervicofacial Fat
Once correction of deep layer neck problems has been made and
platysmaplasty, platysma myotomy, and suspension of PATFs
have been performed as indicated, final contouring of subcu-
taneous superficial cervicofacial fat should be performed. This
is typically performed under direct vision using Metzenbaum
scissors. Final fat sculpting should be continued until all con-
tours are smooth and regular, but it is essential that not all fat
be removed if an attractive appearance is to be obtained. In the
secondary neck lift, typically only high spots should be lowered
and as much subcutaneous fat as possible should be preserved, as
53 Secondary Neck Lift
the subcutaneous layer was already overtreated at the primary
procedure(s).
If a double chin or witch’s chin is present, an extended dissec-
tion of the perimental area and chin pad should be made, if it was
not already performed (Fig. 53.15, Fig. 53.16); fat contributing to
these problems sculpted and excised; and the two regions seam-
lessly sculpted and blended to ensure a smooth transition from
the chin to the submental area.
In full necks where a true excess of preplatysmal fat is present
(Fig. 53.32, Fig. 53.33), preplatysmal lipectomy can be performed
with scissors or with a suction cannula using an open liposuc-
tion technique by placing the cannula hole facing down under the
skin flap and holding the skin flap down as resection is made. In
thin necks, and in most of our cases where some excess prepla-
tysmal fat is present, excision is typically made using the scissors
technique.
53.6.12 Drain Placement
Drains are used routinely in both primary and secondary necklift
procedures, and our experience has shown that they reduce
postoperative ecchymosis and seromas, limit tissue firmness and
induration, and enable patients to return to their work and social
lives sooner. As a practical matter, drains are generally necessary
when deep-neck maneuvers (subplatysmal fat excision and sub-
mandibular gland reduction) are performed, and tissue glues,
advocated by some surgeons to consolidate the subcutaneous
plane, cannot be expected to prevent collections in the subpla-
tysmal area. It should be acknowledged, however, that drains
will not compensate for poor hemostasis in either plane and will
not prevent hematoma formation.
Experience has shown that when subplatysmal fat excision
and submandibular gland reduction are performed, it is prudent
to place a drain in both the subcutaneous and the subplatysmal
space for at least several days after the procedure to reduce edema
and induration in the submental area to reduce the chance of a
fluid collection (lymphatic fluid leakage from the division of
lymphatic vessels during subplatysmal fat excision and/or saliva
leakage from the cut edge of the submandibular gland) and to
speed the patient’s overall recovery. A 10 French round, multiper-
forated ackson-Pratt (or similar) type drain is routinely placed
in both the subcutaneous and subplatysmal spaces. It is safest to
perform the platysmaplasty (suturing of the medial platysmal
borders together) before subplatysmal drain placement and then
to thread the subplatysmal drain into position afterward. If the
subplatysmal drain is placed before platysmaplasty is performed,
there is a chance that the drain could be caught in one of the
platysmaplasty sutures, making its removal problematic.
The vacuum force applied by the subplatysmal drain will capture
and remove lymphatic fluid and saliva, close down the subplatys-
mal space, and pull the underside of the platysmal muscle against
the cut edge of each submandibular gland. It is convenient to place
the exit site of the subcutaneous drain on the opposite side of the
neck (opposite the exit site of the subplatysmal drain) so that it
is clear which drain is which and so that output from each can
readily be monitored. In a male face or in a large female face, two
subcutaneous drains may be required to drain the subcutaneous
space adequately. The vacuum force applied by the subcutaneous
drain captures and removes fluid from the subcutaneous space of
807
 VIII Surgical Rejuvenation of the Face and Neck
both the face and neck if a facelift is concomitantly performed,
and no drains are needed in the face itself.
Subplatysmal drain placement during deep neck lift should
be performed after platysmaplasty is completed as follows: once
platysmaplasty is complete, a stab incision should be made 1 to
2 cm posterior to the occipital incision on the occipital scalp on
the right side and the proximal (reservoir) side of the drain pulled
retrograde through the incision into position and anchored at its
site of exit from the scalp with a 4–0 nylon suture. The part of the
drain distal to its point of anchoring is then placed in the subcu-
taneous space and the tip brought out the submental incision. If
a short-scar neck lift is being performed and a postauricular inci-
sion is not present, a stab incision is made in the right postlobular
skin or scalp and a 2.4- or 3.0-mm liposuction cannula is used
to tunnel under the lateral neck skin and into the subcutaneous
space that has been dissected more anteriorly. The tip of the
cannula is brought out the submental incision, the proximal (res-
ervoir) side of the drain placed firmly over the tip of the cannula,
and the cannula used to drag the drain into position. The drain is
then anchored as previously described.
orking thorough the submental incision, the surgeon then
locates the most inferior platysmaplasty suture, and the platysma
muscle on the right side just inferior to the most inferior suture
is grasped and the tip of a long right-angle (Mixter-type) hemo-
static forceps is placed under the muscle edge; then the forceps is
advanced under the platysma muscle in the subplatysmal space
superiorly and laterally up to the approximate location of the right
submandibular gland. The tip of the instrument is then pushed
through the muscle into the subcutaneous space, and the tip of
the drain is grasped and placed over one jaw of the forceps. The
forceps is then closed and the drain pulled into the subplatysmal
space and back out below the most inferior platysmaplasty suture
and out into the subcutaneous space at the midline. The tip of the
right-angle forceps is then placed under the medial edge of the left
platysma muscle just inferior to the most inferior platysmaplasty
suture, and the forceps is used to retract the muscle outward to
hold open the subplatysmal space on the left. The tip of the drain,
now situated subcutaneously in the midline, is then grasped and
stuffed into the subplatysmal space on the left side and up to the
approximate location of the left submandibular gland. Upon com-
pletion of these maneuvers, the majority of the drain will be in
the subplatysmal space, with a smaller section in the upper lateral
right neck in the subcutaneous space.
53.6.13 Incision Closure
If the secondary procedure is such that a short-scar neck lift
has been performed, only a submental incision will be present,
and this can be conveniently closed in two layers. Prior to closure
it is important to confirm that the wound edge thickness and
amount of subcutaneous fat present are similar on each side of
the incision. Typically the wound edge of the cervical side will
have a thinner edge and have less subcutaneous fat due to con-
tact with instruments and retractors during preceding steps in
the procedure, and the mental, superior side will be thicker and
have more fat. If a discrepancy is present, as it often will be, fat is
carefully removed from the thicker superior side. The first layer
of closure consists of several subcutaneous sutures of 5–0 poli-
glecaprone (Monocryl) or other suture of choice to ensure that
808
equal amounts of fat are present behind the closed wound and so
that a depressed or irregular scar is avoided. Final approximation
is then made with simple interrupted sutures of 6–0 nylon (or
other suture of choice).
If an extended neck lift or a facelift is performed in conjunc-
tion with a secondary neck lift procedure, skin will be excised
from the postauricular area. The postauricular flap is shifted
posteriorly and somewhat superiorly, roughly parallel to trans-
verse neck creases and the mandibular border, in such a manner
that skin is suspended under minimal or no tension and that little
f
border. Excessive trimming of skin from the anterior border of the
postauricular skin flap will require the flap to be shifted along
an incorrect superiorly directed vector, and this will produce
a compromised result. The first point of suspension is located
in the postauricular area at the anteriosuperior aspect of the
occipitomastoid incision. The flap is secured at this point with a
simple interrupted suture of 4–0 nylon. o incision into the flap is
necessary, and no deep suture is used.
Once this suspension suture has been placed, the flap overlying
the inferior portion of the ear should be carefully divided and the
lobule exteriorized. This is a key step in the procedure, which must
be performed incrementally and with great care if a visible scar, lob-
ular malposition, and objectionable “pixie earlobe” (often present in
the patient presenting for secondary neck lift) is to be avoided. If the
incision to exteriorize the lobule is properly made, the apex of the
incision should rest snugly against the most inferior portion of the
conchal cartilage. If the incision into the cheek flap is made too far
anteriorly or inferiorly, however, artistically appropriate resetting
of the lobule will not be possible, and the outcome of the overall
procedure will be significantly compromised.
Postauricular closure along the auriculomastoid sulcus is
performed next and should be completed before trimming and
closure of the occipital portion of the incision and resetting of the
lobule. It is begun by conservatively trimming the anterior border
of the postauricular skin flap into a soft curve to match the curve
of the incision made in the auriculomastoid sulcus. The incision
is then closed with several interrupted sutures of 4–0 nylon. o
deep suture is necessary or used.
It is a fi and to excise any skin over
(superior to) the apex of the occipitomastoid incision or to shorten
the postauricular flap along the long axis of the sternocleidomas-
toid muscle, as commonly practiced and shown in many plastic
surgery textbooks. Despite an apparent redundancy in this area
when the patient is supine on the operating table, there is never
any true skin excess at this location. This pseudoexcess of skin is
present only because of the patient’s high shoulder position in the
supine position. It will vanish when the patient sits up and the
shoulders drop to a normal position. Skin along the axis of the ster-
nocleidomastoid muscle is also needed for side-to-side head tilt.
Inappropriate excision of skin over the apex of the occipitomastoid
defect is the ultimate underlying cause of hypertrophic healing in
the postauricular region and of a wide postauricular scar.
Trimming and closure of the occipital portion of the incision
should be performed after closure of the postauricular area and
suspension without trimming along the transmastoid portion
of the postauricular incision. A facelift marker should be used to
gauge skin flap redundancy along the occipital incision, and all
points along the flap should be intentionally trimmed with 2 to
 53 Secondary Neck Lift

3 mm of redundancy. It must be remembered that the goal of performed, which can disrupt healing incisions and cause wound
skin excision is to remove redundancy, not to tighten the cervical separation. If an elastic neck band is to be used, it is prudent to
skin flap, a point that was not always appreciated at the primary wait 10 to 14 days before using it, and patients should be given
procedure. If trimming is performed correctly, wound edges specific instructions not to apply it too tightly and not flex their
should abut one another, and no gaps should be present, before necks or turn their heads side to side while wearing them. If the
sutures are placed. The incision is then closed in one layer with patient has undergone only a short-scar neck lift, elastic neck
multiple half-buried vertical mattress sutures of 4–0 nylon, with bands can be used sooner typically after the drains have been
the knots tied on the scalp side, and simple interrupted sutures removed.
of 6–0 nylon. o deep sutures are required, and staples should
not be used. This plan will provide precise wound edge alignment
and prevent cross-hatched scars (suture marks). In addition, if the 53.7 Postoperative Care
incision is closed under no tension as described, an inconspicuous
Performance of the secondary neck lift procedure, and all aes-
scar will be obtained.
thetic procedures we perform, fulfills only part of our obligation
If the postauricular skin flap has been shifted along a proper
to the patient, and the care the patient receives postoperatively
vector and tissue distributed appropriately under no tension
is arguably as important as the surgery itself. Diligent postoper-
over the occipital area, a precise fit should be obtained. If neck
ative care will also ensure the best result and limit the likelihood
skin redundancy is large, or if the postauricular flap has been
that problems and complications will occur.
suspended under tension, a dog-ear will often be present at the
Patients are discharged with specific written instructions as
most inferior portion of the occipital incision. This should not be
to how they are to care for themselves, and the surgeon should
chased down the occipital hairline, as an obvious scar will result
always be available to answer questions and see any patient, if
in the fine hair on the nape of the neck. A better result is obtained
needed.
under these circumstances if the dog-ear is inset posteriorly into
the occipital scalp, above the junction of thick and fine hair,
and secured with simple interrupted sutures of 4–0 nylon. This 53.7.1 Sleeping and Head Position
requires that a small ellipse of scalp be excised from the scalp side
All patients are instructed to sleep flat on their backs without a
of the incision, but it moves the end of the incision into dense hair,
pillow. A small cylindrical neck roll is permitted if the patient
where it will be well concealed.
requests or requires it. This posture assures a chin up open
cervicomental angle and averts dangerous folding of the neck
53.6.14 Dressings skin flap and obstruction of regional cervical lymphatics, which
inevitably occur if the patient is allowed to “elevate their head
After all planned procedures have been completed and all
on pillows as is commonly recommended after head and neck
incisions have been closed, the patient’s hair is washed with
surgery. If patients are allowed to elevate their heads on pillows,
shampoo and conditioner, and if long, it is placed in a soft braid.
their necks will inevitably end up flexed and their skin bunched
The hair is then allowed to dry or is blown dry in the recovery
and folded. In addition, a flat-in-bed position encourages swelling
room. A final inspection of sutured incisions is made. If poor
to drain not inferiorly to the anterior neck but rather posteriorly
alignment is found in any area, it is locally reprepped and sutures
to the back of the head, where it is not harmful, less noticeable,
are removed and replaced as required.
and more rapidly transmitted away from the head and neck area
No dressing is required or applied. Patients are typically dis-
when the patient sits upright. This is particularly helpful if a
charged with a hat, scarf, and sunglasses following the procedure.
facelift has been performed as part of the procedure.
The traditional facelift and neck lift dressings consisting of tightly
Patients are shown an elbows-on-knees position for sitting
applied, mineral oil–soaked cotton, and rolled gauze are unnec-
that ensures an open cervicomental angle. This posture places
essary if closed suction drains are used, and a strong argument
the patient’s book, magazine, paperwork, notebook computer,
can be made that they are contraproductive and of potential harm
or meal in a position that allows reading, writing, eating, and TV
to the patient. These dressings place unnecessary and potentially
watching to be performed comfortably and safely with the chin
harmful pressure on thin skin flaps in a critical stage of their
up and the neck skin smoothly and uniformly distributed over the
healing and can compromise already tenuous circulation in them.
neck. If patients are allowed to sit upright during these activities,
In addition, they preclude inspection and monitoring of the
their neck will inevitably end up flexed and their skin bunched
operative site and can disguise and delay the diagnosis of serious
and folded.
problems such as hematoma, flap ischemia, and pressure necrosis.
Finally, patients typically find the traditional face- and neck lift
dressings cumbersome, confining, unhygienic, and claustropho- 53.7.2 Cool Compresses
bic, and their family members are often frightened by them.
Patients are asked to rest quietly and apply cold compresses to
Postoperative facial garments are also not routinely used.
their face and neck for 15 to 20 minutes of every hour they are
Like traditional facelift dressings, these place unnecessary and
awake for the first 3 days after surgery. For most patients, edema
potentially harmful pressure on thin skin flaps and can compro-
peaks at about this time. It is not necessary or productive to apply
mise already tenuous circulation in them. They also can generate
cool compresses continually throughout the day or at night. Ice
significant shear force on cheek skin flaps and periauricular inci-
and ice packs should never be applied directly to the skin.
sions if an extended neck lift or a facelift and neck lift have been

809
 VIII Surgical Rejuvenation of the Face and Neck
53.7.3 Medications
All patients are provided oral (usually nonnarcotic) analgesics,
sleeping pills, oral dissolving antiemetic tablets, and related and
other needed supplies with instructions for their use.
53.7.4 Diet after Surgery
Patients undergoing neck lift are placed on a salivary rest diet
consisting of soft, wet, easy-to-swallow foods and are encour-
aged to avoid sweet, salty, sour, dry, and difficult-to-chew foods
and citrus for several weeks. It is particularly important to avoid
these sorts of foods, which stimulate salivation, for 7 to 10 days if
submandibular gland reduction has been performed if fluid col-
lections and neck induration is to be avoided. Patients are asked
to abstain from the intake of alcohol for 2 weeks after surgery.
53.7.5 Wound Care
Patients are instructed to begin a daily routine of showering
and shampooing no later than 3 days after surgery. Patients are
allowed to shower even if their drains are still in place. This helps
remove crusting about the suture lines, keeps incisions clean,
and usually improves the patient’s general outlook and well-
being. Patients are also informed that they need not be as thor-
ough as usual when washing their hair and assured that shower
water, shampoo, and conditioners are not harmful and will not
interfere with healing or cause infection.
53.7.6 Drain Removal
Drains are usually left in the neck until the patient’s first clinic
visit for suture removal 5 days following their surgery. This is
because drain output often quickly falls on the first or second day
after surgery, during the time the patient is mostly supine and
resting, but then typically picks up again when the patient begins
to spend more time upright, starts to move their head about
more, and begins to eat more. Leaving the neck drains in longer,
for 5 to 7 days, will reduce the likelihood that small collections
will form and it will speed the overall resolution of edema, ecchy-
mosis, and induration in the neck area. At the patient’s first suture
removal visit, 5 days after surgery, the progress and drain output
are assessed. If healing is progressing well, drain output is min-
imal, and no fluid collections are present, and if it appears that
the patient is following dietary and other instructions, drains are
removed at that time. It is prudent to release suction before drain
removal and to have patients on an assistant hold pressure over
their anterior neck as the drain is removed for several minutes, to
avoid inducing the formation of a hematoma.
If a patient’s neck appears congested at the fifth postoperative
day, if drain output is still significant, or if the patient appears
not to be following dietary and other instructions, drains are not
removed and are left in place until the patient’s second suture
removal visit 7 days after surgery. In almost all cases, drains, if
still present, are removed at that time.
810
It is important to monitor the patient’s neck carefully for blood
and fluid collections at each visit, and if found, they should be
addressed. Often small collections resulting from poor drain func-
tion can be removed by milking the exteriorized portion of the
drain tube to restart drain flow. Loculated collections that have
accumulated subcutaneously in an area away from the drain can
often be stroked and massaged toward and to it. Collections that
cannot be evacuated in these ways should be transcutaneously
aspirated. Collections of these sorts may require several serial
aspirations performed over a period of several days. It is prudent
to see the patient and continue aspiration until the collection no
longer reforms. Collections allowed to congeal and consolidate
will result in firm, irregular areas that can take many months to
resorb and can result in permanent contour irregularities.
53.7.7 Suture Removal
hen sutures are removed will vary depending on the type of
procedure performed. If a short-scar neck lift has been per-
formed, only a submental incision will be present, and sutures
are removed on the fourth or fifth day. If an extended neck
lift or facelift and neck lift have been performed, 6–0 sutures
are removed on the fourth or fifth day and half-buried vertical
mattress sutures of 4–0 nylon with the knots tied on the scalp
side are removed on the seventh to ninth day. If sutures are left
in longer, telltale and objectionable suture marks are likely to
occur.
53.7.8 Return to Work after Surgery
hen patients return to work and their social lives will depend
upon their tolerance for surgery, their capacity for healing, the
type of work they do, the activities they enjoy, and how they feel
overall about their appearance. Patients are asked to set aside 7
to 10 days to recover, depending on the extent of their surgery,
and additional time off is recommended if a facelift and related
procedures are simultaneously performed. Patients who are
doing well and not experiencing problems are allowed to return
to light office work and casual social activities at that time. It is
often wise that they begin with a limited workday at first and
adjust their schedules thereafter. If a patient’s job entails more
strenuous activity or physical labor, a longer period of convales-
cence may be required. Patients are advised not to drive for the
first 10 days after surgery and until they are feeling well, their
vision is clear, and they are off pain medications.
53.7.9 After-Surgery Activity
Patients are advised to avoid all strenuous activity during the
first two weeks after surgery. Two weeks after surgery, patients
are allowed to begin light exercise and gradually work up to their
presurgical level of activity. Four to six weeks after surgery they
are allowed to engage in more vigorous activities, including most
sports, as tolerated.

53.8 Case Examples
53.8.1 Case Example 1
The 51-year-old woman in Fig. 53.63 had undergone a previous
facelift, neck lift, and related procedures performed by an
unknown surgeon (left images). Mild atrophy in much of the face
is evident. Loss of attractive facial contour due to deep-tissue
ptosis can be seen in the cheek, perioral region, and jowl. ote
that loss of jawline contour is evident and some submental
fullness can be seen on anterior view (Fig. 53.63a). An untreated
large submandibular salivary gland can be seen on oblique (Fig.
53.63c) and lateral (Fig. 53.63d, Fig. 53.63e) views. The lateral
view also reveals residual prominent anterior belly of the digas-
tric muscles; it is clearly evident in this view that the neck and
submental area have been incompletely rejuvenated.
She underwent a secondary face- and neck lift, including sub-
platysmal fat excision, submandibular salivary gland and digastric
muscle reduction, that included a PATF created from the posterior
margin of the facelift SMAS flap. Closed forehead plasty; upper and
lower blepharoplasty; fat grafts to the forehead, radix, infraorbital
area, piriform, lips, chin, labiomental sulcus, geniomandibular
grooves, and jawline; earlobe reconfiguration; and perioral
laser resurfacing were also performed. o subcutaneous fat was
removed, and no facial implants or suspension sutures were placed.
One year and 7 months postoperatively (Fig. 53.63, right
images), much more youthful, fit, and attractive neck and jawlines
are seen. The PATF has provided soft autologous support along the
cervicomental angle and a reduction in horizontal platysma laxity.
53.8.2 Case Example 2
The man in Fig. 53.64, aged 60, had undergone a previous facelift
and neck lift and related procedures performed by an unknown
surgeon. In preoperative views (left images), atrophy over much of
his face is evident. Loss of facial contour and sagging of tissue in the
submental area can be seen. A large submandibular salivary gland
is partially visible in oblique (Fig. 53.64c) and especially lateral (Fig.
53.64d, Fig. 53.64e) views. In the lateral flexed view (Fig. 53.64e)
the true extent of sagging of redundant tissue in submental area
can be seen and emphasizes the importance of showing facelift
patients in this view. hile modest recurrent aging is present on
other areas of the face, it can be seen that the patient’s poor neck
contour is what degrades his appearance the most.
He underwent a secondary face- and neck lift, including sub-
mandibular salivary gland and digastric muscle reduction that
included a PATF created from the posterior margin of the SMAS flap.
Supraciliary eyebrow lift; lower blepharoplasty; fat injections to the
forehead, radix, temples, midface, cheeks, and perioral areas; minor
otoplasty; earlobe reduction; and upper lip lift were also performed.
No subcutaneous fat was removed, and no facial implants or suspen-
sion sutures were placed.
He is shown 11 months postoperative (Fig. 53.64, right images).
ote that fat grafting has created a bolder and more masculine
chin and jawline, and submandibular salivary gland and digastric
muscle reduction has created a deeper submandibular contour, a
more aesthetic shadow under the mandible, and a more youthful
and natural-appearing neck. The PATF provides autologous sup-
port along the cervicomental angle.
53 Secondary Neck Lift
53.8.3 Case Example 3
The 72-year-old woman shown in Fig. 53.65 had undergone a
previous facelift and neck lift and related procedures that were
performed by an unknown surgeon. In preoperative views (left
images), atrophy over much of her face is evident. Loss of facial
contour can also be seen. Some fullness and sagging of tissue
in submental area can be seen in anterior view (Fig. 53.65a). A
large submandibular salivary gland is partially visible in oblique
view (Fig. 53.65c). Incomplete rejuvenation of her neck can be
seen, and submental irregularities create an unnatural surgi-
cal appearance, with a double chin in flexed lateral view (Fig.
53.65e), indicative of excess volume in the subplatysmal space
and the need to explore it and make appropriate reduction of
excess subplatysmal fat, submandibular salivary gland, and
digastric muscle.
She underwent a secondary face- and neck lift that included
a PATF created from the posterior margin of the SMAS flap.
Secondary forehead lift; upper blepharoplasty; lower eyelid laser
resurfacing; fat injections to the forehead, radix, nasal dorsum,
periorbital, piriform, lips, chin, labiomental sulcus, geniomandib-
ular grooves, and jawline areas; and earlobe reconfiguration were
also performed. No subcutaneous fat was removed and no facial
implants or suspension sutures were placed.
Twelve months postoperatively (Fig. 53.65, right images), neck
contour can be seen to be improved even in anterior view, but
the majority of the visible change is seen elsewhere on the face.
Fat grafting has created an aesthetic confluence of the chin and
the jawline. More fit and attractive jaw- and neck lines are seen.
Submandibular salivary gland and digastric muscle reduction has
enabled the creation of a deeper contour and a more aesthetic
shadow under the mandible. The PATF has provided soft added
support along the cervicomental angle.
53.9 Summary
A well-contoured neckline is essential to a youthful, fit, and
attractive appearance. eck improvement is of high priority to
almost every patient who presents for facial rejuvenation, and
the results of a face lift are often judged on the outcome in the
neck. If the neck is not sufficiently improved, our patients will
feel we have failed them.
Submental liposuction is an incomplete solution to most
patients’ neck problems and can result in the inappropriate
removal of subcutaneous fat essential to a natural and youthful
appearance. Submental liposuction can be particularly prob-
lematic when aggressive techniques are used. Overexcision of
subcutaneous fat may not be evident at the time of surgery or in
the early postoperative period, when cervico-submental tissues
are swollen, but it can result in problems that appear later and are
very difficult to correct once present. Proper treatment of many
necks requires modification of deep-layer structures and cannot
be limited to submental liposuction and the tightening of skin.
A prominent submandibular gland is large, not ptotic, and
aggressive submental liposuction and subplatysmal fat resection
can make a large submandibular gland more obvious and objec-
tionable appearing. Experience has shown that submandibular
gland reduction is safe and more effective than suture suspension
or platysma-tightening techniques.
811
 VIII Surgical Rejuvenation of the Face and Neck

a b

c d

e
Fig. 53.63 Case Example 1. Preoperative views (left) and 1 year and 7 months after secondary face- and neck lift including subplatysmal fat excision,
submandibular salivary gland and digastric muscle reduction, and postauricular transposition flap, along with closed forehead plasty, upper and
lower blepharoplasty, partial facial fat injections, earlobe reconfiguration, and perioral laser resurfacing, with no subcutaneous fat removed and no
suspension sutures placed (right). (All procedures performed by Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a)
Anterior views. (b) Anterior smiling views. (c) Oblique views. (d) Lateral views. (e) Lateral flexed views.

A subset of patients will be encountered who have objection- submandibular gland fullness, and the difference in appearance
ably large anterior bellies of their digastric muscles. Typically, of the two problems is a reflection of their differing anatomic
large digastric muscles will appear as a linear para-median origins. hen large digastric muscles can be identified, additional
fullness lying medial to the rounder and more laterally situated improvement in neck contour can be obtained by performing

812
 53 Secondary Neck Lift

a b

c d

e
Fig. 53.64 Case Example 2. Preoperative views (left images) and views 11 months after secondary face and neck lift along with supraciliary eyebrow
lift, lower blepharoplasty, facial fat injections, minor otoplasty, ear lobe reduction, and upper lip lift (right images). (All procedures performed by
Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a) Anterior views. (b) Anterior smiling views. (c) Oblique views. (d)
Lateral views. (e) Lateral flexed views.

superficial, subtotal anterior digastric myectomy. Failure to iden-
tify and treat large digastric muscles will result in objectionable
fullness and cervical obliquity in the submental region postopera-
tively. Digastric muscle reduction is performed after subplatysmal
fat and protruding portions of the submandibular gland have been
removed.
Subplatysmal fat excision, submandibular gland reduction, and
superficial digastric myectomy, performed in concert as indicated,
provide for the creation of the best neck contour possible, and the
skilled neck surgeon must master treatment of all three of these
“deep-layer” problems and use them in conjunction with each
other as indicated if optimal results are to be obtained.

813
 VIII Surgical Rejuvenation of the Face and Neck

a b

c d

e
Fig. 53.65 Case Example 3. Preoperative views (left images) and views 12 months after secondary face- and neck lift along with secondary forehead
lift, upper blepharoplasty, lower eyelid laser resurfacing, facial fat injections, and earlobe reconfiguration (right images). (All procedures performed
by Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a) Anterior views. (b) Anterior smiling view. (c) Oblique views. (d)
Lateral views. (e) Lateral flexed views.

53.10 Retention of Rights
Publishing Notice
All figures, illustrations, tables, and descriptions of concepts,
methods, and technique included in this chapter are courtesy of
the Marten Clinic of Plastic Surgery and are used with permis-
sion. Opinions expressed in this writing are those of the authors
and are not intended to be construed as, or used to define, a
standard of care.

814

Clinical Caveats
• As in primary procedures, recognizing the problems in the
secondary neck lift patient and appreciating their underlying
anatomic abnormalities is fundamental to planning and per-
formance of a logical and effective surgical repair.
• It is not enough to perform submental liposuction and tighten
the skin in most patients presenting for secondary neck lift,
as such an approach ignores a number of anatomic problems
typically present in many patients seeking secondary neck
surgery including platysmal laxity, platysma bands, excess
subplatysmal fat, large submandibular glands, and digastric
muscle hypertrophy. These problems will require additional
treatment if optimal improvement is to be obtained.
• Submental liposuction is usually of minimal benefit to the
secondary neck lift patient and can actually degrade neck
appearance in that it was typically performed aggressively
at the primary procedure at which time an over-resection of
subcutaneous fat was made. A thick and substantial layer of
subcutaneous fat must be present in the neck if it is to have
a youthful, healthy, soft, attractive and feminine appearance.
Additional targeting of subcutaneous fat is rarely of any ben-
efit to the patient seeking secondary procedures.
• Submental liposuction is a frequent cause of many vexing
patient problems and complications, as it often leads to unin-
tended but inappropriate removal of subcutaneous fat essential
to a natural and youthful appearance. These problems are typ-
ically not evident in the operating room or in the early postop
period, when cervicosubmental tissues are swollen; however,
they appear later and once present, are very difficult to correct.
• It is conceptually flawed and ultimately clinically ineffective
to try to force contour in the neck by “corset” tightening of
the platysma muscles. A young, attractive neck is not tight
and does not have a tight platysma but rather a youthful
distribution of tissue on it, and the surgeon’s goal must be
one of modifying the aging neck in a way that replicates the
distribution of tissue on it in youth, and in a way that produces
a sustained improvement in neck appearance.
• The difference between the presence of poor neck contour
and microgenia is frequently misunderstood, and it is a
common misconception that placement of a chin implant
improves neck contour. A chin implant is a treatment for
a small chin, not for a poor neckline, and the presence or
absence of microgenia and the need for a chin implant is a
cephalometric determination that is independent of the
condition of the neck. Placement of a chin implant when
microgenia is not present is a conceptual and artistic error
that will create unnatural appearances,
• Traditionally the submental incision used in neck lifts is placed
directly in and along the submental crease in a well-intended
but counterproductive attempt to conceal the resulting scar.
This incision plan should be avoided if possible, however,
as it will surgically reinforce the crease and accentuate a
“double chin” or “witch’s chin” appearance. Exposure of the
submental region will also be compromised, difficulty will be
encountered when suturing or dissecting low in the neck, and
the opportunity to sculpt and blend the fat of the chin and
submental region will be lost.
53 Secondary Neck Lift
• Cervical fat is present in three distinct anatomic layers: prepla-
tysmal (subcutaneous), subplatysmal, and deep cervico-sub-
muscular (interdigastric), and one must learn how to recognize
and treat each layer appropriately for the conditions present.
• While our traditional focus has mistakenly been on aggres-
sively resecting the preplatysmal layer, most patients present-
ing with poor neck contour will be primarily troubled instead
by fat excess in the subplatysmal layer. This is even more so
in the patient presenting for secondary neck lift, as typically
the surgeon performing the primary procedure mistakenly
targeted the superficial layer only. Understanding and accept-
ing this anatomic reality, and learning to treat subplatysmal
fat appropriately, is a key part of obtaining consistently good
outcomes in both primary and secondary neck lift procedures.
• Fat situated deep to the plane tangent to the anterior bellies
of the digastric muscles and beneath the deep cervical fascia
(deep cervical or “interdigastric” fat) should not be removed,
and the over whelming temptation to “clean out” the deep
cervical space must be resisted in both primary and second-
ary neck lift procedures.
• Preoperative assessment of the submandibular glands must
be made in patients seeking secondary improvement in neck
contour, as prominent glands are commonly overlooked or
ignored at the primary procedure and typically contribute to
the appearance of a full, “obtuse,” and “lumpy” neck in the
secondary surgery patient.
• Despite various claims to the contrary, prominent subman-
dibular glands are large, not ptotic, and the platysma muscles
contribute little to their position or support. Attempts at
tightening the platysma muscles to treat a prominent gland
usually results in modest improvement that is short-lived.
Large, prominent glands will require that the protruding por-
tion be resected if optimal improvement is to be obtained.
• A subgroup of patients seeking both primary and secondary
neck surgery will present with large, bulky anterior bellies of
their digastric muscles that are visible as linear paramedian
submental fullness When large, digastric muscles are present
excising the protruding portion of the muscle is indicated and
can provide for significant improvement in neck contour.
• When subplatysmal fat excision and submandibular gland
reduction are performed, it is prudent to place a drain in
both the subcutaneous and the subplatysmal space for at
least several days after the procedure to reduce edema and
induration in the submental area to reduce the chance of a
fluid collection and to speed the patient’s overall recovery.
• Anterior platysmaplasty is the procedure in which the medial
borders of the platysma muscle are sutured together to help
consolidate the neck, reduce horizontal platysma laxity, and
improve neck appearance when patients flex their neck and
look down. It is not, however, adequate or effective treat-
ment of excess subplatysmal fat, prominent submandibular
glands, protruding anterior bellies of the digastric muscles,
or the treatment of platysma hyperfunction and “hard”
dynamic platysma bands. Treatment of these problems will
require that other procedures be performed.
• When a facelift and a neck lift are performed together, platys-
maplasty should be performed after cheek SMAS flap dissec-
tion and suspension to prevent an accentuation of the effects
815
 VIII Surgical Rejuvenation of the Face and Neck

of aging and gravity and compromised improvement on the Suggested Reading

face. Although raising and suspending cheek SMAS flaps first
[1] Marten T , Elyassnia D. Male facelift. In: Rubin P, eligan P, eds. Plastic Surgery,
makes platysmaplasty suture placement more difficult by 4th ed. ew ork, : Elsevier; 2017:208–239
superiorly shifting the skin, it allows optimal repositioning of 2 Marten T , Elyassnia D. Facelift: Secondary deformities and the secondary facelift.
the cheek and jowl and provides for the best overall improve- In: Rubin P, eligan P, eds. Plastic Surgery, 4th ed. ew ork, : Elsevier;
ment. If platysmaplasty is performed first, the cheeks and 2017:240–272
3 Marten T , Elyassnia D. eck lift. In: Farhadieh RD, Bulstrode , Cugno S, eds.
jowls will be pulled inferiorly toward and into the neck, and the
Plastic and Reconstructive Surgery: Approaches and Techniques. ew ork, :
effectiveness of the SMAS flap will be significantly diminished iley; 2015:1004–1031
• The cervico-submental region of each patient must be care- 4 Marten T, Elyassnia D. ecklift. In: Scuderi , Toth BA, eds. International Textbook
fully examined both at rest and during platysma activation if of Aesthetic Surgery. ew ork, : Springer; 2016
complete assessment of platysma irregularities is to be made, 5 Marten T. Lamellar high SMAS face and mid-lift: Improved design of the SMAS
facelift for better results in the mid-face and infra-orbital region. In: ahai F, ed.
as secondary neck lift patients commonly have residual or
Aesthetic Plastic Surgery, 2nd ed. ew ork, : Thieme; 2011:1525–1620
untreated platysma problems. 6 Marten T . Facelift with SMAS flaps. In: Guyuron B, ed. Plastic Surgery: Indica-
• Examination of the cervico-submental region with and with- tions and Practice, 1st ed. Saunders; 2008:1445–1472
out platysmal activation allows one to distinguish whether [7] Marten T . High SMAS facelift: combined single flap lifting of the jawline, cheek,
and midface. Clin Plast Surg 2008;35(4):569–603, vi–vii
platysma bands are “hard” dynamic or “soft” adynamic
[8] Secondary facelift. In: Mathes S, ed. Plastic Surgery. Saunders; 2005
bands. Soft, adynamic bands change little during platysma
[9] Marten T . Facelift. Planning and technique. Clin Plast Surg 1997;24(2):269–308
activation and are predominantly a problem of loose skin or
horizontal platysmal laxity. Hard, dynamic bands become
tight or exaggerated upon platysma activation and indicate
a problem of longitudinal platysmal hyperfunction
• It is important to distinguish between “soft,” adynamic plays-
mal bands and “hard,” dynamic bands in both primary and
secondary neck lift patients, as treatment will vary depending
on the type present. Patients with soft bands are usually ade-
quately treated with skin excision and platysmaplasty alone.
Patients with “hard” bands, however, require transverse
platysma myotomy or some other procedure that disrupts
longitudinal platysma muscle hyperfunction and prevents
the muscle from contracting upon itself
• The key to success in treating hard, dynamic bands is to
acknowledge that they are the product of longitudinal pla-
tysma muscle hyperfunction, not one of horizontal platysma
laxity. Pulling medially or laterally on the platysma muscle
borders as commonly advocated does not address the origin
of dynamic platysma bands, and is not a logical or effective
treatment of them
• Patients with prior thermal damage to their platysma as
a result of radiofrequency or ultrasound “skin-shrinking”
treatments (or application of other forms of energy to the
subcutaneous neck and face) are often refractory to standard
treatment by platysmaplasty and platysmamyotomy but
can be significantly improved by partial platysma myectomy
(excising part of the platysma muscle).

816

54 Reoperative Rhytidectomy
James C. Grotting, Nirav B. Patel, and William J. Vinyard
Abstract
Reoperative or secondary rhytidectomy presents unique
challenges to the plastic surgeon. A request for it may be moti-
vated by continued facial aging, a desire for further refinements,
unhappiness with results, or past complications.
Systematic facial analysis is critical in prioritizing goals,
enabling a more manageable operative plan, and maximizing
postoperative satisfaction. Important factors to note during physi-
cal examination include skin quality, laxity, and extent of rhytids;
deflation and descent of soft tissues; change in bony morphology
and dentition; and hypertrophy or ptosis of deep structures of the
neck. Surgeons must be aware of potential anatomic differences
between reoperative and primary facelift surgery. Skin quality,
facial volume and shape, and neck contour may all be improved.
Reoperation may be indicated to correct poor results from early
primary facelift, including conspicuous scars, hairline distortions,
and earlobe malposition. More serious complications such as
hematoma, skin necrosis, and nerve injury can result in emotional
disturbances and can be addressed during reoperative rhytidec-
tomy. One must be judicious with any approach and know when
to decline a patient to avoid an overoperated appearance. As with
any reoperative patient, one should not neglect body dysmorphic
disorder.
Secondary facelift options broadly include liposculpturing,
superficial musculoaponeurotic system (SMAS) manipulation, and
neck contour correction with deep cervicoplasty. Adjuncts that
help maintain a primary rhytidectomy result without resorting to
reoperation can similarly supplement a secondary rhytidectomy.
Staging interventions can be considered to help manage expecta-
tions while minimizing variables one is attempting to control in a
single operation.
Keywords
secondary facelift, rhytidectomy, SMAS elevation, facial rejuve-
nation, facelift complications
54.1 Introduction
Plastic surgeons today are seeing ever-increasing numbers of
patients returning to the practice, or presenting initially, with
requests for facial rejuvenation after previous facial procedures.
Primary facelift patients’ concerns are typically generalized,
whereas concerns of reoperative aesthetic patients vary but tend
to be very specific. A secondary facelift patient will often return
and have common complaints such as My creases nasolabial
folds are back, My neck is loose again, or My kids ask me what
I’m mad about when I’m not mad at all. Reoperative aesthetic
patients are unique in that they can already anticipate what to
expect. They would not have returned to a surgeon if they were
not prepared to have a correction. Generally, they will not be
54 Reoperative Rhytidectomy
dissuaded by financial issues or by anxiety over postoperative
pain or general anesthesia.
Every facial rejuvenation patient inquires about the longevity
of the surgical results. Although it is impossible to answer this
question with precise accuracy, plastic surgeons know that facelift
results do not last forever. Patients must understand that surgery
will turn back the clock, but also that the inexorable march of time
will continue. ith a well-done facelift, patients will always look
better than if they had not undergone the operation. Having a
facelift is a monumental decision for most patients. Nevertheless,
having a second or third procedure is becoming much more
common, especially as cultural norms and stigmas against facial
plastic surgery have softened.
Anticipatory guidance is key. Educating patients about the
possible need to shore things up at a future time helps to keep
patients within a practice and helps to grow one’s experience
with secondary procedures. If the patient’s tissues have lost all
elasticity and the subcutaneous fatty layer is full, the chances of
requiring an early secondary correction are high.
Generally, there are five categories of patients who require reop-
eration. The first category includes patients seeking adjunctive
procedures to improve or enhance previous results. These adjunc-
tive procedures may not require traditional lifting procedures; the
patient may only require less invasive procedures to rejuvenate
the face. The second category consists of those requesting reop-
eration for continued facial aging. ithin this group of patients,
only a tuck-up procedure may be required. The third category
includes patients for whom the surgeon had already planned a
staged approach. There are two subsets to this category: the first
consists of younger patients who require only minimal proce-
dures, such as lipocontouring of the jowls or submental areas, and
who subsequently undergo more traditional lifting procedures as
they age. The other group comprises some of the most difficult
patients to provide satisfactory results for in one procedure. These
patients tend to be older, with doughy, inelastic skin, fatty facial
tissue, and severe neck laxity that extends below the thyroid
cartilage and into the sternal notch. They usually require early
postoperative tightening procedures in the neck, even as early
as 1 year. e find it best to counsel these patients preoperatively
about their risk of early recurrence. The fourth category includes
patients with complications following primary facelifting. The
fifth category includes those who have not had any complications
but who are dissatisfied with the results they obtained from their
primary facial rejuvenation procedure. Often these patients have
undergone a minimal-scar approach to elevate the skin, but the
consequence is inadequate longevity of their rejuvenation. Some
of these approaches have been heavily promoted and marketed as
low downtime or as a mini-lift through extensive commercial
business enterprises, but as unsatisfactory long-term results have
become apparent, they have since begun to fall out of favor.
How is reoperative facial surgery different Frequently, there
are asymmetries created by the previous operation that need
817
 VIII Surgical Rejuvenation of the Face and Neck
to be addressed. The anatomy is different, in part, due to scar
tissue formation and fibrotic adhesions from previously dissected
planes. It is very easy to get into the wrong plane and damage the
facial nerve, which itself can take an unexpected course. This is
especially true in a thin patient who has had multiple previous
procedures. In addition, changes in blood supply may dictate a
novel approach. In one way, the previously undermined skin flap
can be considered a delayed flap, which is safe to re-elevate, but
in other situations it can be quite tenuous, especially in smokers.
In this chapter, we will discuss how to maintain results of suc-
cessful facial rejuvenation, reasons patients request reoperative
facial rejuvenation, aesthetic evaluation for and anatomic differ-
ences that must be considered in secondary rhytidectomy, sec-
ondary facelift options and ancillary treatment of facial subunits,
and management of complications seen in primary rhytidectomy.
54.2 How to Maintain Results
54.2.1 “How Long Will My Facelift Last,
Doctor?”
Most patients want to know the answer to this question during
their initial consultation. Patients who have already undergone
a primary rhytidectomy have a better understanding of what to
expect. It is impossible to accurately predict the longevity of this
procedure for any given patient because of individual differences
in age, skin laxity, actinic damage, genetics, previous procedures,
and many other factors. However, a survey of our postoperative
facelift patients using the FACE- demonstrated that they reported
looking an average of 8.4 years younger than their actual age.
ith experience, we have learned that the final result and
longevity are influenced by the types of procedures performed as
well as the quality of the tissues. Facial rejuvenation has evolved
from merely a skin excision procedure to include manipulation
of deep structures, treatment of facial aesthetic subunits, and
adjuvant procedures, such as chemical peels, laser resurfacing,
dermabrasion, muscle modulation with neurotoxin, and volume
restoration with soft tissue fillers, implant augmentation, and/or
autologous fat injections. ith these various combinations, the
procedures can be tailored to the individual’s desires and goals so
as to obtain the best results and to improve longevity.
54.2.2 Volume Manipulation
i ing i n uring
As facial rejuvenation has evolved, we have learned that the
face should be analyzed and treated as a three-dimensional (3D)
structure. e must correct not only the skin and deep tissue
laxity but also the volumetric changes seen with aging. ith
aging, facial fat begins to descend and involute, deepening
nasolabial folds, labiomental folds, tear troughs, and lid–cheek
junctions. Fat atrophy creates the supraorbital and temporal hol-
lows, tear trough deformities, skeletonization of the zygomatic
arches, and submalar depressions. Fat can also accumulate,
creating stigmata of facial aging such as jowling. After rhytidec-
tomy alone, these areas either are unimproved or develop early
recurrence of the deformities. These volumetric facial changes
818
create shadows at these anatomic transitions, like that created in
a valley between two mountains. To minimize this shadowing,
one needs to fill the troughs or decrease the size of the promi-
nences, or some combination thereof.
The combination of facial rejuvenation lifting techniques with
autologous fat injection and liposuction has significantly advanced
the field of facial rejuvenation by facilitating correction of the
volumetric changes seen with aging. Liposuction can remove the
fat in areas of excess, while fat injection can add the fat needed in
areas of deficiency.
e prefer the use of ultrasound-assisted liposuction (UAL) to
remove jowl fat slowly and precisely in patients with lipodystro-
phy in this area when the excess of fat continues throughout the
whole neck. The key to making this work is to have an aesthetic
eye and not reduce too much fat nor remove fat that will be used to
fill the cheek area. In the neck and submental area, one must also
be cognizant of the expected superior repositioning of soft tissues
with superficial musculoaponeurotic system (SMAS) manipula-
tion techniques and avoid any jawline contour distortions.
Despite limited quantitative evidence of fat survivability, its
benefits have been demonstrated in clinical experience. Fat graft-
ing has influenced longevity of facelifting by creating softness and
aesthetic contours, particularly in the periorbital and perioral
areas. Before repositioning of the malar fat pad and SMAS in a
rhytidectomy, we carefully harvest fat and lipo-fill the areas of
facial fat atrophy. The donor site chosen for fat harvest depends
on the patient’s preference and on adequate adipose stores. e
most commonly use the lower abdomen and, to a lesser extent,
the medial thighs or anterior hip rolls. The combination of reposi-
tioning the malar fat pad with deep tissue support and replacing
lost fat and/or removal of excess fat has significantly improved the
lasting results of facial rejuvenation. These techniques can be used
in a secondary rhytidectomy to help improve contour irregulari-
ties caused by previous facial procedures.
Soft Tissue Fillers
Soft tissue fillers can also be employed to restore facial volume
for temporary nonsurgical treatment of facial aging. Many
products have been used for soft tissue filling, but hyaluronic
acid (HA) products are among the most commonly used. HA
fillers differ based on the degree of cross-linking present and
their particle sizes. In general, the larger the particle size and
the more cross-linking present, the longer the results tend to
last. The soft tissue fillers differ in the material that is injected
and their longevity. They can be used for facial sculpting and are
most frequently used for temporary improvement of prominent
nasolabial and labiomental folds, lip augmentation, and tear
trough deformities to maintain or augment results after primary
or reoperative rhytidectomy.
54.2.3 Improvement of Skin Texture
and Rhytids
Dermabrasion
In dermabrasion, with the use of a small handheld electrically
powered instrument and an abrasive substance, such as a wire
brush or diamond fraise, the epidermis and a portion of the

superficial dermis are removed. The dermal appendages allow
reepithelialization to occur over approximately 7 days, thus
improving the skin’s surface texture. Dermabrasion can be used
to improve acne scars and deep, coarse perioral rhytides (Fig.
54.1). For reepithelialization to occur, the facial pilosebaceous
glands must be present. This technique should not be used on
areas with a paucity of pilosebaceous glands, due to the risk of
abnormal scar formation, and never around the eyelids.
Laser Resurfacing
hen used judiciously, laser skin resurfacing can be performed
simultaneously with rhytidectomy to provide safe and effica-
cious results. Deep tissue penetration, however, should not be
used over the undermined skin of the lateral cheeks, since these
areas are most at risk for healing problems due to decreased
blood supply of the skin flap. It is our preference to use an
erbium:yttrium-aluminum-garnet (Er: AG) superficial laser
peel (MicroLaserPeel, Sciton, Palo Alto, CA) on the central
portion of the face to ablate up to 20 to 30 micrometers of
epidermis to treat superficial skin irregularities, mild rhytids,
and dyschromias. A fractional laser technique (ProFractional,
Sciton, Palo Alto, CA) is then used to create microholes at varying
depths up to 500 micrometers, customized to the patient’s skin
thickness and texture. Reaching the reticular dermis with this
technique, collagen remodeling is stimulated in the basal layer of
the dermis to treat moderate to severe rhytids, enlarged pores,
acne scars, and significantly sun-damaged skin. Deep traditional
resurfacing with ablative with or without coagulation can be
used to improve vertical “barcode” rhytides around the lips that
are not corrected with a rhytidectomy (Fig. 54.2). Similarly,
periorbital laser resurfacing can be used to tighten loose skin
around the eyes in patients who have previously undergone a
blepharoplasty or in those with minimal skin redundancy. In
order to ensure adequate re-epithelialization, fractional laser
technique may be combined with a superficial laser peel but not
with deep resurfacing.
Chemical Peels
A chemical peel can help improve actinic skin changes, either
simultaneously with secondary facelift or 3 to 6 months later
once the patient has healed from surgery. The epidermis and
varying degrees of dermis are removed through chemically
induced injury. A neocollagen-rich layer replaces the dermis and
reepithelialization occurs. As discussed in more detail elsewhere
Fig. 54.1 (a) This case illustrates the power of dermabrasion in
correcting deep perioral rhytides when used in conjunction with
reoperative rhytidectomy, (b) with substantial improvement shown at
long-term follow-up.
54 Reoperative Rhytidectomy
in this book, different peels are available, including croton oil
peels, trichloroacetic acid (TCA) peels, and glycolic acid peels. The
depth of the peel is determined by the type and concentration of
the chemicals used. e prefer to use croton oil for patients who
have very deep perioral rhytids (Fig. 54.3).
mu i ed n r derm Gr ing
Fat grafting has become an essential tool in restoring facial
volume to achieve a rejuvenated youthful facial contour and
appearance. Autologous macro and micro fat grafting involve
fat harvest and processing to preserve adipocyte integrity so
as to restore volume when injected in deep and subcutaneous
planes and specific fat compartments. Recent advances in autol-
ogous tissue transfer have resulted in the advent of nanofat
or fractionated fat, whereby harvested fat is passed through
filters until emulsified, resulting in a dilute consistency that
can be injected in the intradermal plane. Adipocyte integrity is
nearly fully disrupted during the filtration process; therefore,
volume augmentation is not achieved with injection of nanofat.
Emulsified fat, however, has been shown to contain a large
quantity of adipocyte stem cells in the stromal vascular fraction.
hile the technique is new and data are sparse, clinical reports
demonstrate improvements in skin quality, texture, and pigmen-
tation with intradermal injection of emulsified fat. In reoperative
facelifting, nanofat grafts can be precisely injected into rhytids
and traumatic or acne scars to diminish their appearance and
are particularly effective in the perioral region. Given the liquid
consistency of the fat, nanofat grafts can also be placed in the
delicate plane between the thin eyelid skin and underlying
orbicularis oculi muscle to help with dark pigmentation as well
as to blend the lid-cheek junction. anofat grafting can be com-
bined with other methods of skin rejuvenation and remodeling,
including ablative and nonablative lasers and chemical peels for
enhanced skin remodeling and rejuvenative effects.
Radiofrequency Energy–Based Skin Tightening
Radiofrequency (RF) energy devices have emerged as a way
of achieving thermal-induced collagen remodeling and skin
tightening without injuring the epidermal–dermal barrier.
oninvasive RF devices (e.g., Morpheus8, InMode, Lake Forest,
CA) transmit thermal energy through the epidermis to the
dermis or subcutaneous space without skin ablation. The resul-
tant thermal-induced microinflammatory processes promote
Fig. 54.2 (a) This patient benefited from erbium:yttrium-aluminum-
garnet (Er: AG) laser resurfacing to the perioral area, with (b) clear
improvement in skin texturing and barcode lines to supplement facial
rejuvenation results obtained from fat grafting and rhytidectomy.
819
 VIII Surgical Rejuvenation of the Face and Neck

neocollagenesis and production of elastin and ground substance with minimally invasive RF devices (e.g., FaceTite or BodyTite,
production. As a result, progressive significant skin tightening InMode, Lake Forest, CA), which deliver energy through an
effects occur over the ensuing 6 to 12 months. Even greater skin internal probe electrode. The internal probe electrode delivers
tightening and subcutaneous adipose contouring can be achieved directed intense thermal energy to the surrounding subdermal or

Fi

op Ro

nd ro

rd Ro

otto Ro

d
Fig. 54.3 This patient represents a comprehensive facial rejuvenation and maintenance over a span of more than 10 years. (a) Preoperative appear-
ance (b) One year after primary short scar facelift, closed neck treatment, fat grafting, and Erbium Laser resurfacing. (c) Preop secondary facelift
having had a second erbium laser, additional fat grafting, and a croton oil peel at various intervals in the interim. Her complaint at this time is her
neck. (d) One year after secondary facelift, deep cervicoplasty, and additional fat grafting.

820

subcutaneous space. In addition to dermal changes, the internal
energy delivery achieves coagulative tightening of septofascial
cutaneous fibers. oninvasive and minimally invasive RF devices
can be used in combination for even greater tissue tightening as
well as with traditional liposuction techniques for simultaneous
tissue debulking.
RF skin tightening can be used everywhere on the body. In
the patient who has previously undergone rhytidectomy, the
technology can be used for upkeep of the results and/or to offer
additional skin tightening to patients who are unwilling or unable
to undergo additional face- or neck lift surgery.
Neurotoxin
Often, patients who have previously undergone facial rejuvena-
tion have persistence or recurrence of lines and furrows that will
not be responsive to additional surgery. Botulinum neurotoxin is
produced by Clostridium botulinum bacteria and causes muscle
paralysis by inhibiting release of acetylcholine at the presynaptic
cholinergic neuromuscular end plates. eurotoxin injections are
versatile and treat the following: glabellar furrows, formed by
the contraction of the corrugator supercilii and procerus mus-
cles; horizontal forehead rhytides, formed by the contraction of
the frontalis muscles; periocular crow’s-feet rhytides, formed
by the contraction of the orbicularis oculi muscles; marionette
lines, accentuated by the contraction of the depressor anguli
oris (DAO) muscles; and vertical lip rhytides, created by the
orbicularis oris muscles. In addition, with appropriate neuro-
toxin placement, eyebrow shape and position can be changed
to improve aesthetics, particularly for women striving for a
feminine arch to their eyebrows. It is also effective for patients
who complain of dimpling and irregularity of the chin.
Skin Care
Maintaining good skin health helps improve the appearance and
longevity of the surgical results. There is a plethora of available
skin care products today, but the first step to good skin care is
minimizing sun exposure. Genetic factors that contribute to skin
aging cannot be altered through behavioral changes, but effects
of sun exposure can. e recommend that all patients be consis-
tent with sunscreen use and sun exposure protection.
54.3 Indications for Reoperative
Rhytidectomy
It is a hasty mistake to conclude that every patient must have
fi f f , f fi
be lacking your skill. Patients may have sought you because
your reputation is that of a judicious surgeon who does not
immediately want to do another facelift on everyone. ou now
have multiple approaches available, so the first rule is: Listen to
your patient! Ask: hat is it about your face that is beginning
to bother you and ere these features improved after your
first facelift Starting with questions such as these will assist
you in tailoring valuable consultation time toward the patient’s
primary concerns rather than discussing distracting options to
which the patient will simply not be amenable. The consultation
also provides the surgeon with an opportunity to help educate
54 Reoperative Rhytidectomy
the patient about procedures or treatments that will give lasting
improvement, rather than treatment options about which the
patient may have incomplete knowledge but for which he or she
is not a suitable candidate. For instance, botulinum toxin and
soft tissue fillers are simply not going to produce a facelift result,
but patients can often be confused about this issue. In some
situations, injectables are the only interventions certain patients
will consider, especially if they had a difficult recovery from their
first facelift.
In recent years, much more attention has been paid to com-
plementing facial rejuvenation procedures with volumetric facial
shaping, midface repositioning, and rejuvenation of facial aes-
thetic subunits (eyes, nose, mouth, and ears) issues that might
not have been addressed during the patient’s primary facelift.
Volume preservation or enhancement, using fillers or autologous
fat grafting, are now more commonly accepted approaches to
restoring a youthful contour to the face. Continued radial expan-
sion of the midface and aging of aesthetic subunits, particularly
in the central face, are common complaints that bring reoperative
patients back to the office. Ancillary treatments to rejuvenate
the aesthetic subunits can add to the longevity of the secondary
rejuvenation procedure. If assessment reveals an aged midface
appearance, this finding will need to be addressed during surgery.
If the initial surgery was done by someone else, it may be impos-
sible to determine the exact technique and what maneuvers were
performed. Of course, if the patient returns to the surgeon who
performed the initial procedure, access to the original records will
be readily available.
54.3.1 Continued Signs of Aging
The inevitable signs of aging can be mitigated but not halted.
Continued aging is the primary reason for secondary (or tertiary,
quaternary, and beyond) facelifts. A patient may have been
previously happy with the results of a primary rhytidectomy,
but as years pass, facial aging continues. The patient’s genetics
and sun exposure influence the aging process. Frequently, skin
quality has either further deteriorated or had never been treated
in a secondary rhytidectomy patient. Skin quality may be the
primary source of concern for the patient, and therefore less
invasive options, including skin resurfacing, soft tissue filling, or
appropriate skin care can be utilized.
As we later discuss, the appearance of the face as it ages is
different in patients who have already had facial rejuvenation
surgery. Therefore, one’s approach to correcting facial aging is
different in primary than in secondary rhytidectomy patients. It
is helpful if the surgeon knows exactly what was done initially.
In the case shown in Fig. 54.4, the patient’s facelift had been
performed in the subperiosteal plane; therefore, in the secondary
facelift, a formal SMAS elevation was used to achieve the desired
result while remaining in a scar-free surgical plane.
54.3.2 Adjunctive Procedures to Enhance
Previous Results
During the consultation for repeat rhytidectomy, the patient
must be carefully assessed to determine features of aging that
were either purposely or neglectfully not addressed during
the initial procedure. A patient’s previous rhytidectomy may
821
 VIII Surgical Rejuvenation of the Face and Neck

not have included treatment of midface descent, which has

influenced that patient’s decision for a secondary rhytidectomy.
Patients may want to add skin treatments with laser resurfacing,
lipocontouring, autologous fat injections, and periocular or peri-
oral procedures to enhance previous results (Fig. 54.5). The neck
may have been treated with liposuction and skin redraping pre-
viously, but the platysma and deeper structures of the neck may
not have been addressed. Failure to contour jowl fat adequately
initially may lead to the need for secondary lipocontouring and
SMAS re-elevation.

54.3.3 Planned Staged Intervention

As aesthetic procedures become more socially acceptable,
patients are beginning to have facial rejuvenation procedures
at earlier ages. Many start with less invasive procedures, such
as neurotoxin injections for improvement of dynamic rhytides,
soft tissue fillers for static rhytides, and laser resurfacing for fine
rhytides. At the early stage in facial aging, less aggressive surgical
procedures, such as lipocontouring or lipofilling, are required to
satisfy patient expectations. These patients are typically coun-
seled about the continued aging process and will likely request
additional procedures years later.
One should also anticipate employing a staged approach for
patients who are typically difficult to achieve excellent results in
a single stage, or in those with tissues prone to early recurrent
laxity. These patients can be identified by poor skin quality and/
or heaviness of their tissues. They should be counseled regarding
the staged procedure so that the surgeon can achieve results that
both parties can reasonably anticipate. e commonly counsel
patients with severe neck laxity that a revision neck lift may be Fig. 54.4 (a,b) This 58-year-old woman had undergone a subperiosteal
facelift and open brow lift 14 years earlier. She similarly presented for
needed as early as 1 year postoperatively (Fig. 54.6). However, our secondary facial rejuvenation. (c,d) She is shown 1 year after undergo-
understanding of effects of aging on superficial and deep struc- ing a secondary facelift with extended superficial musculoaponeurotic
tures of the neck continues to evolve, and newer techniques have system (SMAS) dissection and endoscopic browlift.
been developed to give more reliable and longer-lasting results.
Deeper structures of the neck, including hypertrophic subplatys-
mal fat, enlarged and ptotic submandibular glands (SMGs), and
divergent digastric muscles, must be recognized and corrected to 54.4 Aesthetic Evaluation for
yield desirable and long-lasting results. Adjunctive measures to
eliminate dead space in the neck and redrape and stabilize the
Reoperative Rhytidectomy
cervical skin are useful in decreasing complications and enhanc- Patients typically present for secondary rhytidectomy, on average,
ing longevity of results (Fig. 54.7). 8 to 12 years following primary rhytidectomy. During this long
interval, morphologic and histologic changes associated with
aging continue to affect the facial skin, soft tissue, and underlying
54.3.4 Dissatisfaction with skeletal framework. Patient evaluation, therefore, must begin
Previous Results with systematic analysis of the stigmata of facial aging. Repeated
tension on the skin, especially in a disadvantageous vector, will not
Even without any surgical complications, some patients are still
restore a youthful appearance. Instead, these types of maneuvers
dissatisfied with the results from their previous rhytidectomy. It
will yield an appearance that betrays repeated surgery and may be
is very important for the reoperative surgeon to spend adequate
exceedingly difficult to correct. A laterally swept cheek and jaw-
time with these patients, both to understand clearly what their
line, but uncorrected midface, is a classic example of this problem.
expectations are and to have a detailed discussion with them
The aesthetic evaluation for a secondary rhytidectomy is
about what results can be reasonably achieved. Patients may not
similar in many ways to that for primary rhytidectomy, but there
have discussed their dissatisfaction with their previous surgeon
are certain physical examination characteristics that can differ.
when they seek correction. In these situations, it is important to
Following a rhytidectomy, some areas of the face retain tightened
obtain the patients’ records from their previous surgeons if at
support, especially laterally, whereas other areas, such as the
all possible. e favor a courtesy telephone call to the previous
midface, continue to descend. Telltale stigmata of a prior rhyt-
surgeon. ou will often learn some things that may influence
idectomy may be present and may include facial asymmetries,
your decision making for the current operative plan.
cross-cheek depressions, earlobe and tragal deformities, hairline

822
 54 Reoperative Rhytidectomy

b
Fig. 54.5 (a) This 68-year-old woman had undergone a primary facelift 8 years earlier, as well as skin resurfacing with trichloroacetic acid peel and
laser on other occasions. She felt that she had lost the rejuvenating glow of her primary facelift. Patients such as this want to maintain a certain look
and are excellent candidates for secondary facelifting. (b) She is shown healing well 6 months after undergoing a secondary full-scar facelift with a
superficial musculoaponeurotic system plication, fat grafting, and genioplasty.

a b

c d e f
Fig. 54.6 (a,c,e) This 60-year-old woman had undergone a primary rhytidectomy 4 years earlier and was concerned about recurrent neck laxity and
skin excess. (b,d,f) She is seen 2 years after an isolated neck lift.

823
 VIII Surgical Rejuvenation of the Face and Neck
and sideburn distortions, and scar visibility. One should recognize
these changes so that an appropriate and effective treatment plan
can be formulated.
Factors to Consider in Secondary Facial
Rejuvenation
• Skin: quality, texture, rhytids, and relaxation
• Soft tissues: fat atrophy and descent; depth of nasolabial,
labiomental, and nasojugal creasing; jowling
• Skeleton and dentition: loss of supportive framework and
volume
• Facial aesthetic subunits:
Periorbital region: brow ptosis, eyelid laxity, dermatocha-
lasis, and fat herniation
Midface: malar flattening
Perioral region: buccal fat pad pseudoherniation, increased
upper lip length, decreased lip volume, downturning oral
commissures
Jawline: loss of mandibular volume, chin atrophy and ptosis
Earlobe: ptosis and deflation
• Neck structures:
Skin laxity
Supraplatysmal and/or subplatysmal fat hypertrophy
Platysmal banding and laxity
Digastric muscle prominence and/or divergence
SMG hypertrophy and ptosis
• Stigmata of previous rhytidectomy: facial asymmetry, visi-
bility and quality of scars, hairline shifts or alopecia, earlobe
malposition or deformities, poor tragal definition, lateral
sweep or poor direction of rhytids
54.4.1 er inen An mi i eren e in
Reoperative Rhytidectomy
Skin and Scars
During the interval between primary and secondary rhytid-
ectomies, the patient’s skin continues to age and thin. There is
ongoing loss of dermal collagen, which causes increased skin
laxity and decreased ability to maintain support with tension.
The degree to which tissues lose support depends on anatomic
area. The preauricular area maintains a high degree of support,
evidenced by the lack of excess skin in this area removed in sec-
ondary rhytidectomy. Preauricular scars, however, can become
more noticeable with a small degree of migration.
The previously elevated skin flap functions as a delayed flap,
which provides better blood supply to the skin. It is less likely to
have cutaneous perfusion issues unless the patient is a smoker. In
such cases, it is important for patients to quit smoking for at least
4 weeks before surgery and for 4 weeks postoperatively. Although
skin perfusion is of less concern in a secondary rhytidectomy,
the previous elevation causes scar tissue to form. As a result, it
has lost some of its elasticity, so care must be taken not to place
too much tension on the skin closure. Importantly, one must be
cautious to ensure adequate perfusion to the area of skin between
the previous scar and the new.
824
Patients’ scars from previous procedures are important con-
siderations when planning reoperative surgery, including the
character of the scars. hile unusual, scars may have developed
into hypertrophic or keloid scars. Scar malposition is much more
common. Postauricular scars often migrate away from the sulcus
and may have been placed too low and in visible locations during
the initial surgery. Scars may be improved with a secondary
procedure, but the patients must be made aware that they may
recur or even worsen. The locations of the scars may limit the
surgeon’s ability to place the secondary procedure scars within
inconspicuous locations. Sometimes there simply is not enough
skin to move the scars into a more hidden position. One must not
make the error of initially incising into the most favorable scar
location only to find later when redraping the skin that one does
not have enough skin to cover the gap (Fig. 54.8).
Hairline
A prior temporal incision may have diminished or eliminated a
patient’s sideburns. If the distance between the lateral canthus
and the anterior portion of the patient’s sideburn is long, an ante-
rior hairline incision should be considered to prevent loss of the
patient’s sideburn. This incision is usually inconspicuous and much
less unattractive than sideburn loss. Our practice is to stay below
the sideburn whenever possible and to extend the incision as
necessary for adequate skin redraping in the lateral temporal area.
This approach is almost always required in secondary facelifting.
Subcutaneous Tissue
In secondary rhytidectomy patients, the subcutaneous tissue
under the previously undermined skin is atrophic. Additionally,
one must exercise extreme caution in secondary rhytidectomy,
as scars can obliterate tissue planes (Fig. 54.9). e recommend
that dissection proceed with the scalpel under direct vision until
tissue planes are sufficiently re-established.
Previous SMAS Elevation
It is important to determine from the patient’s records whether
the SMAS was elevated in the previous rhytidectomy. If not, a
secondary procedure provides a good opportunity to improve
the midface with tension on underlying structures. If the SMAS
has been previously elevated, the scar tissue between the SMAS
and underlying parotid fascia is much more difficult to separate.
Often, there is significant variability in SMAS quality in secondary
cases. Our general approach for treating the SMAS secondarily is
to preserve as much of the tissue as possible through plication
maneuvers rather than re-elevation or resection. However, one
should assess the SMAS’s mobility to determine whether plica-
tion alone will accomplish the desired improvement.
Facial Nerve Risk with Re-elevation of SMAS
hen the SMAS has been elevated previously, the facial nerve
is at a greater risk during dissection. In this scenario, it may be
safer and easier to plicate the SMAS in the areas that produce the
desired effect.
The patient in Fig. 54.10, for example, developed a marginal
mandibular neuropraxia following primary rhytidectomy with
 54 Reoperative Rhytidectomy

One Year Result Facelift and Deep Cervicoplasty

esult Facelift and Deep Cervicoplasty

i j
Fig. 54.7 (a,b,c) This 66-year-old woman had considerable loss of skin elasticity, with very loose cervical tissues and a rounded face. This type of
patient is a candidate for early secondary correction, even as early as 1 year after the primary procedure, because of the probable recurrence of
jowling and tissue laxity. Patients must be informed of this probability in advance to avoid dissatisfaction and unrealistic expectations. She first
underwent an extended superficial musculoaponeurotic system rhytidectomy. The patient developed a postoperative neck hematoma. Although
the hematoma was drained, she developed a fibrous mass in the central aspect of her neck that failed steroid injection therapy. (d) She subsequently
underwent direct mass excision 7 months after the initial procedure. The patient returned 1 year after her primary rhytidectomy with persistent
fullness in the jowls and requested surgical correction. She underwent liposuction of the jowls and was pleased with the early results. However, she
subsequently began to develop early descent of the malar fat pad, prominent nasolabial and labiomental folds, and early signs of neck laxity. (e,f)
Six months after her secondary rhytidectomy (18 months after the primary procedure), the patient was again pleased with the results; the recurrent
jowling and tissue laxity had been improved significantly. Critical appraisal of our traditional method of treating the heavy neck here demonstrates
a near “cobra-shaped” deformity due to persistent divergent digastric muscles and without treatment of prominent ptotic submandibular glands
(SMGs). (g,h) Our approach to patients with heavy necks has since evolved. (i,j) One-year results obtained in the patient shown in g and h. (k) We
routinely assess contribution of deep neck structures to the heavy neck, including supra- and subplatysmal fat hypertrophy, divergence with or
without prominence of anterior bellies of digastric muscles, and enlargement and ptosis of SMGs. Deep cervicoplasty with treatment of each of
the aforementioned contributing structures is undertaken. (l) A hemostatic net is then utilized to redistribute the skin in desired vector, close all
potential deadspaces, and prevent hematoma formation.

825
 VIII Surgical Rejuvenation of the Face and Neck
SMAS elevation. Once recovered 3 years later, she returned to
address early recurrent neck laxity and prominent facial folds. Due
to her prior nerve injury, we preferred to stay away from where
the marginal mandibular and cervical branches of the facial nerve
were most prone to injury. Therefore, a plication of the lateral
border of the platysma was preferred over deep neck dissection.
Use of Primary Facelift Suture Material
One recently described, novel technique for secondary facelift-
ing incorporates previously placed permanent suture from a
patient’s primary facelift. It was found in a series of secondary
facelifts that an anchoring suture to Lore’s fascia had descended
since these patients’ primary facelifts were performed, account-
ing for recurrent neck skin laxity. Re-elevation of the suture
successfully restored facial rejuvenation without resorting to a
more aggressive submental dissection.
54.4.2 Persistent Buccal Fat
Pseudoherniation
Following elevation of midface tissues with SMAS flap, plication,
or resection in a primary facelift procedure, buccal fat pads
may become visible and prominent, whereas before, they were
masked and seemingly continuous with descended superficial
cheek fat compartments. Clinically, the patient may present
with a marble-sized mass in the cheek, lateral to the nasolabial
folds, that is adipose in consistency. A distinguishing feature is
that with upward pressure, the fat pad can be reduced into the
buccal space, with slow recurrence as digital pressure is removed.
Pseudoherniation of the buccal fat pad is due to the weakening of
the overlying fascia. Buccal lipoplasty can be performed in isola-
tion or in conjunction with secondary facelift by conservatively
removing the buccal tail with or without the main body to achieve
midface contouring. Care is taken to be mindful of the anatomy of
the buccal fat pad and the traversing parotid duct and facial nerve
and vein. The buccal fat pad can be approached intraorally (Fig.
54.11) or from the facelift through an anterior SMAS incision.
Fig. 54.8 The surgeon should try to place the final scar in an ideal
location; however, the surgeon should also not commit to the final
location until after the skin flap has been re-elevated and the amount
of excess skin determined. In many cases, there may be much less skin
to excise.
826
54.4.3 Inadequate Correction
of Hypertrophic or
Ptotic Deep Neck Structures
A common complaint following primary rhytidectomy, with
or without a neck lift, is residual fullness in the submental
and suprahyoid neck region. The neck volume is in a large part
accounted for by structures deep to the platysma, including the
subplatysmal fat and the SMGs, which respectively contribute,
on average, 30.7 and 24.5 to the neck fat volume (Fig. 54.7k).
As such, while some contouring of the neck can be achieved with
supraplatysmal fat removal (directly or through liposuction),
platysmaplasty, and neck skin redraping, neck fullness can still
persist due to hypertrophic deep neck structures (Fig. 54.12).
Large pockets of subplatysmal fat can present and herniate cen-
trally through the decussation between separated anterior bellies
of the digastric muscles. hile closed methods of liposuction of
subplatysmal fat have been safely and successfully described, we
prefer direct fat excision through a submental incision, which
allows for adequate visualization of the excess fat below the pla-
tysma and an opportunity to address additional concerns.
ith age, the SMGs can also undergo hypertrophy and/or
ptosis, resulting in blunting of the mandibular angle laterally and
loss of superior definition of the sternocleidomastoid muscles. In
patients with significant supra- or subplatysmal adipose excess,
this fullness can be masked, whereas in thinner patients, enlarged
and hanging SMGs can be distinctly visualized through the skin.
hile some surgeons propose correction of ptotic glands with a
hammock-like suspension, we feel that relying on weakened and
lax connective tissues for repositioning alone is insufficient and
cause for revisional surgery. Partial resection of SMG is advocated
in cases where the gland lies beyond the mandibular border,
typically inferolaterally. The SMG can be approached safely from
medially through a submental incision or alternatively from
laterally through the rhytidectomy incision. An intracapsular
dissection and excision will minimize risk of injury to the facial
vessels and marginal mandibular nerve, which lie posterolateral
to the gland in the extracapsular space. Adequate cauterization
Fig. 54.9 The surgeon can be faced with an inability to dissect distinct
layers, combined with atrophic subcutaneous tissue, as in this patient,
who had undergone three previous rhytidectomy procedures.

a b
c d
Fig. 54.10 (a–d) This patient developed a marginal mandibular
neuropraxia following primary rhytidectomy with superficial muscu-
loaponeurotic system (SMAS) elevation. Once recovered 3 years later,
she returned to address early recurrent neck laxity and prominent
facial folds. Due to her prior nerve injury, we preferred to stay away
from where the marginal mandibular and cervical branches of the facial
nerve are most prone to injury. Therefore, a plication of the lateral
border of the platysma was preferred over deep neck dissection.
of the raw gland surface and capsular closure minimizes any
postoperative hematoma and/or sialoma collection. Prophylactic
use of intraglandular botulinum toxin injection intraoperatively
may be considered but is not typical in our practice.
54.4.4 Failure of Skin Redistribution
and Contouring
In the event of hematoma or fluid collection, loss of skin contact
to underlying tissues and induration can compromise rhytid-
ectomy results. Even in the absence of such complications the
desired facial and neck contour can often be achieved intraoper-
atively, but the results may seem semipermanent and be lost as
the patient progresses through the stages of edema and healing.
A relatively novel concept, introduced by Andr Auersvald as
the “hemostatic net,” is the use of transcutaneous temporary
a b
Fig. 54.11 (a,b,c) Intraoral excision of pseudoherniating buccal fat pads.
54 Reoperative Rhytidectomy
sutures in all areas of skin undermining in the face and neck
following facelift and/or necklift. The sutures traverse from the
skin to the underlying SMAS and/or platysma, minimizing dead
space and eliminating any potential space for fluid or hematoma
to collect. More important, the net helps redistribute skin and
hold the redraped position and contour as early tissue healing and
adhesion take place, leading to long-term stability of results. This
technique is particularly useful in challenging cases of significant
lower neck laxity and redundancy by allowing the skin to be
advanced superiorly and contoured to define the cervicomental
angle and mandibular border. By removing the sutures in 48
hours, undesirable scarring is avoided.
54.5 Surgical Options for
Reoperative Rhytidectomy
Determining which procedure is best for a patient depends on
multiple variables. A good understanding of the patient’s goals
will help narrow options. Once this is done, determining what
techniques the previous surgeon used will help establish limita-
tions and potential reoperative risks.
Secondary Facelift Options
• Facial shaping and volume restoration with autologous fat
injection
• Facial lipocontouring with liposuction
• Threads/suspension suture technique
• Endoscopic approach to the midface
• Tuck-up procedure/mini-facelift
• SMAS procedures (complete, extended, or plication)
• “Closed” facelift with skin redistribution and hemostatic net
technique
• Isolated neck lift
• Ancillary procedures for periorbital (brow lift, blepharoplasty)
and/or perioral rejuvenation (lip augmentation, lip lift, DAO
weakening)
c
827
 VIII Surgical Rejuvenation of the Face and Neck

54.5.1 Author’s Preferred Approach to

Secondary Rhytidectomy
The senior author has developed a simplified approach to the
primary and reoperative facelift using a rotation-advancement
SMAS plication approach with the Delta technique. The neck
is carefully assessed, and an algorithmic approach is utilized to
address superficial and/or deep structures as needed.

Delta Facelift
Intraoperative markings before the plication can be seen. The
junction of the fixed and mobile SMAS has been demonstrated as
it transitions to the platysma more caudally. In this case, a platys-
mal window has been created prior to platysmal transection. A
triangular configuration, or Delta, design of the SMAS has been
marked with methylene blue, with a horizontal limb spanning
just anterior to the tragus, along the zygomatic arch, and ending
at the malar adipose mound. The hypotenuse of this triangle
follows the fixed–mobile SMAS junction caudally to 4 to 5 cm
below the mandibular angle, so as to minimize risk for injury to
the marginal mandibular branch of the facial nerve. The vertical
limb is marked, thus completing the Delta markings. At the
superomedial apex of the Delta, the malar fat pad is first secured
to the underlying periosteum and in turn to the overlying SMAS
using a figure-of-eight 2–0 polyglycolic acid (Vicryl; Ethicon,
Somerville, ) suture soaked in povidone–iodine (Betadine,
Avrio Health, Stamford, CT). Improvement in malar projection is
achieved immediately.
Suturing continues in this manner to plicate the hypotenuse of
the Delta toward the horizontal limb until tension becomes appar-
ent, at which point attention is redirected toward the platysma.

Neck Lift
The neck is carefully assessed for tissue hypertrophy, ptosis, and
laxity. The tissues are approached algorithmically depending
on the plane relative to the platysma. Supraplatysmal fat excess
and skin laxity can typically be corrected without a submental
incision. Conversely, correction of tissues deep to the platysma,
including the subplatysmal fat, SMGs, and anterior bellies of
the digastric muscles, may necessitate an open neck approach
through a submental incision.
Supraplatysmal Fat Liposuction
Supraplatysmal fat excess can be palpated and isolated by asking
the patient to contract the platysmal muscles. Cases of mild to
moderate fat excess isolated to the supraplatysmal space can
be treated with liposuction and/or direct fat excision from the
rhytidectomy incision. Care must be taken to avoid completely
denuding the subcutaneous layer and to maintain at least a
5-mm skin flap thickness to avoid irregularities and skeletoniza-
tion of the neck. Addition of subdermal energy through either
ultrasound-assisted liposuction or bipolar RF thermal energy,
can be utilized to achieve additional skin tightening and remod-
eling effects.
Fig. 54.12 (a) This patient, with significant sun damage and aging
changes in skin quality and facial morphology, presented for overall
facial rejuvenation. She underwent a facelift with autologous fat
transfer for volume restoration, delta superficial musculoaponeurotic
system (SMAS) plication, complete platysmal transection, and lateral
platysmaplasty. To achieve comprehensive facial rejuvenation, adjunc-
tive procedures, including bilateral upper and lower blepharoplasty
with ptosis correction, open rhinoplasty, bilateral earlobe reduction,
and erbium laser skin resurfacing, were also performed. (b) At 9
months postoperatively, she had insufficient correction of her neck
with ptotic deep neck structures including bilateral submandibular
glands as well as poor skin redraping in the cervicomental angle. (c)
One year following her initial surgery, she underwent revision necklift
through a submental approach with deep cervicoplasty, including
supraplatysmal and subplatysmal fat resection, bilateral excision of
ptotic submandibular glands, tangential debulking and plication of
hypertrophic and divergent anterior bellies of digastric muscles, hyoid
suspension, and medial platysmaplasty. No additional skin was excised;
rather, a hemostatic net was used to ensure proper redraping of the
skin against the defined cervicomental angle during the immediate
postoperative period and removed 48 hours later. At the same time,
she was also treated with a gliding brow lift and hemostatic net for
elevation of lateral eyebrows and second treatment of erbium laser
skin resurfacing. Results of the secondary procedure are shown 3
months postoperatively.

828

Platysmal Transection and Lateral Platysmaplasty
e routinely treat the platysma through complete transection
and lateral platysmaplasty. A platysmal window is created by
scissor dissection. Insertion of a blunt instrument in this case,
a ankauer suction tip enables safe platysmal transection by
electrocautery. The medial and lateral cut edges of the platysma
are secured with figure-of-eight 2–0 Vicryl sutures to the
sternocleidomastoid fascia and to Lore’s fascia, respectively.
The Delta plication is then completed with 2–0 Vicryl sutures
before smoothening the plication with a running, looped 4–0
barbed ( uill; Surgical Specialties, estwood, MA) suture, pro-
ceeding from inferolaterally to superomedially. In cases of large
platysmal midline decussation and banding, additional midline
platysmaplasty is performed using a dual row of running 2–0
Vicryl sutures through a submental incision.
ith aging, the anterior platysmal fibers undergo medial and
downward migration, whereas the posterior fibers are relatively
unchanged. Lateral traction on the anterior fibers therefore
restores the muscle to a more natural configuration. In isolation,
lateral platysmaplasty has been shown to cause greater adjust-
ment of the platysma and results in greater cranial pressure and
ptosis correction of nearby subplatysmal structures such as the
SMG or digastric muscle compared with the medial platysma-
plasty. Recurrence of platysmal banding is a common problem
that can be attributed to residual muscle fibers or reapproxima-
tion of previously transected fibers. Complete division of the pla-
tysma as well as suture repositioning of the muscular cut edge has
been shown to limit band recurrence. In our described technique,
further measures against recurrence are taken by repositioning
of platysmal fibers laterally, thereby intentionally eschewing the
anatomy to prevent muscle fiber reattachments as suggested by
Pelle-Cervaolo. Additional plication of the superior cut platysmal
edge to itself also prevents readhesion of the healing edges of
the muscle.
Subplatysmal Fat Excision
Adipose excess below the platysma can herniate through
platysmal decussation and obliterate the cervicomental angle.
Some authors have described debulking of the subplatysmal
fat with liposuction techniques. Our preference, however, is to
perform excision of the fat compartments below the platysma
under direct visualization and control. The medial edges of the
platysma are visualized along the decussation and carefully
elevated. The subplatysmal fat is then carefully excised with
monopolar electrocautery, taking care to debulk the central
prominence as well as the smaller lateral extensions below the
muscle. From this approach, additional deep cervicoplasty can
be performed as necessary to treat the SMGs, anterior bellies of
digastric muscles, and hyoid.
Partial Resection of Submandibular Glands
In cases of isolated SMG hypertrophy and ptosis, partial resec-
tion of excess gland protruding below the angle of the mandible
is performed effectively and safely through a lateral approach
from rhytidectomy incisions. After the platysma has been
divided, the SMG is visualized and bluntly dissected away from
surrounding tissues. The capsule is then opened with monopolar
54 Reoperative Rhytidectomy
electrocautery, and excess gland is trimmed. The raw surface of
the resected gland is cauterized, and the capsule is closed for
hemostasis and to minimize sialoma formation. The marginal
mandibular nerve and facial vessels lie posterolateral to the
SMG in the extracapsular space and are protected during this
approach. The lateral approach to the SMG avoids the need for
submental incision and extensive neck dissection and overcomes
the limited visibility, gland retraction, and instrument maneu-
verability often encountered with the submental approach.
Additional elevation of the SMG is achieved with plication of the
platysma with a barbed suture that is carried superiorly along
the SMAS delta plication.
In cases where a submental incision is utilized for approach
to other deep structures of the neck, the SMGs are dissected and
resected from the traditional medial approach. Given that the
inferolateral edge of the SMG is the portion that is most commonly
involved in protrusion below the mandibular border, excess gland
excision may still be visualized from the lateral approach and
further excision may be indicated.
Tangential Excision or Plication of Anterior Bellies
of Digastric Muscles with Hyoid Suspension
Hypertrophy and laxity of the anterior bellies of the digastric
muscles can contribute to submental fullness that is best visual-
ized in flexed lateral (Connell’s) view. Typically muscular bulging
is present in the posterior extent of the anterior bellies, which
can be corrected with tangential excision and debulking with
monopolar electrocautery as required. Diastasis of the anterior
bellies can then be corrected by plication of the medial edges of
the muscles together using 3–0 polydioxanone suture (PDS) to
create a more refined submental contour. e anchor the first of
the plication sutures to the deep cervical fascia over the hyoid,
which helps further to define the cervicomental angle sharply.
The most caudal suture of a medial corset platysmaplasty can
additionally be anchored to this point for augmentation of an
acute neck profile.
Hemostatic Net
If there is significant skin laxity, a notable amount of subplatys-
mal fat has been excised, or deep cervicoplasty with treatment
of submandibular glands and/or anterior bellies of the digastric
has been performed, a hemostatic net is utilized to eliminate
deadspace, redistribute the skin, and contour the cervicomental
angle. Running 4–0 nylon transcutaneous sutures are placed
from the skin to the underlying platysma and SMAS only, where
skin undermining has been performed. The sutures are removed
at 48 hours.
54.5.2 Ancillary Treatment of Facial
Aesthetic Subunits
Periorbital Rejuvenation
The eyes are two of the most expressive subunits of the face,
second only to the mouth. The ongoing movements of the peri-
orbital mimetic muscles result in visible rhytids, particularly
in the forehead, glabella, and lateral periocular region, that can
829
 VIII Surgical Rejuvenation of the Face and Neck

become permanently deep and static over time. Targeted muscle should also be paid to the temples, which are specifically subject
denervation in these regions with neurotoxin is an excellent to soft tissue loss as part of the aging process. Temporal hollowing
method of prevention and can be used to smooth the appearance can markedly contribute to the aged periorbital appearance.
of deep rhytids. It is an integral component of upkeep of results Moderate cases of lateral brow descent are best treated with
and ongoing rejuvenation following primary rhytidectomy. elevation through a temporal hairline incision with subfascial and
Deeper rhytids can be improved with skin resurfacing, judicious subcutaneous dissection and fascial suspending sutures. Lateral
use of HA fillers, or use of microfat or emulsified fat transfers. In brow elevation can also be achieved minimally invasively with the
patients not willing to undergo repeat neurotoxin treatment for gliding brow lift procedure, which utilizes blunt subcutaneous
glabellar rhytids, selective myotomy of the procerus, corrugator dissection to just below the eyebrow and temporary transcuta-
supercilii, and depressor supercilii muscles can be performed neous sutures placed while superolateral tension is applied to
either through a transblepharoplasty approach or concurrently the skin (Fig. 54.13). In patients who also exhibit central brow
with an endoscopic brow lift. depression, an endoscopic brow lift is recommended for harmo-
The orbit undergoes predictable volumetric changes with nious brow elevation. The opposite can be done for patients who
aging, including infraorbital rim retrusion and expansion of the show excessive central brow elevation or a surprised look (Fig.
superomedial and inferolateral rims. These changes in morphol- 54.14). Direct brow lift is considered in selected cases, including
ogy increase orbital volume and contribute to brow descent and men with prominent eyebrows and receding hairlines.
hooding, deepening of sulci, fat pad prominence, enophthalmos or
ptosis, and deepening of the nasojugal groove. Selective soft tissue
Perioral Rejuvenation
volume augmentation in the medial suborbital space, tear trough
Facial aging results from a complex interplay of volume loss and
and nasojugal grooves, and lateral brows can restore a youthful
tissue migration. Gravity is a major and constant external cause
appearance to the eye.
of tissue descent. Internally, shear and tensile forces exerted by
It is important to maintain a volume-preserving approach to
the movement of mimetic muscles also contribute to laxity of
the eyelids as well. Laxity of skin and investing septum and fascia
connective fibers, radial expansion of the soft tissues, and herni-
over deep fat compartments can result in tissue malposition. In
ation of fat compartments. The latter is perhaps most evident in
upper blepharoplasty, the skin is excised and a thin strip of orbi-
the perioral region: ith aging, the malar fat pad and overlying
cularis oculi muscle is removed to enable access to the underlying
skin slides over the SMAS until it reaches the adherent nasolabial
septum and fat compartments. The septum is opened minimally
crease, resulting in a prominent nasolabial fold. Similarly, descent
over the fat compartments as required, and conservative trim-
and juxtaposition of lower cheek fat compartments against
ming of only fat that herniates beyond the septum is performed.
mandibular cutaneous ligaments result in marionette lines and
Levator plication and/or advancement may be indicated to
correct a high-riding crease and senile attenuation of the levator
aponeurosis. Numerous approaches to the lower eyelid have been
described. Our preference in the older patient seeking a secondary
facelift is to use a transconjunctival approach to address fat hyper-
trophy or excess combined with skin pinch excision for treatment
of dermatochalasis. Mild skin laxity and crepey skin of the eyelids
may be addressed with ablative skin resurfacing including care-
ful chemical peel or laser (with or without coagulative thermal
tightening) in lieu of skin resection. In the lower eyelid, blending
of the lid–cheek junction and correction of deep tear troughs and
nasojugal grooves is paramount. Careful placement of fat grafts
along the infraorbital rim periosteum can correct hollowing in
this region. Additionally, nanofat grafts can be placed subdermally
along the lower eyelid to help blend the lid–cheek junction and
improve skin quality including dark circles and dyschromias.
Laxity of the lower eyelid can result in functional problems
as well as aesthetic concerns, including increased scleral show,
rounding out of the lower lateral eyelid, and apparent descent
of the lateral canthus. Cases of mild lower lid laxity can be suc-
cessfully treated with canthopexy, whereas moderate to severe
lid laxity may necessitate more reconstructive options, including
canthoplasty or tarsal strip procedure. In all cases, consideration Fig. 54.13 (a) This 73-year old patient presented for facial rejuvenation
and underwent a secondary facelift with periocular rejuvenation with
should be given to a Frost temporary tarsorrhaphy suture to autologous fat transfer, erbium laser skin resurfacing, and bilateral
help support the lower eyelid during the initial phases of edema temporal brow lift. (b) At 1 year postoperatively, she had improved
and healing. skin texture and fullness around the eyes, but the lateral tails of the
brows were not adequately elevated. (c) She underwent revisional
In most female patients, descent and brow malposition is surgery with a gliding brow lift and hemostatic net as well as a second
confined to the lateral tail of the brow. In mild cases, the lateral treatment with laser resurfacing. (d) She is shown at 3 months postop-
brow descent can be corrected with autologous fat transfer to eratively with satisfactory elevation of the lateral eyebrows and further
improvement of the skin quality around the eyes.
restore support where underlying volume has been lost. Attention

830
 54 Reoperative Rhytidectomy

Fig. 54.14 (a) This 60-year-old woman had undergone endoscopic brow lift, mini-facelift, and lower lid blepharoplasty 4 years earlier. She was
displeased with her eyebrows’ appearance and felt she had a continually “surprised” look. She requested correction of the eyebrow position. We
performed a “reverse brow lift,” with mobilization of the forehead in the subcutaneous plane and release of the periorbital ligaments through an
endoscopic approach and suture fixation of the medial brow through an upper lid blepharoplasty incision. (b,c) The patient was very pleased with the
improvement of the eyebrow shape; the medial portion of the brow had been moved more caudally, correcting her static “surprised” appearance.

jowling. Perioral movement by the zygomaticus and risorius
muscles augment clotheslining of the malar fat pad against the
nasolabial crease, whereas that of the lateral platysma and DAO
accentuate marionette lines. Techniques aimed at weakening
mimetic muscles can be used as adjuncts for facial rejuvenation
and treatment of deep creases of the central face. Targeted
chemical denervation of the lateral platysma and DAO can be
used for prophylaxis against, and treatment of, mild to moderate
marionette lines and downturning of the oral commissures.
Additionally, conservative volume restoration just inferior to the
oral commissures with HA fillers or autologous fat transfer can
help support the commissure in a more neutral position. More
severe cases can be treated by selective surgical myotomy of the
muscles through external or mucosal approaches (Fig. 54.15).
The lip undergoes predictable changes in volume and structure
with aging. The white lip undergoes soft tissue volume loss as well
as loss of bony and possibly dental support, resulting in elonga-
tion of the upper lip and blunting of the Cupid’s bow. The red lip
itself also undergoes volume loss, resulting in overall decreased
vermilion show, fullness, and projection. Repetitive movement of
the orbicularis oris muscle results in formation of deep rhytids
around the lips, which are accentuated by activities that involve
pursing of the lips, such as smoking. All features of the aging lip
must be recognized and appropriately addressed to achieve a nat-
ural and youthful restored appearance. Lip volume can be restored
nonsurgically with the judicious use of HA fillers or surgically
with autologous fat injection. Care is taken to attain appropriate
ratio of upper to lower lip fullness (1:1.6 in Caucasian women).
A common mistake demonstrated by injectors is to attempt to
increase vertical red lip height with fillers alone, which results
in proportional anterior projection and the unnatural duck lip
appearance. In order to correct attenuation of the white lip with
aging, either subnasal lip lift or direct vermilion advancement
can be used. The subnasal lip lift is typically preferred due to
inconspicuous placement of the scar, preservation of the native
vermilion, and predictable improvement of the red–white lip
ratio (Fig. 54.16). Direct vermilion advancement may result in
a noticeable white scar in a prominent area of the face and is
typically reserved for partial elevation of the lateral lip, which can
become less visible with aging.
Deep perioral rhytids can be a prominent feature of aging and
environmental exposure. They can be treated with conservative
use of HA fillers (with lower G ), taking care to avoid overfull in the
white roll, which can impart a simian appearance. Alternatively,
ablative skin treatments with or without the use of emulsified
intradermal fat grafts can be used to promote skin remodeling.
Earlobe Rejuvenation
The ear undergoes volumetric and morphologic changes
with aging that are most pronounced in the lobular segment.
Gravitational pull, augmented by weight of earrings, results in
elongation of the free caudal segment of the earlobe. Additionally,
the earlobe undergoes volume atrophy, which creates rhytids and
deep creases. During a secondary rhytidectomy, an elongated
earlobe can be easily corrected with inferior tangential excision
of the lobe along the caudal border to decrease the overall height.
A slight dog-ear deformity may result in the superolateral aspect
of the excision and will settle with time. Attempts to chase the
dog-ear can result in extension of the scar unnecessarily along
the helical border. In cases of a cleft deformity from piercing and
heavy jewelry, either tangential excision of the piercing, alone
or extended as a wedge resection to the inferior lobule border,
can be used to restore native ear anatomy. The ear can then be
repierced 6 weeks later away from the scar. Volume restoration
of the earlobe can be achieved with either the use of HA fillers or
autologous fat grafting with predictable results.

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 VIII Surgical Rejuvenation of the Face and Neck
Fig. 54.15 (a,c) This patient presented at age 60 desiring facial rejuve-
nation for an irregular jawline contour and jowling. She first underwent
a short-scar facelift with fat grafting. Fifteen months postoperatively,
she desired additional correction of marionette lines at the oral
commissural region, and subsequently underwent depressor anguli
oris (DAO) division and fat grafting to the geniomandibular groove
(GMG). (b,d) After staged interventions, the lower third of the face
now appears more tapered and with a much softer look.
54.5.3 Preventing and Correcting the
“Overoperated” Look
Know When to Say No
If a surgeon has performed multiple facial aesthetic procedures
on a patient who is now requesting improvements that will
inevitably produce an unnatural, overoperated look, the surgeon
must exercise discretion and decline to proceed. The surgeon
must thoroughly explain why further surgical intervention
could cause an unnatural and uncorrectable appearance, lest
the patient seek ill-advised surgical correction elsewhere, which
inevitably leads to further patient dissatisfaction and could also
damage the reputation of the surgeon and the practice.
The Lateral Sweep
The term lateral sweep describes the unnatural appearance
of the cheeks after facial rejuvenation surgery when there is a
distinct curve of the lower facial skin from the jawline toward
the superior portion of the ear. The curved rhytides establish an
obvious overoperated look.
The lateral sweep results from skin tension differences between
the pulling vectors of the lifted tissues. The greatest tension on the
skin is superolateral toward the superior aspect of the ear, where
the skin is anchored. The midface, the central portion of the face,
832
Fig. 54.16 This 61-year-old patient underwent perioral rejuvenation at
same time as facelifting with autologous fat injection in the nasolabial
folds and geniomandibular grooves, improvement of skin texture
and deep perioral rhytids with croton oil peel (two treatments), and a
subnasal lip lift to correct upper lip lengthening. (a) Preoperative view.
(b) View 20 months postoperative.
is farthest from the skin anchoring and therefore has the least skin
tension.
ith facial aging, skin descends as its tension diminishes. In an
unoperated face, the tissues descend at equal rates, creating the
normal stigmata of facial aging: an obvious lid–cheek junction,
prominent nasolabial folds, marionette lines, downturned oral
commissures, jowling, loss of a crisp jawline, and cervical laxity
with development of an obtuse cervicomental angle. However, in
a patient who has undergone facial rejuvenation surgery, tissues
descend at differing rates, because the skin and deeper tissues are
under different tensions postoperatively. As the postoperative face
ages, the midfacial areas under least tension begin to relax earlier,
whereas the inferolateral tissues retain their tensions longer, and
the lateral sweep becomes evident.
The culprit maneuver is skin elevation with a vector that is
too superior, rather than a more oblique, superolateral vector
(Fig. 54.17). Appropriate skin redraping during rhytidectomy is,
therefore, key. The surgeon can additionally minimize the risk of
a lateral sweep via deeper tissue manipulation using the SMAS
and by resuspending the midfacial tissue under appropriate ten-
sion. However, this tissue’s fixation point is less durable than the
skin’s and therefore ages earlier still. The composite rhytidectomy
described by Hamra involves repositioning the orbicularis oculi
muscle to attempt to strengthen midfacial support and minimize
periorbital bunching.
Tragal Distortion
Tragal distortion can be caused by excessive tragal skin tension
when the incision is brought behind the tragus to disguise the
scar. Preventing this finding entails placement of key sutures that
will hold the majority of skin tension at the superior extent of the
incision, at the root of the helix of the ear and the highest point
of the postauricular sulcus. After placement of these tension
sutures, excess skin can be excised judiciously near the tragus
to facilitate a tension-free closure (Fig. 54.18). An anteriorly dis-
placed tragus can be corrected by incision of the cartilage at the
base during reoperative rhytidectomy and temporary anchoring
of the tragus to the concha posteriorly using 5–0 nylon mattress
suture during the acute healing phase.

Hairline Distortion
Secondary rhytidectomy can cause hairline distortion, especially
at the sideburn level. If the previous rhytidectomy incision
extended into the temporal hair, then chances are that the
patient’s sideburn length has shortened. To mitigate the problem,
it is prudent to extend the incision just below the sideburn and
then cephalad anteriorly. The surgeon should bevel the incision
at a 30 to 45 angle to the external skin surface to enable hair
growth through and anterior to the scar. The resulting scar can
be inconspicuous with less risk of hairline distortion (Fig. 54.19).
Pixie Ear and Earlobe Scar Migration
Secondary rhytidectomy presents an opportunity to correct
earlobe scar migration, which may occur after primary rhytid-
ectomy. Once the incision has healed and scar has maximally
matured, the scar malposition can be corrected in office under
local anesthesia. The scar tissue anterior and posterior to the
earlobe is deepithelialized; the skin is then rotated posteriorly
to secure the dermis to the conchal cartilage to provide added
support and recreate the natural aesthetic of the earlobe-cheek
junction (Fig. 54.20).
One can prevent pixie ear deformity by redistributing skin
tension appropriately with key 3–0 nylon sutures at the superior
Fig. 54.17 (a,b) This patient presented after undergoing rhytidectomy
elsewhere with telltale lateral sweep and excess skin tension. (c,d)
Upon animation, she had misdirected prominent horizontal rhytids.
54 Reoperative Rhytidectomy
extent of the pre- and postauricular incisions. Once the surgeon
places key sutures and removes tension from all portions of the
ear itself, one can excise skin judiciously. Always leave a little
more skin at the earlobe than you think is optimal with a trans-
verse cut, as opposed to a V-shaped skin removal that just delivers
the earlobe above the skin flap. To further reduce the potential of
developing a pixie ear, one can de-epithelialize excess skin at the
auricular base and suture it to the conchal base (Fig. 54.21). This
maneuver, espoused by Dan Baker, is especially helpful during
a short-scar facelift, where the postauricular incision stops just
posterior to the earlobe. ith the short-scar approach, there is
no posterosuperior key suture to redistribute skin tension. The
described maneuver thus acts to minimize skin tension at the
earlobe inset base.
Obvious Scars
Visible scars betray a primary rhytidectomy but are amenable to
correction during revision surgery (Fig. 54.22). If the posterior
horizontal incision is placed low, the scar is quite obvious and
hinders the patient’s ability to hide it when his or her hair is cut
short or pulled back. One may be able to reposition these scars
higher if the incisions were placed low initially, or if tissue laxity
recurred and moved the incision lower. The surgeon should
not commit to the final scar location before having re-elevated
the entire skin flap and become cognizant of the posterior skin
excess. ith this incision design, well-healed scars will be very
difficult to visualize.
Another rare complication of rhytidectomy is hypertrophic
or keloid scar formation. Surgeons should routinely ask patients
about prior posttraumatic or surgical scars to assess for a tendency
to form poor scars. Despite being counseled on the risks of obvious
scar formation, patients who have such a history may nonetheless
elect to proceed. e have also encountered patients without a
poor scarring history who nonetheless later develop periauricular
hypertrophic scarring following rhytidectomy. Persistent or wors-
ening cases of keloid scarring may require formal scar revision
combined with steroid injection and/or radiation therapy. Tension
on the closure is the likely etiology and must be avoided.
Recognizing Body Dysmorphic Disorder
hen discussing any reoperative aesthetic surgery, one must
recognize patients with body dysmorphic disorder (BDD). There
are three diagnostic criteria:
a b
Fig. 54.18 (a,b) Removal of excess directly pretragal fascial tissue
to recreate a natural depression. The closure is secured using deep
dermal 4–0 polydioxanone suture.
833
 VIII Surgical Rejuvenation of the Face and Neck

1. Preoccupation with an imagined or slight defect in appearance

2. Marked distress or impairment in social, occupational, or
other areas of functioning resulting from preoccupation with
appearance
3. Absence of another psychiatric disorder to which the preoccupa-
tion may be attributed

Patients with BDD may visit the plastic surgeon for correction
of their perceived deformities. The surgeon must recognize signs
of this disorder and refer patients with BDD to appropriate mental
health specialists. Patients with this disorder who have undergone
corrective surgery have high rates of dissatisfaction with their
results and have even turned violent. (See elsewhere in this book
for more detailed discussions of patient selection issues involving
a b
this disorder.)

54.6 Management of Complications

from Primary Rhytidectomy
Facelifts, like any other aesthetic procedures, present risks for
early complications as shown.

Early Complications of Rhytidectomy

• Hematoma
• Infection
• Skin slough
• Nerve injury (sensory and motor) c d
• Dysphagia
• Emotional issues

54.6.1 Hematoma
Hematoma following facelift is a significant source of morbidity.
Various authors report the incidence among all patients to range
from 1 to 12.9 . Risk factors associated with hematoma follow-
ing rhytidectomy include hypertension (especially if poorly con-
trolled preoperatively), male sex, bleeding disorders, and the use
of medications that interfere with coagulation. The incidence of
hematoma among patients undergoing facial rejuvenation with
local anesthesia and sedation alone may be slightly lower than e f
for those who are administered general anesthesia. However,
Fig. 54.19 (a,c,e) This 47-year-old woman complained of continued
with either group, pre- and perioperative blood pressure control facial aging and prominent scars following an initial facelift at age 36
is paramount in reducing the risk of postoperative hematoma. and a short-scar facelift at age 41. The presideburn scars were visible,
If the patient’s blood pressure remains greater than a systolic as was descent of the malar fat pad and minor jowling. We performed
a tertiary facelift that included an extended superficial musculoapo-
of 180 mm Hg or diastolic of 90 mm Hg after initial sedation,
neurotic system technique to anchor the malar fat pad to the malar
we do not proceed until blood pressure has been normalized. periosteum. (b,d,f) Her results are seen at 1 year.
Persistent hypertension is an indication for referral and workup
by the patient’s primary physician or cardiologist. Clonidine is
an effective agent for preoperative control of blood pressure
at doses of 0.1 to 0.2 mg orally the morning of surgery. e ask not prevent hematoma but are nonetheless useful as a mechanism
our anesthetists to avoid spikes in blood pressure as the patient for monitoring the amount of bleeding. Use of a hemostatic net
emerges from general anesthesia, because this is a precarious to eliminate dead space in regions that have been undermined
time for hematoma development. can help to prevent collections of fluids, including hematomas.
Use of fibrin glue has also shown some benefits for rhytid- Head elevation, cool compresses, pain and nausea control, and
ectomy. hile sealant glue does not decrease the incidence of continued sedation are all useful for maintaining an acceptable
hematomas, it does decrease drainage and ecchymosis. Drains do blood pressure.

834
 54 Reoperative Rhytidectomy

Fig. 54.20 (a) Earlobe scar migration can also be a problem following primary rhytidectomy. Although the patient’s hair or makeup can hide most
scars, the earlobe scar can be very upsetting. After the scar has matured, one can easily treat this abnormality in the office under local anesthesia. (b)
The surgeon can deepithelialize scar tissue and suture it to the caudal portion of the conchal cartilage to provide added support. (c) Rotating the skin
posteriorly recreates the natural aesthetic of the earlobe-cheek junction.

Fig. 54.21 (a) This 50-year-old patient developed a pixie ear deformity on the right side 2.5 months following a primary short-scar rhytidectomy.
(b) The pixie ear deformity was corrected with wide undermining of the skin anteriorly, inferiorly, and posteriorly to mobilize the skin adequately.
The dermis of the inferior skin apex was advanced superiorly and secured to the conchal fascia. The skin was then closed in a V-to-Y fashion. (c) The
patient is shown following the repair with correction of the deformity and a better-defined lobule.

Men have a higher incidence of intraoperative bleeding than
women during rhytidectomy and more frequently develop
postoperative hematomas (between 4.0 and 12.9 of cases). This
phenomenon is probably attributable to the presence in men’s
faces of more sebaceous glands and hair follicles, each of which
is surrounded by a more extensive capillary network. As a result,
the vascularity of male skin is greater, in turn leading to greater
potential for blood vessel disruption. More limited undermining
in men, as well as a conservative, closed approach to the neck, can
decrease the surface area at risk for postoperative bleeding.
Hematomas developing after rhytidectomy can be generalized
into two categories: (1) small collections that are drainable at the

835
 VIII Surgical Rejuvenation of the Face and Neck

bedside without returning the patient to the operating room and

(2) large ones in which the cheek and/or neck must be reopened
and explored to control the bleeding source.
The key to successful hematoma management is early detection.
hen detected early, it is more likely that the hematoma can be
managed without a return to the operating room. Bedside man-
agement is accomplished by removing sufficient sutures or staples
to be able to express clots and fresh blood manually. Preparation
for bedside evacuation should include oral pain medication or
sedation if the patient is overly anxious. Blood pressure must be
controlled. Chlorpromazine and nitroglycerin ointment are useful
agents for decreasing blood pressure by vasodilation. Towels are
spread beneath the patient’s head, and the area prepared with a
solution such as povidone–iodine (Betadine) solution. A ankauer
suction tip or red Robinson catheter is helpful for evacuating all
the clots; the surgeon can then assess ongoing bleeding. The area
is irrigated with copious saline solution until the e uent runs
clear. A solution of 20 to 30 mL of 0.25 lidocaine with 1:200,000
epinephrine is injected under the flap. Compression is held for 5
to 10 minutes and a supportive circumferential dressing applied.
If the hematoma is large and seems to involve both cheeks and the
neck, a return to the operating room is indicated (Fig. 54.23). Other
factors that should influence the surgeon toward a return to the
operating room are the following:

• An uncooperative patient
• An overly anxious patient
• A large, delayed hematoma
• Labile blood pressure
• Bilateral hematomas
• A compromised airway
If the patient is experiencing dyspnea, immediate suture
removal and decompression are essential. Since intubation and
airway control in the presence of a large hematoma can be exceed-
ingly difficult, we prefer to achieve initial situational control with
the patient under local anesthesia with minimal sedation. Often
very little premedication is required, because tissues are fre-
quently still numb from the initial procedure, and anxiolytic and
pain medications may already have been given. The surgeon must
attempt to locate the primary source of fresh bleeding and pack
that area while evacuating the remaining field. ith large hema-
tomas, we usually remove most sutures to ensure that all bleeding
sources have been controlled. The worst scenario is to assume
that one has controlled the bleeding source only to find that the
hematoma has recurred after the patient has left the operating
room. Profuse irrigation with saline and dilute hydrogen peroxide
will usually reveal the bleeding source. Of course, the surgeon
can feel most confident about hemostasis when a single culprit
pumper has been identified. hen multiple bleeding vessels are
encountered, we prefer to keep the patient in the operating room
under observation until we are certain no further bleeding is
going to occur. Drains should always be replaced and their proper
functioning confirmed. Elimination of dead space with the use of
temporary transcutaneous sutures, as described earlier, is a useful
adjunct for prevention of hematoma formation. The hemostatic
net can also be used as an adjunct for in treatment of hematomas
Fig. 54.22 Most patients prefer to have their scars hidden from view.
(a) This patient had undergone a primary facelift 10 years earlier. She
now expressed concern about continued facial aging and obvious
scars. At the time of her reoperative rhytidectomy, the anterior
incision was designed adjacent to the anterior helix and earlobe and
at the tragal margin. (b) Posteriorly, the scar was continued in the
postauricular crease and continued superiorly to allow for elevation
of the postauricular scar higher behind the ear and to restore the gap
in the hairline. A carefully designed incision can create inconspicuous
anterior and posterior scars, regardless of patient hairstyle. One can
accomplish this goal by placing anterior incisions in or near the hairline.
Other helpful targets include natural rhytides. In continuing the
incision around the posterior aspect of the ear, one should do so within
the posterior auricular crease. The incision should continue high before
extending horizontally into the posterior hairline. The secondary
procedure was designed to elevate the postauricular scars up higher
behind the ear and restore the gap in the hairline, elevate the midface,
and tighten the neck; we also performed an endoscopic brow lift.
(c,d) She is seen 4 years postoperatively. Postauricular scars are also
vulnerable to migration and visibility. Surgeons should make every
effort in either primary or secondary rhytidectomies to place scars in
least-noticeable positions.
to prevent recurrence, especially in instances where diffuse pin-
point bleeding is encountered.
If a patient presents with the results of a prior untreated hema-
toma, as with any significant deformity due to complications, the
mainstay of treatment is not to reoperate too soon and to avoid
additional traumatic injury by manipulation or injections. Release
of scar tissue and autologous fat grafting can ameliorate the dev-
astating effects.

836
 54 Reoperative Rhytidectomy

Fig. 54.23 (a,b) Preoperative views of a 59-year-old woman who underwent a facelift, endoscopic brow lift, and upper and lower blepharoplasty.
(c) Four hours postoperatively, she developed an obvious hematoma involving both cheek pockets and the neck. Exploration revealed two arterial
bleeding points in the neck, which were controlled. All regions were washed out and the skin was reclosed. (d,e) The patient was seen 4 months
postoperatively with near-complete resolution of this complication. This complication can be prevented with the application of hemostatic net over
undermined areas.

54.6.2 Skin Slough
Skin slough usually occurs because of closure under excessive
, , - usually indicated. If the patient is a smoker, the surgeon should
tioning, smoking, and diabetes are all contributing factors to skin
compromise. If one diagnoses impending tissue necrosis in the
early postoperative period by flap cyanosis or lack of capillary
refill, sutures should be removed immediately and the skin
should be allowed to retract. The open wound can be covered
with a nonadherent petrolatum gauze dressing (e.g., Xeroform;
various manufacturers) and a light dressing for 5 to 7 days, at
which time one is often able to reclose the wound with salvage of
the skin flap. If hyperbaric oxygen therapy is available, once- or
twice-daily treatments for 5 days can help salvage underper-
fused skin flaps.
If skin necrosis is clearly demarcated, conservative treatment is
ensure that the patient has complied with smoking cessation. These
patients require repeated reassurances, because this complication
may seriously affect their ability to return to work or other social
activities. On the other hand, little wound care is necessary in the
eschar phase. hen spontaneous separation begins to occur, any
nonviable tissue is d brided and wound dressing changes initiated.
Allowing the wound to heal secondarily and contract usually gives
a result that is a better color and texture match than a skin graft
would be. If possible, flap advancement and reclosure is the best

837
 VIII Surgical Rejuvenation of the Face and Neck

option. However, there is usually too much tension to accomplish
this approach in the acute period (Fig. 54.24).
54.6.3 Infection
Fortunately, infection following rhytidectomy is rare, but it can
have devastating consequences. As with other complications,
prevention is key. Our patients wash their faces at least three
times with an antibacterial soap on the morning of surgery. It is
difficult to maintain a strict sterile field with facial rejuvenation
surgery because of the presence of hair and inclusion of the oral
and nasal cavities, as well as the endotracheal tube or other
airways and oxygen sources, within the field. evertheless,
every attempt must be made to avoid contamination, especially
when the procedure is prolonged. e have found that soaking
braided sutures in povidone–iodine before use has decreased
small suture infections, especially in the region of the platysma
plication. In addition, before closure of the cheek dissection, we
meticulously irrigate all open areas with dilute povidone–iodine
to wash out any debris, particularly loose fat globules.
Infections may arise from undrained hematomas or seromas and
are often seen as collections in dependent portions of undermined
areas. Overlying skin erythema is usually the first sign, but there
may be little to no associated pain or fever. Drainage is paramount,
and cultures should be obtained to guide antibiotic therapy. If the
combination of drainage and antibiotic agents fails to resolve the
problem rapidly, one should consider operative exploration to rule
out an infected foreign body. External auditory meatus plugs (e.g.,
cotton or petrolatum gauze) have been known to drop into the
wound and should be accounted for in sponge and needle counts.
In severe facial infections, thorough irrigation, d bridement of non-
viable tissue, and wide drainage are generally effective, in addition
to administration of an appropriate antimicrobial. Hospitalization
and intravenous medication are rarely required, but they may be
indicated if rapid resolution of the infection is not achieved with
aforementioned treatments (Fig. 54.25).
54.6.4 Salivary Gland Problems
Parotid Fistula
Parotid injury has become a more common event with facelift
techniques that involve dissection in the sub-SMAS plane.
Unfortunately, injury is even more likely when the SMAS has

Fig. 54.24 Although superficial skin resurfacing (to a depth of no more than 20–30 micrometers) of undermined skin can be performed safely,
deeper skin resurfacing should not be performed, as it can result in skin necrosis, especially in patients with possible skin vascular compromise. (a)
This patient had diabetes mellitus and underwent primary rhytidectomy and erbium laser resurfacing, resulting in frank necrosis of the malar skin.
(b) Skin necrosis was managed conservatively. (c) Good secondary healing in progress. (d) Scar contraction is substantial. (e) Immediately following
revisional surgery. (f) The patient exhibits excellent healing with a barely visible scar.

838
 54 Reoperative Rhytidectomy

Fig. 54.25 (a,b) This 61-year-old patient presented for facial rejuvenation. (c,d) Four weeks after undergoing a primary rhytidectomy with Delta
superficial musculoaponeurotic system plication, fat grafting to face, endoscopic browlift, upper and lower blepharoplasties, depressor angulis oris
division, and erbium laser resurfacing, she presented with a hemifacial rash that was initially attributed to cellulitis. On further consideration and an
infectious workup, the rash was revealed to be trigeminal herpes zoster (shingles), consistent in its dermatomal nerve distribution. She went on to
heal after expectant medical management and without further sequelae. (e,f) One year later, she had persistent neck laxity and deep perioral rhytids,
which were addressed with revision necklift with medial and lateral platysmaplasty and croton oil facial chemical peel. (g,h) Final results are shown 2
years postoperatively.

been previously elevated, as encountered in some secondary
facelifts. ith secondary rhytidectomy, the parotid is at greater
risk of injury because of altered anatomy and scarring. The
gland is at highest risk over its superficial lobe and just at the
mandibular angle. The superficial fascia can usually be separated
from the parotid fascia, unless the plane has already been oblit-
erated surgically. However, raising both the superficial fascia
and the parotid fascia in continuity can be advantageous when
the superficial fascia is thin, because the combined fasciae add
strength for deep tissue fixation. If this approach is undertaken,
one is dissecting directly superficial to the glandular lobules of
the parotid, which can be confused with sub-SMAS fat and thus
susceptible to injury. This misidentification is how most parotid
injuries occur. The parotid duct is rarely injured but can be
obstructed if one torques the gland with suture fixation.
Management of parotid injury hinges on immediate recognition
so that the dissection plane is promptly corrected. The injured
parotid is coagulated with electrocautery or, rarely, oversewn with
fine sutures if the injury appears to involve the terminal ductules.
A drain is left in situ, and compression is applied for 48 hours.
If there is frank saliva in the drainage, the drain should remain
in place until output is minimal. Generally, as long as the duct is
unobstructed, these salivary fistulas are self-limited. Sialography
or duct endoscopy can be helpful if ductal obstruction is sus-
pected. Injuries late in the postoperative period are diagnosed by
swelling and fluid collection over the parotid that, on aspiration,
yields a high amylase titer. Generally, the patient is afebrile, and
eating often exacerbates the swelling. Mainstays of management
include insertion of a closed suction drain, placement of a pres-
sure dressing, and administration of antibiotics. Botulinum toxin,
atropine, glycopyrrolate, and scopolamine have been reported to
be helpful as antisialagogues.
Submandibular Gland Sialoma
Incidence of sialocele formation following SMG resection is
infrequent. During surgery, preventative measures to decrease
fluid collection postoperatively include cauterization of the

839
 VIII Surgical Rejuvenation of the Face and Neck

raw gland surface and closure of the capsule with one or two
suture mattresses to minimize drainage into the subcutaneous
space. Placement of a temporary subplatysmal drain for 1 week
following surgery can further help to decrease the incidence of
sialomas. If a clear fluid collection presents in the submental
space following surgery, a sialocele can be diagnosed and distin-
guished from seroma by fluid aspiration and testing for amylase.
Sialomas can be treated conservatively with needle aspiration(s)
and compression. Pharmaceutical treatment with intraglandular
injection of botulinum toxin type A is effective for decreasing
secretions and has replaced traditional treatment with scopol-
amine, which carries untoward anticholinergic side effects.
54.6.5 Nerve Injury
Any branch of the facial nerve can be injured during a facelift.
ith altered anatomy from primary rhytidectomy, deeper dis-
section beneath the SMAS during secondary rhytidectomy risks
injury to the facial nerve. Although nerve branch transections
do occur, injury more typically results from traction or thermal
damage from nearby electrocautery use. Motor nerve dysfunc-
tion presenting immediately postoperatively is typically due to
local anesthetic, and patients should be reassured accordingly.
erves still in continuity recover well without intervention. Most
neuropraxias recover within 2 weeks to 3 months, although this
process can take up to a year or more, and patients should be
counseled accordingly. In case of nonimproving nerve injuries,
one should consider obtaining electrodiagnostic studies at 6
weeks to 3 months postoperatively, with surgical exploration
reserved at 3 months, including neurolysis and neurorrhaphy.
hen facial nerve injury does occur, the buccal branch is most
commonly affected. However, the frontal branch of the facial
nerve is the most commonly injured nerve with notable clinical
significance, followed by the marginal mandibular branch. hen
frontal branch weakness is observed postoperatively and persists
beyond 1 month, and if the patient is agreeable, we favor admin-
istering botulinum toxin to weaken the unaffected side of the
face for symmetry while the injured side recovers. Commonly, by
the time the botulinum toxin effect wears off, the injured nerve
has recovered, and symmetric motor function is reestablished.
If the nerve has not recovered by 1 year postoperatively, a more
permanent solution is to perform a brow lift on the affected side,
either directly or endoscopically, as well as on the unaffected side
if indicated (Fig. 54.26).
A similar strategy can be used for the marginal mandibular
branch with weakening of the DAO on the unaffected side with
botulinum toxin (Fig. 54.27). Resection of the DAO muscle has
been described for perioral rejuvenation and could also be consid-
ered if the smile remains asymmetric beyond 1 year.
The great auricular nerve is the nerve most commonly recog-
nized as injured in up to 7 of cases. Injuries to the great auricular
nerve are typically managed conservatively, and sensation will
often return spontaneously with resolution within 12 months.
Nonetheless, we recommend that any acute nerve transection
be repaired primarily in a tension-free manner if diagnosed
intraoperatively.
54.6.6 Dysphagia
Dysphagia is attributable to platysmal tightening, which is a
dramatic change for patients accustomed to their lax necks. In
fact, we are routinely pleased to hear the patient mention neck
tightness in the first week following facelift. Diazepam is an
effective relaxant for early symptoms, and surgical intervention
is not indicated, as the muscle invariably relaxes with time.
Patients are reassured and otherwise managed expectantly.

Fig. 54.26 (a,b) This patient had undergone primary facelift and presented with a desire for further rejuvenation. She underwent secondary facelift-
ing with fat grafting and genioplasty. Additional temporal scalp incisions and temporal undermining were performed to redrape the skin better.
Bleeding was encountered along the left temporal dissection, requiring significant electrocautery use for hemostasis. (c,d) Frontal branch injury on
the left was readily apparent postoperatively, which was treated with nerve stimulation, coupled with neurotoxin treatment to the unaffected right
side for symmetry. (e) The patient went on to recover motor nerve function by 6 months postoperatively.

840

Fig. 54.27 (a) This patient was referred for management of marginal
mandibular nerve injury and smile asymmetry 4 years following
a primary rhytidectomy performed elsewhere. (b) She has been
managed conservatively with restoration of smile symmetry and high
patient satisfaction with routine chemical paralysis of the contralateral
lower lip depressor using botulinum toxin.
54.6.7 Emotional Issues
Recovery from a facelift can be an emotional rollercoaster for
some. Effects of anesthesia, steroids, and other medications,
combined with anxiety over their eventual appearance, can take
a serious toll on patients’ emotional well-being. Anticipatory
guidance can help prepare patients for depressive symptoms
that frequently accompany the recovery process. Having an
established relationship with a reliable and local clinical psychol-
ogist can pay great dividends if both referral and an intervention
seem necessary. For most patients, reassurance is sufficient until
swelling and associated tissue distortion have resolved. A recent
long-term patient satisfaction study demonstrated that an over-
whelming majority of our patients described their improvement
in facial appearance postrhytidectomy as very good or beyond
expectations.”
54.7 Concluding Thoughts
Facial reoperative conditions vary, depending on the patient’s
concerns and altered anatomy. One may include the need to
correct complications such as hematoma and nerve injury.
54 Reoperative Rhytidectomy
Today, adjunctive procedures are becoming more prevalent and
being used to a much greater extent. One can anticipate staged
procedures in which the patient may need early intervention
or can use them to delay more definitive facelifting. Improving
the results for dissatisfied primary rhytidectomy patients can
present more challenging cases. In secondary rhytidectomy, the
surgeon may struggle to achieve results that both surgeon and
patient will accept. The most common reasons for reoperation
are persistent or recurrent stigmata of aging.
The surgeon must make an accurate preoperative diagnosis and
design an appropriate reoperative plan. One can retain patients in
the practice by advising them on maintenance strategies such as
skin care, neurotoxin therapy, dermal fillers, laser skin resurfac-
ing, and ultimately, additional surgery.
Clinical Caveats
• The surgeon must educate the patient that a facelift does not
last forever.
• It is a mistake to conclude that every patient must have your
definitive procedure, as if the surgeon who performed the
primary procedure lacked your skill.
• Attend to what bothers the patient about his or her face.
Listen to the patient
• In a secondary procedure, there may be asymmetries result-
ing from the primary procedure combined with anatomic
differences. The facial nerve may be in a different place.
• It is very helpful to determine exactly what was performed in
the previous surgery and in what tissue plane.
• Because increasing emphasis on the midface and volumetric
shaping has happened more recently, these issues might not
have been addressed in the initial facelift.
• Patients with poor-quality skin and/or heavy tissues should
be counseled that a staged procedure may be necessary to
achieve optimal results.
• Men have a higher incidence of postoperative hematoma than
women do, probably due to increased facial skin vascularity.
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 VIII Surgical Rejuvenation of the Face and Neck
55 Avoidance and Management of Complications in Facial
Aesthetic Surgery
Foad Nahai
Abstract
Reported rates of complications following facelifts range from 1
to 10 . I classify the complications as common, rare, devastating,
or craftsmanship issues. By far the most common complication
is hematoma. All classes of complications are represented, and
their avoidance and management are discussed.
Keywords
hematoma, nerve injuries, skin slough, seroma, motion distor-
tion, scars, ear deformities, hair line changes, infection, contour
irregularities, parotid fistula, sialocele, overgrafting of fat
55.1 Introduction
The only surgeons who have no complications are those who do
not operate, or those who deny having complications. The rest of
us take measures and make every effort to minimize our compli-
cations. The overall complication rate for facial aesthetic surgery
is reported to range from 1 to 10 ; this rate is a little higher in
men. Pitanguy’s 2012 review of close to 9,000 facelifts reported
an overall complication rate of 4.5 .
Data from the American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF) reported by eyes et al in
2008 included four deaths from facelifts and related procedures.
These deaths were caused by venous thromboembolism (VTE) or
oversedation and were associated with facelifts in combination
with other procedures. Updated AAAASF data in 2012 confirmed
the earlier numbers. Our Paces Plastic Surgery 4-year review
of 468 facelifts showed a complication rate of 3.6 in patients
who underwent facelifts and blepharoplasties. However, when
an additional procedure was performed, this incidence almost
doubled to 6.2 , and if two or more procedures were added to the
facelift, the incidence more than quadrupled to 14.9 .
The list of potential complications includes the following:
• Hematoma
• Hair problems
• Skin necrosis
• Scars
• Contour irregularities
• Ear deformities including the lobe and tragus
• Nerve injury
• Seroma
• Infection
• Parotid fistula
• Deep venous thrombosis/VTE
• Facial distortion
844
• Overfilling with fat
• Death
Hematoma is by far the most common complication, accounting
for almost 70 of all facelift complications. Some complications
are rare, some are devastating, and still others are not true com-
plications but rather quality or craftsmanship ( finesse ) issues.
Facelift Complications
• Common
• Rare
• Devastating
• Craftsmanship “finesse” issues
Common complications include hematoma and temporary
nerve paralysis. Rare complications include infection parotid
fistula and sialocele. Devastating complications include
unrecognized or untreated hematomas, skin slough, perma-
nent nerve injury, VTE, facial distortion, and overgrafting of
fat. Although an expanding hematoma is not uncommon, an
unrecognized or untreated hematoma is a real disaster that can
lead to significant skin necrosis or even airway compromise.
Finesse issues include unfavorable results, unsightly scars,
ear distortions, hairline distortions, hair loss, and contour
irregularities. In terms of litigation, facelift ranks fifth among
aesthetic procedures, representing 9 of the total number of
lawsuits filed, according to data from The Doctor’s Company
( apa, CA) for 1997 to 2002.
55.2 Hematoma
The incidence of hematomas with facelifts (Fig. 55.1) ranges
from 1 to as high as 10 . According to data from the AAAASF,
hematoma after a facelift and related procedures managed on an
outpatient basis ranked only second to hematoma after breast
augmentation and revision and second to abdominoplasty for
hematomas managed on an inpatient basis. Pitanguy’s 2012
series reported a 3 hematoma rate, and more recent publi-
cations, reporting on CosmetAssure (Birmingham, AL) data,
included a very low rate of 0.7 . The incidence in men and in
patients with a history of hypertension is significantly higher.
Steps to minimize the risk of hematoma are taken before,
during, and immediately after the operation as discussed in the
following subsections.
55.2.1 Preoperative Measures
Preoperative measures include a workup and control of blood
pressure and instructing the patient to avoid medications, dietary
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery
supplements, and herbal remedies that may affect bleeding (Fig.
55.2). There have been recent reports that some antidepressants
may play a role in the development of hematomas after facelifts.
e advise our patients to stop all vitamins other than C and to
stop all nutritional supplements of all kinds. e do allow them
to continue on antidepressants. All men are questioned about
prostatic symptoms, and it is essential that such symptoms be
controlled before a facelift operation.
The lists shown in Fig. 55.2 are only a sampling of medications
to be avoided, and lists of aspirin-containing products and nonste-
roidal anti-inflammatory drugs ( SAIDs) will vary from country
to country.
55.2.2 Intraoperative Measures
Intraoperative measures to avoid hematoma include close coop-
eration between the anesthesiologist and the surgeon. hen
these two work as a team, the incidence of hematoma can be
significantly reduced. Rigorous control of blood pressure during
the procedure is important. The actual blood pressure, whether
high or normal, is not as important as avoiding fluctuations in
blood pressure. A report by ones and colleagues suggested that
postoperative hematoma might be related to the rebound effect
through the use of vasoconstrictors; they recommended that
vasoconstrictors be avoided. However, I still inject vasoconstric-
tors and rely on meticulous hemostasis. Appropriate fluid man-
agement during the procedure is also important. e routinely
place a Foley catheter for procedures taking 4 hours or longer so
that the patient will not have a full bladder in the recovery room.
The routine use of clonidine (a long-acting alpha-2-adrenergic
blocker with central and peripheral effects) has been advocated
perioperatively to control the systolic blood pressure. Most if not
all of my patients undergo facelifts under general anesthesia, and
I do not initiate clonidine therapy before the operation. All male
patients are routinely treated in the recovery room with oral
clonidine and, if need be, with parenteral antihypotensive agents
until the clonidine becomes effective. omen are given clonidine
on an individual basis.
Recently there have been reports that the administration of
Tranexamic acid (TXA) systemically or locally will significantly
reduce intraoperative bleeding. Any effect on post op hematoma
is yet to be proven.
55.2.3 Immediate Postoperative
Measures
I think the immediate postoperative period is the most critical
for avoiding hematoma. In my experience most hematomas
occur in the recovery room or within the first 12 to 18 hours
postoperatively. Although delayed hematomas (up to 3 weeks)
have been reported, these are most likely caused by bleeding
from the superficial temporal or other relatively large vessels.
Close monitoring and observation in the recovery room and
during the first 12 hours postoperatively are the key to minimiz-
ing hematoma.
Patients are monitored for pain, anxiety and agitation, blood
pressure elevation, restlessness, nausea and vomiting, and a
full bladder. Aggressive control and treatment of each of these
Fig. 55.1 Large expanding and bilateral hematoma following facelift
and laser resurfacing.
will significantly reduce the incidence of hematoma (Fig. 55.3).
Therefore, in all our male patients, in addition to clonidine, we
administer postoperative sedation and antianxiety medication.
e do the same selectively in female patients. I have found that
by working with the same anesthesia team, the same operating
room team, and the same recovery room team, the incidence of
hematoma in my personal practice has been significantly reduced.
hen I was first in practice at a university medical center, I did
not always work with the same team in the operating room, nor
did the same team always take care of my patients in the recov-
ery room. During that time, the incidence of hematoma in my
patients was 6 ; over my time in private practice and again in an
academic aesthetic center always working with the same team,
the incidence has been lowered to less than 1 . This parallels the
experience reported by Baker et al in private practice, after they
instituted the guidelines that we have since adopted.
55.2.4 Sequential or Repeat Hematomas
Sequential or repeated hematomas may indicate an underlying
deficiency in the blood-clotting system. Even a bilateral hema-
toma may point to blood-clotting problems. e routinely review
the patient’s platelet count and solicit a history of bleeding
tendencies, hematoma, or prolonged bleeding associated with
previous dental or surgical procedures. In patients with unusual
bleeding during the procedure or those with sequential or
bilateral hematoma, administration of desmopressin acetate
(DDAVP; Ferring Pharmaceuticals, Saint-Prex, Switzerland) has
proved effective. The recommended dose is 0.3 mcg/kg given
intravenously over a 10-minute period. More recently there has
been interest in tranexamic acid. Although it has proven to be
effective in resulting in a drier field during surgery, as yet it has
not proven to reduce hematoma rates.
55.2.5 Management of Hematoma
Expeditious and appropriate management of hematoma will
minimize its consequences. Immediate decompression of an
845
 VIII Surgical Rejuvenation of the Face and Neck

Fig. 55.2 Medications to avoid before surgery.

846
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery

expanding hematoma in the recovery room or at the bedside can

often defuse the situation. Patients with expanding hematomas
are agitated, apprehensive, fearful, and in pain. Cutting the
sutures and inserting a gloved finger or sterile instrument will
deliver the clots, relieving some of the tension, pain, and anxiety.
It is important to assure the patient that the blood pressure, anxi-
ety, and pain are all under control. Baker and colleagues advocate
not only drainage but also complete management of facelift
hematomas at the bedside. I prefer to take the patient back to
the operating room for exploration and control of the hematoma
rather than trying to deal with it in the recovery room or at the
bedside. Once the hematoma has been decompressed, there is
time to call a team if needed and prepare an operating room. In
the operating room, with the patient under general anesthesia (if
appropriate), or otherwise under sedation and local anesthesia
with full monitoring, enough sutures are removed to allow access.
If need be, all of the sutures are removed. I resist the temptation
to trivialize the hematoma and to minimize my treatment of it.
Once the wound has been adequately opened, all of the clots are
evacuated. A dilute 10 solution of hydrogen peroxide is useful
in breaking up the clots. The wound is thoroughly explored, and
sometimes no actual source of bleeding is identified. If a source of
bleeding is identified, it is suture-ligated or cauterized as needed.
The open wound is then observed for any further evidence of
bleeding and then closed over a suction drain.

Management of Hematoma Fig. 55.3 Key conditions to avoid to prevent postoperative hematoma.
• Control blood pressure
• Control anxiety and pain
• Remove sutures
• Evacuate all clots In the final analysis, it is unlikely that hematomas can be totally
• Irrigate with dilute peroxide to break up clots eliminated. However, experienced surgeons, anesthesiologists,
• Close over drains and operating room and recovery room nurses can reduce the
incidence of hematoma to 1 or less by focusing on details.

The patient shown in Fig. 55.4, whose primary facelift was

performed elsewhere, developed a small localized hematoma in
her right cheek. This was initially observed and was aspirated at a
later date. It has left her with a contour irregularity.
I have emphasized that an undrained, expanding hematoma
can lead to disastrous skin slough or even airway compromise.
Even a small, undrained hematoma will lead to problems such as
contour irregularities, prolonged ecchymosis, prolonged swelling,
seroma, and scarring. I prefer to open and drain all postoperative
hematomas, regardless of size, to minimize these sequelae.
55.3 Skin Slough
Skin slough most commonly results from tension on the skin
rather than direct vascular compromise. The two most common
causes of tension are tight closures and expanding hematomas.
Factors leading to underlying circulatory problems that can
increase the risk of skin loss include smoking, acne scarring,
and diabetes. I do routinely ask all patients interested in facial
rejuvenation whether they have had fillers and, if so, what type

a b
Fig. 55.4 (a,b) Contour irregularity of the right cheek that developed at the site of a localized hematoma after a facelift, managed nonoperatively.

847
 VIII Surgical Rejuvenation of the Face and Neck
of filler and any barbed suture lift, which may rarely aeffect the
subdermal circulation. Unusual and devastating infections may
also lead to skin necrosis (Fig. 55.5).
55.3.1 Avoiding Skin Slough
Skin sloughs are minimized through measures taken before,
during, and after the operation. High-risk patients, including
smokers and those with acne scars, are identified preoperatively.
Smokers are advised to stop smoking 3 or 4 weeks before and after
surgery. However, it is impossible without a urine test to establish
that patients have followed directions, because they all claim to
have done so; I do not routinely ask for a urine test to confirm that
the patient has ceased smoking. These high-risk patients are also
started on systemic and local antioxidants, such as oral and topical
vitamin C. The surgical approach to these patients is modified. Skin
incisions, planes of dissection, and the extent of skin undermining
are significantly altered in high-risk patients. henever possible,
skin incisions are minimized and modified to avoid long retroau-
ricular flaps. Skin undermining is limited, and deeper planes of
dissection, such as subperiosteal, subgaleal, and sub-superficial
musculoaponeurotic system (SMAS), are preferred. I have found
that the short-scar facelift, which limits retroauricular incisions
or undermining, is a good option in smokers. In some smokers I
recommend a two-stage procedure to achieve an excellent result.
I explain to all of them that given the restraints on the degree or
extent of undermining, they should not expect an outstanding
result. Concomitant skin resurfacing is restricted to the areas
that have not been undermined or is postponed for a later time.
Heavy or tight dressings are avoided, and the tissues are kept moist
through the judicious application of petrolatum-based ointments.
Postoperatively, a strict no-smoking policy is strongly emphasized.
55.3.2 Treatment of Skin Slough
The early treatment of skin ischemia or a pending slough is
reduction of tension by removing the sutures. If necessary,
nitroglycerin ointment ( itrol; Paladin Labs, Montreal, Canada)
Fig. 55.5 Skin slough following facelift.
848
is applied to the compromised flap. In the rare patient in whom
infection is the cause of sloughing, the infection is aggressively
treated. Hyperbaric oxygen has been advocated for the treat-
ment of facelift flap compromise and necrosis. This may well be
an option, especially in a patient who smokes. Long-term treat-
ment of skin slough requires patience from the surgeon and the
patient. The surgeon must show a great deal of understanding
and must frequently reassure the patient that eventually all of
the wounds will heal. It is best to allow open wounds to heal
secondarily and to deal with the consequences once the wound
is healed. Late treatment of skin slough includes compression,
topical agents, steroid injection, and eventually scar revision or
even secondary procedures.
The patient shown in Fig. 55.6 had a full-thickness skin loss
after a staphylococcal infection. She was treated conservatively,
and the area was kept moist. It had almost completely closed
through contraction and spontaneous epithelialization by 6
weeks. The resultant scar matured sufficiently, so no scar revision
was necessary.
55.4 Nerve Injuries
Motor branches of the facial nerve and sensory nerves, mostly
branches of the trigeminal nerve, are at risk during facelifts.
Rarely, injuries to the accessory nerve have also been reported.
55.4.1 Sensory Nerves
Sensory nerve injuries in facial aesthetic surgery are uncommon
and are rarely of serious consequence. The great auricular nerve
is at risk during standard facelift procedures; the supraorbital,
supratrochlear, and zygomaticotemporal nerves are at risk
during brow lifts; the infraorbital nerve is at risk during subperi-
osteal midface lifts and during the placement of cheek implants;
the zygomaticofacial nerve is at risk during subperiosteal
midface procedures; and the mental nerve is at risk during chin
augmentation (Fig. 55.7).
The great auricular nerve is most at risk during face- and neck
lifts. It emerges around the posterior border of the sternocleido-
mastoid muscle at Mc inney’s point, 6.5 cm below the external
a b
Fig. 55.6 (a) Full-thickness skin loss after a staphylococcal infection.
(b) Near-complete healing by secondary intention at 6 weeks.
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery
Fig. 55.7 Sensory nerves at risk during facial aesthetic surgery.
a b
Fig. 55.8 (a,b) Anatomy of the great auricular nerve.
auditory meatus, and courses almost directly upward to the
earlobe (Fig. 55.8). The surgeon can avoid injury to this nerve
through knowledge of its anatomy and cautious flap elevation over
the sternocleidomastoid muscle. Leaving the sternocleidomastoid
fascia intact will usually protect this nerve. It is advisable in sec-
ondary face- and neck lifts to perform this dissection under direct
vision rather than blindly, because the preexisting scar tissue may
distort the planes of dissection. Injury to the nerve will lead to
numbness of the lower two-thirds of the ear. This sensory loss is
not debilitating, but a painful neuroma of the greater auricular
nerve can be. If an injury to the nerve is recognized, the surgeon
should attempt to repair it with the aid of magnification. If this is
not possible, the proximal stump should be buried well within the
sternocleidomastoid muscle to prevent a neuroma. Painful great
auricular nerve neuromas are rare, and even more rarely these
neuromas may present as a neck mass and be mistaken for an
enlarged lymph node.
The supraorbital nerve emerges from the orbit through a notch or
a foramen, usually in the midpupillary line, and provides sensory
innervation to nearly half of the forehead and anterior scalp. The
lateral branch, which courses along the temporal crest, is respon-
sible for most of the innervation of the anterior scalp. Injury to the
supraorbital nerve during endoscopic brow lift is rare. However,
the surgeon must be aware that this nerve can emerge through
a foramen up to 2 cm above the orbital rim, so blind dissection
should be limited to a distance of 2 to 4 cm above the orbital rim,
and the orbital rim should be approached endoscopically to avoid
nerve injury. The lateral, sensory branch of the orbital nerve is
almost always divided during a transcoronal brow lift, resulting
in forehead sensory loss, paresthesias, and dysesthesias. These
849
 VIII Surgical Rejuvenation of the Face and Neck
sensory changes, fortunately, are usually temporary but can be
permanent.
The supratrochlear nerve has multiple branches, emerges
through the orbit medially within 1 or 2 cm of the midline, and
usually courses within the corrugator muscle. It provides sensory
innervation for a narrow strip of medial forehead and brow on
each side. During an endoscopic brow lift, one or two branches of
the supratrochlear nerve may be disrupted during the corrugator
muscle excision. This is rarely of any clinical significance.
The zygomaticotemporal nerve is a very small nerve that
emerges through the temporal fascia, usually accompanying the
more lateral of the two sentinel veins. hen viewing this nerve
during an endoscopic brow lift, I make every attempt to preserve
it, although injury to the nerve is of little consequence.
The infraorbital nerve emerges through a foramen 1 or 2 cm
below the inferior orbital rim in the midpupillary line and inner-
vates the cheek, lips, and teeth. It is rarely at risk during subcuta-
neous or sub-SMAS facelift procedures. It is at greatest risk during
subperiosteal midface dissections, whether through the mouth,
lower eyelid, or temporal area. However, injury to this nerve is
extremely rare because it is very large, easily identified with or
without an endoscope, and difficult to injure with a periosteal
elevator.
The zygomaticofacial nerve is a small nerve that emerges through
a foramen 1 to 2 cm lateral to and below the lateral canthus. It is
at risk only during subperiosteal dissection of the periorbital area.
Unlike the infraorbital nerve, the zygomaticofacial nerve is very
small and very easily divided. It is always accompanied by a small
blood vessel, and often the only indication that the nerve has
been divided is the bleeding. I make every attempt to identify and
preserve this nerve during subperiosteal midface lifts. Division
of the nerve is of little consequence in terms of sensory loss, but
Fig. 55.9 Anatomy of the facial nerve.
850
irritating discomfort in the area has been attributed to division of
the nerve.
The mental nerve emerges through the mandible in the midpu-
pillary line at the level of the second premolar. This nerve is at risk
during subperiosteal dissection for placement of chin implants.
Fortunately, it is a large nerve that is easily identified and not
easily injured with a periosteal elevator. Injury to the nerve results
in debilitating sensory loss in the lips and teeth.
55.4.2 Facial Nerve
One of the most devastating and long-lasting complications after
facial rejuvenation surgery is permanent injury of a branch of the
facial nerve. Fortunately, the incidence of facial nerve paralysis
is fairly low. In a reported series of 6,500 patients, facial nerve
paralysis was seen in 0.7 , with only 0.1 permanent. ith
endoscopic brow lifts, the incidence of temporary paresis to the
frontal branch of the facial nerve has been consistently reported
at 1 , with permanent injury of 0.1 . My personal experience
parallels these reported series, but I have been fortunate enough,
in over 41 years, not to have permanent paralysis in any of my
patients.
The facial nerve branches most at risk include the buccal,
frontal, and marginal mandibular branches. Recently concern has
been raised about the zygomatic branches in association with
complex periorbital procedures (Fig. 55.9).
Most commonly reported injuries involve the buccal branches;
however, because these are multiple branches rather than a single
nerve, recovery is usually seen within 3 to 4 months. The frontal
branches are the next most frequently reported injured nerves,
and these are also multiple branches rather than a single nerve,
so recovery is the rule; however, recovery takes longer than after
buccal branch injury. The marginal mandibular branch is a single
nerve, and complete recovery after injury is rare. Fortunately, the
resulting asymmetry of the mouth can be improved through the
judicious administration of botulinum toxin on the opposite side.
Buccal Branches
The buccal branches are multiple, and injury to all branches is
rare. Dissection below the SMAS, beyond the parotid gland and
masseter muscle, puts these nerves at risk. Therefore, in any
facelift procedure necessitating sub-SMAS dissection beyond
the parotid gland and the masseter, the dissection should be
performed bluntly and with caution. These branches are readily
visible, and injury is easily avoided. Blind or sharp dissection
beyond the parotid gland and masseter should be avoided.
These branches all run deep to the zygomaticus major muscle,
so dissection beyond the zygomaticus major toward the nose
and nasolabial fold is safe as long as it is in a plane above the
zygomaticus major (Fig. 55.10).
Temporal and Zygomatic Branches of
the Facial Nerve
The temporal and zygomatic branches of the facial nerve are at
risk not only during forehead lifts (coronal and endoscopic) but
also with sub-SMAS facelifts, especially techniques requiring a
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery
a b
Fig. 55.10 (a) The buccal branches of the facial nerve course deep to the superficial musculoaponeurotic system (SMAS) beyond the parotid gland.
(b) Medial to the zygomaticus major, the nerve branches run deep to the muscle.
high SMAS dissection. Classically the landmark for identifying
the course of this nerve has been a diagonal line drawn from a
point 5 mm below the tragus to a point 2 cm above the lateral
brow. However, I have found that if the sentinel vein is visible
through the skin, a point 5 mm above the vein will usually mark
the course of the vein. I then draw a diagonal line toward the
tragus and use this as the guideline. Because this nerve runs
under the temporoparietal fascia above the zygoma and very
deep to the SMAS below the zygoma, the surgeon can avoid
injury to the nerve by performing the temporal dissection of
any forehead lift well below the temporoparietal fascia. In fact,
I make a point of placing all of my instruments directly over the
deep temporal fascia, pushing on the fascia as I dissect toward
the zygoma and orbital rim. Below the zygoma, injury is avoided
by staying above the SMAS. However, if high sub-SMAS dissec-
tion is undertaken, injury to the nerve is avoided by dissecting
just below the SMAS. Recent anatomic data demonstrate that
the nerve lies much deeper and closer to the periosteum of the
zygoma rather than just below the SMAS. During a combined
temporal and facial dissection, the development and mainte-
nance of a “mesotemporalis” made up of the temporoparietal
fascia and SMAS will ensure the safety of this nerve (Fig. 55.11).
Marginal Mandibular Branch
Although the marginal mandibular branch is deep to the SMAS
and the platysma along all of its course, it is still susceptible to
Fig. 55.11 Path of the frontal (temporal and zygomatic) branches of
the facial nerve.
injury, especially as it courses over the facial vessels at the level
of the mandibular notch. The two factors contributing to this
area of risk are (1) the thinning of the SMAS and platysma in that
area and (2) the presence of perforating branches of the facial
vessels. The thinning of the SMAS and platysma puts the nerve
at risk during blind dissection, where the scissors can easily
slip through the thin platysma and injure the nerve. The other
mechanism of injury is the use of electrocautery in an attempt
to control bleeding from the perforating vessels. As a general
rule, I prefer to use bipolar rather than the unipolar coagulat-
ing current for hemostasis during facial rejuvenation, because
there is less electrocautery current that can damage the nerve.
In thin individuals I prefer to perform the dissection along the
mandibular border under direct vision to minimize the risk of
subplatysmal penetration (Fig. 55.12).
hen performing subplatysmal dissection of the neck, the
surgeon must keep in mind that the relationship of the marginal
mandibular branch to the inferior border of the mandible is
variable; in fact, it can run 1 to 2 cm below the mandible along
its entire course, not just proximal to the facial vessels and the
mandibular notch.
Although permanent injuries to the branches of the facial nerve
are rare, it is vital that the surgeon be familiar with the anatomy
of these branches, their relationships to the various layers of
the face, their specific danger zones, and the risk afforded each
branch by the more complex and deeper dissections. Familiarity
with specific techniques is essential to minimize risk and avoid
complications. I encourage anyone performing facial rejuvenation
a b
Fig. 55.12 (a,b) Anatomy of the marginal mandibular branch of the
facial nerve.
851
 VIII Surgical Rejuvenation of the Face and Neck
to dissect the layers of the face and branches of the facial nerve in
the cadaver laboratory (Fig. 55.13).
55.4.3 Accessory Nerve
Although extremely rare, injury to the accessory nerve and a
resultant shoulder drop have been reported. The nerve is most
at risk during posterolateral dissection in the neck. The nerve
emerges behind the posterior border of the sternocleidomastoid,
almost at Mc inney’s point or just above, coursing posteriorly
and laterally toward the trapezius (Fig. 55.14).
55.5 Deep Venous Thrombosis
Venous thromboembolism (VTE) and its consequences, deep
venous thrombosis (DVT) and pulmonary thromboembolism
(PE), are devastating, life-threatening, and fortunately uncom-
mon. The exact incidence of DVT in facial aesthetic surgery is not
known. Reinisch et al reported an incidence of 0.35 for DVT and
0.14 for PE in facelifts. A 4-year review of 468 facelifts at Paces
Plastic Surgery revealed two patients with DVT, an incidence of
Fig. 55.13 Facial danger zones where motor and sensory nerves are at
greatest risk during aesthetic facial surgery.
Fig. 55.14 Anatomy of the accessory nerve (called spinal accessory
nerve here). The nerve is at greatest risk as it emerges behind the
posterior border of the sternocleidomastoid muscle.
852
0.4 , with no PE. Our 0.4 compares to the 0.35 reported by the
Reinisch group. Spring and Gutowski surveyed 3,797 plastic sur-
geons in the United States, who reported 15 DVT and PE events
associated with facial cosmetic procedures. Every precaution
should be taken to minimize the risk of DVT. Factors increasing
the risk include the following:
• Age
• eight (BMI)
• Length of procedure
• Family history
• Use of oral contraceptives
• Type of anesthesia
• Underlying risk factors such a Factor V Leiden mutation
The Caprini scale remains the standard for risk assessment for
surgical procedures.
In my practice almost all patients undergoing facial rejuve-
nation fall into the high-risk category. All of these patients are
operated on under general anesthesia; support is placed behind
their knees, and intermittent pneumatic compression garments
are used in all of them (Fig. 55.15). Stuzin et al have reported zero
incidence of DVT in over 10,000 facelifts spanning 30 years, all
of which were performed under local anesthesia with sedation.
They comment that patients operated on with intravenous seda-
tion moved during the procedure, thus reducing the tendency of
venous stasis and DVT.
Risk factors are summarized in Table 55.1.
55.6 Craftsmanship Issues
Some postoperative concerns are not true complications; I prefer
to call them issues of finesse, quality, or craftsmanship. However,
they are the issues that make all the difference in the patient’s
b
Fig. 55.15 (a) Standard pneumatic pressure garments extending from
knee to ankle. (b) PlexiPulse intermittent pneumatic compression
devices (Kinetic Concepts, Inc., San Antonio, T ) placed on feet.
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery

Table 55.1 Venous thromboembolism risk factors for plastic surgeons to consider
Solid, consistent evidence that these are the most important risk factors*
• Prior history of VTE (DVT or PE)
• Malignancy (active or in patient history)
• Thrombophilia disorders (inherited or acquired)
• Factor V Leiden mutation (makes factor V resistant to activated protein C)
• Prothrombin 20210A mutation (found exclusively in whites)
• Antithrombin deficiency
• Protein S and protein C deficiency
• High levels of fibrinogen or plasminogen, factor VIII, factor I , factor I, thrombin activatable fibrinolysis inhibitor (TAFI), or protein C inhibitor
• Low levels of tissue factor pathway inhibitor (TFPI)
• Hyperhomocysteinemia (plasma homocysteine level 18.5 mmol/L)
• Dysfibrinogenemia and polycythemia vera
• Antiphospholipid antibodies (lupus anticoagulant and anticardiolipin)
• Obesity (risk may be highest for those < 40 years of age)
• Use of oral contraceptives, tamoxifen, hormone replacement therapy, or other estrogen-containing drugs
Known to be risk factors but probably not in the top tier; do not disregard as unimportant
• Age ≥ 40 years (risk rises as age rises)
• General anesthesia (risk rises with each hour in surgery, regardless of procedure)
• Varicose veins
• Inflammatory disease (inflammatory bowel disease, rheumatologic diseases, especially systemic lupus erythematosus)
• Abdominal surgery (carries higher risk than most other types of surgery)
• Pregnancy, abortion, or miscarriage within 3 months
• Smoking
• Recent hip or knee replacement or hip fracture
• Recent surgery of any kind
• Prolonged travel by air, train, or car
• Recent physical trauma
*Important risk factors that are rarely encountered in plastic surgery practices include prolonged immobilization, ischemic stroke, heart failure, chronic lung disease,
respiratory failure, serious infection, pneumonia, central venous catheterization, paralysis, and spinal cord injury. Some risk factors are permanent (such as a history of VTE or
cancer, chronic disease, thrombophilia, age) and some are transient (such as surgery, travel, estrogen use, pregnancy).

perception of the quality of the result. In this category I include

the following:

• Scar placement and scar quality

• Ear distortion
• Hair loss and hairline distortion
• Contour irregularities

55.6.1 Scar Placement and Scar Quality

I regularly talk to patients to explain where the incisions and
scars will be. Occasionally the patient looks back at me and
comments, ell, there won’t be any scars, will there This is
plastic surgery, after all. I reply that all incisions leave scars and
that the best I can offer them is to place the scars where they will
be imperceptible or at least less noticeable, and that I will make
every effort to ensure the quality of the scars, although this will
depend as much on the location, the tension, and the patient’s
biology as it will on surgical technique.
The key to avoiding undesirable scars is to manage tension
appropriately. Special attention is required in those who are prone
to hypertrophic scarring, especially redheaded individuals with a
ruddy complexion and patients who are keloid prone.
The man shown in Fig. 55.16 underwent a minimal-access
cranial suspension (MACS) lift elsewhere and has hypertrophic
scars in front of and behind his ear, most likely related to tension. Fig. 55.16 Hypertrophic preauricular scar following minimal-access
Note that the horizontal scar below his sideburn has healed well. cranial suspension (MACS) lift.

853
 VIII Surgical Rejuvenation of the Face and Neck
Incisions are planned so that they will be inconspicuous and
allow appropriate distribution of tension. Meticulous closure
under minimal tension and aggressive early management of scar
problems are important. Incisions in the hair are made parallel
to the hair roots; the use of cautery is judicious and limited to
preserve hair roots. Closure must avoid excessive tension, which
damages the hair roots. Incisions along the hairline are also made
in the direction of the hair roots to preserve and encourage hair
growth through the resulting scar.
The preauricular incision should never be a straight line. It
should be broken up above and below the tragus. I prefer the
intratragal incision whenever possible. This incision is made in
such a way that the tragus has a beginning and an end. Far too
often this is not done, and the tragus blends into the lower face,
with a telltale sign of a face lift. The incision behind the ear is
placed either within the sulcus or 1 to 2 mm on the posterior
surface of the ear. My preference is to make it on the ear rather
than within the sulcus (Fig. 55.17).
The woman shown in Fig. 55.18 underwent a facelift by a non-
surgeon who left her with a hypertrophic straight-line scar in front
of her ear and little in the way of facial rejuvenation. I saw her in
consultation and performed a secondary facelift with appropriate
a b
Fig. 55.17 (a–c) The preauricular incision should be broken up above and below the tragus and should never be a straight line.
a b
Fig. 55.18 (a,c) Hypertrophic straight-line preauricular scar. (b,d) Seven-year postop photos following secondary facelift demonstrate a normal-ap-
pearing tragus and favorable scar.
854
placement of the incisions. Seven years later, the tragus appeared
natural and there was no hypertrophic scarring or distortion.
Distribution of tension during the closure defines the quality
of the resultant scar. Tension should usually be placed at the level
of the concha, behind the earlobe, and behind the ear, never in
the preauricular or tragal area or the earlobe. Once the skin
tension has been appropriately distributed, the excess skin along
the preauricular area and behind the ear is excised and closed in
two layers under no tension. Usually this closure will not require
a suture any larger than a 6–0. If sutures stronger than 6–0 are
required for this closure, there is too much tension and the scar
will widen unacceptably (Fig. 55.19).
The patient shown in Fig. 55.20 had a facelift with the full classic
incision including preauricular intratragal incisions; scars are
inconspicuous in early postoperative and late postoperative views.
Preoperative and 4-year postoperative views of a patient who
underwent a short-scar facelift with a preauricular intratragal
incision ending at the earlobe are shown in Fig. 55.21.
Closure of the retroauricular incision requires as much atten-
tion to detail as, or perhaps even more than, the preauricular
incision. It is very unusual to see hypertrophic scarring in front
of the ear; however, it is not so uncommon to see it behind the
c
c d
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery

b c
Fig. 55.19 (a) Excess skin is excised only after tension is distributed at key sutures. (b,c) The incision is closed in two layers and under no tension.

a b c
Fig. 55.20 (a) Preop, (b) early postop, and (c) late postop photos following facelift with the full classic incision including preauricular intratragal
incisions.

855
 VIII Surgical Rejuvenation of the Face and Neck
a b
Fig. 55.21 (a) Preop and (b) 4-year postop views following a short-scar
facelift with a preauricular intratragal incision ending at the earlobe.
ear. I think this is related to excessive tension and overresection
of retroauricular skin. Another problem is scar migration in an
outward direction from the retroauricular sulcus. This is avoided
by anchoring the posterior ear skin and the facelift flap skin to the
mastoid fascia with every bite or every other bite when closing
the retroauricular portion of the incision.
Treatment of undesirable scars includes intralesional injection
of steroid medications and the application of topical creams,
silicone gels, or 5 Fluorouracil (5FU). Scar revision may also be an
appropriate treatment.
55.6.2 Ear Distortion
Very often, close observation of the tragus and earlobe will
reveal telltale signs of a facelift. ot only the appearance of the
scar but distortions of the tragus and earlobe attract the eye and
scream out: es, I have had a facelift
The tragus must have a beginning and an end, and it must
project outward from the face and external auditory meatus with
a gentle posterior tilt. Forward displacement renders the external
auditory meatus more visible, creating the impression that it has
been enlarged. This is a result of excessive tension with no break
a b
Fig. 55.22 (a) Nearly ablated tragus and wide-open external auditory
meatus from a prior facelift. (b) Intraop view prior to surgical
correction.
856
above or below the tragus. An extreme example is the ablation
of the tragus. This is avoided by deepening the pretragal sulcus,
especially in secondary face lifts, and, if necessary, by suturing the
pretragal skin into the sulcus.
The patient shown in Fig. 55.22 had had a previous facelift that
resulted in near-complete ablation of her tragus with wide-open
external auditory meatus. Her earring conceals the pixie ear
deformity. On the right, her ear is seen on the operating table
before a secondary facelift.
Earlobe problems are related to improper closure around the
earlobe. I prefer to leave the earlobe hanging free rather than
suturing it to the skin flap. This allows the natural angle of the
dangle described by Connell. Suturing the earlobe leads to pixie
earlobe deformity and a migration of the earlobe into the neck,
another telltale sign of a facelift.
Another finesse issue with the earlobe is the concomitant
reduction of the earlobe at the time of a rhytidectomy. This is
especially important in older patients who have large, pendulous,
creased earlobes. The addition of autologous fat or filler into
the aging earlobe will eliminate the creases and render a more
youthful appearance.
55.6.3 Hair Loss and Hairline Distortion
Hairline distortion is one of the most common stigmata of a
facelift. Possible distortions include the following: elevation or
elimination of the sideburns, irregular retroauricular hairline or
a stepoff, and frontal hairline elevation. The most common prob-
lem, however, is scar alopecia. This is also the simplest problem
to resolve.
Elevation or Elimination of Sideburns
Sideburn elevation or elimination is avoided by appropriate
placement of the incision. In a primary facelift in a patient with a
short sideburn, I will make a prehairline incision, and in all patients
undergoing secondary facelifts I will also make a prehairline inci-
sion. This affords ample exposure for the facelift without any change
in sideburn position. An alternative is to continue the preauricular
incision into the temporal area and to take out the skin triangle
below the sideburns. This will also maintain sideburn length.
After a previous facelift, the woman shown in Fig. 55.23 had
elevation of the hairline, with elimination of sideburns and a
wide, depigmented preauricular scar.
In Fig. 55.24, preoperative and postoperative views are shown
of a patient who had a secondary facelift. Hairline distortion and
sideburn shortening were avoided through a prehairline incision
extending into the preauricular, intratragal, and retroauricular areas.
Irregular Retroauricular Hairline
Retroauricular hairline stepoffs and distortion are avoided by
aligning the occipital hairline first and then resecting the excess
retroauricular skin and scalp. A certain amount of tailoring is
needed in patients with excess or loose neck skin.
Frontal Hairline Elevation
The high-forehead hairline is seen more commonly with coronal
rather than endoscopic brow lifts, although brow elevation is
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery
Fig. 55.23 Elevated hairline, absent sideburn, and wide preauricular
scar following facelift.
also seen with the endoscopic approach. This problem is best
avoided by techniques that allow shortening of the forehead; all
of these techniques entail an incision in the frontal hairline, an
incision that some patients are not willing to accept.
Scar Alopecia
Hair loss is avoided through minimization of tension and with
gentle tissue handling. Overuse of the electrocautery, tight
sutures, and staples will damage hair roots. The most common
a b
Fig. 55.24 (a) Preop and (b) postop photos following secondary
facelift. Hairline distortion and sideburn shortening were avoided
through a prehairline incision extending into the preauricular, intratra-
gal, and retroauricular areas.
scar alopecia that I have encountered has been at the external
screw fixation site associated with the endoscopic forehead
lift. All of these problems are relatively easy to correct through
simple excision of the bald spots under local anesthesia.
Very rarely, after facial aesthetic surgery and brow lift (notably
endoscopic brow lift), there may be partial or full alopecia of the
entire scalp. Fortunately, most of these are self-limiting. Topical
use of minoxidil (Rogaine) and steroids may accelerate the
recovery. In patients with thinning hair, as a preventive measure
I encourage the preoperative and postoperative use of Rogaine on
the scalp.
55.6.4 Contour Irregularities
Contour irregularities result from improper defatting, SMAS
plication, and mismanaged hematoma. By far the most common
cause is injudicious or excessive fat grafting.
Oversuction or suction too close to the dermis, especially in
the neck, will lead to banding and skin adhesion to the platysma.
These irregularities may not be visible at rest but are very
distracting on animation of the facial muscles, especially the
platysma. This is best avoided by leaving 3 to 5 mm of fat on
the deep surface of the skin, keeping the suction cannula hole
pointed away from the dermis, and limiting the number of passes
in each tunnel.
Excessive fat removal in the subcutaneous plane to mask or
correct problems deep to the platysma is a common error that is
often difficult to reverse, as is seen in Fig. 55.25. Overaggressive
fat removal from her neck and submental area has unmasked
platysma bands and prominent digastric muscles.
SMAS plication with or without SMAS resection can lead to
contour irregularities. These are best avoided by inspecting and
ensuring a smooth subcutaneous contour before closure. Multiple
sutures should be placed to ensure that the plication and suture
lines are smooth without any discernible irregularities.
Even the smallest hematoma, if inadequately drained, will lead
to prolonged swelling, subcutaneous scarring, and irregularities.
These irregularities are best treated through lymphatic drainage
a b
c d
Fig. 55.25 (a–d) Excessive fat removal in the neck and submental area
has unmasked platysma bands and prominent digastric muscles.
857
 VIII Surgical Rejuvenation of the Face and Neck
and skin massage. I have also found external ultrasound useful,
especially with the banding in the neck. Steroid injections may
also be helpful. Reoperation is also an option.
Some patients refer to these contour irregularities as waves.
There are some patients, however, in whom the waves are seen
only on animation, representing what I think is an imbalance of
the mimetic muscles of the cheek after deep and subperiosteal
procedures. These are difficult problems to correct and may be
related to disruption and reattachment of muscle origins and
partial denervation.
55.6.5 Motion Distortion
One of the more difficult problems to correct following a facelift
is the distortion observed on animation, especially in the cheek
area. The cause of such distortions is not fully understood, which
makes the problem difficult to correct. It is thought to be related
to a change in the relationship of the muscles of facial expres-
sion with the overlying soft tissues and/or the underlying bony
skeleton.
55.7 Infections
Infections after facial aesthetic surgery are extremely rare,
because the face has a plentiful blood supply. Recent data from
CosmetAssure report a 0.2 incidence of surgical site infection
with facelifts. However, the sequelae of infection can be serious
and include skin slough and scarring. All patients undergoing
facial aesthetic surgery should have their faces washed and hair
shampooed with antiseptic shampoo on the day of the proce-
dure. The face and hair should be prepared and draped as with
any other surgical procedure. I still use perioperative antibiotics
on all patients undergoing facial aesthetic surgery, although this
is controversial.
Very rarely, Pseudomonas infection of the face is seen in swim-
mers who harbor this organism in their auditory canals. As a pre-
caution, we always soak the earplugs in povidone-iodine solution
(Betadine, Avrio Health, Stamford, CT) before placing them in the
external auditory meatus.
55.8 Other Rare Complications
Although perforation of the parotid gland capsule or even the
gland itself is encountered with sub-SMAS dissections, such
violations of the gland and its capsule are very rarely of any
consequence. However, a few cases of parotid fistula and even
parotid cysts have been reported after rhytidectomy. The fistula
may present as serous drainage through the wound, often mis-
taken for a seroma. Evaluation and definite diagnosis includes
testing the drainage for amylase. Sialoceles present as swell-
ings along the mandibular angle, typically 10 days to 2 weeks
postoperatively. The swelling may well be mistaken for a delayed
hematoma, but, in contrast to a hematoma, there is no bruising
and it is insidious in origin, enlarging slowly. If encountered,
these problems are usually self-limiting and will resolve spon-
taneously. However, it is important to ensure that the parotid
duct is intact. If the problem does not resolve spontaneously,
858
exploration and open drainage will be required. Scopolamine,
which decreases salivary secretion, may be helpful in managing
this problem. Injections of botulinum toxin A into the parotid
gland will reduce its secretions and is the preferred treatment.
55.9 Concluding Thoughts
The results of a facelift are at best temporary. The consequences of
complications may be permanent.
Claudio Cardoso de Castro
Although complications cannot be totally eliminated, careful
patient selection and preparation, attention to surgical and
anesthesia detail, and attentive postoperative management by
an experienced team will significantly reduce complications.
In contrast to any other field of surgery, or even to other areas
in aesthetic surgery, complications and unfavorable results
affecting the face and neck cannot be concealed or otherwise
protected from public view. The problems are out there, not only
for you and the patient to see, but for the entire world! This is
especially true for the patient’s family and close friends and hair
stylist. It is vital to understand that, regardless of how minor or
inconsequential the problem may seem to the surgeon, these
problems are significant for the patient. The patient’s concerns
must be openly discussed, the patient must be reassured, and
every attempt should be made to rectify the problem as expedi-
tiously as possible with minimum or no expense to the patient.
After evacuation and closure of facial hematomas, I routinely
reassure the patient that the hematoma will in no way affect
the quality of the result but may delay the recovery, especially
the resolution of the ecchymosis. Patients with temporary facial
nerve paresis are reassured that in all likelihood the weakness
is temporary and that permanent facial nerve weakness is
extremely rare. None of us is happy about complications, least
of all me. I make every attempt to see and take care of all my
patients personally whenever possible. This becomes even more
important with patients who have a complication. It is their own
surgeon they want to see, not the surgeon’s partner, assistant, or
nurse. Their own surgeon should see them on every visit, and it is
important that the visits become more frequent. Anything short
of this will lead patients to believe that at best their surgeon is
avoiding them and at worst their surgeon has abandoned them.
Complications and patient dissatisfaction with results test
not only the established doctor-patient relationship but also
our abilities as physicians and compassionate human beings.
The confidence and trust of the patients gained over a period of
weeks, months, or even years is threatened or lost very easily if
the situation is not handled sensitively.
Do not hesitate to consult partners or colleagues when dealing
with complications, especially in patients who express anger or
even undue concern that their problems have not been as self-
limiting as you have indicated. In patients who will need extensive
revisions, it is important to seek the advice of partners and other
colleagues and to resolve financial issues up front and as soon as
possible.
The best way to deal with complications is to avoid them. If
we cannot avoid them, we must remedy them expeditiously and
effectively.
 55 Avoidance and Management of Complications in Facial Aesthetic Surgery
Clinical Caveats
• Preoperatively, patients should be given a list of medications,
herbal remedies, and dietary supplements to avoid.
• Appropriate blood pressure management should be initiated
before, during, and after the operation to reduce the risk of
hematoma.
• The perioperative use of clonidine is recommended.
• Pain, anxiety, nausea, and blood pressure elevation must be
treated aggressively in the recovery room.
• An expanding hematoma must immediately be decom-
pressed; it is a potential disaster.
• Excessive tension on the skin should be avoided.
• The surgeon should be familiar with the anatomy of the
sensory and motor nerves at risk.
• Sub-SMAS dissection beyond the parotid gland should con-
tinue under direct vision.
• Blunt instruments are best for sub-SMAS dissection beyond
the parotid gland.
• If possible, bipolar is preferred over unipolar coagulation of
bleeders below the SMAS.
• Preventive measures should be taken to avoid DVT in all
patients.
• The surgeon should be an artisan, taking the time necessary
to produce a satisfactory result.
• The sideburns and hairline should be respected, keeping
changes minimal.
• A natural-appearing tragus and earlobe should be maintained.
• The surgeon should be kind to the hair roots.
• Oversuction of neck fat should be avoided.
• A smooth facial contour must be left under the skin flap.
• Complications must be treated expeditiously.
• Autologous fat grafting should be judicious, avoiding
overgrafting.
• It is important to remember that the patient’s facial compli-
cation is on view all the time.
Suggested Reading
[1] Abboushi , ezhelyev M, Symbas , ahai F. Facelift complications and the
risk of venous thromboembolism: a single center’s experience. Aesthet Surg J
2012;32(4):413–420
2 Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas.
Plast Reconstr Surg 2005;115(7):2119–2122, discussion 2123
3 Baker DC, Stefani A, Chiu ES. Reducing the incidence of hematoma requiring
surgical evacuation following male rhytidectomy: a 30-year review of 985 cases.
Plast Reconstr Surg 2005;116(7):1973–1985, discussion 1986–1987
4 Baker DC, Conley . Avoiding facial nerve injuries in rhytidectomy. Anatomical
variations and pitfalls. Plast Reconstr Surg 1979;64(6):781–795
5 Baker T , Gordon HL. Complications of rhytidectomy. Plast Reconstr Surg
1967;40(1):31–39
6 Baker T , Gordon HL, Mosienko P. Rhytidectomy: a statistical analysis. Plast
Reconstr Surg 1977;59(1):24–30
[7] de Chalain T, ahai F. Amputation neuromas of the great auricular nerve after
rhytidectomy. Ann Plast Surg 1995;35(3):297–299
[8] Connell BF. Correcting deformities of the aged earlobe. Aesthet Surg J
2005;25(2):194–196
[9] DDAVP: official FDA information, side effects and uses. Drugs.com. http://www.
drugs,com/pro/ddavp.html Accessed December 4, 2019
10 Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after
platysmal face-lift operation. Plast Reconstr Surg 1979;63(3):364–368
[11] Freilinger G, Gruber H, Happak , Pechmann U. Surgical anatomy of the mimic
muscle system and the facial nerve: importance for reconstructive and aesthetic
surgery. Plast Reconstr Surg 1987;80(5):686–690
12 Grover R, ones BM, aterhouse . The prevention of haematoma follow-
ing rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg
2001;54(6):481–486
13 ones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a person-
al 8-year quest. Reviewing 910 patients. Plast Reconstr Surg 2004;113(1):381–
387, discussion 388–390
14 ones BM, Grover R. Reducing complications in cervicofacial rhytidectomy by
tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts.
Plast Reconstr Surg 2004;113(1):398–403
15 eyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety
using an Internet-based quality improvement and peer review program. Plast
Reconstr Surg 2004;113(6):1760–1770
16 eyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Recon-
str Surg 2008;122(1):245–250, discussion 251–253
[17] aoutzanis C, Gupta V, inocour , Shack B, Grotting C, Higdon . Incidence
and risk factors for major surgical site infections in aesthetic surgery: analysis of
129,007 patients. Aesthet Surg J 2017;37(1):89–99
[18] Lawrence T, Murphy RC, Robson MC, Heggers P. The detrimental effect of
cigarette smoking on flap survival: an experimental study in the rat. Br J Plast
Surg 1984;37(2):216–219
[19] Lawson GA III, reymerman P, ahai F. An unusual complication following rhyt-
idectomy: iatrogenic parotid injury resulting in parotid fistula/sialocele. Aesthet
Surg J 2012;32(7):814–821
20 McDevitt B; American Society of Plastic and Reconstructive Surgeons. Deep
vein thrombosis prophylaxis. Plast Reconstr Surg 1999;104(6):1923–1928
21 Mc inney P, atrana D . Prevention of injury to the great auricular nerve during
rhytidectomy. Plast Reconstr Surg 1980;66(5):675–679
22 Patronella C , Ruiz-Razura A, ewall G, et al. Thromboembolism in high-risk
aesthetic surgery: experience with 17 patients in a review of 3871 consecutive
cases. Aesthet Surg J 2008;28(6):648–655
23 Pitanguy I, Machado BH. Facial rejuvenation surgery: a retrospective study of
8788 cases. Aesthet Surg J 2012;32(4):393–412
24 Peterson RA, ohnston DL. Facile identification of the facial nerve branches. Clin
Plast Surg 1987;14(4):785–788
25 Rees TD, Barone CM, Valauri FA, Ginsberg GD, olan B III. Hematomas
requiring surgical evacuation following face lift surgery. Plast Reconstr Surg
1994;93(6):1185–1190
26 Reinisch F, Bresnick SD, alker , Rosso RF. Deep venous thrombosis and
pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast
Reconstr Surg 2001;107(6):1570–1575, discussion 1576–1577
27 Rees TD, Lee C, Coburn R . Expanding hematoma after rhytidectomy. A retro-
spective study. Plast Reconstr Surg 1973;51(2):149–153
28 Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap surviv-
al in the face lift patient. Plast Reconstr Surg 1984;73(6):911–915
29 Schwember G, Rodr guez A. Anatomic surgical dissection of the extraparotid
portion of the facial nerve. Plast Reconstr Surg 1988;81(2):183–188
30 Spring MA, Gutowski A. Venous thromboembolism in plastic surgery patients:
survey results of plastic surgeons. Aesthet Surg J 2006;26(5):522–529
31 Stuzin M, agstrom L, awamoto H , olfe SA. Anatomy of the frontal branch
of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg
1989;83(2):265–271
32 Trinei FA, anuszkiewicz , ahai F. The sentinel vein: an important reference
point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32
33 oung VL, Botney R. Patient Safety in Plastic Surgery. St Louis, MO: uality
Medical Publishing; 2009
34 oung VL, atson ME. The need for venous thromboembolism (VTE) prophylax-
is in plastic surgery. Aesthet Surg J 2006;26(2):157–175
859
 Part IX
Rejuvenation of
the Cheeks, Chin,
Lips, and Ears

IX
 56 Rejuvenation of the Aging Mouth

56 Rejuvenation of the Aging Mouth

Christopher D. Knotts, Byron D. Poindexter, Robert K. Sigal, and George W. Weston

with around-the-mouth surgery a thorough understanding of

Abstract
how and when to use these operations safely. In the current era
Evaluation of the perioral region is an absolute requirement when of social media, instant gratification, and the industry-driven
talking to patients about facial rejuvenation. An aged mouth left hordes of noncore practitioners armed with hyaluronic acid (HA)
surgically untouched in the setting of rejuvenating the rest of fillers, adding volume to the lips is touted to patients as a solution
the face will leave the patient looking out of proportion, done, for all that ails the perioral region. hile volume has a place in
and unnatural. In this chapter we present how to evaluate the rejuvenation, we will discuss how to address the mouth in terms
aging mouth, the most common surgical procedures to correct of both shape and size.
normal perioral aging, and clinical pearls relevant to both sea-
soned plastic surgeons and those starting to implement perioral
rejuvenation into their aesthetic practice. e provide photo- 56.2 Pertinent Anatomy
graphs, videos, and insight accumulated over 40 years of private
The aging mouth has several predictable anatomic changes, each
aesthetic practice borrowed from five board-certified plastic
carrying its own symbol. ith time, the upper lip lengthens,
surgeons with over 100 years of combined clinical experience.
covering the upper incisors like a curtain and concealing the
attractiveness of dental show. This is particularly evident in
Keywords the nonvermilion skin between the nasal sill and the upper lip
vermilion, known as the ergotrid. As the soft tissue support of
lip lift, corner mouth lift, vermilion advancement, direct excision
the lips becomes lax and atrophic, the corners of the mouth
droop and widen, mimicking displeasure or disgust. ith bony
56.1 Introduction loss, the vermilion falls into the mouth, which looks gaunt, aged,
and ill. The vermilion thins and deflates. Lines form and deepen
Perioral rejuvenation has a certain degree of subtlety compared around the mouth and in the nasolabial and marionette regions,
to other areas of aesthetic plastic surgery. Foremost, many ideal symbolizing advancing age.
patients do not know they are candidates for the procedures. hile patients may not recognize the specific anatomy, they
hile a breast augmentation patient will often present with are astute to the symbols their face conveys to others. It is this
most of an operative plan already developed, and facial rejuve- incongruency between external facial symbolism and internal
nation patients will often present knowing they want a facelift, emotional state that leads some patients to seek plastic surgery
seldom does a patient request around-the-mouth surgery. The (Fig. 56.1). Perioral surgery aims to align the internal state with
burden falls on the surgeon to broach the subject. Leaving an the desired external symbolism.
untouched mouth in the setting of surgically addressing the rest
of the face leaves the patient looking disharmonious, unnatural,
and operated-on.
Perioral surgery may be a small part of a larger discussion
about total facial rejuvenation. In that context, patients readily
understand that the mouth ages along with the rest of the face,
and that if they want an overall youthful look, the mouth will
also need correction. However, some patients lack facial harmony
simply because of an imperfection in their perioral anatomy, and
like the patient who requires an isolated chin implant to balance
the face, some patients require only a perioral operation to restore
proportion. The procedures outlined in this chapter are most
often used to make an aged mouth look younger in the setting of a
full facial rejuvenation, but each can also be used as a stand-alone
procedure.
As regular speakers at plastic surgery meetings over the last
several decades, we have observed a trend of aesthetic surgeons
at our talks to embrace perioral surgery as a key component of Fig. 56.1 This patient with an aging mouth exhibits the typical charac-
total facial rejuvenation. This chapter is intended to offer the teristics of a long upper lip, loss of maxillary dental show, downturned
experienced surgeon some nuances developed over years of corners, numerous perioral rhytids, vermilion deflation, deepening
folds, and lower lip vermilion falling into the mouth.
experience and also to offer the plastic surgeon inexperienced

863
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
56.3 Preoperative Assessment
The preoperative assessment involves two main parts: first,
choosing the right patient for surgery and second, choosing
the right surgery for that patient. The ideal patient is willing to
accept a facial scar, typically imperceptible at conversational dis-
tance, for a more youthful appearance. This is an easy discussion
in the full facial rejuvenation patient preparing for incisions on
the forehead, eyelids, around the ears, and so on. In all patients,
high-quality pre- and postoperative photographs are a critical
part of the process. e routinely show patients photographs and
also have the luxury of multiple staff members and surgeons
who have had procedures performed themselves and can show
the patients exactly what a real and mature scar looks like in
person.
Specific anatomic considerations to note for perioral surgery
include presence of nasal sill, nasolabial angle, condition of teeth,
occlusion class, incisor show in repose, oral commissure position,
perioral rhytids, deflation changes, existing scars, nasolabial lines,
marionette folds, and philtral effacement.
56.4 Surgical Procedures
56.4.1 Lip Lift
The lip lift is used to shorten a long upper lip and involves a
final surgical scar under the nasal base. The procedure was
first presented in the 1970s by the Brazilians, and we have been
perfecting this procedure since the early 1980s in our group
practice. There have been several adaptations of the procedure
and different names employed by others to describe essentially
the same operation, but the general concept of removing excess
Fig. 56.2 Some of the varieties of lip lift that can be performed based on patient anatomy.
864
skin from below the nasal sill to shorten a long upper lip is the
same. This procedure is indicated for patients with an aged and
long upper lip in the setting of a normal bite and good dentition.
Caution should be exercised in patients with a long lip and max-
illary dental show in repose, as shortening the lip can worsen the
appearance of maxillary excess. Lip lifts in these patients should
be conservative. If a patient has a lip shorter than 10 mm or a
highly arched Cupid’s bow before surgery, the lip lift should be
minimal or combined with a corner mouth lift. Similarly, in the
setting of downturned corners and a long lip, the corners should
be addressed concomitantly, as a lip lift can make the corners
look more drooped if they are not also addressed.
Markings
The markings of the lip lift vary based on patient anatomy (Fig.
56.2). The ideal upper lip is short enough to reveal several milli-
meters of incisor show, and this is generally no shorter than 10
mm when measuring from the nasal sill to the vermilion. The
ideal candidate has a well-defined nasal sill. Often patients may
show effacement of the nasal sill below the nostrils, and in these
patients the markings are done as a bull’s horns so that the
final scar is concealed cephalad, inside the floor of the nostril.
The lateral extent of excision is the nasal ala. Extending the
scar out beyond the ala in the region of a eir excision makes
the scar more visible with minimal improvement in result and
is not recommended. Caution is exercised in patients with
an obtuse nasolabial angle, as the scar will be more visible. In
these patients, altering the nasolabial angle by taking down the
nasal spine at the time of lip lift can be beneficial. A lip lift is
not recommended in patients with poor condition of maxillary
dentition, as a shortened lip in the setting of unattractive teeth
leaves a poor aesthetic result.
 56 Rejuvenation of the Aging Mouth

Operative Technique
An isolated lip lift can be performed under local or general anes-
thesia. Local 1 lidocaine with epinephrine is infiltrated beneath
the surgical marks. After adequate time for the anesthetic to take
effect, the upper and lower incisions are made straight down
through dermis. The muscle is not disturbed or manipulated. A
conservative undermining of 1 to 2 mm is done inferiorly, and
hemostasis achieved with electrocautery. The temptation to
undermine farther distally to release perioral rhytids should
be avoided, as this can result in a tethered and irregular final
scar with unnatural orbicularis oris movement postoperatively.
Closure is carried out in two layers: 6–0 polyglactin (Vicryl,
ohnson ohnson, ew Brunswick, ) suture is placed in an
everting, interrupted, buried fashion and at least three sutures
are used. This suture can be used to grasp the nasal spine supe-
riorly to minimize inferior scar migration. The skin is closed
with everting mattress polypropylene (Video 56.1). A good result
will look overdone in the early postoperative period but relaxes
significantly (Fig. 56.3).
56.4.2 Corner Mouth Lift
The corner mouth lift comes in several varieties depending on the
degree of aging present. Attention should be paid to preoperatively
assessing the upper vermilion and commissure. ith normal
aging, the upper lip vermilion can disappear as it approaches
the oral commissure (Fig. 56.4a). ith more advanced cases, the
commissure itself may also droop (Fig. 56.5a), and occasionally
the droop will continue on as a marionette fold (Fig. 56.6a).
Depending on the deformity and on the patient’s tolerance for
a facial scar, the operative plan may include a standard corner
mouth lift, a wraparound corner mouth lift, or a boomerang
corner mouth lift. All of these procedures involve placing a surgical

Fig. 56.3 (a) This patient is deemed a good candidate for a lip lift with a long lip, revealing her mandibular dentition in repose. (b) Because her
nasal sill is effaced below the nostril, her markings are taken up into the nasal floor in a “bull’s horns” pattern. (c) At day 1 postop, the patient has an
overdone result. (d) Lip relaxes significantly by 1 week. (e) Result is socially acceptable by 3 weeks. (f) By 3 months, the scar is fading and the result
shows restored facial harmony.

Fig. 56.4 (a) This patient underwent a traditional corner mouth lift with fat grafting and no other perioral surgery. Note that her upper lip vermilion
disappears several millimeters before the oral commissure. This is a sign of normal aging. (b) The markings for a standard corner lift terminate in
the oral commissure and should extend no farther medially than the philtral column. (c) In her 3-month postop photograph, the vermilion has been
rolled up and out, so it now extends to the commissure, giving a more natural and youthful appearance.

865
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears

Fig. 56.5 (a) This patient underwent a wraparound corner mouth lift with lip lift, dermabrasion, fat grafting, and neuromodular treatment of
depressor anguli oris and mentalis muscles. Note the symbolism in her preoperative state of looking grumpy and disappointed. (b) The markings
show the new location of the oral commissure will be toward the blue dot. (c) In her postoperative photograph, there is a dramatic improvement in
her facial symbolism.

Fig. 56.6 (a) This patient shows minimal commissure descent preoperatively, but her vermilion begins to disappear approaching the commissure,
making her a good candidate for a boomerang corner mouth lift. (b) In this case, the loss of vermilion continues on as a marionette fold, and thus the
markings connect a corner mouth lift to excise the fold as well. (c) In her postoperative state the scar is nearly imperceptible.

scar from the lateral commissure extending medially along the In planning the corner mouth lift, the excision should be
upper lip vermilion edge. onvermilion tissue from the ergotrid planned with the expectation of some postoperative relaxation.
is excised and removed to advance the vermilion into an aesthetic hile the degree of relaxation is not as dramatic as in a lip lift,
location. This is essentially an upward advancement of vermilion the result on the table should be slightly overdone to allow for
near the oral commissure. relaxation.
The differences in the three types of corner mouth lift are in
what happens with the scar near the commissure. For a standard
Markings
corner mouth lift, the scar terminates at the commissure. For a
A standard corner mouth lift is performed by hovering the
wraparound, the final scar continues around the commissure
marker over the commissure and then using the nonmarking
and extends into the lower vermilion border. For a boomerang,
hand to simulate the degree of lift desired. The hovering marker
the scar continues down into the beginnings of a marionette fold,
is then touched to the skin and the nonmarking hand is removed,
essentially combining the corner mouth lift with a direct excision,
dragging the skin across the marker tip to leave behind a vertical
which is discussed later on. In cases where the commissure
line that shows the extent of the skin to be removed. The inferior
requires lifting, a wraparound corner mouth lift can be a powerful
marking edge is the vermilion border, and the marks are tapered
tool in lifting this tissue to its normal anatomic location. A boo-
out to allow for closure without standing deformity (Video 56.2).
merang will also alter the commissure position.
Examples including markings of the three types of corner
It is not recommended that the scar along the upper lip vermil-
mouth lifts are demonstrated in Fig. 56.4b, Fig. 56.5b, and Fig.
ion edge traverse any farther medially than the philtral column, as
56.6b, respectively.
this can distort the delicate anatomy in this region.
Another version of the corner lift, which left a final scar
extending out straight laterally from the commissure as a small Operative Technique
whisker line, has essentially been abandoned (Fig. 56.7). This An isolated corner mouth lift can be performed under local
sometimes scarred quite well, but in the cases where it did not, or general anesthesia. As in a lip lift, the incisions are made
the scar became a lipstick bleed line in an unnatural location and down to but not through muscle. Minimal if any undermining
was difficult to correct. is undertaken before two-layer closure with interrupted 6–0

866

Fig. 56.7 Original corner mouth lift with final resulting “whisker” scar, now abandoned due to patient concern for lipstick bleed postoperatively.
polyglactin and skin polypropylene. The sutures are removed
before 7 days, and the scar is typically excellent by 3 months.
For a wraparound corner lift, conservative undermining is done
over the commissure to allow the tissues to lift into their new
location with minimal tension. A boomerang marries a corner
mouth lift to the direct excision, discussed later in the chapter.
Results of the three types are shown in Fig. 56.4c, Fig. 56.5c, and
Fig. 56.6c, respectively.
56.4.3 Vermilion Advancement
A vermilion advancement is a lower lip procedure used to pull
collapsed vermilion that has fallen into the mouth with aging
and bone loss back to its normal anatomic location (Fig. 56.8a).
This is done by excising nonvermilion tissue below the lower lip
and advancing the vermilion into its place. The final surgical scar
is along the red vermilion junction.
e do not recommend performing a vermilion advancement
of the upper lip, as the necessary peaks and valleys of the final
scar traversing the Cupid’s bows can distort terribly if the scar
contracts at all. This is unnatural and difficult to manage, though
other surgeons have reported convincing results. In the patient
with severe collapse of upper lip vermilion, there is almost always
a long upper lip, and substantial improvement can be achieved
with a lip lift, fat grafting, and often also a corner mouth lift.
Markings
The markings for vermilion advancement span the length of
the lower lip. The superior marking is at the edge of pigmented
vermilion, and the inferior edge of the marking is placed just
below the desired final border to account for the small amount of
relaxation of tissues that typically occurs (Fig. 56.8b).
Operative Technique
Vermilion advancement is almost always performed in conjunc-
tion with other perioral procedures. This means scars will be in
close proximity. hen combining this procedure with a corner
mouth lift, it is generally recommended to allow for a gap of sev-
eral millimeters of untouched tissue between the two final scars
to minimize the risk of scar contracture around the corner of the
mouth. This means a wraparound corner mouth lift is seldom
performed with a full lower lip advancement, or that a gap is left
56 Rejuvenation of the Aging Mouth
between the lower limb of the wraparound and the start of the
vermilion advancement.
A vermilion advancement can be performed under local or
general anesthesia. If under local anesthesia, mental nerve blocks
are performed as well as direct injection of local for hemostasis.
The upper and lower incisions are made, and the lower lip skin
is excised without manipulating the muscle. After hemostasis is
achieved, closure is carried out with a single-layer skin closure
(Fig. 56.8c).
Sutures are removed before 7 days, and the scar is typically well
concealed. Any scar irregularities can be touched up with revision,
but that is a rare occurrence, and the scars typically are acceptable
to patients (Fig. 56.8d).
56.4.4 Direct Excision
The difficult area of facial rejuvenation between the commissure
and cheek led us to extend the incisions from around the mouth
down onto the bare cheek skin. This courageous endeavor has
now been undertaken thousands of times in our practice and
matured from being a backup plan or staged secondary proce-
dure after primary facelift and fat grafting to being now part of
the primary facelift.
It is a matter of experience to determine whether deep folds
can be remedied with fat grafting and a facelift alone or whether
direct excision will be required. One useful tool is to mimic the
tension of a facelift preoperatively and carefully assess the naso-
labial region. If the folds are still deep or unchanged, it is unlikely
they will be eliminated with facelift alone. That being said, we are
still sometimes surprised with the results obtained without direct
excision (Fig. 56.9).
Often patients may be reluctant to have a direct excision
because of the concern for a poor scar, and surgeons unfamiliar
with direct excision techniques are unable to disabuse them. It is
a reasonable option to stage a direct excision until after facelift
and fat grafting. If the patient is counseled preoperatively about
the chance of requiring a later excision of nasolabial or mario-
nette tissue under local, they will not find it surprising if that
happens.
If the decision is made to perform the direct excision at the time
of primary facelift, however, it is our recommendation to do the
direct excision first, partially close it, and then perform a slightly
more conservative facelift than usual. If the facelift is performed
867
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
Fig. 56.8 (a) This patient shows severe collapse and thinning of the
lower lip in the setting of facial aging. (b) The markings are shown for
lower lip advancement among other perioral procedures. Note that
the lower lip markings do not extend all the way to the commissure,
as she is having a concurrent corner mouth lift. (c) The immediate
postoperative suturing is shown with a single-layer closure. (d) The
postoperative result at 3 months shows a rejuvenated perioral region
as part of a full-face rejuvenation. Procedures performed include brow
lift, upper blepharoplasty, lower blepharoplasty, midface lift, lip lift,
corner mouth lift, lower lip advancement, facelift, neck lift, facial fat
grafting, and fractionated laser resurfacing to face, neck, and chest.
first, the swelling of the flap will give the impression that there
is no excess tissue in the nasolabial region, and the surgeon will
lose the courage to perform the direct excision. Once the swelling
begins to subside in the weeks following surgery, the excess tissue
will again manifest itself.
The prediction of which patients would benefit from direct
excision as well as facelift comes with experience and choosing
the right patients. In those with multiple or very deep nasolabial
and/or marionette lines, direct excision is a powerful addition to
the traditional facelift (Fig. 56.10).
Markings
The markings for direct excision extend across the area of
deformity (Fig. 56.11). Ideally the distal ends of the excision fall
into a tissue depression to hide any dog-ears. The excision may
encompass an entire nasolabial fold, an entire marionette fold,
a combination of both, or be combined with a corner mouth
lift as a boomerang corner mouth lift (Fig. 56.6b). A video of a
patient being marked for direct excision and corner mouth lift is
provided (Video 56.3).
868
Fig. 56.9 (a) This patient shows disappearing vermilion near the
commissure and also a deep marionette fold. (b) She declined any
direct excision at the time of primary facelift and was still able to
achieve a good result in the marionette region from facelift, fat
grafting, lip lift, and standard corner mouth lift.
Operative Technique
Direct excision can be performed under local anesthesia or as
part of facial rejuvenation. As in the other perioral procedures, the
incisions are through dermis only. Because the direct excision is
more prone to having some fullness at the tapered ends, superfi-
cial fat may require removal beneath the tapered incision ends.
Closure can be with temporary staples if this is performed at the
time of primary facelift, as this allows the tension of the facelift
to be set so facelift skin can be excised, and then formal closure
of all incisions can be done at the end of the case. The closure
of the direct excision is ultimately done in two layers with 6–0
polyglactin in the deep dermis and polypropylene in the skin. The
scars in the region of direct excision are pinker for longer than
those of other perioral surgeries, and patients should be coun-
seled regarding this. By 3 months the scars are well concealed at
conversational distance.
56.5 Postoperative Care
After perioral surgery, patients are continued on antibiotics
for less than 24 hours and placed on a short course of antiviral
to prevent a herpetic eruption. e encourage the use of topical
bacitracin ointment to keep any scabs soft and make the suture

Fig. 56.10 (a) This patient exhibits preoperative findings of the loss of upper lip vermilion near the commissure, a deep marionette fold, multiple
perioral rhytids, and a relatively well-defined Cupid’s bow with a slightly long upper lip. (b) She is shown marked for corner mouth lift and direct
excision of a marionette fold as well as fat grafting to rhytids. (c) At 3 months, the scars are near invisible. Her lip aesthetics are drastically improved,
and the stern symbolism is improved compared to preoperatively.
removal process easier. The sutures are removed before 7 days
and patients can wear makeup 24 hours after suture removal.
Scars are treated with topical silicone cream and reassessed at 6
weeks for evidence of hypertrophy. In this rare instance, a dilute
injection of steroid and 5-fluorouracil (5-FU) typically arrests the
condition. Management of other postoperative complications has
been detailed elsewhere.
56.6 Ancillary Surgical Procedures
56.6.1 Mucosal Advancement Flaps
If there is inadequate red upper lip vermilion to accept fat
grafting, and the lip is too short, an intraoral V- mucosal
advancement flap can be performed, but this is rarely used in
our practice. In the patient with adequate upper lip vermilion
volume and an already short lip without the appropriate amount
of incisor show, cosmetic dentistry to lengthen the incisors can
be used if the teeth are short, or a LeFort operation can be used
to lengthen a short maxilla.
Fig. 56.11 Some of the varieties of direct excision that can be tailored
to excise existing facial creases.
56 Rejuvenation of the Aging Mouth
56.6.2 Fat Grafting
Fat grafting is performed in the vast majority of our facial reju-
venation procedures. It is first line for adding volume to lips and
perioral rhytids during facial surgery. Although the lips seem
to be a challenging area for consistent graft take, it remains a
workhorse thanks to low cost, availability, and ease of use. e
also routinely freeze fat for later “touchups” in the immediate
postoperative course. Although cell culture research we have
performed shows loss of viability with freezing, we see results
with the frozen fat and believe this to be achieved through the
scarring process. In patients with deep folds and unwillingness
to undergo excision, we will use sharp subcision, fat grafting,
and horizontal mattress sutures removed at 4 days to allow the
fat a space to heal while minimizing suture train tracking.
56.6.3 Dermis Grafts
In patients resistant to fat grafting, or those with significant
collapse and unwillingness to tolerate a lip scar, we use de-
epithelialized dermis threaded through the lip with a tendon
passer. e have used this technique below very deep perioral
rhytids as well with limited success.
56.6.4 Alloplastic Implants
The use of implants for lip augmentation has lost favor in our
practice. The unnatural movement, occasional migration, and
asymmetry have led us to use the methods previously outlined
to create an ideal lip aesthetic.
56.6.5 Perioral Resurfacing
For patients with severe and numerous perioral rhytids, skin
resurfacing using dermabrasion, chemical peels, or lasers can
be a useful addition to the surgical plan. Often patients with
the worst perioral skin conditions are the least likely to tolerate
the significant recovery associated with complete skin resur-
facing. These kinds of skin changes take a lifetime of neglect to
accumulate, and patients may find it difficult to hear that the
damage cannot be simply undone without significant tradeoffs.
Perioral resurfacing methods are seldom used in our practice as
869
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
a stand-alone solution and are typically coupled with excisional
procedures.
Care must be taken in treating any areas that have been sub-
sequently undermined. Another limitation to the use of perioral
resurfacing is the associated pigmentation changes. In attempts
to eliminate fine rhytids completely, there is often a residual
pinkness or hypopigmentation that we have found to be an unac-
ceptable tradeoff. e generally lean toward undertreating and
leaving some lines rather than creating a pigmentation problem
that may be impossible to correct.
For relatively superficial lines, we employ dermabrasion by
painting the skin with methylene blue and using a coarse dia-
mond fraise to remove all the blue pigment, occasionally cleaning
the fraise with a brush and hydrogen peroxide to maintain a
consistent epithelial removal.
In patients with deeper rhytids, we use a tunable full-field
erbium laser at a depth of up to 800 microns ablation to induce
peel or use several sessions of fractional treatment in the post-
operative period. For those with the most sun damage and deep
lines, we will use phenol/croton oil peels and do not treat any
undermined areas simultaneously.
56.7 Ancillary Nonsurgical
Procedures
56.7.1 Alloplastic Fillers
e use HA fillers almost exclusively to add volume to young
patients simply wanting more fullness. In the aging mouth, fillers
work up to a certain point for such areas as nasolabial folds, but
when the effect is no longer as good, or if we worry the patient
will look overplumped and odd, we have the conversation about
surgically correcting the shape of the perioral region and then
going back to fillers and volume as a maintenance treatment.
Fillers are also used as a “touchup” in the instance of poor fat
graft survivability. Fillers are best used in lips that have been
already made youthful using the excisional techniques described.
e find a volumized lip that is still long, downturned, or collapsed
to be a dead giveaway the practitioner did not appreciate the
anatomy and used the wrong procedure to treat the patient. In
these instances, the filler often requires dissolving so that the
underlying structure can then be addressed properly.
56.8 Results
The excisional procedures outlined in this chapter have been
used in thousands of patients and are a component of the surgical
plan in over half of the hundreds of facial rejuvenation cases we
870
perform annually. ith astute preoperative analysis and patient
counseling, we have found no better substitute.
56.9 Concluding Thoughts
Much as the periorbital region cannot be rejuvenated without
making incisions around the eyelids, the aging mouth cannot be
successful without the addition of direct surgical excisions. This
ethos is gaining acceptance in aesthetic plastic surgery, and we
believe the tradeoff of a well-planned surgical scar for a shapely
perioral region is worthwhile and necessary.
Clinical Caveats
• The ideal upper lip height is no shorter than 10 mm.
• A lip lift relaxes significantly and should be overdone on the
operating table.
• A corner mouth lift relaxes some and should be only slightly
overdone.
• Vermilion advancement is recommended chiefly for the lower
lip.
• Vermilion advancement combined with corner mouth lift
should have an untouched gap of tissue between the final
scars.
Suggested Reading
[1] Austin H . The lip lift. Plast Reconstr Surg 1986;77(6):990–994
2 Austin HA. Rejuvenating the aging mouth. Perspect Plast Surg 1994;8:27–56
3 Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip. In: Heuston T, ed. Trans-
actions of the Fifth International Congress of Plastic and Reconstructive Surgery.
Butterworth, Australia, 1971
4 Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg
2006;33(4):567–577
5 Fanous . Correction of thin lips: lip lift . Plast Reconstr Surg 1984;74(1):33–41
6 Guerrissi O, Sanchez LI. An approach to the senile upper lip. Plast Reconstr Surg
1993;92(6):1187–1191
[7] Haworth RD. Customizing perioral enhancement to obtain ideal lip aesthetics:
combining both lip voluming and reshaping procedures by means of an algorith-
mic approach. Plast Reconstr Surg 2004;113(7):2182–2193
[8] notts CD, Poindexter BD, Sigal R , eston G . Perioral aesthetic surgery. In:
Cohen M , Thaller SR, eds. The Unfavorable Result in Plastic Surgery: Avoidance
and Management, 4th ed. ew ork, : Thieme; 2018:402–410
[9] notts CD, Sigal R , eston G . Rejuvenation of the aging mouth. Presented at
the American Society of Plastic Surgeons. Boston, MA, October 16, 2015
10 Penna V, Iblher , Bannasch H, Stark GB. Proving the effectiveness of the lip lift
for treatment of the aging lip: a morphometric evaluation. Plast Reconstr Surg
2010;126(2):83e–84e
[11] eston G , Poindexter BD, Sigal R , Austin H . Lifting lips: 28 years of experi-
ence using the direct excision approach to rejuvenating the aging mouth. Aesthet
Surg J 2009;29(2):83–86

57 e nemen in y e
Kayvan Shokrollahi and Jamie Barnes
Abstract
This chapter describes an approach to otoplasty that is patient
focused and, to a certain extent, patient led. The request for treat-
ment is introduced as a new concept in consent, and emphasis
is placed on patient wishes over strict anatomic descriptions of
the aesthetic ear, in keeping with published evidence supporting
this concept.
In recent years, suture-based otoplasty techniques have been
augmented by use of the postauricular fascia system. Evidence-
based scar placement, the use of fascia both to detension sutures
and to protect them from extrusion and also to provide further
repositioning of the ear, and the use of glue as a dressing charac-
terize the approach described. This facilitates a safe, reproducible
technique with a low complication rate and can obviate the need
for head bandages, with simple gluing of the helical rim adequate
for wound closure and cover.
A considerable amount of focus is placed on the patient
experience, from consultation through the procedure to the
postoperative stage and healing process. ith technically sound
outcomes achievable in a reproducible manner, these previ-
ously secondary considerations now come to the fore. Prone
positioning is discussed to facilitate teaching, dual operating,
and optimization of the patient experience by using hand-held
devices as distraction. Discharge from the operating theater
with an open, optional follow-up appointment is proposed
as a potential option for this low-risk and low-maintenance
technique.
Keywords
otoplasty, postauricular fascia, fascial flap, request for treatment,
head bandage
57.1 Introduction (Philosophy)
The oft-quoted principles of A. . McDowell have guided the
myriad approaches to otoplasty that have been developed over
the last 50 years. These include correcting all aspects of upper
pole protrusion, a smooth helical rim, an intact postauricular
sulcus, symmetry to within 3 mm, acceptable predetermined
distances between pinna and head (10–12 mm, 16–18 mm, and
20–22 mm in the upper, middle, and lower thirds, respectively),
and, finally, that both helices should lie lateral to the antihelices
when viewed from the front.
These goals have been widely accepted and targeted and cer-
tainly have significant merit, yielding consistently aesthetically
pleasing results where they are met. However, while under-
correction” is obviously unsatisfactory, “overcorrection” or “an
operated look is equally to be avoided. The standard definition
of this phenomenon, however, is slightly dogmatic in origin and
possibly contrary to clinical evidence.
e nemen in y e ni ue
ni ue
A small clinical study has demonstrated that, for example,
an ear with a prominent antihelix can be quite aesthetically
pleasing to many independent observers and actually prefera-
ble to a more traditional McDowell ear. This study also noted
that some observers who were plastic surgeons critiqued ears
as “overdone” only to discover that in fact they had not been
operated on. This variation in the natural appearance of ears
is to be expected, but the aesthetic acceptance of the general
public can lie in contrast with traditional teaching about ideal
parameters.
ith this in mind, the search for a natural -looking ear widens
and, while deviating wildly from McDowell’s principles is unlikely
to yield pleasing results, it is possible to be slightly less rigid in the
pursuit of a pleasing and natural result.
The key question for surgeons remains, of the numerous
otoplasty techniques, which one should they adopt, or at least
which are the key principles they wish to incorporate into their
own practice Our advice is that the answers to these questions
should be formulated based on the patient experience with a
holistic view, rather than based on anatomy. For example, will the
patient need head bandages with this technique hat are the
risks of this technique over another How many appointments are
required Is local anesthesia possible How quick is the recovery
How much does it cost to do it this way And so forth.
57.2 Indications and
Contraindications
There are several anatomic, psychological, and logistic consider-
ations to be taken into account when planning otoplasty surgery.
The pliability of neonatal ear cartilage has been demonstrated
clinically with successful correction of deformity using splints
in the first few weeks or months after birth. Later interventions
require longer splintage times and offer more variable results.
After the first few months of life, splintage is unlikely to be suc-
cessful, and for those that employ it, it can be traumatizing for an
infant and parents.
The ear is expected to reach 85 of adult size between ages 3
and 6, and indeed, growth restriction has not been demonstrated
in comparisons of ear growth between operated and nonoperated
ears of children as young as 9 months old. It is worth noting that
most authors advocating for surgery in children under 5 years old
advocate suture-based techniques, and this may play a role in the
lack of growth restriction.
Anatomic parameters for an aesthetic ear are well described
but are rarely used in the assessment stage as an indication for
surgery. In general terms, a reasonable case would present as a
prominence of the ear that is noticeable and undesirable to the
patient with or without underdevelopment of the antihelical fold,
which the surgeon feels can be reasonably corrected to within
socially acceptable proportions to the patient’s satisfaction. The
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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
normal morphology of the ear has been demonstrated to vary
widely in the relative positions of the anatomic components, and
ultimately an anatomic change is sought that can be impactful
enough to enact a psychological benefit.
The psychological benefit may be sought by parents or the
patient themselves. Of course, a patient-driven consultation with
a clear anatomic problem is straightforward. A parent-driven
consultation can present challenges that must be dealt with sen-
sitively. Parents are often anxious about potential for bullying or
social exclusion because of ear prominence, sometimes based on
personal experience.
Evidence abounds for the social benefit of otoplasty surgery;
however, evidence for avoiding the onset of social difficulties
by pre-emptive surgery, as opposed to surgery after the onset
of social difficulties, is lacking. hile many children with ear
prominence may go on to live happy and successful lives without
intervention, others will receive comments that inspire them to
seek surgical intervention. In the absence of evidence that delayed
surgery yields inferior benefits, early surgery may result in unnec-
essary procedures being carried out and can risk resentment in
adulthood in the case of an unfavorable aesthetic result.
hile some advocate waiting for children to be sensitized to
their ear prominence before carrying out surgery, the sensitiza-
tion” of the child by parents can possibly be predicted based on
the strength and nature of their assertions.
A patient presenting with minimal anatomic abnormality and
high levels of distress should raise alarm bells. This is true of any
aesthetic patient, and with the increasing pervasiveness of social
media, it seems that ever younger children are under increasing
levels of pressure to seek a physical perfection that may be beyond
reach.
Logistics in our practice mandate that a patient should be able
to comply with postoperative instructions to avoid complications
such as hematoma and wound healing problems. In general terms
this usually means delaying surgery until around the age of 6
to 7. A delay in surgery to a timepoint where local anesthesia is
feasible is also another important consideration to be discussed
with parents and children.
Fig. 57.1 Anatomy of external ear.
872
57.3 Pertinent Anatomy
The anatomy of the external ear is illustrated in Fig. 57.1.
57.3.1 Cartilaginous Framework
The main anatomic contributor to ear prominence is the concha.
The concha can be large and/or effaced, causing underdevelop-
ment of the antihelical fold. Many excisional surgical strategies
have been proposed to reduce the size of the enlarged concha;
however, combing a posterior rotational movement of the concha
with recreation of the antihelix by folding can almost always pro-
duce a pleasing result without the need for excision of the excess
concha. True macrotia is vanishingly rare, and in fact, promi-
nence rather than size is the cause of offense in most instances.
57.3.2 Postauricular Fascia
The postauricular fascia has come into common consciousness
for its use as a flap both to provide structural support while
reshaping the ear and also to provide soft tissue cover to under-
lying sutures, aiming to reduce the risk of recurrence and suture
palpability or extrusion.
The anatomic basis of this tissue has recently been described
in detail. The posterior auricular fascia is characterized by a
well-defined and reliable blood supply as well as being thin and
strong. It has been used in otoplasty as a posteriorly based flap
that is sutured to the helical rim simply to provide suture cover
and, more recently, a flap based on the helical rim and sutured
to the mastoid periosteum to provide the same cover with the
added benefit of holding the ear in its retroverted position, either
destressing the other sutures used to reposition the cartilage or
indeed to provide further repositioning. Use of this fascial flap can
therefore contribute to shape, resilience of repair, and avoidance
of recurrence as well as fine tuning of the end result.
The postauricular fascia has an intrinsic and an extrinsic compo-
nent. The intrinsic postauricular fascia (IPF) consists of fibrofatty
tissue, vessels and nerves, and perichondrium and covers the back
 e nemen in y e ni ue

of the pinna. The extrinsic postauricular fascia (EPF) is continuous

with the occipital musculature and overlies the mastoid area. It
is much thicker, containing the posterior auricular muscles, and
consists of the thick superficial mastoid fascia caudally and the
elastic superficial temporal fascia (STF) cranially. Beneath the STF
is the deep mastoid fascia, which is thin and fibrous in comparison
and attaches to the periosteum of the petrous part of the temporal
bone. The boundary between the IPF and EPF is the auriculoce-
phalic sulcus (Fig. 57.2).
The IPF is supplied by the superficial temporal artery and the
posterior auricular artery and by an anastomotic branch between
these two vessels. The EPF is supplied by the same two vessels
as well as the occipital artery and is served neurologically by the
greater auricular and lesser occipital nerves.
There is a wealth of anastomotic connections throughout the
IPF. This allows a well-vascularized flap to be raised, based ante-
riorly or posteriorly, which can easily support a skin graft if used
for reconstruction.

Fig. 57.2 Anatomy of the intrinsic postauricular fascia (IPF) and the
57.4 Preoperative Assessment extrinsic postauricular fascia (EPF), separated by the auricular fascial
incisura (AFI).
At the initial outpatient assessment a standard medical history,
focused on the nature of the concern regarding the appearance of
the ears, is taken. As with all aesthetic procedures, identification
Risks and complications should be discussed in detail, focusing
of specific anatomic concerns is useful; however, many patients
on common or significant complications such as hematoma,
may simply complain that their ears stick out. Psychological
suture extrusion, infection, and recurrence.
and social issues related to the problem should be explored
ritten consent should ideally be taken in the clinic, with
and documented, and psychological red flags suggestive of
consent being reconfirmed on the day of surgery. Filling in the
overvalued ideas or body dysmorphia should prompt referral for
consent form reflects a process of the patient taking on all of the
psychological assessment. In revision cases, details of the initial
information needed to understand the nature of the procedure,
procedure and, ideally, an operation note should be sought.
what outcome to expect, and what can go wrong. Simply signing
Medical comorbidities and medications are identified and miti-
the form does not provide solid legal evidence that this process
gated appropriately. Care should be taken, if a child demonstrates
has taken place, and this should be supplemented with detailed
syndromic issues, to exclude cardiac abnormalities.
and clear clinic notes.
Examination of the ears should focus on identifying promi-
An alternative approach has been proposed in the form of a
nence in the upper, middle, and lower thirds of the ear; the lobe;
Request for Treatment. This process is patient centered and
presence of an antihelical fold; and any other abnormalities of
patient driven. The paperwork is similar to a standard consent
skin or cartilage (Darwin’s tubercle, Stahl bar, etc.)
form, but rather than the patient consenting to a procedure, the
Examination should then take place with the patient in a
patient requests the procedure, detailing in the patient’s own
mirror, identifying specific anatomic complaints and manually
words and writing, the nature of the procedure and the risks as
correcting the prominence to identify the desires of the patient.
the patient understands them. This process can align patient and
A small proportion of patients will desire an overcorrected look,
surgeon expectations or reveal discrepancies ahead of time and
and in such instances, surgeons would be well advised to ensure
may provide more solid legal evidence of the level of understand-
patient expectations are completely aligned with the surgeon in
ing of the patient and hence the robustness of the consent process
terms of the end result to avoid patient dissatisfaction.
and its documentation.
Asymmetry and any other anatomic abnormalities must be
ritten information regarding the procedure, postoperative
pointed out to the patient, photographed, and documented, as
course, and risks should be given to the patient to take away, and
these may compromise the final result and often may not have
this should be documented.
been noticed by the patient prior to surgery. In revision cases,
Photographs should be taken using anterior, oblique, lateral,
previous access incisions can be assessed for suitability of reuse
and posterior views as standard and with hair positioned out of
or compromise of planned approach.
the way as needed.
Photographs of previous cases are also of great value in demon-
strating expected outcomes, including potential suboptimal
outcomes.
Details of the patient’s expected journey from anesthetic through
57.5 Preoperative Planning
the procedure to postoperative clinic review should be discussed General or local anesthesia can be employed depending on
in detail, including any dressings, postoperative instructions, and patient age, compliance, comorbidity, and preference. Generally
restrictions in terms of personal hygiene and work/play. the lower age limit for local anesthetic in our practice is around

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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
8 to 9 years for carefully selected children, and we can avoid
general anesthesia in up to a third of the younger children and in
two-thirds of older children.
57.5.1 Head Positioning
Otoplasty is traditionally performed with the patient in the
supine position, with the head being turned from side to side
to approach each ear. This conventional approach has been the
preferred option and is certainly the only option for general-an-
esthetic procedures. However, for local anesthetic cases there are
some advantages to considering a prone position, with a number
of potential benefits for patient and surgeon.
A neurosurgical head support is used to allow the patient to lie
comfortably face down more specialist equipment such as this
is preferred over makeshift strategies, mainly in terms of better
surgeon access to the operative site. Gamgee Tissue (Robinson
Healthcare Ltd., orksop, U ) or gauze is padded around the
head to absorb any dripping blood. A platform can be fashioned
underneath the opening in the support to allow the patient
to rest reading material, a tablet, or a smartphone in view (Fig.
57.3). Patients should be made aware that they should inform the
surgeon should they wish to move at any point.
This approach allows two surgeons to operate, facilitating
training cases for a real-time follow my lead approach as well as
reducing operative time by operating on both ears simultaneously
(Fig. 57.4). Full exposure of the posterior approach to both ears is
available throughout without moving the head and without ear
retraction, which greatly facilitates the closure of the skin at the
end of the procedure. This position avoids blood accumulation
in the ear canal, which can be uncomfortable, disorienting, and
nausea inducing and limits hearing. The use of hand-held video
games, books, or tablets can improve the experience for young or
anxious patients and introduce an interesting element of fun into
the proceedings for them.
57.5.2 Hair Preparation
Hair preparation always proves difficult if hair is long. In the
prone position, plaiting of hair with or without antimicrobial gel
Fig. 57.3 Use of a neurosurgical head support to facilitate prone
otoplasty with the patient viewing a tablet screen during the
procedure. Use of a headpiece with a cut-out section is possible, but it
affords less access to the patient.
874
in the periauricular hair is often sufficient. In the supine position,
a combination of hair plaiting plus a swimming cap, which can
be cleaned and reused, and antimicrobial gel can usually deal
with the majority of offending stray hairs. Swimming caps are
difficult to put on without patient cooperation, so the advice is to
ask the patient to put the cap on prior to induction of anesthesia.
57.5.3 Access Incisions
Marking of the posterior access has traditionally been described
in the auriculocephalic sulcus. Ideal scar placement should there-
fore be geared toward adequate access to perform the procedure
as well as final scar visibility. Three-dimensional (3-D) analysis
of a range of posterior scar placements has demonstrated that a
scar in the helical rim has the smallest arc of visibility when the
patient is viewed from behind (Fig. 57.5).
Finally, optimizing the theater environment should be consid-
ered for performing otoplasty, particularly for young patients. The
use of on-table entertainment in the prone position has anecdot-
ally been very well received by patients. Even in the supine posi-
tion, young patients under local anesthetic can be encouraged to
bring their own music playlist to make the experience as relaxing
and as enjoyable as possible.
57.6 Operative Technique:
Using the Postauricular Fascia
to Enhance Otoplasty
The aim of this technique is an operation that provides consistent
good results, low complication rates, with good patient experi-
ence (no suture removal, no dressing changes, no head bandages,
and minimum number of hospital visits).
A posterior, elliptical skin excision is centered over the groove
of the antihelix measuring 8 to 10 mm in width, the length being
determined by the need to address the upper or lower pole.
Superiorly the excision should follow the curve of the antihelix
medially.
Fig. 57.4 Use of neurosurgical head support allows surgeons better
access, and the surgery can also proceed with two surgeons.

Fig. 57.5 The arc of visibility, when viewed from behind, of three potential scar placements: auriculotemporal sulcus (red), helical rim (blue), and in
between (green).
Skin is excised at the subdermal level, leaving behind as thick a
fascial layer as possible over the posterior concha (Fig. 57.6). The
inferior border of the excision is then incised full-thickness down
to the chondral surface, and an anteriorly based fascial flap is then
raised toward the sulcus of the helical rim using blunt dissection
in the subfascial plane, facilitated by the curve of the tenotomy
scissors. The fascial flap is left in continuity with cartilage along
the entire length of the rim (Fig. 57.7). Dissection is completed
when adequate exposure is provided for suture placement.
In instances where a deep conchal bowl is evident, a concho-
mastoid suture using 4–0 poly(ethylene terephthalate) (Ethibond,
ohnson ohnson, ew Brunswick, ) is used to rotate the ear
posteriorly. This is the cornerstone for other aspects of the surgery
to have a more refined and natural look. In the presence of this
suture, the surgeon may demand much less of any other suture
placed. In the overwhelming majority of cases this maneuver will
negate the need to excise excess conchal bowl cartilage, which
is often described in the literature, and avoids the challenges and
e nemen in y e ni ue
potential complications associated with this excision. e have
never needed to cut out cartilage.
ide access to the mastoid can easily be achieved through blunt
dissection and indeed is necessary to allow the needle holder to
be maneuvered comfortably when placing the suture through
mastoid periosteum (Fig. 57.8).
This suture is first passed through mastoid periosteum at
roughly the midpoint of the ear. The auricularis posterior
muscle is an ideal anatomic landmark, and the suture can be
passed around the back of this muscle for consistency of suture
placement between cases and between ears. The strength of this
suture’s attachment to periosteum should be tested rigorously
(Fig. 57.9). The optimum position for the conchomastoid suture
on the concha is often at the midpoint in terms of height, but
superior or inferior placement can subtly lower or lift the ear,
respectively, as well as preferentially add to the correction of the
upper or lower pole if needed. Placement closer to the helical rim
will result in further posterior rotation, but placement too close
875
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
Fig. 57.6 Thin skin excision exposing the postauricular fascia.
Fig. 57.8 Wide exposure of the mastoid fascia as medially as possible to
facilitate suture placement without obliterating the postauricular sulcus.
to the rim can result in a telephone deformity by constricting
the middle third. This should be judged on table, and these two
elements should be balanced when choosing the medial/lateral
position of the conchomastoid suture on the concha.
e advise tying this knot first and leaving the needle attached
on an artery clip for use at the end of the procedure in reinforcing
this suture and providing Mustarde cover by picking up the fascial
flap in the same suture.
Accurate positioning of Mustarde sutures is paramount and will
make the difference between a natural and appropriately corrected
ear and an operated look. A fine-gauge needle can be used to
skewer the desired antihelical fold (Fig. 58.10) to facilitate suture
placement, but this step can often be omitted with sufficient expe-
rience. If the skewer technique is used, the needles can be removed
by an assistant one by one as each Mustarde suture is placed, or the
needle can be used to facilitate marking of proposed suture place-
ment points using ink, and all removed prior to suture placement.
Three Mustarde sutures addressing the inferior, central, and
superior pole are often sufficient, although, if required, there
should be no hesitation in using more.
Mustarde sutures should be tied from inferior to superior. The
reason for this is that manipulation of the ear inferiorly tends to
876
Fig. 57.7 Incision of the inferior border and blunt dissection of the
postauricular fascia to the helical sulcus.
Fig. 57.9 Testing the pullout strength of the mastoid suture.
bring the superior portion along with it to a certain extent. This
means that by tying a superior suture in the desired position first,
subsequent sutures tied inferior to this can result in overcorrec-
tion of the superior pole. Often, superior pole position is the most
critical element, and the placement of this suture should be the
final step, using millimeter precision to position it perfectly.
Once all sutures have been placed, the long conchomastoid
suture is passed through the fascial flap and tied. This provides
cover to the Mustarde sutures and can also be used to tweak the
posterior rotation further by picking up the fascia more anteriorly
or address lobe prominence by picking it up inferiorly.
e advocate the use of 4–0 Ethibond for conchomastoid/
Mustarde sutures, as we have found that these permanent braided
sutures hold well, handle well, and do not form the crystalline
sharp knots of monofilaments, which can easily extrude or
cause discomfort.
The skin is then closed with a subcuticular running 5–0 absorb-
able monofilament poliglecaprone suture (Monocryl; ohnson
ohnson, ew Brunswick, ) with buried knots. The use of the
fascial flap that takes the tension off the suture repair and approx-
imates the skin edges, in addition to the use of glue as splint,
obviates the need for a strong suture for closure. This fine suture
 e nemen in y e ni ue

Fig. 57.10 The use of fine-gauge needles to skewer the antihelical fold into position and provide reference points for suture positioning.

ensures hairline scars with limited potential for knot abscess or and this can cause distress, unplanned reattendance, and other
issues (Fig. 57.11). issues as outlined in the following subsections.

57.7 Ancillary Procedures 57.8.1 Disadvantages of Head Bandages

The earlobe is most easily corrected by a section of fascia dis-
sected from the inferior ear, used as a lever, and sutured pos-
teriorly to achieve the desired position. Alternatively, a suture
positioned inferiorly into the cartilage just above the lobe and
fixed posteriorly can achieve a very good result. A trial-and-error
strategy is simple to employ with minimal risk in this scenario
and, with experience, provides an easy option.
57.8 Dressings and Postoperative
Care
Head bandages are a significant cause of annoyance for patients
and surgeons alike. There is a high rate of accidental removal,
• Patient discomfort, itching and sweating; intolerable in hot
weather
• Patient embarrassment; delayed return to normal activities
(school or work)
• Restriction of bathing, showering, hair washing
• Stigma of surgery for those wishing to be discreet
• Hearing, balance, and nausea issues in some
• Reattendance due to bandages falling off
• Pressure necrosis to skin of ear
• Disguising early signs of postoperative problems (hematoma
or infection)
• Smell of blood retained in hair

877
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
57.8.2 Advantages of Skin Glue
e first published the use of skin glue for postoperative splinting
in 2008, leading to widespread adoption of this safe and simple
technique that both dresses the wound and further de-tensions
any sutures holding the ear in position, among a number of other
benefits:
• Avoids use of head bandages
• Safe
• Simple and quick to apply
• Avoids one clinic appointment for removal of head bandage
and dressing
• Hides stigmata of surgery in those wishing to be discreet,
especially those with long hair
• Allows bathing and hair washing from the first postoperative
day
• Allows for immediate observation of potential complications
and early reattendance
The advantages of skin glue in otoplasty are best epitomized by
the disappointingly frequent request by patients for our services
Fig. 57.11 A hairline scar following otoplasty.
878
specifically to avoid head bandages, rather than any perceived
surgical prowess or reputation
After skin closure, the skin is cleaned and dried and a cyano-
acrylate skin glue is applied to the helical rim from root to lobe.
This is then pressed firmly against the head for up to 10 seconds
(Fig. 57.12). In the awake patient, this can be carried out sitting
up, with the benefit that gravity will drip the glue down the rim
rather than onto the neck, which can be an issue in the asleep
patient. This procedure seals the wound and further retroverts the
ear, taking tension off the sutures. The glue usually holds for 1–3
weeks, and the ear is released through the process of desquama-
tion. Patients can shower and wash their hair from day 1 postop-
eratively. Patient with long hair can cover the ears immediately
and continue daily social interactions with no stigmata of surgery.
o postoperative dressing clinic appointment is required for
removal of bandages. Patients should be counseled preoperatively
that they will have an overcorrected look until the skin glue comes
away and that one ear may be released before the other.
High-risk activities, including contact sports, should be avoided
for at least 6 weeks, and the use of a headband at night to avoid
shearing on the pillow is considered optional. Postoperative
Fig. 57.12 Glue used to stick the helical rim to the head as dressing. (a)
Application of glue to the medial surface of the helix. (b) Pressing the
helix against the head. (c) Second application of glue to the helical rim.
(d) Adhesion of helical rim to head.
 e nemen in y e ni ue

review is at 2–3 months, at which time photographs are taken for
the medical record. ith our technique only one postoperative
appointment is required, and the majority often end up being for
our own benefit to capture the after photograph. Patients trav-
eling a long distance or from abroad can be discharged from the
operating room with appropriate advice and recourse to follow
up only as needed: there are no after-care tasks, head bandages,
dressings, or sutures.
57.9 Outcomes
ith the myriad proven techniques available to choose from,
the discerning surgeon should now be asking which outcomes
can and should be optimized in order to maximize patient
satisfaction. A focus on antihelical angles and nuances of
technique does not necessarily translate into desirable expe-
riences and outcomes for patients. This struck home to me in
a consultation when one patient’s parent stated the reason for
choosing me as the surgeon was simply that you don’t use
head bandages. There are descriptions of techniques that
necessitate three postoperative clinic visits, not including
the obligatory impromptu return for a slipped head bandage.
Outcomes such as these are not routinely captured in eval-
uations of technique but form a major part of the decision
making process for patients when they are fully informed of
all of the options.
Technical outcomes may be taken as read to a certain extent
at this point, and surgeons should now be asking whether their
technique necessitates head bandages, suture removal, and more
outpatient appointments than other techniques. If so, can the
surgeon still justify this, and has the patient been given a choice
57.10 Results
Fig. 57.13 shows the results of unilateral correction in a 7-year-
old boy presenting with prominence and underdevelopment of
the right antihelical fold.
Fig. 57.14 shows the results of bilateral correction in a 13-year-
old boy who presented with asymmetric, bilateral prominence,
deep conchal bowls, and a poorly developed left antihelical fold.
Fig. 57.15 shows the results of bilateral correction in a 16-year-
old girl who had an asymmetry amounting to only a few millime-
ters although it was noticeable.
57.11 Concluding Thoughts
Ear prominence is a significant cause of psychological morbidity
for adults and children alike. Timely intervention can resolve the
majority of this morbidity; however, an unfavourable outcome
will be obvious and, in the worst instances, deforming.
The importance of patient experience should not be under-
stated. In the pursuit of the optimal patient experience in oto-
plasty, we can now be asking ourselves questions such as Should
I be discharging patients from the operating room with perhaps
only a pro re nata follow-up appointment ould the patient
prefer to have a head bandage after surgery or not ’ and How
many times would the patient like to return to the hospital for
follow-up after surgery

Fig. 57.13 This 7-year-old boy presented with unilateral prominence and underdevelopment of the antihelical fold on the right. The right ear is also
larger than the left. (a) Anterior, (b) lateral, and (c) posterior views are shown. (d,e,f) Three-months post-op. (d) After unilateral correction, the ears
have good symmetry in terms of prominence and contour and the size discrepancy is much less apparent. (e) The right antihelix is now well formed.
(f) The scar is subtle in the helical sulcus and has limited visibility from behind with the ear in its usual position.

879
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears

Fig. 57.14 This 13-year-old boy presented with asymmetric, bilateral prominence with a present, but poorly developed, left antihelical fold and deep
conchal bowls bilaterally. (a) Anterior, (b) oblique, (c) lateral, and (d) posterior views are seen. (e,f,g,h) Three-months post-op. (e) A symmetrical and
aesthetically pleasing result is achieved. (f) Resection of the “hypertrophic” conchal bowl was not necessary. (g) The lateral view demonstrates the
soft and natural contour, which is achieved with cartilage sparing. (h) Posterior view shows inconspicuous scars.

This chapter presents a simple, safe and reproducible approach
that produces consistently good results with a low complication
rate. If a suture comes undone, it can be revised, whereas once
tissue is lost or distorted, we step into the realm of reconstruction,
and our optimum aesthetic goal is often out of reach. As impor-
tantly, this technique allows for minimal downtime and stigma of
surgery, no head bandage, and minimal need for further hospital
visits, which, personal experience has demonstrated to me, can
be significant contributing factors to the development of the
reputation of the otoplasty surgeon.
Clinical Caveats
• Skin excision must be at the level of the dermis to allow
adequate thickness of the fascial flap—this can be achieved
by avulsing the skin having incised the edges and lifted one
end in the correct plane.
• Conchomastoid sutures must have sufficient traction on peri-
osteum to move the head of the patient off the table without
pulling out.
• Consider reinforcing Mustarde sutures with complementary,
supportive sutures holding the same position to halve the risk
of any given suture failure causing a recurrence.
• Bites through cartilage for Mustarde sutures must be deep
enough not to pull through but not so close to anterior
skin as to be visible. On table testing of pull out and visual
assessment of anterior skin can reveal an excessively deep
or shallow bite.
• Dissection down to the mastoid should be kept medial to
avoid obliteration of the postauricular sulcus.

880
 e nemen in y e ni ue

a b c

d e f
Fig. 57.15 This 16-year-old girl presented with unilateral right-sided prominence which was subtle but noticeable. This case presents the unique
challenge of creating a noticeable change of a matter of millimeters. (a) Anterior, (b) lateral, and (c) posterior views are shown. The posterior rotation
of the conchomastoid suture provided most of the correction with subtle use of Mustarde sutures, achieving good symmetry with the unoperated
side. (d,e,f) Three-months post-op. (d) Postoperative anterior view. (e) Lateral view. (f) Posterior view showing inconspicuous scar.

Suggested Reading 10 Shokrollahi , Manning S, Sadri A, Molajo A, Lineaweaver . The prominent

[1] Adamson E, Horton CE, Crawford HH. The growth pattern of the external ear.
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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
58 Rejuvenation of the Chin
Stephen E. Metzinger, Salvatore Lettieri, and Aldo B. Guerra
Abstract
Chin deformities are commonly encountered defects in patients
seeking profile plasty. Careful preoperative evaluation may
identify patients who could benefit from concurrent augmen-
tation or reduction mentoplasty. Alloplastic chin implants and
sliding genioplasty represent the main accepted methods of chin
augmentation, although fat grafting and fillers may be useful
adjuncts or primary tools for minor augmentations or asymme-
tries. Although many procedures may be used for retrognathia
or microgenia, sliding genioplasty may also be used in chin
asymmetry, prognathia, and vertical height discrepancies. This
chapter outlines the methods to analyze the chin and discusses
the treatment options available for correction of chin deformities
as an adjunct to profile plasty.
Keywords
genioplasty, chin augmentation, fat grafting, filler, deoxycholic
acid, profileplasty
58.1 Background
The chin, which is an area defined by the labiomental crease
superiorly, the oral commissures laterally, and the submental-
cervical crease inferiorly, is often overlooked when it comes
to the aesthetic alteration of the face. However, a chin with an
appropriate size, shape, and contour is important for a well-
balanced and harmonious face. e often hear the terms weak
or strong chin to describe menta of certain morphologies
that have both emotional and psychosocial implications for our
patients. Therefore, the art and science behind the surgical alter-
ation of the chin, whether in isolation or as part of an integrated
facial rejuvenation or enhancement procedure, are an important
component of profile plasty.
Genioplasty the alteration of the chin through either osse-
ous manipulation, implant augmentation, fat grafting, or filler
placement is one of the more commonly performed cosmetic
procedures. However, alteration of the chin will cause both
predictable and unpredictable changes to the balance between
maxillomandibular morphology, dental relationship, and the
skin–soft tissue envelope that must be accounted for prior to per-
forming any proposed procedure. Pertinent anatomy and histor-
ical background have been described elsewhere in the literature.
e present pertinent points on proper assessment and treatment
planning, present minimally invasive options, describe different
surgical and nonsurgical techniques, and discuss complications
and results to optimize outcomes.
882
58.2 Preoperative Assessment
Gender, ethnicity, age, and medical comorbidities are important
factors to consider in the overall treatment planning for profile
plasty. From a morphologic standpoint, men tend to have wider,
squarer faces, often with more projected chins and a two-point
light reflection. omen, on the other hand, tend to have nar-
rower faces with a single-point light reflection on the chin (Fig.
58.1). Transgendered individuals may request a combination of
the two. Age can be a factor in the young and elderly popula-
tions. In younger patients, one must avoid performing mandible
surgery too early because the lower facial skeleton is not fully
developed. The dentition is not fully erupted until 15 years of
age, putting it at greater risk of injury during osteotomies. In
elderly or edentulous patients, on the other hand, one must
evaluate whether alloplastic augmentation, fat, or filler materials
might be more suitable due to poor bone stock or problems with
the skin–soft tissue envelope. Most importantly, profile plasty is
an elective procedure and should be performed only in patients
who are medically and psychologically fit. Smoking, though not
an absolute contraindication, increases the risk of complications,
including delayed wound healing and graft failure in both genio-
plasty and fat grafting.
Next, a complete analysis of the lower face and its relationship
to the rest of the face should be undertaken, taking into consid-
eration the dental relationship, maxillomandibular skeletal mor-
phology, deep fat pad volume, and the skin–soft tissue envelope.
The purpose is to determine whether genioplasty alone or formal
orthognathic surgery addressing maxillary and/or mandibular
dysmorphology would best fit the patient’s aesthetic goals.
Sometimes fat grafting or filler is all that is needed, or perhaps a
combination procedure such as genioplasty and fat, or alloplastic
implant with filler. The procedure must be customized to the
individual and the conditions at hand.
58.2.1 Dental Morphology
Evaluation of the occlusal and dental relationships is crucial in
determining whether a procedure is necessary, and if so, which
procedure would best address the patient’s dysmorphology.
Edward Angle’s classification is used to establish the relationship
between maxillary and mandibular dentition. In patients with
normal class I occlusion, any chin deformities can be managed
with isolated manipulation of the chin or overlying skin–soft
tissue envelope. However, patients with class II or III occlusion
require further evaluation to decide whether they will be better
served with a combination of mandibular and maxillary osteot-
omies with or without genioplasty. The presence of any dental
compensation or history of previous orthodontic treatment
is an important part of the patient’s dental history because

underlying skeletal dysmorphology could be revealed upon
evaluation. Lastly, poor or infected dentition should be treated
prior to any discussion about profile plasty. Poor dentition can
lead to increased risk of infection, bone loss, malunion, and poor
outcome.
58.2.2 Skeletal Evaluation
Cephalometric analysis remains the primary guiding principle
behind any manipulation of the facial skeleton. A formal lateral
cephalogram may be useful in some cases. Most patients can be
adequately examined with a combination of proper soft tissue
and dental evaluation. otwithstanding, cephalometric princi-
ples remain central to guide treatment planning, as they form
the basis for many of the soft tissue relationships. In complex
cases, formal osseous cephalometric examination, such as the
Steiner analysis, is helpful in grasping the relationships among
the skull base, the maxilla, and the mandible. The relationship
between sella–nasion–subspinale (S A in Fig. 58.2) and sella–
nasion–supramentale (S B), as well as the relationship between
the maxilla and mandible (A B), can help to ascertain whether
formal orthognathic surgery is necessary. Furthermore, adding
chin points pogonion (Pg) and menton (Me) to the analysis can
help determine whether concomitant genioplasty or soft tissue
manipulation is recommended.
Soft Tissue Analysis
Several tools exist to help with soft tissue analysis, and each
surgeon has a preferred set of methods he or she uses in
determining whether genioplasty or soft tissue manipulation
is needed and the level of movement required. Some of the
more commonly used analytical tools will be presented here,
but this is not comprehensive review of all available methods.
Three-dimensional (3-D) computer imaging and analysis may be
helpful as well as virtual modeling and virtual surgery (Crisalix,
Lausanne, Switzerland).
Fig. 58.1 Average proportions of the human face according to Da
Vinci’s rule of thirds and rule of fifths. Around these averages, men
tend to have wider, squarer faces and more projected chins, while
women tend to have narrower faces.
58 Rejuvenation of the Chin
Every patient should be viewed from frontal, lateral, oblique,
and sagittal views. A life-size photograph to include bilateral
lateral, frontal, and bilateral oblique views can be helpful. From
the front, lip competence and facial height and symmetry can be
analyzed. In addition, the face should be analyzed with lips in
repose and while smiling to see the dynamic soft tissue changes
with animation. Video can be a useful tool in this evaluation. The
following parameters are particularly significance:
1. Lip competence: Patients with lip incompetence may prefer the
aesthetic outcomes of osseous genioplasty over implant aug-
mentation to correct this deformity.
2. Facial height: Facial proportion the height of the lower third of
the face in relation to the middle third of the face should be
measured to decide whether augmentation or reduction is rec-
ommended. Incisor show is a physical evaluation tool used as a
reasonable indicator of facial height dysmorphology. Increased
incisor show and/or mentalis strain can point to a long-face
syndrome pattern, whereas decreased incisor show can signal
a short-face pattern, both of which may be better corrected by
addressing the underlying maxillomandibular skeletal dysmor-
phology with orthognathic surgery.
3. Facial symmetry: Asymmetries of the mandible and chin may
require asymmetric movements and/or multiple osteotomies in
addition to incremental soft tissue adjustment with fat or der-
mal filler.
Fig. 58.2 Cephalometric analysis is the primary guiding tool in
manipulation of the facial skeleton. The relationship between sella–
nasion–subspinale (SNA) and sella–nasion–supramentale (SNB), as well
as the relationship between the maxilla and mandible (ANB), can help
to ascertain whether formal orthognathic surgery is necessary.
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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
ext, the profile view of the face is analyzed, and the following
points should be addressed:
1. Labiomental fold: The indentation between the lower lip and
lower portion of the mandible is an important characteristic to
recognize in chin aesthetics. In doing so, the vertical proportion
of the mandible to the facial length needs to be assessed, and
both the height and depth of the fold should be studied. Ideally,
the fold should fall at the junction of the upper and middle thirds
of the distance between stomion and menton. The fold should be
4 mm in men and 6 mm in women. A deep fold may be ex-
aggerated in horizontal augmentation, whereas a shallow fold
may be effaced further by vertical augmentation. Patients with
a long lower face and a deep labiomental fold should not be of-
fered genioplasty, as these patients require formal orthognathic
correction with or without soft tissue filling.
2. Lip-chin relationship: A simple line connecting the most promi-
nent portions of the upper and lower lips (Riedel line; Fig. 58.3)
should touch the pogonion on a balanced face. Generally speak-
ing, the lower lip should be 2 to 3 mm posterior to the upper lip,
and the pogonion should never project beyond this line.
3. Cervicomental angle: The angle between the chin and the neck
should be 105 to 120 . Adjunctive treatments to enhance soft
tissue contour of the neck during genioplasty should be con-
sidered and are discussed further in the chapter. Surgical and
nonsurgical treatments such as submental lipectomy, neck
lift, high-intensity focused ultrasound (HIFU; e.g., Ultherapy,
Ulthera, Mesa, A ), lipolysis with deoxycholic acid ( ybella,
Allergan, Irvine, CA), and cryolipolysis (e.g., CoolSculpting, eltiq
Aesthetics, Pleasanton, CA) can enhance chin aesthetics.
4. ose-chin evaluation: The aesthetics of the nose and the chin
should harmonize. Ideally, chin projection should lie 3 mm
posterior to a line drawn in the nose–lip–chin plane (Fig. 58.4).
Fig. 58.3 Riedel line: a line drawn vertically down the facial plane
connecting the most prominent portions of the upper and lower lips.
This line should touch the most prominent anterior portion of the chin
in a balanced face.
884
Lastly, the skin of the lower face should be examined in both
frontal and lateral views, noting the quality, thickness, and laxity
as well as any irregularities and/or aging signs. Because these
factors can impact outcome, a patient’s expectations should be
managed by discussing these findings in the preoperative setting.
Presence of ptosis of soft tissue caudal to the menton and an exag-
gerated submental crease ( witch’s chin ) may require soft tissue/
muscle resection, alteration of volume, and/or repositioning of
the tissues. ith this presentation, implant augmentation may
exaggerate the deformity. On the other hand, excess submental
skin can be addressed with a submental incision to remove an
elliptical segment around the incision to avoid skin ptosis. Video
analysis of facial animation can be helpful in documenting chin
fat pad deformities. Dynamic and static chin pad analysis can then
be used to address the proposed movements or augmentation
procedures of the mentum.
58.3 Treatment Approach
Once preoperative assessment is complete, it is important to
organize the information gathered to formulate an optimal
treatment plan. As expected, each surgeon’s subjective opinion
and previous experience will influence decision making. Further,
the patient’s desires and goals should be carefully considered in
the decision tree as well. As an example, a formal orthognathic
surgery is time consuming and costly and not something all
patients are willing to undertake. It is important in these situ-
ations to discuss with the patient whether genioplasty, alone or
Fig. 58.4 Nose–lip–chin line: A line drawn vertically down the facial
plane connecting the most projecting point of the nose and the most
prominent portion of the upper lip. The most prominent anterior
portion of the chin should be ~ 3 mm posterior to this line.

in conjunction with treatments other than orthognathic surgery,
can achieve some of the desired goals, and if so, whether to
proceed with an alternative surgical intervention. For example,
genioplasty combined with fat grafting and/or submental lipec-
tomy can make a significant difference with very high patient
satisfaction.
Surgical technique for genioplasty falls into five broad catego-
ries: osseous genioplasty, alloplastic augmentation, structural fat
grafting, filler augmentation, and combination therapy. Generally
speaking, most surgeons are more comfortable with inserting
an implant than with performing osteotomies. Fillers are easier
than alloplastic augmentation, and fat grafting requires finesse
and experience with the complexity level, somewhere in between
implants and fillers. ith proper patient and implant selection,
implant augmentation achieves desirable results and is relatively
easy to execute. However, osseous genioplasty, contrary to some
surgeons’ beliefs, is not a difficult procedure to perform; moreover,
it is a highly versatile procedure that can allow movement in all
dimensions. It can ameliorate conditions that an implant cannot,
such as a chin that is too long, too short, or asymmetric. In addi-
tion, patients who have had one or more failures of an alloplastic
chin implant are perhaps best treated by an osseous genioplasty.
The skin–soft tissue envelope can be further manipulated by
adding fat or filler to the genioplasty.
Osseous genioplasty, alloplastic augmentation, fat grafting, and
filler usage involve different levels of anesthesia; therefore, each
patient’s overall health, tolerance to anesthesia, and anesthetic
preference should be acknowledged in the analysis, as they may
dictate the patient’s personal preference in selecting a procedure.
The majority of implant augmentations can be performed under
local anesthesia, with or without sedation. Fat grafting can be
performed under local or general anesthesia. Most fillers require
topical anesthesia alone. Osseous genioplasty, however, should
be performed with at least intravenous sedation in a controlled
setting for both optimal pain and airway control. Most patients
undergoing osseous genioplasty, in fact, choose general anesthe-
sia, which in many ways make the operative steps easier for the
surgeon and can shorten surgery time.
58.4 Surgical Techniques
58.4.1 Osseous Genioplasty
Incision
An intraoral incision is used and preferred for osseous genio-
plasty. After appropriate sedation or anesthesia is achieved, the
chin is injected with a mixture of lidocaine containing 1:100,000
epinephrine and bupivacaine containing 1:200.000 epinephrine
in and around the proposed incision as well as areas of dissec-
tion and osteotomy. Next, the lower lip is stretched outward to
allow visualization of the mental nerve through the mucosa. The
incision should remain between the visible nerves. An incision
is made, leaving a generous cuff of mucosa and muscle that will
allow a watertight closure. The incision is carried down through
the mucosa and muscle with electrocautery.
58 Rejuvenation of the Chin
Dissection
Dissection is then performed in the subperiosteal plane with
a periosteal elevator to expose the anterior surface of the chin
while visualizing and protecting the mental nerve coming
out of the mental foramen. It is important to avoid extensive
dissection, as the soft tissue attachments help to stabilize the
skeletal alteration, minimize unpredictable soft tissue changes,
and lessen postoperative osseous resorption. As much tissue as
possible should be left on the anterior surface of the symphysis
to prevent ptosis of the chin pad. There is also no need to dissect
above the mental nerve on either side, as that can increase the
chances that the nerve will be excessively stretched or avulsed.
Osteotomy
After proper retraction, a sterile marking pen is used to mark the
location of the osteotomy, which should lie at least 5 mm below
the apices of the canine teeth and 6 mm below the mental fora-
men to reduce the chance of injuring the tooth roots or nerves.
The exact location and angle of the osteotomy will depend on the
planned movement (Fig. 58.5). First, an oscillating saw is used
to make a vertical groove in midline perpendicular to planned
osteotomy that will be used as a midline reference point. A drill
hole can be placed at this point in the midline within the distal
chin, where a screw can be partially inserted later to be used
as a convenient retractor for the osteotomized chin segment. A
wide saw is preferred, as it tends to maintain orientation and
limit canting while performing the osteotomy of the central
portion. An osteotomy of the lateral segments is then performed
with a narrow saw. It is important to make complete cuts, and
particular attention should be paid along the posterior lingual
cortex to prevent an incomplete osteotomy. If a wedge resection
is planned, the caudal cut should be made first so that the second,
cephalad cut can be made on stable bone that remains attached
to the mandibular symphysis. An ample amount of contact
irrigation is recommended throughout the osteotomy to prevent
burning the bone and focal osteomyelitis.
Planned Movement and Fixation
The distal chin is then moved into the desired position, with the
direction and amount of movement dependent on preoperative
planning (Fig. 58.5). For positioning of the distal segment, a screw
can be partially inserted into a predrilled hole (as described in
the preceding subsection), and a wire twister can be used to hold
this screw as a retractor. A three- or four-hole straight titanium
plate can be contoured and secured to both proximal and distal
segments on either side of the osteotomy (usually inferior and
in between the lateral incisor and canine on each side). Prebent
genioplasty plates can also be used, with size dependent on
degree of advancement. At this point, the positioning screw can
be removed.
e nemen
If significant vertical or horizontal lengthening is planned ( 5
mm), then an interpositional graft (autograft, allograft, or off-
the-shelf material such as hydroxyapatite) is shaped and placed
in the defect.
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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears

Fig. 58.5 Horizontal osteotomy techniques. (a) Sliding oblique horizontal osteotomy; (b) step horizontal osteotomy; (c) horizontal osteotomy for
asymmetry; (d ) sandwich horizontal osteotomy; (e) horizontal osteotomy with ostectomy; (f) correction of macrogenia by horizontal osteotomy.

The greater the angle of osteotomy from the occlusal plane, the
shorter the chin will be. Moreover, a greater angle also leads to
a larger stepoff along the inferior border of the mandible as the
osteotomized segment is advanced, which may be visible and pal-
pable in some patients. A rasp can be used to soften the contour if
there is any doubt.
Lastly, an attempt can be made to improve on contour irregular-
ities and pre-existing asymmetry with a bur. However, multiple
osteotomies or asymmetric osteotomies may be better in provid-
ing more predictable and symmetric results.
Closure
The wound is copiously irrigated to remove any debris. The
muscle is then reapproximated with resorbable suture and the
incision is closed using 4–0 chromic mattress sutures.
S in S i ue di i n
Contour irregularities or volume discrepancies can then be
addressed with fat grafting or filler in the subcutaneous and/
or dermal plane. Caution should be exercised with overfilling
secondary to vascular compromise and pressure necrosis.

886

58.4.2 Alloplastic Chin Augmentation
Implant Selection
Silicone (Silastic, Dow Corning, Midland, MI), polytetrafluoroeth-
ylene (Gore-Tex, Implantech, Ventura, CA), polyester (Mersilene,
ohnson ohnson, ew Brunswick, ) mesh, and porous poly-
ethylene are the most commonly used implants for genioplasty
today (Fig. 58.6, Fig. 58.7). The type of implant, for the most part,
is dependent on each surgeon’s preference and experience. Porous
polyethylene and Mersilene implants may be more difficult to
place and remove due to soft tissue adherence and tissue ingrowth,
respectively. A myriad of implant shapes and sizes are available
depending on the magnitude of deficiency. Some chin implants
extend beyond the chin territory to contour the mandibular body.
Incision
Although both intraoral and submental incisions can be used,
we prefer to use the submental incision, as it allows better
visualization and more accurate contouring and placement of
the implant. It also provides a slightly lower risk of infection and
a lower rate of nerve injury. Intraoral incisions are an alternative
and can be placed either vertically or horizontally. The disadvan-
tage of external incisions are visible scars and the possibility of
hypertrophy.
Dissection
Dissection is performed in the subperiosteal plane. ide dissection
is performed to improve visualization and allow more accurate
implant placement. Dual-plane dissection can be supraperiosteal
in the midline to theoretically reduce bone resorption. Silastic
implants have higher propensity to erode the underlying bone, so
consideration should be given to placing this type of implant in a
supraperiosteal plane. However, the chances of soft tissue injury
and skin irregularities are increased in the supraperiosteal plane,
so this approach should be performed with caution. e tend to
prefer subperiosteal laterally and supraperiosteal centrally. This
approach may offer additional stability and fixation.
Implant Placement and Fixation/Closure
A one- or two-piece porous polyethylene implant is shaped and
contoured to fit as closely as possible to the native contour of the
symphysis and, if desired, the body of the mandible. Decreasing
the dead space between the implant and the underlying bone
is important to prevent complications. The implant is fixed to
Fig. 58.6 (a) Skull with Mersilene implants. (b) Mersilene mesh
implants.
58 Rejuvenation of the Chin
the mandible with titanium screws. The wound is irrigated and
closed in layers. Mesh material is easier to contour and can be
suture-fixated to the periosteum. Gore-Tex and silicone can
use screw or suture fixation. All implants should be fixated to
prevent migration and distortion. Fixation must be accurate and
unobtrusive.
Fig. 58.8 and Fig. 58.9 show pre- and postoperative images
for implant augmentation using silicone and Mersilene mesh,
respectively.
58.4.3 Autologous Fat
Background
Autologous fat is a filler with ideal properties, which were
recognized by surgeons over a century ago and proposed by
many for the treatment of congenital deformity, traumatic
wounds, and tissue loss from oncologic resection. The actual
procedure of fat transfer, however, did not become popularized
until the 1980s with the introduction of several advancements
in liposuction anesthesia and small-bore cannulas. In 1987,
Coleman introduced a new technique for fat transfer involving
three important steps to minimize traumatic handling of fat
during liposuction. The three steps are manual lipoaspiration
under low pressure; centrifugation at 3,400 rpm for 3 minutes;
and a 3-D reinjection approach. Less traumatic methods for
lipoharvesting result in improved adipocyte viability and fat
graft survival. The quest for an ideal harvest and lipofilling
technique is motivated by the observed long-term resorption
rates of 30–70 , often making the outcome of fat transfer as
a stand-alone procedure unpredictable, operator dependent,
and variable. These variabilities have led to many significant
modifications of Coleman’s technique that are often operator
specific and can include fat washing, filtering, sedimentation,
incubation with bioactive agents, core graft, block harvesting,
and many others too numerous to list.
Despite the many challenges seen with fat transfer, adipocytes
are noteworthy as fillers because they naturally integrate into
Fig. 58.7 (a) Skull with silicone implants on the cheekbones.
(b) Anterior view.
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 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears

Fig. 58.8 Chin augmentation with silicone implant. (a) Preoperative Fig. 58.9 Chin augmentation with Mersilene mesh implant. (a)
anterior view. (b) Postoperative anterior view. (c) Preoperative lateral Preoperative anterior view. (b) Postoperative anterior view. (c)
view. (d) Postoperative lateral view. Preoperative lateral view. (d) Postoperative lateral view.

tissues, are autologous, and exhibit 100 biocompatibility. preoperatively sitting upright in an area with direct overhead
Furthermore, adipocytes are transferred into the recipient site as lighting, often supplemented with side lighting as needed to
parcels of cells and supporting connective tissue serving to pro- identify the areas of volume deficiency to be grafted.
vide additional functions in lipofilling. These parcels also deliver
fibroblasts, endothelial cells, and adipogenic progenitor cells,
Donor Site
which may provide additional long-term benefits for patients.
Several donor sites have been advocated for harvest of autoge-
e present our technique in the following subsections, which has
nous fat. For convenience, the abdomen is preferred, as it is
been modified based on our observations of improved fat graft
easily accessible, and incisions can be hidden in the umbilicus or
survival in our series of patients. However, we believe there are
hair-bearing pubic area. Other common sites include the thighs,
many effective methods, and our descriptions are neither all-in-
knees, and arms. Some prefer the flank and buttocks, because
clusive nor dismissive of alternative techniques. The technique for
these areas seem resistant to alterations in body weight, or the
autologous fat transfer can be divided into three parts: harvesting
gluteal-femoral region, as these cells are larger and demonstrate
the graft, processing of the graft, and reinjection of the graft. Each
a higher lipogenic activity. Adipocytes harvested from the thigh
is equally important to the success of the procedure.
have been felt to have less resorption when transplanted.

Preoperative Planning
Tumescent Solution
Preoperative photographs are taken with and without a flash. The
Sterile technique is employed for fat harvesting and reinjection.
photographs taken without a flash will often accentuate areas
e recommend prophylactic antibiotics. Local anesthesia is used
of volume loss not apparent in standard flash photography. It is
for a small stab incision. Then a long injection cannula is used to
helpful to compare preoperative photographs to pictures taken
introduce tumescent fluid to the region. Our standard solution
of patients in their teens or early twenties, preferably full-face,
consists of 1 mg of epinephrine, 200 mg of lidocaine, and 5 mEq
nonsmiling views, to appreciate better the degree of volume loss
of sodium bicarbonate in 1 L of normal saline.
presentable at the time of consultation. The patient is marked

888

Low Negative Pressure
Trauma to the adipocytes in the process of harvesting affects
survival of the graft. Fat consists of adipose cells with thin cell
membranes enmeshed in a fibrous network. Harvesting fat while
retaining as much supporting structure as possible preserves the
integrity of the cells. In Coleman’s technique, a small (17-gauge)
cannula harvests parcels of fat with intact architecture. e
typically attach a 10-mL Luer lock syringe to the cannula and
withdraw the plunger to provide a low level of negative pressure,
minimizing trauma to the adipose tissue.
Processing
After fat harvesting, the next step is preparation. Our strategies
have included systems such as LipiVage (Genesis Biosystems,
Lewisville, TX) or Viafill (Lipose Corporation, Greenwich, CT),
centrifuge, or gravity separation. There are advantages and
disadvantages to all techniques. Both the LipiVage and Viafill kits
offer closed filtration systems, reduce exposure to excessive g
force, and provide sterility and protection from exposure to air.
Our current technique uses filtration and gravity separation.
After fat is harvested, it is filtered using the LipiVage system and
transferred to 60-mL syringes, where it is allowed to separate by
gravity for 30 minutes. The excess blood, fluid, and serum are
then removed, and the fat is transferred to a 1-mL syringe for
reinjection.
Reinjection
ith reinjection, the goal is to place each graft in a well-
vascularized bed to maximize survivability. Each graft should
be within 1.5 mm of vascularized tissue. Grafted adipocytes most
removed from the blood supply may not survive. The compacted
most viable fat cells are transferred to a 1-mL syringe. A Coleman
2 (Byron Medical, Tucson, A ) 7-cm straight injecting cannula is
used for microaliquot placement. The cannula should be inserted
through a 2-mm stab incision made with a o. 11 blade scalpel.
The cannula is guided into the target region while a tunnel is
created by advancing the cannula, and the fat is injected 0.1–0.2
mL at a time in retrograde fashion. The small channels for the
grafts help keep them adherent to the recipient site. Care should
be taken not to overfill the tract, as this can adversely affect graft
survival. The fat should be injected only while withdrawing
the cannula. One should always avoid high pressure, as this
will deposit an uncontrolled graft, which is unlikely to survive.
However, feeling a small amount of resistance while injecting is
important. If the aspirate injects too easily, it is likely that fat
has already been placed in this location and additional injection
would be detrimental to graft survival. Slight overcorrection
is important to compensate for some absorption of the liquid
carrier that occurs. A general recommendation is for a 30 over-
correction. After the fat is deposited, gentle digital pressure is
used to check for placement and contour irregularity.
Pearls for Fat Reinjection in the Chin
and Jawline
The chin and the jowl are intimately related, as they both become
accentuated in aging by the development of the prejowl sulcus.
58 Rejuvenation of the Chin
This sulcus can be caused by osteoporosis of the mandible,
age-related facial volume loss, and laxity of the overlying skin
envelope. In combination with regional lipoatrophy, the patient
can develop the appearance of prominent jowls as well as loss of
chin prominence. Volume restoration to this area can lessen the
effects of aging to both the chin and the jowl. Overapplication of
fat grafting to the chin in isolation can lead to an unaesthetic fatty
chin. Fat transfer to the chin might be done with orthognathic
surgery as a means to camouflage any bony ridges. ust as the
prejowl sulcus can contribute to the appearance of prominent
jowls, volume loss in the area of the mandibular angle can also
produce this effect. This effect can be reduced by facelift, and
one of the most common indications for autologous fat grafting
in this area is postrhytidectomy volume loss and persistent
jowls. hen volume replacement in this area is combined with
treatment of the prejowl sulcus, the jowls can be concealed and
a smooth mandibular contour obtained.
Postoperative Care
Massage and excessive facial animation are discouraged imme-
diately following fat reinjection. These restrictions are in place
to reduce the risk of fat graft migration away from the desired
treatment sites. Ice compresses are applied for 48 hours to mini-
mize swelling, improve pain, and reduce inflammation.
Results of this technique are demonstrated in Fig. 58.10 and
Fig. 58.11.
58.5 Nonsurgical Techniques
58.5.1 Dermal Fillers
Rationale for Use
onsurgical chin and submental enhancement techniques have
become more acceptable to a growing population of patients
seeking the least invasive approaches for facial rejuvenation and
for those looking to achieve more subtle results. Some patients
seek nonsurgical chin enhancement because they are not willing
to commit to a permanent change in their profile. Dermal filler
injections can offer a trial run for the new profile and a period of
time between 6 and 18 months (depending on filler selection) for
the patient to evaluate the results and possibly to pursue a more
permanent solution via surgery. For injectables, serious com-
plications are uncommon and manageable, in most situations,
with nonsurgical modalities. For the practitioner, many of these
nonsurgical approaches have the advantage of adjustability, even
with small increments of improvement, empowering the injector
to deliver small but reliable changes in facial appearance.
Dermal Filler Selection
Generally speaking, dermal fillers with high G´ (see Chapter 16)
tend to be also highly crosslinked (making them heavier with
higher viscosity and cohesivity) and are better suited for volumiz-
ing and tissue lifting in the chin. Highly crosslinked, high-G fillers
are also better suited for deeper soft tissue injection (away from
the dermis), including the subperiosteal plane. These types of fill-
ers, such as Restylane Lyft (Galderma, Lausanne, Switzerland), are
889
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
a b
d e
Fig. 58.10 Autologous fat grafting to chin. (a) Preoperative anterior. (b) Postoperative anterior. (c) Preoperative lateral. (d) Postoperative lateral. (e)
Preoperative oblique. (f) Postoperative oblique.
our preference when addressing aesthetic chin deficiencies that
are related to volume loss or to a lack of projection (Fig. 58.12).
However, familiarity with hyaluronic acid (HA) fillers better
suited for dermal plane injection will be important when a lack
of chin prominence is addressed simultaneously with treatment
of marionette lines and other surface creases in and around the
oral commissure (Fig. 58.13). For chin projection enhancement,
the preferred depth of injection will be the periosteal plane, but
filler material can also be placed in the subcutaneous and up to
890
c
f
the subdermal plane. Practitioners should avoid the temptation
to place high-viscosity fillers in the dermal plane; instead, they
should rely on an armamentarium of filler combinations to
address most associated fine lines and other deformities in the
chin and jawline. For volume enhancement, we prefer a highly
viscous filler such as Radiesse (calcium hydroxyapatite; Merz
Pharmaceutical) or Sculptra (poly-L-lactic acid; Galderma,
Lausanne, Switzerland). However, more subtle results and trial
chin enhancements are best accomplished with high-G´ HA fillers.

Fig. 58.11 Autologous fat grafting to chin. (a) Preoperative anterior.
(b) Postoperative anterior. (c) Preoperative lateral. (d) Postoperative
lateral.
58.6 Complications and Outcomes
58.6.1 Surgical Techniques
Both early and late complications can occur after profile plasty,
including poor aesthetic results, hematoma, infection, malposi-
tion, and nerve injury. Guyuron and Raszewski retrospectively
reviewed their genioplasty outcomes and found that patients
had a high satisfaction rate after genioplasty, with osseous
genioplasty having a slightly higher satisfaction rate (90–95 )
than alloplastic augmentation (85–90 ). Morbidity was the same
for both types of procedure. The incidence of reoperation after
genioplasty is extremely low and usually involves replacement
of implant or removal of implant and conversion of alloplastic
genioplasty to an osteotomy. Fat grafting and filler can help
with small contour irregularities and can be used to enhance
results. The rate of relapse is low, and the ratio of soft tissue to
hard tissue advancement on long-term follow-up has been found
to be stable over time. However, surgical efforts to correct an
excessively prominent chin are less predictable and should be
approached with caution, as the soft tissue response to posterior
repositioning of the chin is, at best, unpredictable.
The major complications and concerns of fat grafting are under-
correction and overcorrection. Undercorrection results from
58 Rejuvenation of the Chin
placing less than the required amount of fat, from resorption, or
from graft loss. Excessive resorption of the graft can occur even
with overcorrection. Although placing too little fat obviously fails
to correct the defect, increasing the volume of injected fat may
actually exacerbate graft loss. Overfilling can also lead to increased
graft necrosis, resulting in palpable irregularities and eventual
disappearance of the grafted material. Coleman described about
a 40 resorption rate for fat graft augmentation in the chin pad.
Undercorrection is generally easier to treat than overcorrection.
Once the patient is judged to be fully healed, additional fat may
be grafted at a separate sitting to complete correction. Removing
excess graft is more difficult. If overcorrection is the diagnosis, then
waiting the appropriate period of time for resolution of edema is
recommended. If the overcorrection persists, microliposuction
can be performed. Transient mild ecchymosis, tenderness, and
swelling are more common complications of fat injections. Small
hematomas are more unusual and are sometimes associated with
the use of sharp needles for graft placement. Donor site scarring
is a potential concern, but with care during the procedure most
issues at the donor site can be avoided.
Although rare, infections can occur wherever the skin envelope
is violated. The most common source of infection is the oral
mucosa. Importantly, atypical mycobacterial infections have been
associated with inadequately sterilized surgical instruments.
Low-cost, single-use systems should eliminate the risks of
atypical mycobacterial infections from the use of contaminated
instruments. Severe systemic infections are rare with fat grafting
but have been recently reported in association with large-volume
fat injections and can lead to life-threatening sepsis and residual
postoperative deformity.
Embolization and arterial occlusion can be seen with a variety
of injectable fillers including autologous fat. Tissue necrosis,
blindness, and fatal stroke can result. Cases of blindness by central
retinal artery occlusion often involve injection into the glabellar
area, but there are reports of cases resulting from injection into the
nasolabial folds and lower lip as well. The risks of embolization can
be minimized by using a low-volume, low-pressure, blunt cannula
and injecting only while withdrawing the cannula from the area.
Avoidance of sharp needles for injection is also recommended.
58.6.2 Nonsurgical Techniques
Filler injections to the chin and for the face are becoming more
popular, and practitioners should be able to recognize the
complications associated with their usage. The vast majority
of complications seen with dermal fillers are self-limiting and
can include localized bruising, erythema, swelling, and small
bumps underneath the skin and mucosa (Table 58.1). However,
serious sequelae, such as vascular penetration with or without
embolism, permanent visual loss, biofilm infections, and nerve
paralysis, are not uncommonly reported, and practitioners
should be familiar with the process of making these diagnoses
and delivering appropriate treatment.
Fortunately, HA fillers account for approximately 80 of the
facial fillers in current use, and such fillers can notably be dis-
solved with hyaluronidase in case a serious complication arises.
Importantly, it should be noted that while hyaluronidase has
been approved as a dispersion agent, its use to dissolve HA fillers
currently remains an off-label procedure, and appropriate patient
891
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
Fig. 58.12 Restylane Lyft chin augmentation/Restylane lip augmentation. (a) Preoperative anterior view. (b) Postoperative anterior view. (c)
Preoperative right lateral view. (d) Postoperative right lateral view. (e) Preoperative left lateral view. (f) Postoperative left lateral view.
consent should be obtained. The recommendation on dosage sug-
gests that approximately 30 units of hyaluronidase are required to
dissolve 0.1 mL of HA. e prefer to use the human recombinant
form of hyaluronidase (Hylenex, Halozyme Therapeutics, San
Diego, CA), and once we confirm the need to dissolve the product,
we commit to dissolving all of it within 24 hours.
The most common reason to dissolve HA fillers in clinical
practice is related to overcorrection or patient dissatisfaction.
Overfilled lips, laugh lines, and chins do not convey an attractive
appearance postinjection. odules and lumps in the first few
weeks after injection are most likely from overfill and not inflam-
matory in nature and may be treated with vigorous massage,
extruded with a needle, or dissolved. Most commonly, if a lump
is noted for longer than 2 to 3 weeks, the option to dissolve with
hyaluronidase is offered to the patient. Delayed edema in the area
of injection is likely the result of the HA filler tendency to draw
water and osmolality. Chronic prolonged edema, on the other
hand, may be treated as a hypersensitivity reaction with antihis-
tamines and possibly steroids.
Vascular injury and infection are more serious complications
associated with all dermal fillers. Vascular injury can involve pen-
etration, embolic events, and/or compression of arteries and veins.
Generally speaking, arterial injury presents with a rapid onset of
ischemic pallor and pain. However, in some patients, pain can be
variable and is not always a reliable sign. Embolization typically is
seen antegrade down the distribution of the injured vessel. Venous
892
occlusion due to direct injury or compression typically presents in
a more delayed fashion as a venous mottling, termed livido. hile
serious vascular and embolic events have been reported to arise
in all parts of the face, there are certain regions, such as the gla-
bella, nasal dorsum, nasolabial folds, and lips, where retrograde
embolization has been reported more frequently. Prevention of
vascular events by patient and filler selection and avoidance of
danger zones is the best approach. However, it is impossible for
the busy injector to avoid these complications in all cases, and we
therefore recommend keeping a vascular injury emergency kit in
the office (Table 58.2).
Infections can occur with dermal filler injections. Most infections
are thought to be related to breaks in sterile technique. Adherence
to the methods described in the section on injections and sterile
techniques is recommended. It is also recommended not to apply
makeup for 4 hours after dermal filler injection. hen infection is
suspected, a broad-spectrum antibiotic with activity against atyp-
ical mycobacteria should be prescribed. Clarithromycin (Biaxin;
AbbVie, orth Chicago, IL) is usually a good choice and well tol-
erated. Herpetic outbreaks are a more frequent type of infection
seen with dermal fillers. Reactivation of the virus can be treated
with oral valacyclovir. Delayed infection presenting several weeks
after injection can be more difficult to treat and can be caused by
a biofilm: an aggregate of encapsulated microorganisms, possibly
including bacteria, protozoans, and fungi, that are permanently
attached to an implant or other inert biomaterial. These can
 58 Rejuvenation of the Chin

Fig. 58.13 Restylane Lyft chin augmentation. (a) Preoperative anterior view. (b) Postoperative anterior view. (c) Preoperative right lateral view.
(d) Postoperative right lateral view. (e) Preoperative left lateral view. (f) Postoperative left lateral view.

Table 58.1 Common adverse events of dermal filler injections Table 58.2 Filler crash cart contents and procedure

• Tenderness (most common) • Skin irregularities • If the filler site has severe pain (or no pain) and blanching or mottled
skin discoloration, immediately administer:
• Swelling • Chewing complaints
Warm compresses
• Pain • Jaw ache
Nitropaste
• Headache • Hyperpigmentation (least
Baby aspirin
• Bruising common)
Supplemental oxygen
• Redness
Hyaluronidase
For hyaluronidase, Inject 300 units (2 vials) with 0.2 mL of lidocaine
(2%) using a 27-gauge needle into area of injection and area of
present as a painful nodules that tend to resist oral antibiotics. discoloration. Repeat every 40 to 60 minutes until the skin circulation
is restored to a bright red color. Restock hyaluronidase after usage.
Some nodules can be due to foreign body reaction granulomas. Always keep 12 vials on hand.
Granulomatous reactions can present months or even years after • In the event of blindness, immediately consult an ophthalmologist
injection and may require intralesional steroids and 5-fluorouracil and retinal specialist for retrobulbar injection. (It is important to
establish a relationship before any event and agree to a referral
for treatment. pattern with ophthalmologists.)
Known ller complication risk factors:
58.7 Concluding Thoughts • Deep injection (nasal radix and lateral nasal wall)
• Upper lip philtrum (vessel is surperficial)
Genioplasty using implant augmentation, fat grafting, filler • Large-volume bolus (greater than 0.1 mL)
placement, or osteotomy, whether performed in isolation or as • High-pressure injection
a component of formal orthognathic surgery or as an integral • Small, sharp needles
component of the aesthetic alteration of the face, can lead to an
extremely high level of satisfaction for both patients and surgeons.
hen performed with proper preoperative assessment and face. Both implant and osseous genioplasty, along with fat grafting
precise execution, the results can harmonize and restore balance and/or filler placement with proper understanding of underlying
among skeletal, soft tissue, and dental components of the lower dysmorphology, preoperative assessment, and surgical technique,

893
 IX Rejuvenation of the Cheeks, Chin, Lips, and Ears

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40 Rosen HM. Aesthetic refinements in genioplasty: the role of the labiomental fold.
augmentation. Facial Plast Surg Clin North Am 2015;23(4):479–488
Plast Reconstr Surg 1991;88(5):760–767
6 Breithaupt A, Fitzgerald R. Collagen stimulators: poly-L-lactic acid and calcium
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[7] Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast
42 Shamban AT. oninvasive submental fat compartment treatment. Plast Reconstr
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43 Shaughnessy S, Mobarak A, H gevold HE, Espeland L. Long-term skeletal and
[9] Cohen SR. Genioplasty. St. Louis, MO: Mosby; 2000
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10 Cohen SR, Mardach OL, awamoto H r. Chin disfigurement following removal of
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[17] Guyuron B. MOC-PS(SM) CME article: genioplasty. Plast Reconstr Surg
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 Part X
Rhinoplasty

X

59 Applied Anatomy of the Nose
Rod J. Rohrich, Paul N. Afrooz, William P. Adams Jr., and Joel E. Pessa
This chapter is dedicated to the memory of Dr. Jack P. Gunter.
Abstract
The nose consists of bone, cartilage, muscle, connective tissue,
soft tissue, and skin. Successful rhinoplasty begins with a thor-
ough understanding of each of these individual components of
nasal anatomy. Manipulation of any one of these components
requires a thorough knowledge of their interrelationships and
dynamic interplays. In addition, accessing the underlying anat-
omy of the nose requires an understanding of nasal blood supply.
This chapter discusses the pertinent anatomy of the nose and the
significance of the anatomy in rhinoplasty.
Keywords
nasal anatomy, rhinoplasty, open rhinoplasty, closed rhinoplasty,
nasal blood supply, nasal framework, nasal bones, nasal cartilage
59.1 Dedication
The authors would like to dedicate this chapter to Dr. ack P.
Gunter. Dr. Gunter was a true rhinoplasty pioneer. His pursuit of
Fig. 59.1 Illustration of the nasal framework, consisting of the paired
nasal bones, the paired upper lateral cartilages, the nasal septum, and
the paired lower lateral cartilages.
59 Applied Anatomy of the Nose
excellence and contributions to our understanding of rhinoplasty
have paved the way for generations of rhinoplasty surgeons.
59.2 Introduction
The nose consists of three elements: framework, support, and
external cover. The nasal framework consists of the skeletal
components of bone and cartilage (Fig. 59.1). Support is provided
by connective tissue and ligaments that hold the framework
together. The skin and soft tissue provide the external covering
of the nose. These components are intricately related and must
be anatomically visualized in every step of the rhinoplasty
sequence. In this chapter we will review the clinically relevant
anatomy encountered in rhinoplasty.
Principles in the anatomic sequence of a rhinoplasty include
the following:
1. Precise definition of anatomic goals preoperatively
2. Adequate anatomic exposure of the nasal deformity
3. Preservation/restoration of the normal anatomy
4. Correction of the specific deformity with precise and incremen-
tal control
5. Maintenance/restoration of the nasal airway
The skin is thinner and more mobile in the upper two-thirds of
the nose and thicker and more adherent in the distal third in the
nasal lobule (Fig. 59.2).
Fig. 59.2 Variations in skin thickness along the length of the nose.
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 X Rhinoplasty
Vessels and nerves pass within the subcutaneous tissue above
the muscle. It is important to note the type, texture, and sebaceous
content of the skin., because these factors will affect the final
result. Overzealous alteration of the underlying framework in a
thin-skinned tip may have a long-term undesirable outcome. In
contrast, in a patient with thick sebaceous skin, more aggressive
alteration of the underlying framework is possible, and necessary,
to obtain significant tip definition and refinement of the nose.
59.3 Muscles
Although several muscles affect the nose, the two most clinically
significant are the levator labii alaeque nasi and depressor septi
muscles (Fig. 59.3). The levator labii alaeque nasi assists in
keeping the external nasal valve open and can cause functional
nasal obstruction with facial paralysis if alar flaring is impaired.
The depressor septi nasi, when clinically significant, shortens the
upper lip and can decrease tip projection on animation.
The nasal muscles interconnect so that animation of one affects
the others (Fig. 59.4). For example, contraction of the lip elevators
pulls the transverse nasalis. This has the effect of opening the
internal valve by distracting the upper lateral cartilages. asal
airway patency is therefore also a function of dynamic muscle
activity, in addition to proper skeletal and cartilaginous support.
In a cadaver study to define the anatomic variations of the
depressor septi muscle, we identified three types of depressor
Fig. 59.3 Depiction of the levator labii aleque nasi and depressor septi
nasi muscles.
Fig. 59.4 Cadaveric demonstration of the interconnection of nasal
musculature.
898
septi muscles (Fig. 59.5). Type I depressor septi muscles (62 ) are
visible and identifiable and can be traced to full interdigitation
with the orbicularis oris from their origin at the medial crural
footplate. Type II muscles (22 ) are visible and identifiable, but
unlike the first group, these muscles insert into the periosteum
and demonstrate little or no interdigitation with the orbicularis
oris. In type III muscles (16 ), no muscle or only a rudimentary
depressor septi muscle is visible.
Routine preoperative examination of rhinoplasty patients
should easily identify those who demonstrate a drooping nasal
tip and shortened upper lip on animation, particularly when smil-
ing. In such patients (types I and II), transection of the depressor
septi muscles reliably and effectively corrects this dynamic facial
deformity. Follow-up of up to 2 years shows well-maintained aes-
thetic results without signs of relapse. Specifically, the technique
achieves the following goals:
• Enhancement of the tip-lip relationship
• Relative upper lip lengthening
• Maintenance of tip rotation/projection on animation
59.4 Blood Supply
There has been concern, especially with the growing popularity
of the external approach to rhinoplasty, that a transcolumellar
incision may compromise the blood supply to the nasal tip.
However, one must take into account the considerable blood
supply to the nose, with contributions from both the internal and
external carotid arteries (Fig. 59.6).
The ophthalmic artery and its branches, anterior ethmoids,
dorsal nasal, and external nasal arteries supply the proximal
portion of the nose. The nasal tip area is supplied primarily by
branches of the facial artery, including the superior labial and
angular vessels, with the lateral nasal branch coursing above the
alar groove, and the columellar branches, which are branches of
the superior labial vessels. In the dissection shown in Fig. 59.7,
one can see that even the infraorbital artery provides collateral
supply to the tip via the nasal arcades.
This vasculature has been confirmed by an angiographic study
in 22 fresh cadaver heads injected with lead oxide dye (Fig. 59.8).
The lateral nasal vessels were consistently identified 2 to 3 mm
above the alar groove in this study. The columellar and lateral
nasal arteries arise deep at the nasal base and end in the sub-
dermal plexus at the nasal tip area. The lateral nasal artery was
consistently present either bilaterally or unilaterally (100 ). The
presence of the columellar branches was noted 68.2 of the time;
however, there was a predictable crossover arcade between the
lateral nasal and columellar branches in 10 specimens in which
a transcolumellar incision was made before the dye was injected.
The clinical relevance of this study is twofold. First, it is excessive
defatting that jeopardizes the nasal tip supply. In nasal tip proce-
dures the surgeon should reconstruct the underlying framework
to redefine the tip rather than defatting the nasal tip, which is
anatomically dangerous. The other clinical point is that collateral
blood supply enters the nose via the alar arcades. Prior incisions
in this region can jeopardize collateral supply to the nasal tip in
secondary procedures.
 59 Applied Anatomy of the Nose

Fig. 59.5 Anatomic variations of the depressor septi nasi muscle.

Fig. 59.6 Illustration of nasal blood supply with contributions from

both the internal and external carotid arteries. Fig. 59.7 Cadaveric depiction of nasal blood supply.

899
 X Rhinoplasty

In a fresh-cadaver study, Adams et al reported the clinical sig-

Fig. 59.8 Angiographic demonstration of nasal blood supply.
59.5 Nasal Vaults
There are three nasal vaults: the bony, upper cartilaginous, and
lower cartilaginous vaults (Fig. 59.9).
nificance of different structures for nasal tip support using open
versus closed rhinoplasty techniques. Multiple nasal manipula-
tions using fresh cadaver heads, including cephalic trim, cephalic
trim and interruption of the lower lateral cartilages, dorsal hump
resection (1–4 mm), submucous resection of the septum, and
complete septal removal, were performed using both the open
and closed rhinoplasty approaches. Changes in nasal tip support
were recorded. Comparing similar procedures, the mean loss of
tip projection for the open approach was 3.43 mm versus 1.98
mm for the closed approach (p 0.001). There was a significantly
larger loss of tip projection for the open versus the closed pro-
cedure for cephalic trim, cephalic trim plus interruption of the
lower lateral cartilage, and cephalic trim/interruption of the lower
lateral cartilage/septum removal (all three p 0.001). The differ-
ences between the open and closed approaches were attributed
to an increase in ligamentous disruption using the open approach.

59.5.1 Bony Vault

The bony vault consists of paired nasal bones as well as the
ascending frontal process of the maxilla, which make up the
proximal third to half of the nose (Fig. 59.10).
The bones are comparatively narrow and thick above the can-
thal level. The clinical correlation is that osteotomies are rarely
indicated above the canthal level because it is quite narrow and
the bone is thick.

59.5.2 Upper Cartilaginous Vault

The upper lateral cartilages underlie the nasal bones for 6 to
8 mm as well as the lower lateral cartilages in the scroll area
between the upper and lower lateral cartilages (Fig. 59.11).
The keystone area is defined by the junction of the upper lateral
cartilages with the nasal bones and the septum (Fig. 59.12). It is
important to stress the relationship of the upper lateral cartilages
to the septum, especially at the keystone area, where the contour is
T-shaped (Fig. 59.13). Loss of these intricate relationships results
in the loss of the dorsal aesthetic lines and a potential inverted-V
deformity, as seen on frontal view.

59.5.3 Lower Lateral Cartilaginous Vault

The lower cartilaginous vault comprises the medial, middle,
and lateral crura of the lower lateral cartilage (Fig. 59.14). The
support factors for tip projection are:

• Length and strength of lower lateral cartilage and piriform

abutment
• Fibrous connections between the upper lateral and lower
lateral cartilage
• Medial crural ligaments
• Anterior septal angle Fig. 59.9 Cadaveric depiction of the three nasal vaults: the bony vault,
the upper cartilaginous vault, and the lower cartilaginous vault.

900

Fig. 59.10 The bony vault consists of the paired nasal bones (outlined)
and the ascending frontal process of the maxilla.
Manipulation of the septum in general resulted in greater losses of
tip support for both the open and closed approaches.
The combination of skin, ligaments, and cartilage ultimately
provides tip support (Fig. 59.15). As progressively more of these
structures are disrupted, greater loss of tip projection occurs.
Sheen subdivided the lower lateral cartilage into the medial,
middle, and lateral crura. The angle of divergence is formed by
the domal angulation of the middle crus (Fig. 59.16). This is an
important factor in determining tip type, specifically whether
there is a bulbous or a boxy tip. The tip-defining points are
important: these consist of two equilateral triangles from the
supratip area to the apex of the domes to the columellar lobule
angle. The surgeon must use these reference points in assessing
tip definition and identifying tip asymmetries. Furthermore,
a classification system based on the angle of divergence of the
middle crura and the width of the domes can aid in the diagnosis
and treatment of nasal tip deformities (Fig. 59.17).
59 Applied Anatomy of the Nose
Fig. 59.11 Cadaveric demonstration of the upper cartilaginous vault.
Fig. 59.12 Schematic illustration of the keystone area. The keystone
is defined by the junction of the upper lateral cartilages with the nasal
bones and septum. The relationship of the upper lateral cartilages and
septum creates a T-shaped configuration.
59.6 Nasal Function
The functional portion of a nose comprises three areas: the
septum, nasal valve areas, and turbinates. The septum includes
three primary components: the quadrangular cartilage, the
perpendicular plate of the ethmoid, and the vomer (Fig. 59.18).
The bony septum is made of the perpendicular plate of the
ethmoid, which is in continuity with the cribriform plate. hen
performing a septal reconstruction and removing posterior septal
deviations, the surgeon must perform a sidewise fracture/sepa-
ration removal of the bony part of the perpendicular plate of the
ethmoid so as not to remove or dislodge the cribriform plate, which
can cause cerebrospinal fluid rhinorrhea. The most projecting part
of the premaxilla is the nasal spine, and it very infrequently needs
to be removed or altered. In contrast, the caudal portion of the
septum is the most protruding part of the columella and may
need to be altered if there is an alar–columellar discrepancy.
The internal nasal valve is defined as the junction between
the septum and the caudal border of the upper lateral cartilage
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Fig. 59.13 Cadaveric illustration of the keystone area. The keystone

is defined by the junction of the upper lateral cartilages with the nasal
bones and septum. The relationship of the upper lateral cartilages and Fig. 59.14 Depiction of the lower cartilaginous vault containing the
septum creates a T-shaped configuration. paired lower lateral cartilages.

Fig. 59.16 The lower lateral cartilages are subdivided into the medial,
Fig. 59.15 Cadaveric depiction of the combination of skin, ligaments, middle, and lateral crura. The angle of divergence is defined by the
and cartilage providing nasal tip support. angle between the middle crura.

Fig. 59.17 Anatomic classification of nasal tip anatomy based on the angle of divergence and domal width.

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 59 Applied Anatomy of the Nose

(Fig. 59.19). This angle is usually 10 to 15 . This must be pre-

served or reconstructed with a spreader graft in a primary or
secondary rhinoplasty.
Of the three turbinates (nasal conchae), the inferior turbinates
are the most significant functional component in nasal airway
breathing, and this occurs in the lower third of the nasal airway.
Submucous resection of the turbinate is indicated for airway
correction and yields excellent functional results.

59.7 Concluding Thoughts

asal anatomy is well defined, and knowledge of this anatomy
enables the surgeon to analyze nasal form and shape precisely.
Operative goals can be defined to restore normal anatomic rela-
tionships, preserving function while improving nasal aesthetics. Fig. 59.18 Schematic illustration of the nasal septum composed of the
quadrangular cartilage, the perpendicular plate of the ethmoid, and
the vomer.
Clinical Caveats
• Excellent rhinoplasty results can be obtained only if the
surgeon has a thorough knowledge of nasal anatomy and
understands the surgical relevance of alteration of the ana-
tomic structures.
• The type of framework modification is closely related to the
skin type.
• An active depressor septi muscle can be identified on preop-
erative clinical analysis, and its modification intraoperatively
can enhance the tip–lip complex.
• Following the open rhinoplasty approach, the blood supply to
the nasal tip is derived primarily from the lateral nasal arteries
2 to 3 mm above the alar groove.
• Multiple structures contribute to nasal tip support, including
the strength of the lower lateral cartilage, anterior septal
angle, upper lateral cartilage/lower lateral cartilage liga-
ments, medial crural ligaments, and nasal skin. Clinically
one must account for surgical disruption of these structures,
taking specific measures to provide nasal tip support, partic-
ularly in open rhinoplasty.
• The most common cause of functional nasal airway obstruc-
tion is inferior turbinate hypertrophy; however, septal devia-
tion and internal or external nasal valve abnormalities must
also be considered.

Suggested Reading
[1] Adams P r, Rohrich R , Hollier LH, Minoli , Thornton L , Gyimesi I. Anatomic
basis and clinical implications for nasal tip support in open versus closed rhino-
plasty. Plast Reconstr Surg 1999;103(1):255–261, discussion 262–264
2 Afrooz P , Rohrich R . The keystone: consistency in restoring the aesthetic
dorsum in rhinoplasty. Plast Reconstr Surg 2018;141(2):355–363
3 Beekhuis G . asal septoplasty. Otolaryngol Clin North Am 1973;6(3):693–710
4 Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin
North Am 1975;8(3):599–613 Fig. 59.19 Cadaveric illustration of the internal nasal valve. The
5 Dingman RO, atvig P. The infracartilaginous incision for rhinoplasty. Plast internal valve is defined as the junction of the septum and the caudal
Reconstr Surg 1982;69(1):134–135 border of the upper lateral cartilages.
6 Ford C , Battaglia DG, Gentry LR. Preservation of periosteal attachment in lateral
osteotomy. Ann Plast Surg 1984;13(2):107–111
[7] Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr [9] Hewell TS, Tardy ME. asal tip refinement reliable approaches and sculpture
Surg 1987;80(2):161–174 techniques. Facial Plast Surg 1984;1(2):87–124
[8] Gunter P, Rohrich R . Management of the deviated nose. The importance of 10 Hilger A. The internal lateral osteotomy in rhinoplasty. Arch Otolaryngol
septal reconstruction. Clin Plast Surg 1988;15(1):43–55 1968;88(2):211–212

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[11] aneke B, right . Studies on the support of the nasal tip. Arch Otolaryngol
1971;93(5):458–464
12 McCollough EG, Mangat D. Systematic approach to correction of the nasal tip in
rhinoplasty. Arch Otolaryngol 1981;107(1):12–16
13 Millard DR r. Alar margin sculpturing. Plast Reconstr Surg 1967;40(4):337–342
14 Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg
1983;71(1):27–39
15 Pollock RA, Rohrich R . Inferior turbinate surgery: an adjunct to successful treat-
ment of nasal obstruction in 408 patients. Plast Reconstr Surg 1984;74(2):227–
236
16 Sheen H. Achieving more nasal tip projection by the use of a small autoge-
nous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg
1975;56(1):35–40
904
[17] Rohrich R , Gunter P, Friedman RM. asal tip blood supply: an anatomic study
validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr
Surg 1995;95(5):795–799, discussion 800–801
[18] Rohrich R , Afrooz P . Rhinoplasty refinements: the role of the open approach.
Plast Reconstr Surg 2017;140(4):716–719
[19] Rohrich R , Huynh B, Muzaffar AR, Adams P r, Robinson B r. Importance
of the depressor septi nasi muscle in rhinoplasty: anatomic study and clinical
application. Plast Reconstr Surg 2000;105(1):376–383, discussion 384–388
20 Sheen H. Spreader graft: a method of reconstructing the roof of the middle nasal
vault following rhinoplasty. Plast Reconstr Surg 1984;73(2):230–239
21 Sheen H, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis, MO: uality Medical
Publishing; 1998
22 Tardy ME, Denneny C. Micro-osteotomies in rhinoplasty a technical refine-
ment. Facial Plast Surg 1984;1(2):137–145

60 Clinical Decision Making in Rhinoplasty
Farzad R. Nahai
Abstract
Rhinoplasty is a uniquely challenging endeavor and significantly
benefits from detailed analysis and planning. The author would
argue that of all the procedures in plastic surgery, successful
rhinoplasty is the most dependent on thorough analysis and
planning. Time spent on understanding your patient’s goals and
motivations, analyzing the nose, imaging the nose, formulating a
plan, then executing that plan to the best of your ability is more
likely to be rewarded with a happy patient and therefore a happy
surgeon. This chapter illustrates the author’s method of analysis
and planning in rhinoplasty from consultation to operation.
Keywords
rhinoplasty, analysis and planning, digital imaging, red flag
patient
60.1 Introduction
For those surgeons who enjoy rhinoplasty, it is the challenge and
reward that is appealing. The challenge exists in analysis, pre-
planning, attention to detail, and meticulous surgical technique,
which is often rewarded with the results that make our patients
happy and, in turn, us as well. The foundation of successful rhi-
noplasty is analysis and planning. I would argue that when con-
sidering the three aspects of rhinoplasty analysis, planning, and
surgical technique 50 of a successful outcome rests with anal-
ysis and planning and the remaining 50 with surgical technique
(Fig. 60.1). This relationship may vary from surgeon to surgeon
and practice to practice, but the point cannot be overemphasized
that, if you want to achieve consistently excellent results, analysis
and planning are critically important in rhinoplasty. This chapter
will focus on the aspects of nasal analysis and surgical planning
for rhinoplasty, from consultation to the operation.
60.2 Basic Anatomy of the Nose
Basic clinical anatomy of the nose is covered in Chapter 59. For
the purposes of analysis and planning, the rhinoplasty surgeon
must have a clear and in-depth understanding of what gives the
nose its shape and what anatomic elements are responsible for
proper nasal function as it relates to breathing. The skin itself
is generally of two varieties: thinner and more mobile over the
dorsum and sidewalls, transitioning to thicker and more glabrous
skin with much less mobility on the tip and nostrils. At the tip,
a variable amount of fatty tissue can be found depending on the
genetic/ethnic background of the patient. A thin muscular layer
also exists, made up of paired nasalis muscles along the side-
walls, the procerus along the radix, and the depressor septi nasi
at the base of the columella. The extrinsic levator labii superioris
60 Clinical Decision Making in Rhinoplasty
alaeque nasi elevates and dilates the ala, and the finer intrinsic
pars alaris muscles flare the nostrils.
The underlying bony and cartilaginous structures are the
principal features that give the nose its shape and are the areas
where the majority of the surgical effort is typically spent. Of
course, there are significant variations based on genetic/ethnic
background, but the paired nasal bones shape the upper third of
the nose on average, and the septum, upper laterals, and lower
laterals shape the lower two-thirds and tip especially. From a
functional standpoint the septum and its relationship to the nasal
bones, the vomer on which it rests the upper lateral cartilages,
and the inferior turbinates and the integrity of the ala dictate
nasal breathing function.
The qualities of the skin, muscle, bone, and cartilage that shape
the nose are clinically correlated to the shapes and contours of the
nose, some of which have their own descriptive labels or preferred
terminology when it comes to clinical correlations. More detail
can be found in the anatomy section, but a few key concepts are:
dorsal aesthetic lines, bony base, intercanthal distance, radix,
dorsal hump, supratip break, tip-defining points, infratip lobule,
nasolabial angle, columellar show, and alar rim contour; there are
many more.
60.3 Initial Consultation
60.3.1 Interview
The minute you meet the patient, your analysis of the nose (and
the patient) starts. ith experience, the surgeon can often for-
mulate an initial plan for rhinoplasty within seconds of seeing
Fig. 60.1 The process of successful rhinoplasty can be broken down
into three aspects: analysis, planning, and execution. Analysis and
planning are the foundation on which a successful rhinoplasty can be
done. While it may differ from surgeon to surgeon, I would argue that
analysis and planning make up about 50% of what it takes to deliver
a successful procedure, with the remaining half being the actual
performance of the procedure.
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the patient. It is what happens during the interview, formal report that they prefer one side over the other when there is
exam, and imaging (which is highly recommended) that leads a difference. Lastly, assess the function of the nose by asking
to the final plan. Ask two questions of your patient: hat is whether the patient breathes better through one nostril or the
it about your nose that you want to change and How is the other; then listen to the nasal breathing with both nostrils open
breathing through your nose Listen to the answers. then with each one closed individually. This can clue you in to
internal obstruction issues and the function of the internal and
external nasal valves. I find Cottle’s maneuver only somewhat
Two Principal Questions to Ask a New helpful, as almost all patients breathe better when it is done.
Rhinoplasty Patient Once the external exam is done, the internal nasal exam is
• “What is it about your nose that you want to change?” performed. ith a speculum and a light, observe the base of the
• “How is the breathing through your nose?” nose, making note of the alar base width, position of the columella,
any asymmetries, and the position of the anterior septum. Often
an anterior septal deviation is easily noted here. Next, shine the
our patient will tell you a lot with their answers to those two
light into the nose; the remaining septum and inferior turbinates
questions, and by a lot I mean more than just the actual answers
are seen, along with any evidence of septal spicules occluding the
to the actual questions. hat do I mean The detail or lack of
nasal airway. The occasional septal perforation is also identified. All
detail your patients report tells you not only the areas of the nose
external and internal findings are recorded in the patient’s chart.
you need to address during the consultation but also the degree of
their own understanding of their appearance and how their nose
interacts with the rest of their face. Furthermore, by listening, you
can tell the degree of concern the patient has with the features of
60.4 The Initial Conversation with
his or her nose and, by extension, what it is going to take to have the Patient
a happy patient should the patient choose to have surgery. For
Once the exam is done, an initial conversation takes place. A
minor patients, pay attention to what extent they themselves are
brief review of your findings is done; then specifics of surgery
reporting on their nose versus their parents.
are presented. This includes a general discussion of the process
Once you have listened to your patient, review the pertinent
of rhinoplasty, the surgeon’s preferred approach and location of
medical and surgical history; especially anything related to the
incisions, the aspects of the nose that will be addressed, where
nose, such as trauma, previous rhinoplasty, seasonal allergies,
the surgery will take place, type of anesthesia used, the type of
obstructive sleep apnea, frequent use of nasal sprays, epistaxis,
dressings/splinting that will be used, and what kind of recovery
drug use, and smoking.
is anticipated. In addition to what kind of pain they will have,
Sometimes you can gather information about the patient from
patients are usually quite keen on when they can go back to
your staff. How did the patient interact with your front desk How
school or work without attracting too much attention. This can
is the patient with your clinical staff and back office staff Often
be broken down several ways, but one way I like to do it is the
patients are on their best behavior when the physician is around,
time it will take to go out without attracting a lot of attention (1
so if you are questioning your patient’s disposition or motivations,
week with some sunglasses or makeup perhaps), 2 weeks until
you can look to your staff to fill in any gaps in the patient’s profile.
minimal or no cover is needed, and 6 weeks until we see 95 of
If a patient is rude or out of line with your staff, ask yourself how
the result. I tell patients that for the most part the nose will look
that individual will behave toward you in the event of any difficul-
final to them at about 6 weeks, but it will take 6 to 12 months to
ties after surgery.
look final to my eye. At this point questions from the patient and
family are elicited and answered. Throughout the entire consul-
60.3.2 Exam tation process, the surgeon is constantly assessing the patient
as a candidate for surgery by paying attention to the patient’s
Examine the patient with them sitting up and facing you at eye
maturity level, degree of concern with the nose versus degree
level. Before focusing on the nose, take into account the overall
of findings of the nose, motivations for surgery, and ability to
facial appearance with attention to asymmetries and, in partic-
understand what has been discussed to this point, and response
ular, to the relationship between the upper, middle, and lower
to the surgeon’s recommendations.
thirds of the face, with the nose being the dominant feature of
If the patient is a good candidate for fillers to the nose, this is
the middle third of that face. Ask yourself what the relationship
a good time to introduce that option. If the patient is not a good
of the nose is to the upper and lower thirds of the face. Does it
surgical candidate, this is a good time to start dropping hints to
dominate (as in a very large nose) or is it overshadowed (as a
that effect. If the patient is likely to be a good surgical candidate,
small nose with low bridge or one that has been overoperated
the next step is digital imaging.
on) Once this is done, start your systematic exam of the nose,
looking at it from the anterior view and laterally, taking into
account all the shapes and contours (dorsal aesthetic lines, dorsal
hump, tip width, etc.). By asking the patient to smile and observ-
60.5 Digital Imaging
ing laterally, you can assess whether or not the tip dips down Imaging and morphing the nose in one manner or another (by
due to the depressor septi nasi muscle. Furthermore, look at the hand drawings or digital software) can be an incredibly useful
nose from both the right and left sides, as often the appearance is tool during the process of consultation. My preference is digital
different in the case of nasal deviations. Patients will sometimes imaging using software specifically made for aesthetic surgery

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(Mirror suite, Canfield Scientific, Parsippany, ). Before I used
digital imaging, I simply printed the patient’s photos and used
pens and pencils to morph the nose. Some patients, especially
millennials and younger, may present having imaged their nose
themselves using filters available on popular platforms such as
Snapchat or something similar. Rather than disregard this effort
by patients, you should take a look at what they have done, as it
is a window into their impression of themselves and rhinoplasty
goals; then it is up to you to decide whether they are realistic or
not and move from there.
In any event the imaging that is done in your office during the
consultation serves three primary purposes, plus one if you and
your patient agree to surgery:
1. It gets you and your patient on the same page as to what the goal
appearance is.
2. The imaging helps answer the questions of whether or not that
goal is in balance with the rest of the face.
3. Once the imaging is done, it helps you decide whether those
results are achievable through surgery in your hands (Fig. 60.2).
If the first three goals of imaging are met and favorable for
surgery, then the fourth purpose of imaging is to use it to make
your surgical plan (a more in-depth explanation of this will come
later). If the first, second, or third aspect of imaging is a stumbling
block for you or your patient, you must reassess the goals of the
consultation and whether or not rhinoplasty is recommended. All
imaging is done with the expressed understanding that it is not
a guarantee of a result but simply a tool used to help achieve a
desired outcome. The imaging portion of the visit is a great time
to make sure you and your patient are on the same page and that
you believe the patient is a good candidate for surgery. In a busy
rhinoplasty practice, you may identify one patient a month who is
not a good candidate for one reason or another and decide not to
operate on that patient, saving you and them a lot of distress and
heartache. Conversely, the imaging can cement the beginning of a
very good patient–doctor relationship and aid in the planning of
an operation that can meet all the goals set forth.
60.6 The Red Flag Patient
The entire spectrum of plastic surgery sees patients who, for one
reason or another, are not a good candidate for surgery. One term
applied to these patients is red flag patient. The red flag patient
is very present and evident within the pool of patients seeking
rhinoplasty. Identifying the red flag patient before the patient
has surgery is very important, and (as mentioned earlier) may
take the assistance of your staff to identify. The red flag patient
can present in many ways. One of the easiest to identify is the
patient who has excessively high concerns related to minimal
findings on exam. This observation was popularized by Mark
Gorney, who then coined the Gorney-Gram (Fig. 60.3). By
plotting where your patient is on the Gorney-Gram, you may be
able to ferret out the patient who will not be happy no matter
what you do, before you do it.
Another classic red flag patient is the single, immature, male,
overly narcissistic (SIMO ) patient. Should a SIMO patient have
surgery, you run the risk of not only an unhappy patient postoper-
atively but also one who can become angry and aggressive toward
60 Clinical Decision Making in Rhinoplasty
the surgeon. Red flags can also be more subtle. The Debbie
Downer” type of patient is one to be wary of as well. This is the
patient who just never seems happy in your office, the one who
during imaging just never seems to be happy with any appearance
of the nose you generate or can’t seem to settle on one preferred
image. This type of patient will not be happy after a successful
procedure either. Another red flag is the patient who is rude or
abusive to your staff. Such individuals will not show this side of
themselves to you, so you have to empower and rely upon your
staff to inform you when this happens. In the right circumstances
it is possible they will turn their venom and meanness on to you.
Avoid taking these patients on; you will do yourself a favor and
your staff will greatly appreciate it.
Some information may be harder to come by. For example, some
patients may present having seen numerous other rhinoplasty
surgeons, and you may not know it. Having had multiple consul-
tations in and of itself is not necessarily a red flag, but it may be an
indicator of a patient who is in constant search of the one surgeon
who can meet goals that in fact may not be realistic. Or, possibly
that patient saw numerous other surgeons who did not agree
to do the requested surgery, and now that patient is seeing you.
Sometimes these patients who have been rejected several times
by other surgeons alter their behaviors so as not to be identified
as a red flag patient. There are also grey areas here, meaning some
patients who may appear as red flag patients but perhaps are not.
Maybe that patient who is doctor shopping needs the time and
consultations to feel finally comfortable making the decision to
have surgery. Some patients may show up having done their own
imaging and spent hours online looking at noses and present their
findings to you with specific goals already laid out before you have
assessed them fully. I know that early in my carrier it was harder
for me to take on the very particular patients who brought in their
own drawings or exhibited very particular goals with the imaging,
but with time, better patient management skills, and frankly better
rhinoplasty skills, such patients have been less of a red flag for me.
ou must rely on your experiences, take an honest inventory of
your surgical skills, maybe even have a sixth sense, if you will,
about each situation, then make a decision. Lastly, remember that
you never regret the patient you did not operate on.
60.7 Formulating a Plan
ith the consultation done and digital imaging in hand, a
surgical plan can be put together. The plan should take into con-
sideration the patient’s goals, your exam findings, your comfort
level, and the imaging. Every surgeon’s mind works differently,
and there is no one best approach to surgical planning that will
be universally applicable. ith that in mind, what is presented is
one way that I have found to take something rather complex and
make it into something that is simple, very effective, repeatable,
documentable, and easy to teach.
By simple planning, I mean it’s as easy as creating an if . . .
then” proposition. For example, “if” there is a dorsal hump, “then”
perform a hump reduction. Or “if” there is a deviated septum,
“then” perform a septoplasty. This “if . . . then” formula can be
applied down the line as it pertains to all the maneuvers that were
done on the nose during the morphing process, so that eventually
a step-by-step multipoint plan is developed (Fig. 60.4). The plan
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Fig. 60.2 This is a 19-year-old woman who presented with an interest in reduction rhinoplasty (a, left). During the imaging portion of her consulta-
tion two proposed images where made from the A/P view: one with doral hump reduction, nasal bone infracture, and tip defining work (a, middle).
The second image (a, right) shows the same work PLUS a bilateral weir excision. Morphing the nose with and without the weir really demonstrates
the improvement in the overall nasal balance to the patient and confirmed my suspicion that she would look good with it. Having done the weir on
the computer and confirming that both my patient and I liked it, the weir was incorporated into her procedural plan. (b) A similar situation where
the left photo is unmorphed, the middle photo shows morphing that includes a weir excision, and the photo on the right shows her result at 1 year.
Morphing can be very helpful when it comes to counseling a patient on your recommendations and (as in example b) a tool you use to measure your
own results against the morphing and learn from it.

908

Fig. 60.3 The Gorney-Gram: Patients who are in the lower right-hand
corner of the graph demonstrate a lower degree of concern with a
nose that needs a lot of work. These patients are more likely to be
happy after surgery. Patients in the upper left-hand portion of the
graph have a high degree of concern for a nose that may not need
much done to it. These patients are at risk for being unhappy after
surgery. (Courtesy of Mark Gorney, MD.)
can be written and posted in the operating room and used as a
reference list during the procedure. This eases the burden on the
surgeon, who does not have to memorize what he or she intends
to do on any given case. ith the plan/list up in the operating
room, each maneuver can be checked off as the case progresses so
that proposed maneuvers will not be missed or skipped (Fig. 60.5).
If additional procedures are performed, they are simply added to
the list so that by the end of the case a complete record exists of
what was done during the procedure. The same list can then be
used during the dictation process and eventually included as a ref-
erence in the patient’s chart. Furthermore, the list can be used as a
teaching tool for residents and for surgeons interested in assessing
and reviewing their own results over time. I have personally found
these lists and procedure plans incredibly helpful in my practice.
60.8 Performing the Procedure
Five Times
Looking back over this chapter and the process that it presents
for assessing and planning for rhinoplasty, the surgeon essen-
tially goes through the process of performing rhinoplasty on
any given patient fi times from beginning to end. To explain, as
it was to me by Robert Simon, MD, many years ago, the surgeon
repeats the procedure as follows (Fig. 60.5).
1. The first time you perform the rhinoplasty is the minute you
walk into the exam room, meet your patient for the first time,
and think about what needs to be done. It is based on your initial
gut reaction to the nose and the patient’s appearance.
2. The second time you perform the rhinoplasty is at the imaging ses-
sion: essentially doing the surgery on the computer with the software.
3. The third time you perform the rhinoplasty is when coming up
with the point-by-point surgical plan that is written down. A good
time to do this is the night before or morning of the procedure.
60 Clinical Decision Making in Rhinoplasty
Cosmetic
• Dorsal hump >>>>>>> hump reduction
• Open roof/wide base >>> osteotomies
• Wide tip >>>>>>> tip sutures ++
• NAO >>>>>>> septoplasty/turbs
• Tip over-projected >>>> set back
• Tip under-projected >>> columellar strut
Nasal airway obstruction
• Deviated septum >>>>>> septoplasty
• Crooked septal spine >>>>>> resect spine
• Enlarged turbinates >>>>>> outfracture or resect
• Support internal valve >>>>>> spreader graft
• External valve collapse >>>>>> alar batten graft +/- rim grafts
Fig. 60.4 Matching the maneuver with the problem.
4. The fourth time you “perform” the rhinoplasty is the actual pro-
cedure itself in the operating room.
5. Lastly, the fifth time you perform the rhinoplasty is when you
review your notes from the operation and dictate the procedure.
This is the after review, if you will, when you take a moment to look
back at what you did and make the notes part of the patient’s record.
So, taking a look at this list and doing the procedure five times, one
“performs” the rhinoplasty three times before the actual procedure.
How does this help hat are the benefits ell, they are many.
Through the first three times the surgeon is given the opportunity
to assess the nose and make a plan each time, helping refine the plan
and lowering the chances of missing something. By the time you go
to the operating room, you have prepared yourself and had three dry
runs on the rhinoplasty before actually performing it. It stands to
reason that the more you prepare for any event, especially a complex
procedure, the higher the likelihood that procedure will go well.
Recording the procedure while performing it and keeping a
record for later reference are also very beneficial. By checking
the boxes during the procedure, you are making sure everything
that you intended to do is getting done. At the same time, you are
relieving yourself of having to commit a whole surgical plan to
memory, therefore allowing yourself more attention to the task of
performing the procedure. o two rhinoplasties are the same, so
detailed notes for later reference help you assess your own results
and are a permanent resource that can help you evolve your tech-
nique over time when you review your results.
60.9 Case Examples
60.9.1 Case 1
The patient shown in Fig. 60.7 presented when she was 16 years
old with an interest in reducing the size of her nose. Because she
is rather tall at 180 cm, it would not have been appropriate simply
to reduce the size of her nose as one might for someone shorter.
After the imaging was done, her surgical plan included dorsal
hump reduction, autospreader flaps, septoplasty, turbinate
outfracture, nasal bone infracture, caudal trim of the septum,
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Fig 60.5 Surgical plan posted on the operating room wall during the procedure. (a) Preoperative photos and morphed images of patient. (b)
Procedure plan in the form of a checklist with boxes that are checked off as the maneuvers are done. This way the preop photos, morphed images,
and plan can all be referenced directly during the procedure. This helps the surgeon remember all the portions of the procedure to be performed and
helps when it comes to dictating the procedure and critiquing the results a year later.

60.9.2 Case 2
The patient shown in Fig. 60.8 presented at age 22 years with
complaints of a dorsal hump and overall wide nose with a wide
and droopy tip. Her surgical plan originally contained 14 points,
indicating the advantage in displaying it in the operating room
as a checklist, which was further altered as a result of intraop-
erative findings. One year postoperatively, she was very pleased
with her results.

60.10 Concluding Thoughts

Fig. 60.6 Doing the surgery five times. (Credit to Robert Simon, MD.)
cephalic trim of the lower lateral cartilages, transdomal and
interdomal tip sutures, horizontal mattress sutures of the lower
laterals, tip defatting, tip setback with suture, columellar strut,
infratip lobule reduction, and bilateral modified weir excisions.
Rhinoplasty has its challenges and rewards. As one of the more
complex plastic surgery procedures, detailed preparation is of
enormous benefit to the surgeon and, in turn, the patient. Careful
analysis and planning are the foundation on which a successful
procedure is performed with benefits that extend beyond the day
of surgery (i.e., teaching, reference, and improving the surgeon’s
technique). A systematic approach to the patient and the use of
digital imaging can simplify the process of surgical planning
in rhinoplasty. Along the way the surgeon needs to be aware of
red flag patients and be judicious about patient selection. hen
everything comes together, rhinoplasty can be very rewarding
and create a very positive change in your patients.

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 60 Clinical Decision Making in Rhinoplasty

a b c

d e f
Fig. 60.7 Case 1. (a,b,c) This patient presented when she was 16 with an interest in reducing the size of her nose. She is a model who is 5 feet 11 inches
(180 cm) tall with an interesting genetic background: a Caucasian mother and an Indian father. After the imaging was done, her surgical plan included
dorsal hump reduction, autospreader flaps, septoplasty, turbinate outfracture, nasal bone infracture, caudal trim of the septum, cephalic trim of the
lower lateral cartilages, transdomal and interdomal tip sutures, horizontal mattress sutures of the lower laterals, tip defatting, tip setback with suture,
columellar strut, infratip lobule reduction, and bilateral modified weir excisions. Keeping in mind that she is rather tall for a woman, it would not have
been appropriate to reduce the size of her nose to the same degree as one might for someone shorter. (d,e,f) Her 4-year result is shown.

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a b c

e f g
Fig. 60.8 Case 2. (a,b,c) This woman presented at age 22 years with complaints of a dorsal hump and overall wide nose with a wide and droopy tip.
Her background is Egyptian, and she desired a smaller nose. (d) The actual plan from the operating room. This was originally a 14-point plan that
would be difficult to memorize and keep track of during surgery. Note the boxes that are checked off during the procedure by the circulating nurse,
who also recorded additions to the plan based on intraoperative findings. (e,f,g) She is seen 1 year postoperatively and remains very pleased with her
results. Note the balance with her face and maintenance of her Egyptian heritage.

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61 Primary Rhinoplasty
Paul N. Afrooz and Rod J. Rohrich
Abstract
Rhinoplasty is one of the most complex and challenging oper-
ations in plastic surgery and also one of the most commonly
performed aesthetic surgery procedures. Successful rhinoplasty
begins with a thorough understanding of nasal anatomy, accurate
clinical analysis and definition of the anatomic deformity, and
precise surgical execution. This chapter discusses the history of
rhinoplasty surgery, nasal anatomy, clinical nasal analysis, and
operative approaches and principles as well as preoperative and
postoperative management.
Keywords
rhinoplasty; open rhinoplasty; endonasal rhinoplasty; closed
rhinoplasty; septoplasty
61.1 Introduction
Rhinoplasty is one of the most complex and challenging oper-
ations in plastic surgery. The rhinoplasty surgeon must have a
thorough understanding of the three-dimensional anatomy of
the nasal region, a proficiency in nasal and facial analysis, and
a firm grasp of the core concepts in manipulating nasal soft
tissues, cartilage, and bone. The surgeon must also be able to
appreciate the dynamic interplay between these structures and
have sound aesthetic judgement in order to create a result that
will produce a balanced, harmonious nose in relationship to the
rest of the face. The initial operation is critical to the long-term
result because the tissues are virginal and undistorted by prior
operative procedures.
61.2 Evolution of Technique
Aesthetic rhinoplasty has its roots in nasal reconstruction. The
first recorded treatment of nasal injuries dates back to approx-
imately 3000 BC, as recorded on the Egyptian Edwin Smith
surgical papyrus. Reconstructive surgery for nasal deformities is
described as early as 600 BC by Sushruta in India. After a long
period of quiescence during the Dark Ages, descriptions of nasal
reconstruction again appeared as the Renaissance brought forth
advances in science and medicine. The Indian methods for nasal
reconstruction with forehead and cheek skin were practiced and
modified by Italian surgeons into the Italian method, using arm
skin to reconstruct the nose. In the early nineteenth century,
German surgeons including Carl von Graefe and ohann Friedrich
Dieffenbach continued to develop methods for nasal reconstruc-
tion; Dieffenbach was one of the first to describe surgery for
aesthetic improvement of the nose.
ohn Orlando Roe, an American otolaryngologist, is credited
with describing the first aesthetic rhinoplasty and introducing
61 Primary Rhinoplasty
the endonasal approach. In 1887 Roe published The Deformity
Termed Pug ose’ and Its Correction, by a Simple Operation, and
in 1891 The Correction of Angular Deformities of the ose by a
Subcutaneous Operation. Roe’s descriptions preceded those of
acques oseph, a German orthopedic surgeon often regarded as
the father of modern rhinoplasty, given his contribution to the
analysis, classification, and repair of various nasal deformities,
outlined in his two-volume textbook on plastic surgery of the
nose.
In the first half of the twentieth century, the emergence of
plastic surgery as a specialty was spurred forward by experience
gained reconstructing devastating war injuries. The second half
of the twentieth century saw significant contributions to the
rhinoplasty literature, with gains in preoperative assessment and
diagnosis, management of the nasal airway, cartilage-grafting
techniques, and popularization of the open approach to rhino-
plasty. The open approach was first described by Aurel R thi of
Budapest in 1921 but did not gain popularity. In the 1960s his
approach was rediscovered by Ante Sercer of agreb and intro-
duced to orth America by his associate, Ivo Padovan, in 1970.
illiam Goodman of Toronto was the first orth American to
adopt the open approach, and this technique has gained in popu-
larity since the 1980s.
61.3 Indications and
Contraindications
Rhinoplasty can be performed for many indications, which fall
along a spectrum from purely functional to purely aesthetic.
However, each individual’s nasal anatomy must be taken into
account when deciding whether the patient is a good surgical
candidate and what approach should be used to address the
problem. o single approach is appropriate for all situations.
Obviously, there can be great advantages for the patient when
rhinoplasty is properly performed. Patients who suffer from nasal
airway obstruction ( AO) can achieve significant amelioration, if
not total eradication, of their symptoms. Frequently these patients
have had difficulty breathing for several years. hether the defor-
mity is congenital or traumatic, patient satisfaction is extremely
high after corrective surgery is performed.
Similarly, a patient who undergoes rhinoplasty for purely
aesthetic reasons stands to benefit significantly with respect to
self-image and self-esteem after a successful rhinoplasty. One
must be wary, however, of patients who perceive a significant
deformity in themselves when the deformity appears minor
to the surgeon. Such patients may never be satisfied with the
outcome, no matter how well the rhinoplasty is executed (see
Chapter 1). Multiple preoperative visits may be necessary, not
only to understand completely what the patient desires but also
to confirm whether the patient’s expectations are realistic.
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61.3.1 The Open versus the
Endonasal Approach
In modern rhinoplasty, both the open and the endonasal (closed)
approaches have their staunch proponents. The open approach
continues to gain in popularity over the endonasal approach
for both primary and secondary rhinoplasty. There are advan-
tages and disadvantages to both techniques, with the correct
approach determined by the patient’s anatomic deformity and
the surgeon’s experience. Clearly, what is performed to alter
the underlying anatomy is far more important than the type of
incision used (Table 61.1).
Despite the disadvantages to the open approach, in our expe-
rience we have not had patient dissatisfaction related to these
specific factors, other than prolonged nasal tip edema. As long as
the expectation level is set preoperatively, this has not proved to
be a problem.
Those who favor the endonasal approach to rhinoplasty submit
that the advantages offered by the open approach are outweighed
by its disadvantages (Table 61.2).
e prefer the open approach, in general, because it provides
full visualization of the nasal framework to diagnose the cause
of the nasal airway obstruction or the aesthetic deformity more
accurately. The various structures, from the dorsum to the septum
to the tip, can be manipulated with precision to yield reproduc-
ible results. e strongly recommend the open approach when
addressing a posttraumatic deformity or in secondary/revisional
surgery, as well as when complex tip modifications are necessary.
e find the endonasal approach to be advantageous in patients
with an isolated dorsal hump deformity or when minimal
modification of the tip is required. In these instances, we prefer
access through a marginal incision (approximately 1 mm cephalad
to the caudal margin of the lateral crus). e combine this with
Table 61.1 Open rhinoplasty approach rationale
Distinct advantages
• Binocular visualization
• Evaluation of complete deformity without distortion
• Precise diagnosis and correction of deformities
• Allows use of both hands
• More options with original tissues and cartilage grafts
• Direct control of bleeding with electrocautery
• Suture stabilization of grafts (invisible and visible)
Table 61.2 Endonasal approach
Advantages
• Leaves no external scar
• Limits dissection to areas needing modification
• Permits creation of precise pocket so graft material fits exactly without • Prohibits simultaneous visualization of the surgical field by a teaching
need for fixation
• Allows percutaneous fixation when large pockets are made
• Promotes healing by maintaining vascular bridge
• Encourages accurate preoperative diagnosis and planning
• Produces minimal postsurgical edema
• Reduces operating time
• Results in fast patient recovery
• Creates intact tip graft pocket
914
an intercartilaginous incision in cases of minor tip refinement
to allow adequate cartilage delivery and exposure. If the caudal
septum needs to be corrected as well, we perform a concomitant
hemitransfixion or transfixion incision.
61.4 Pertinent Anatomy
As in every other area in plastic surgery, thorough knowledge of
anatomy is paramount to obtaining a superior result. The nose is
divided into external skin and soft tissue, the underlying osseo-
cartilaginous framework, and ligamentous support. Rhinoplasty
surgeons must be familiar with each structure’s native mor-
phology and its variants and must have an appreciation for the
dynamic interplay between the components.
61.4.1 Skin
The thickness, mobility, and sebaceous character of the nasal
skin vary along its length, with the upper two-thirds being
thinner, more mobile, and less sebaceous than the inferior third
(Fig. 61.1). The nasal dorsum thickness averages approximately
1.3 mm, whereas the lobule skin thickness averages 2.4 mm. A
straight dorsum actually has a slight underlying convexity of its
osseocartilaginous framework in the cephalic area; therefore a
straight dorsal profile is actually produced by the combination
of this convexity in the osseocartilaginous framework with the
variation in dorsal skin thickness.
Some ethnic subgroups, such as those of African descent,
Hispanics, and those of Mediterranean descent, can have thicker,
more sebaceous skin. These differences are important because
the skin over the underlying nasal framework can either reveal
or mask changes depending on its characteristics. For instance,
it is advisable to err on the conservative side when operating on
Potential disadvantages
• External nasal incision (transcolumellar scar)
• Prolonged operative time
• Protracted nasal tip edema
• Columellar incision separation
• Delayed wound healing
Disadvantages
• Requires experience and great reliance on accurate preoperative
diagnosis
surgeon and students
• Does not allow direct visualization of nasal anatomy
• Makes dissection of alar cartilages difficult, particularly in cases of
malposition

a white woman with thin skin compared with a man of African
descent with thick, sebaceous skin. More dramatic manipulation
to the underlying nasal framework will be necessary in the patient
with thick skin to obtain an appreciable change in the external
appearance.
61.4.2 Muscle
Two muscles, in particular, are important in rhinoplasty the
levator labii alaeque nasi and the depressor septi nasi (Fig. 61.2).
The levator labii alaeque nasi helps to maintain the patency of
the external nasal valve, whereas the depressor septi nasi, if
overactive, can shorten the upper lip, cause a transverse upper
lip crease, and alter tip projection.
Evaluation of the depressor septi nasi is routine in our pre-
operative assessment. Its effect on depressing the nasal tip and
shortening the upper lip can be appreciated in some patients on
animation, particularly when smiling. In the subgroup of patients
in whom this muscle significantly alters the nasal appearance, we
transect this muscle. By doing so, several goals are achieved:
1. Enhancement of the tip–lip relationship
2. Relative upper lip lengthening
3. Relative fullness to the upper lip
4. Maintenance of tip rotation/projection on animation
61.4.3 Blood Supply
The blood supply to the nose is derived from both branches of the
ophthalmic artery and branches of the facial artery (Fig. 61.3).
It is important to note the vascularity to the nasal tip because
an open rhinoplasty approach using a transcolumellar incision
will transect the columellar vessels (when present), leaving the
lateral nasal and dorsal nasal arteries as the remaining blood
Fig. 61.1 Variations in nasal skin thickness along the nose.
61 Primary Rhinoplasty
supply. In our 1995 study, we found the lateral nasal arteries
to be present (either singularly or bilaterally) in 100 of cases,
with the columellar branches present 68.2 of the time. Since the
lateral nasal vessels are found approximately 2 to 3 mm above
the alar groove, extended alar resections to this level are pro-
hibited because injury to these vessels after the transcolumellar
approach would severely compromise blood flow to the nasal tip.
Furthermore, one must be extremely cautious when debulking
the nasal tip after an open approach, because the subdermal
vascular plexus connecting the dorsal nasal and lateral nasal
blood supplies may be damaged, leading to a similarly disastrous
result, with necrosis of the nasal tip skin.
Tardy and Toriumi studied the vascular and lymphatic anatomy
of the nose and determined that the transcolumellar incision
itself did not compromise major venous or lymphatic outflow.
Furthermore, they recommend dissection just above the perichon-
drium in the deep areolar plane, leaving the musculoaponeurotic
layer intact, which preserves the major arterial vascular supply
and avoids damage to the venous and lymphatic vasculature
that lies in a more superficial (subcutaneous) plane. In this way,
bleeding and postoperative edema are minimized.
61.4.4 Nasal Vaults
The osseocartilaginous nasal framework can be subdivided into
three separate vaults: bony, upper cartilaginous, and lower carti-
laginous. The bony vault constitutes the upper third to half of the
nose and is made up of the paired nasal bones and the ascending
frontal process of the maxilla (Fig. 61.4). It is important to note
that the nasal bones are narrowest and thickest above the level
of the medial canthi. As a result, osteotomies are rarely indicated
above this level.
Fig. 61.2 The levator labii alaeque nasi and depressor septi nasi
muscles.
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 X Rhinoplasty

Fig. 61.3 Blood supply of the nose.

The upper cartilaginous framework begins where the nasal

bones overlap the upper lateral cartilages (ULCs) and septum
for 4 to 6 mm, creating what is known as the keystone area. This
area should be the widest part of the dorsum and resembles a T
shape in cross-section. The remainder of this vault is composed
of the paired ULCs and dorsal cartilaginous septum (Fig. 61.5).
Overresection during dorsal hump reduction in this area can lead
to deformities such as the inverted-V deformity or disruption of
the dorsal aesthetic lines. A component dorsal hump reduction is
advised to avoid these complications.
The lower cartilaginous framework begins where the ULCs
interdigitate with the lower lateral cartilages (LLCs) in what is
called the scroll area (Fig. 61.6). Each of the LLCs comprises the
medial, middle, and lateral crura. These cartilages are connected
to each other, the ULCs, and the septum by fibrous tissue and
ligaments. Disruption of these ligaments can result in diminished
tip projection during rhinoplasty. Thus, if these structures are Fig. 61.4 The bony vault of the nose is made up of the paired nasal
bones and the ascending frontal process of the maxilla.
violated, maneuvers that increase tip support (for example, col-
umellar struts, extended spreader grafts, suture techniques) may
be necessary.
to prevent iatrogenic damage to the cribriform plate, which can
lead to cerebrospinal fluid rhinorrhea, olfactory impairment, and
61.4.5 Nasal Function potential ascending infection/meningitis.
The septum, turbinates, and internal and external nasal valves The turbinates help to guide the transport of air during res-
serve as the anatomic functional foundation for the nose, con- piration and condition/humidify inspired and expired air (Fig.
tributing to respiration, filtration, humidification, temperature 61.8). These structures are mucosa-lined extensions of the lateral
regulation, and protection. nasal cavity and undergo a normal autonomically mediated cycle
The septum is made up of the septal cartilage, the perpen- of expansion and contraction. Of all the turbinates, however, it
dicular plate of the ethmoid bone, the nasal crest of the maxilla, is the inferior turbinate that has the greatest impact on airway
and the vomer (Fig. 61.7). Deformities in the septum can lead to resistance, providing up to two-thirds of the total airway resis-
significantly impaired airflow through the nose as well as com- tance from its most anterior aspect. However, overresection of the
pensatory turbinate pathology. Restoration of a normal straight anterior inferior turbinate can have a deleterious effect on its reg-
septum will help reestablish laminar airflow. hen addressing ulatory and physiologic functions and can lead to crust formation,
septal deformities, it is important to assess all septal components. bleeding, and nasal cilia dysfunction.
hen performing a septal resection, it is important to remem- The internal nasal valve can contribute up to 50 of the total
ber that the perpendicular plate of the ethmoid is contiguous airway resistance and is the narrowest segment of the nasal airway.
posterosuperiorly with the cribriform plate. Therefore, a sidewise It is composed of the angle formed by the intersection of the nasal
fracture of the perpendicular plate should be performed with care septum and the caudal margin of the ULC and is usually 10 to

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Fig. 61.5 The keystone area is the junction of the bony vault and the upper cartilaginous vault. The upper cartilaginous vault is composed of the
paired upper lateral cartilages and the dorsal cartilaginous septum.

Fig. 61.7 The septum is made up of the septal cartilage, the perpen-
Fig. 61.6 The lower cartilaginous framework is composed of the dicular plate of the ethmoid, the nasal crest of the maxilla, and the
paired lower lateral cartilages. vomer.

Fig. 61.8 The turbinates help to guide the transport of air during Fig. 61.9 The internal and external valves.
respiration and condition/humidify inspired and expired air.

15 (Fig. 61.9). In some cases, the anterior portion of the inferior at this area. Traditionally, improvement in airflow with lateral
turbinate may be a significant contributor to the decrease in the traction on the cheek (positive Cottle’s sign) diagnoses collapse of
cross-sectional area of this region. Patients with short nasal bones the internal nasal valve and signals the need for spreader grafts to
and long, poorly supported ULCs have a propensity to have collapse increase the patency of the valve and stent the airway open.

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The external nasal valve is the cartilaginous vestibule bounded

by the nares and lateral alar sidewalls (Fig. 61.9). It is caudal to the
internal valve. Obstruction at this area may be caused by foreign
bodies, weak or collapsed LLCs, loss of vestibular skin, or scar
tissue. Several options are available to reestablish proper airflow
through this area, including alar contour grafts, lateral crural strut
grafts, lateral crural cephalic turnover flaps, lysis of adhesions,
scar revision, mucosal grafts, skin grafts, or composite grafts.

61.5 Preoperative Assessment

61.5.1 Initial Consultation
Before proceeding with a rhinoplasty, it is important to evaluate
the patient’s motivations and expectations for surgery com-
pletely to determine whether the patient is a suitable surgical
candidate. Gunter and Gorney have both commented on danger
signs that may be exhibited by certain patients. Patients that
meet these criteria should be approached with caution because
surgical intervention may not be in the best interests of either
the patient or the surgeon. Gunter identified the following 13
danger signs that may signify underlying psychological issues:
Fig. 61.10 Plot of patient concerns relative to deformity.
1. Minimal disfigurement
2. Delusional distortion of body image
3. Identity problem or sexual ambivalence
4. Confused or vague motives for wanting surgery recommended to reiterate the patient’s desires, develop a realistic
5. Unrealistic expectations of change in life situation as a result of operative plan, and reaffirm the patient’s understanding of the
surgery anticipated procedure.
6. History of poorly established social and emotional relationships Although there are different methods for integrating the
7. Unresolved grief or currently in a crisis situation patient into the surgical process, we find that computer imaging
8. Present misfortunes blamed on physical appearance provides an excellent way for patients to gain a realistic under-
standing of the anticipated outcome. Although the images are not
9. Older neurotic man who is overly concerned about aging
meant to guarantee surgical results, they do provide a visual level
10. Sudden dislike for one’s anatomy, especially in an older man
of understanding that may otherwise be lacking. These images,
11. A hostile, blaming attitude toward authority figures
combined with standardized anterior, lateral, oblique, and basal
12. History of consulting physicians and being dissatisfied with
photographs, serve as an integral element of the preoperative
them
surgical plan.
13. Indication of paranoid thoughts

Similarly, Gorney uses two systems to identify potential prob-

lem patients. The first uses the acronym SIMO (single immature
males, overly expectant, narcissistic) to describe certain traits to
be wary of. The second method Gorney uses plots the patient’s
concern on one axis and the degree of deformity on the other (Fig.
61.10). Patients with an appropriate amount of concern relative to
their degree of deformity are excellent candidates for treatment.
However, those with minimal deformity but disproportionate
concern should be avoided, because frequently their expectations
exceed the amount of aesthetic improvement that is possible.
Furthermore, regardless of the degree of deformity, if the level of
skill and expertise required to perform the rhinoplasty exceeds
the surgeon’s ability, the patient should be referred to a more
proficient surgeon.
It should also be noted that men in general tend to have a poorer
understanding of their deformity than women do. Furthermore,
they tend to have a more difficult time articulating the desired
changes. Thus, for this subgroup of patients, during the initial
consultation the physician must determine the patient’s goals
and whether they are realistic. A second follow-up consultation is
61.5.2 Facial Analysis
An essential element to proper preoperative surgical planning is
critical facial analysis. Each individual nose has different propor-
tions, morphology, and relative relationship with the surround-
ing face. To preserve nasofacial harmony, it is crucial to perform
a systematic and meticulous analysis of the nose and face to
diagnose the deformity accurately and then to determine the
optimal surgical plan to correct the problem. It is also important
to point out natural facial asymmetries to the patient preoper-
atively so the patient gains a better understanding of what is
actually present before any operative intervention is performed.
e begin by evaluating the patient’s skin type, thickness, and
texture. As previously mentioned, this is important because
thicker, more sebaceous skin tends to camouflage changes made
to the underlying osseocartilaginous framework, whereas thinner
skin tends to show even minor changes.
e then proceed with the remainder of the facial analysis.
There are some proportions and relationships of facial structures
that make up an attractive face. Although more proportions

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have been described, the following are some of the fundamental

relationships that we routinely use in our preoperative evaluation
of the rhinoplasty patient. e will describe these relationships
briefly for Caucasian women and point out when the proportions
differ between men and women.
e start by evaluating for disproportions and anomalies of the
underlying facial skeleton, including the maxillomandibular rela-
tionship. To do this, we divide the face into thirds using horizontal
lines adjacent to the hairline, brow (at the level of the supraorbital
notch), nasal base, and menton (Fig. 61.11). The upper third
(between the hairline and the brow) is the least important, as it is
the most variable (depending on the hairstyle). The lower third of
the face is then subdivided into thirds by visualizing a horizontal
line between the oral commissures (stomion). The upper third of
this subdivision lies between the nasal base and the oral com-
missures, and the lower two-thirds between the commissures Fig. 61.11 The face is divided into thirds using horizontal lines adjacent
to the hairline, brow, nasal base, and menton. The lower third of the
(stomion) and the menton. If there are significant deviations from face is then subdivided into thirds by visualizing a horizontal line
these proportions, the patient may have underlying craniofacial between the oral commissures (stomion). The upper third of this sub-
disproportion (e.g., vertical maxillary excess) that may need to be division lies between the nasal base and the oral commissures, and the
lower two-thirds between the commissures (stomion) and the menton.
addressed in addition to rhinoplasty.
The nasal length (radix to tip, or RT) is verified against the
stomion-to-menton distance (SM), which should be equal, as was
described by Byrd and Hobar (Fig. 61.12). differ between patients, this line may or may not correspond to
For future reference, a natural horizontal facial plane is deter- Frankfort’s line.
mined by drawing a line perpendicular to a plumb line superim- The lip–chin relationship is assessed next. Byrd determines
posed over the head in repose and the eyes in straightforward ideal chin projection by dropping a vertical line from a point one-
gaze (Fig. 61.13). As the external auditory canal position may half the ideal nasal length tangential to the vermilion of the upper
lip. The lower lip should be no more than 2 mm behind this line.
The ideal chin position varies with gender, with the chin lying
slightly posterior to the lower lip in women but even with the
lower lip in men. If there is a discrepancy in these relationships,
orthodontics, orthognathic surgery, or a chin implant may be
necessary to improve facial harmony.
asal deviation is noted by drawing a line from the midglabel-
lar area to the menton, bisecting the nasal ridge, upper lip, and
Cupid’s bow (Fig. 61.14). This line will pass between the central
incisors in patients with normal occlusion. Any deviation of the
nose from this line will likely require septal surgery.

Fig. 61.13 (Left) A natural horizontal facial plane is determined by

drawing a line perpendicular to a plumb line superimposed over the head
in repose and the eyes in straightforward gaze. (Right) Ideal chin position
Fig. 61.12 The nasal length (radix to tip, or RT) is verified against the is determined in reference to a vertical line dropped from one-half the
stomion-to-menton distance (SM), which should be equal. ideal nasal length and tangential to the vermilion of the upper lip.

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 X Rhinoplasty
The nasal dorsum is then assessed on frontal (anterior) view.
The curvilinear dorsal aesthetic lines are traced from where they
originate at the supraorbital ridges, and then follow along the
corrugators to converge at the medial canthal ligaments, from
which they begin to diverge slightly. From this point, they track to
the tip-defining points, slightly diverging from each other along
the dorsum during their course (Fig. 61.15). Ideally, the width of
the dorsal aesthetic lines should match either the width of the
tip-defining points or the interphiltral distance. These lines may
be ideal, narrow, wide, asymmetric, or ill-defined.
The widths of both the bony base and the alar base are then
assessed. The width of the bony base should be 80 of the normal
alar base width (which is typically equal to the intercanthal
distance) or the width of the palpebral fissure (Fig. 61.16). If the
bony base is greater than 80 of the alar base width (assuming
the alar base width is normal), it is likely that osteotomies will be
required to narrow the bony vault. Although men tend to have a
wider bony base than women, it is important not to narrow the
dorsum too much in males, since this could feminize the nose.
The alar base is analyzed, as is the geometry of the alar rims
(Fig. 61.17). If the alar base width is greater than the intercanthal
distance, it must be determined whether this is the result of a
narrow intercanthal distance, a true increased interalar width, or
alar flaring. If the intercanthal distance is smaller than the width
Fig. 61.14 Nasal deviation is noted by drawing a line from the
midglabellar area to the menton, bisecting the nasal ridge, upper lip,
and Cupid’s bow.
920
of the palpebral fissure, it is better to maintain a slightly wider
alar base. If there is true increased interalar width, a nostril sill
resection may be indicated. If the increase in width is secondary
to alar flaring (greater than 2 to 3 mm outside the alar base), an
alar base resection should be considered. Again, the alar rims
should also be assessed for symmetry and should flare slightly
outward in the inferolateral direction.
hile still addressing the frontal view, the surgeon assesses the
nose tip to determine the supratip break, the tip-defining points,
and the columellar-lobular angle. These points serve as landmarks
to draw two equilateral triangles with their bases opposed (Fig.
61.18). If these triangles are asymmetric, the underlying reason
should be investigated, and the patient will likely require tip
modification.
The final assessment on frontal view is of the outline of the
alar rims and the columella, which should resemble a seagull in
gentle flight, with the columella lying just inferior to the alar rims
(Fig. 61.19). If the curve is too drastic, the patient may have an
increased infratip lobular height, or a hanging columella, which
will need correction. If, on the other hand, the curve is flattened,
the patient probably has decreased columellar show, which may
require columellar augmentation or alar rim modification.
Fig. 61.15 The dorsal aesthetic lines originate at the supraorbital
ridges and then converge at the medial canthal ligaments, from
which they begin to diverge slightly. From this point, they track to
the tip-defining points, slightly diverging from each other along the
dorsum during their course.

Fig. 61.16 The width of the bony base should be 80% of the normal
alar base width or the width of the palpebral fissure.
Fig. 61.18 The supratip breakpoint, the tip-defining points, and the
columellar-lobular angle make up the landmarks of the nasal tip. These
points serve as landmarks to draw two equilateral triangles with their
bases opposed.
The basal view of the nose is addressed next, with the outline
of the nasal base described as an equilateral triangle with a
lobule-to-nostril ratio of 1:2 (Fig. 61.19). The nostril itself should
61 Primary Rhinoplasty
Fig. 61.17 The alar base should be analyzed for width and geometry.
Fig. 61.19 The outline of the alar rims and the columella should
resemble a seagull in gentle flight, with the columella lying just inferior
to the alar rims. In the basal view, the outline of the nasal base should
resemble an equilateral triangle with a lobule-to-nostril ratio of 1:2.
have a teardrop-like geometry, with the long axis from the base to
the apex oriented in a slight medial direction.
The lateral view is then analyzed, beginning with the position
and depth of the nasal root at the radix. The nasofrontal angle
connects the brow and the dorsum through a soft concave curve
at the radix. The apex of this angle should lie between the upper
lid eyelashes and the supratarsal fold, with the eyes in natural
horizontal gaze. Although this angle can vary from 128 to 140 ,
921
 X Rhinoplasty
it is ideally 134 in women and 130 in men. Other important ref-
erence measurements from this view include the nasion–medial
canthal distance, which should be approximately 15 mm, and the
nasion–corneal plane distance, which is approximately 11 mm.
hile still concentrating on the lateral view, it is important to
remember that the perceived nasal length and tip projection can
be altered by the position of the aforementioned nasofrontal angle.
For instance, if the nasofrontal angle is positioned more anteriorly
and superiorly than normal, the nose will appear elongated, the
nasofacial angle will be decreased, and the tip projection will
appear diminished (Fig. 61.20, yellow line). Conversely, if the
nasofrontal angle is too posteriorly or inferiorly positioned, the
nose will appear shorter, and the tip more projecting (Fig. 61.20,
red line). Ideally, the nasofacial angle (as defined by the junction
of the nasal dorsum with the vertical facial plane) should measure
32 to 37 .
Tip projection is addressed next, still from the lateral view.
Although several methods have been described to assess this, we
prefer the following two ways. In a patient with normal upper
lip projection, we begin by drawing a horizontal line from the
alar–cheek junction to the tip of the nose (Fig. 61.21). The tip pro-
jection is considered normal if 50 to 60 of this line lies anterior
to a vertical line tangent to the most projecting part of the upper
lip. The tip is considered to be overprojected if greater than 60 of
the horizontal line lies anterior to the vertical reference line and
may therefore require deprojection. Conversely, if less than 50
of the tip lies anterior to the line, the projection may need to be
augmented (in any number of ways).
Fig. 61.20 The perceived nasal length and tip projection can be
altered by the position of the nasofrontal angle. If the nasofrontal
angle is positioned more anteriorly and superiorly than normal, the
nose will appear elongated, the nasofacial angle will be decreased, and
the tip projection will appear diminished (yellow line). Conversely, if the
nasofrontal angle is too posteriorly or inferiorly positioned, the nose
will appear shorter, and the tip more projecting (red line).
922
The second method we use to help assess tip projection is by
comparing it to the alar base width (they should be equal) and
by comparing the ratio of nasal length (radix to tip, RT) to the tip
projection length (alar base to tip, as described in the preceding
paragraph). In the latter, the ideal tip projection is 0.67 RT (Fig.
61.22).
After the tip projection is assessed, the dorsum is analyzed. The
aesthetic nasal dorsum should lie approximately 2 mm behind
and parallel to a line from the radix to the tip-defining points in
women (Fig. 61.23). The norms for men are discussed in a later
subsection.
The degree of supratip break is appraised when the nasal tip
projection and dorsum are evaluated. A slight supratip break is
preferred in women (but not in men). This gives the nose more
definition and distinguishes the dorsum from the tip.
The nasolabial angle is used to determine the degree of tip rota-
tion (Fig. 61.24). This angle is obtained by measuring the angle
between a line coursing through the most anterior and posterior
edges of the nostril and a plumb line dropped perpendicular to
the natural horizontal facial plane. This angle should be between
95 and 100 in women.
The nasolabial angle should not be confused with the columel-
lar–lobular angle, which is formed at the junction of the columella
with the infratip lobule (Fig. 61.25). Increased fullness in this area
is usually caused by a prominent caudal septum. This angle is
normally 30 to 45 .
The alar–columellar relationship is then assessed in the lateral
and frontal views. A line is drawn along the long axis of the nostril,
and a perpendicular line is drawn from alar rim to columellar rim
Fig. 61.21 The tip projection is considered normal if 50–60% of the tip
lies anterior to a vertical line tangent to the most projecting part of the
upper lip.
 61 Primary Rhinoplasty

Fig. 61.22 Another method used to assess tip projection is to compare it to the alar base width and to compare the ratio of nasal length, radix to tip
(RT), to the tip projection (alar base to tip). In the latter, the ideal tip projection is 0.67 RT.

Fig. 61.23 The aesthetic nasal dorsum should lie approximately 2 mm

behind and parallel to a line from the radix to the tip-defining points in Fig. 61.24 The nasolabial angle should be between 95° and 100° in
women. women.

that bisects this axis (Fig. 61.26). The distance from the alar rim to
the long axis line should equal the distance between the long axis
line and the columellar rim if the alar-columellar relationship is
normal ( 2 mm). If these measurements are not normal,
the deformity can be categorized into six classes. Classes I to III
describe increased columellar show, whereas classes IV to VI
demonstrate decreased columellar show (described later in the
section on operative techniques). These may be treated differently
depending on the class of deformity.

923
 X Rhinoplasty

Fig. 61.25 The columellar–lobular angle is formed at the junction of

the columella with the infratip lobule. This angle is normally 30° to 45°.

Proportions in Male Patients

The proportions discussed so far generally apply to Caucasian
women. Generally, the male face tends to have a squarer, less
rounded appearance, with stronger, more pronounced features.
The key differences in the nose for men are as follows:

• The male dorsum tends to be straighter and wider, with

decreased concavity at the superciliary ridges.
• The male nasal dorsal profile should hug a line drawn from the
radix to the tip-defining points instead of falling 2 mm behind
and parallel to this line, as in women.
• There should be minimal to no supratip break, consistent with
the dorsal profile not falling behind the radix-to-tip line.
• Tip rotation in men is slightly less than in women (90 to 95
versus 95 to 100 in women).
• In general, men have a broader, more bulbous nasal tip.
• Male skin is usually thicker, masking the amount of perceiv-
able change.
It is important to remember that these proportions are gen-
eral guidelines and can vary tremendously between different
individuals. In addition, it is important to consider the patient’s
ethnicity and culturally accepted aesthetic ideals, as rhinoplasty
is becoming increasingly popular among different ethnic groups.
Fig. 61.26 The alar–columellar relationship (ACR) is assessed in the
lateral view. A line is drawn through the long axis of the nostril, and a
perpendicular line is drawn from alar rim to columellar rim that bisects
this axis. The distance from the alar rim (point A) to the long axis line
(point B) should equal the distance between the long axis line to the
columellar rim (point C) if the alar–columellar relationship is normal
(AB = BC 2 mm).
Rhinoplasty in Patients of African Descent
Compared with the nasal ideals for Caucasians, the noses of
patients of African heritage typically feature a wide, low nasal
dorsum, decreased nasal length and tip projection, less nasal tip
definition, an acute nasolabial angle, and alar flaring (Fig. 61.27).
The goals of rhinoplasty in a patient of African descent include
achieving a narrower, straight dorsum, improved tip projection
and greater definition, and decreasing alar flaring and alar base
width (Fig. 61.28). Improvement of the typically low nasal dorsum
may require dorsal augmentation. Tip definition is improved by
suture techniques and cartilage grafting, as needed.

924

Rhinoplasty in Patients of
Middle Eastern Descent
The complex nasal morphology of the Middle Eastern nose war-
rants discussion. It demonstrates a combination of features seen
in individuals of African, Mediterranean, and Hispanic origin.
The Middle Eastern nose features thick, sebaceous skin and
is most prominent at the supratip. The radix may overproject,
the bony and middle vaults tend to be wide, and a significant
dorsal hump is common. The LLCs can feature malposition of
the lateral crura and weak middle and medial crura, resulting
in various characteristic deformities of the tip, including poor
tip definition, underprojection of the tip, or a droopy tip with
Fig. 61.27 Compared with the nasal ideals for Caucasians, the noses of
patients of African heritage typically feature a wide, low nasal dorsum,
decreased nasal length and tip projection, less well defined nasal tip,
an acute nasolabial angle, and alar flaring.
Fig. 61.29 The Middle Eastern nose features thick, sebaceous skin
and is most prominent at the supratip. The radix may overproject, the
bony and middle vaults tend to be wide, and a significant dorsal hump
is common. The lower lateral cartilages can feature malposition of the
lateral crura and weak middle and medial crura, resulting in various
characteristic deformities of the tip, including poor tip definition, under-
projection of the tip, or a droopy tip with an acute nasolabial angle.
61 Primary Rhinoplasty
an acute nasolabial angle (Fig. 61.29). The tip deformities may
be exacerbated by hyperdynamic depressor septi nasi muscles.
Nasal deviation and nostril asymmetry are also common.
Achieving ethnic nasofacial harmony in a Middle Eastern patient
includes moderate dorsal hump reduction; narrowing of the wide
nasal bones; debulking of soft tissue, particularly at the supratip;
modest correction of underrotation and underprojection of the
nasal tip; improvement of tip definition; repositioning of the alar
bases; and correction of nostril asymmetries (Fig. 61.30).
These guidelines are meant only as a systematic method of anal-
ysis with general proportions and relationships. Each nose should
Fig. 61.28 The goals of rhinoplasty in a patient of African descent often
include achieving a narrower, straight dorsum, improved tip projection
and definition, and decreasing alar flaring and alar base width.
Fig. 61.30 Achieving ethnic nasofacial harmony in a Middle Eastern
patient includes moderate dorsal hump reduction; narrowing of the
wide nasal bones; debulking of soft tissue; modest correction of
underrotation and underprojection of the nasal tip; improvement of
tip definition; repositioning of the alar bases, and correction of nostril
asymmetries.
925
 X Rhinoplasty
be individualized to the patient’s facial structure and tempered by
the patient’s desires to create facial harmony and balance.
61.5.3 Intranasal Examination
The final part of the preoperative analysis of the rhinoplasty
patient is the intranasal examination. This is performed with a
nasal speculum, headlight, and vasoconstriction. The septum,
turbinates, and external and internal nasal valves are evaluated
for obvious deformities or pathology.
Septal perforation or deviation should be identified. Septal devi-
ation can involve deviation of the septal cartilage, perpendicular
plate of the ethmoid bone, or vomer and can cause obstruction of
one or both of the nasal airways, along with external deviation of
the nose.
Guyuron et al classified septal deviation as follows (Fig. 61.31):
1. Septal tilt (40 )
2. Anteroposterior C-shaped deviation (32 )
3. Cephalocaudal C-shaped deviation (4 )
4. Anteroposterior S-shaped deviation (9 )
5. Cephalocaudal S-shaped deviation (1 )
6. Localized deviation or septal spur (14 )
Septal tilt is the most common type, where the quadrangular
cartilage and perpendicular plate of the ethmoid are straight but
the quadrangular cartilage is tilted to one side internally and to
the opposite side externally. Hypertrophy of the inferior turbinate
contralateral to the side of internal deviation is usually present.
If inferior turbinate hypertrophy is identified, the underlying
cause should be investigated. Turbinate enlargement can be con-
genital or acquired. If acquired, it may be the result of autonomic,
environmental, medical, or anatomic factors. A complete workup,
especially a detailed history, is essential.
The external nasal valve should be examined for patency
on normal and forced inspiration. Collapse of the alar rim from
weakness of the lower lateral crus should be evaluated.
A Cottle test should be performed to assess the internal nasal
valve. Septal deviation or midvault collapse can contribute to
airway obstruction in this area. Finally, nasal polyps or masses
may require further evaluation and treatment.
61.6 Preoperative Planning
After the initial history-taking and physical examination, the
procedure is fully discussed with the patient. The risks and
benefits of the procedure are detailed, and all questions are
answered. The patient is provided with a written, detailed
estimate of surgical charges with complete explanations by the
practice’s billing staff. e ask the patient to return for a second
clinic visit to review the previous discussion and to assess the
patient’s psychological and emotional stability to ensure that he
or she is a good surgical candidate. e also reiterate the defor-
mities we plan to correct and answer any further questions.
The consent form is reviewed again and signed. Our patients
sign a form accepting financial responsibility. A preoperative
instruction sheet and a list of medications to be avoided are also
provided.
926
Preoperative Instructions
Two Weeks Before Surgery
1. Some medications can interfere with anesthesia and cause
undesirable side effects that can affect your surgery. Please
read over the enclosed medication information list and let
us know if you take any of them. Aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs) should not be taken at
least 2 weeks before or after surgery. Acetaminophen (e.g.,
Tylenol) is a good medication to take for any aches or pains
you may have before surgery.
2. Smoking will affect how you heal. It is very important to
stop smoking 4 weeks before your surgery.
3. If you develop a cold, a facial sore, or any other illness before
surgery, please notify us.
4. If you are having surgery as an outpatient, please ensure
that arrangements have been made for a responsible adult
to drive you to the surgery center and pick you up after your
surgery and to stay with you for the first 24 hours.
Evening Before Surgery
5. Shampoo your hair and wash your face. Do not use condi-
tioner or hair spray after shampooing.
6. Make some Jell-O and/or soup for after surgery.
7. Get a good night’s rest.
8. Do not eat or drink anything after midnight.
Morning of Surgery
9. Arrive at the surgery center/hospital by
__________________.
10. Do not eat or drink anything if your surgery is scheduled
before noon. If your surgery is scheduled after noon, you
may have coffee or tea and dry toast no later than 6 hours
before your scheduled surgery time.
11. Do not wear wigs, hairpins, hairpieces, or jewelry. Dress in
old, loose, comfortable clothes. Do not wear pullover tops
or pantyhose. Wear slip-on shoes.
12.Have someone drive you to the surgery center and make
certain a responsible adult will be available to take you home
and stay with you for 24 hours. Put a pillow and blanket in
the car for the trip home.
e convert our operative plan into a graphic representation
(using Gunter Graphics; Austin, TX) to assist us in the operating
room. Any modifications to the plan are documented intraop-
eratively on a worksheet, transposed to the graphic depictions
afterward, and placed in the patient’s chart for future reference.
On the morning of surgery, any final questions are answered,
and the patient is taken to the operating room and positioned
supine on the operating table. oninvasive hemodynamic mon-
itoring devices are placed, and all pressure points are padded
appropriately. One gram of cefazolin is administered intravenously
for perioperative antibiotic prophylaxis. e prefer general anes-
thesia for our patients, although local anesthesia with intravenous
sedation may certainly be used. After anesthetic is administered,
the nasal vibrissae are clipped and the nares are swabbed with
povidone-iodine (Betadine) solution.
 61 Primary Rhinoplasty

a b c

d e f
Fig. 61.31 Septal deviation can be caused by: (a–c) septal tilt, anteroposterior C-shaped deviation, cephalocaudal C-shaped deviation, (d–f) antero-
posterior S-shaped deviation, cephalocaudal S-shaped deviation, or localized deviation or septal spur.

e mark a line for the anticipated incision (transcolumellar use 4 cocaine because comparable hemostasis can be obtained
stairstep, if using an open approach) and then inject approx- using lidocaine with oxymetazoline, thus avoiding the use of a
imately 10 mL of 1 lidocaine with 1:100,000 epinephrine into controlled substance with potential cardiac effects that may be
the intranasal mucosa, along the septum, and into the soft tissue seen with cocaine. A throat pack is placed in the oropharynx to
envelope. The inferior turbinates are injected if we anticipate prevent possible ingestion of blood during surgery, which could
performing an inferior turbinoplasty (Table 61.3). lead to postoperative nausea and vomiting. At this point the
After the local anesthetic is injected, the nasal mucosa is shrunk patient is prepared and draped for surgery.
with cottonoid pledgets soaked in oxymetazoline. A drop of meth-
ylene blue is added to the oxymetazoline to differentiate this from
the local anesthetic and prevent inadvertent injection. e do not 61.7 Operative Technique
61.7.1 Incision: Endonasal Approach
Table 61.3 Location and volume distribution of 1% lidocaine with hen deciding on what incision to use in the endonasal
1:100,000 epinephrine approach, once again the surgeon must employ accurate preop-
Location Amount (mL) erative nasofacial analysis. Because the objective is to minimize
Vestibules/aperture 2 incisions, any incision that can be used to access multiple areas
should be used so that separate incisions become unnecessary.
Dorsum 1
For example, if an alar contour graft will be needed as well as
Lateral walls 2 rasping of a dorsal hump, the access incision can be made on the
Tip/columella 2 same side as the alar contour graft.
Distal septum 2 There are two basic techniques for access in endonasal rhino-
plasty: nondelivery and delivery. The nondelivery approach can
Inferior turbinates 1
use either a transcartilaginous (cartilage-splitting) incision or a
Total 10 retrograde or eversion incision (Fig. 61.32). The transcartilaginous

927
 X Rhinoplasty
incision is made several millimeters cephalad to the caudal
margin of the lateral/middle crura, thus preserving a rim strip to
support the ala. Double-hook retraction combined with digital
alar eversion provides the necessary exposure to facilitate this.
The vestibular skin is carefully dissected off the overlying
cartilage to expose the cartilage for resection. In the retrograde
approach, the vestibular incision is made at the most cephalic
margin of the LLC rather than through it (Fig. 61.33). Again, a
double-hook retractor and digital manipulation are used to facil-
itate exposure. The theoretical advantage to this incision is that
it maintains the caudal alar margins and prevents potential scar
contracture deformities in this area.
The delivery approach is used in cases in which moderate tip
modifications are necessary, especially if the angle of divergence
(as a measure of tip bifidity) is large. Again, using a double-hook
Fig. 61.32 Cartilage-splitting and transfixion incisions.
Fig. 61.33 In the retrograde approach, the vestibular incision is made
at the most cephalic margin of the lower lateral cartilage rather than
through it.
928
retractor in the ala and digital counterpressure to expose the
cartilaginous margins, a o. 15 blade scalpel is used to create
an intercartilaginous incision starting laterally just above the
cephalic margin of the lateral crus. It is extended medially
approximately 2 mm caudal and parallel to the limen vestibuli.
An infracartilaginous incision is then created along the caudal
margin of the L (from lateral crus to medial crus), ending at the
columellar–lobular junction (Fig. 61.34). Sharp scissors are then
used to dissect the soft tissue off the cartilage just above the
perichondrium, including over the dorsal cartilaginous septum.
The same incision is made on the contralateral side, and the two
incisions are connected in the midline over the anterior septal
angle, ending in a hemitransfixion incision. If necessary, this may
be extended to a full (complete) transfixion incision. The LLC is
then dissected free from the surrounding tissue and delivered
outside the incision. If there is difficulty delivering the cartilages,
the incisions may be extended and the soft tissue undermined to
a greater extent. Once the cartilages (and domes) are delivered,
modifications may be made.
61.7.2 Incision: Open Approach
In the open approach, we use a stairstep transcolumellar incision
across the narrowest portion of the columella with a o. 15 blade
scalpel (Fig. 61.35). The stairstep is important because it helps
to provide landmarks for accurate closure, prevents linear scar
contracture, and camouflages the scar.
Bilateral infracartilaginous extensions are then performed (Fig.
61.36). These begin first from lateral to medial along the caudal
border of the lateral crus, then from medial to lateral, from the
level of the transcolumellar incision to the apex of the middle
crus, where it joins the lateral incision. A double-pronged skin
hook placed along the alar rim is used to perform this maneuver.
External digital pressure is used to evert the ala and facilitate
visualization of the lateral crus.
Important points during this step are as follows:
Fig. 61.34 In the delivery approach, the intercartilaginous incision is
started laterally just above the cephalic margin of the lateral crus. It
is extended medially approximately 2 mm caudal and parallel to the
limen vestibuli. An infracartilaginous incision is then created along the
caudal margin of the lower lateral cartilage (from lateral crus to medial
crus), ending at the columellar–lobular junction.
 61 Primary Rhinoplasty

Fig. 61.36 After the stairstep transcolumellar incision, bilateral inf-

racartilaginous extensions are then made, first from lateral to medial
along the caudal border of the lateral crus, then from medial to lateral,
from the level of the transcolumellar incision to the apex of the middle
crus, where it joins the lateral incision.

Fig. 61.35 In the open approach, we use a stairstep transcolumellar

incision across the narrowest portion of the columella with a No. 15
blade scalpel. The stairstep provides a landmark for accurate closure,
prevents linear scar contracture, and camouflages the scar.

• Take your time most mistakes are made trying to obtain

exposure.
• eep the incisions superficial to prevent unnecessary injury to
the underlying cartilages.
• Identify the caudal border of the LLC before cutting. Fig. 61.37 At the level of the bony pyramid, the scissors are traded
for a Joseph periosteal elevator, which continues the dissection in a
subperiosteal plane to the radix.
61.7.3 Skin Envelope Dissection
Dissection of the skin envelope should be done meticulously. As
mentioned previously, it is important to perform the dissection in be disrupted, leading to prolonged wound healing and potential
the supraperichondrial/submusculoaponeurotic plane, because nasal bone malposition, especially after osteotomy.
this avoids injury to the arterial, venous, and lymphatic supply ey points are as follows:
to the nose. There should be no residual soft tissue remaining on
the LLCs if the dissection is performed properly. This dissection is
• Take your time it is easier to go slowly through the correct
dissection than to spend more time fixing mistakes from
then continued in a superior direction, exposing the cartilaginous
inadvertent mishaps resulting from haste.
dorsum and ULCs. At the level of the bony pyramid, the scissors
are traded for a Joseph periosteal elevator, which continues the • Stay just above the perichondrium in the submusculoaponeu-
rotic plane.
dissection in a subperiosteal plane to the radix (Fig. 61.37). It is
important to limit the extent of the subperiosteal dissection to • Limit lateral subperiosteal dissection over the bony pyramid.
just the area of the bony dorsal hump that needs to be addressed; • Make certain the ULCs are not detached from the nasal bones by
otherwise, all the periosteal attachments to the nasal bones may accidental dissection under the nasal bones (rather than on top).

929
 X Rhinoplasty
61.7.4 Nasal Dorsum
e prefer to perform component dorsal hump reduction of
the osteocartilaginous hump instead of composite reduction
because component reduction offers incremental control and
greater precision. This process involves four basic steps, after the
skin envelope dissection just described:
• Separation of the ULCs from the septum
• Incremental reduction of the septum proper
• Incremental dorsal bony reduction (using a rasp)
• Three-point palpation test
Separation of the Upper Lateral Cartilages
From the Septum
To minimize mucosal trauma, which could result in internal
nasal valve stenosis or vestibular webbing, it is critical to create
bilateral dorsal submucoperichondrial tunnels before embarking
on reduction of the dorsal hump. This is done by elevating the
mucoperichondrium of the dorsal septum from caudal to cepha-
lad with a Cottle elevator until the nasal bones are reached (Fig.
61.38). The transverse processes of the ULCs are then sharply
separated from the septum using a o. 15 blade scalpel without
damaging the mucosa. If necessary, spreader grafts or dorsal
grafts can then be placed in this enclosed space, separated from
the nasal cavity (later in the case).
Incremental Component Cartilaginous Dorsal
Septal Reduction
At this point, the cartilaginous dorsum is separated into three
components: the septum centrally and the transverse portions
of the ULC laterally. The cartilaginous septum is addressed by
serially shaving down the dorsal hump deformity with a sharp
scalpel under direct vision. This maneuver is done carefully,
avoiding damage to the adjacent ULCs. The ULCs are then trimmed
incrementally to the desired height, taking great care to avoid
overresection. Overresection of the ULCs relative to the septum
may lead to an inverted-V deformity. Although reduction of the
ULCs may not be necessary in the case of small dorsal humps,
Fig. 61.38 Elevation of the mucoperichondrium of the dorsal septum
is carried out from caudal to cephalad with a Cottle elevator until the
nasal bones are reached.
930
it may be necessary in the presence of larger hump reductions.
If so, it must be done after the septal cartilaginous hump and
bony dorsal hump are addressed. It is important to reiterate that
overresection of the ULCs must be avoided in order to prevent
internal nasal valve collapse and long-term dorsal irregularity.
Component Bony Dorsum Reduction
The method of reducing the bony dorsum depends on the amount
of deformity that requires resection. Large humps (generally
greater than 5 mm) are reduced either by a power burr with a
dorsal skin protector or a guarded 8-mm osteotome. For humps
smaller than 5 mm, a sharp rasp is used (we prefer a down-biting
diamond rasp). hen rasping, it is important to maintain a
slightly oblique bias to minimize potential mechanical avulsion
of the ULCs from the nasal bones. The rasping is done in a con-
trolled, methodical fashion, proceeding along the left and right
dorsal aesthetic lines, and then centrally. The nondominant
thumb and index finger simultaneously stabilize the nasal bones
for maximum control during dorsal reduction (Fig. 61.39).
Three-Point Dorsal Palpation Test
The three-point dorsal palpation test is performed repeatedly
throughout the component dorsal hump reduction process,
after redraping the skin envelope. This test is performed with
a saline-moistened dominant index fingertip, which is used to
gently palpate the left and right dorsal aesthetic lines, as well as
centrally, to detect any dorsal irregularities or contour depres-
sions (Fig. 61.40).
61.7.5 Septal Reconstruction/
Cartilage Graft Harvest
If the septum is deformed, or if cartilage is needed for graft
material, the septum is harvested. The septum is ideal for car-
tilage graft harvest in rhinoplasty because of its close proximity
to the operating field and its minimal donor site morbidity. In
the endonasal approach, a illian or hemitransfixion incision
is generally used because a full-transfixion incision can lead to
decreased tip projection, especially if dissected down over the
anterior nasal spine.
In the open approach, the cartilage harvest is begun by sep-
arating the middle crura, incising the interdomal suspensory
ligament, and exposing the anterior septal angle. A o. 15 blade
scalpel is used to incise the septal perichondrium, exposing the
distinct bluish-gray underlying cartilage. A Cottle elevator is used
to create a submucoperichondrial plane posteriorly to the perpen-
dicular plate of the ethmoid down to the nasal floor and across the
face of the septum (Fig. 61.41).
If the dissection is difficult at first, it may be because the
improper plane has been accessed, and a deeper plane should be
sought. The dissection should be more difficult at the junction
of the cartilaginous and bony septum, and therefore one should
proceed with caution in this area because perforation of the
overlying mucoperichondrium is more likely. It may be advanta-
geous to dissect two separate tunnels, one subperichondrial and
one subperiosteal, and then divide the junction sharply to help
avoid potential perforation in this area. The same dissection is
 61 Primary Rhinoplasty

Fig. 61.40 The three-point dorsal palpation test is performed with a

Fig. 61.39 The nondominant thumb and index finger are used simulta- saline-moistened dominant index fingertip, which is used to gently
neously to stabilize the nasal bones for maximum control during dorsal palpate the left and right dorsal aesthetic lines, as well as centrally, to
reduction. detect any dorsal irregularities or contour depressions.

then performed on the contralateral side. After this is complete,
a Vienna speculum is used to visualize both sides of the septum
directly to identify underlying deformity and to help achieve
exposure for the septal harvest.
hen harvesting septal cartilage, it is necessary to preserve
an L-strut with 10 mm of dorsal septum and 10 mm of caudal
septum retained to support the lower nasal vault (Fig. 61.42).
After the cartilage is resected, it is preserved in saline solution.
Any residual deviations in the ethmoid or vomer are rongeured or
resected, and any mucosal perforations are repaired.
61.7.6 Correction of the Deviated Nose
Septal deviation, described previously in this chapter, can man-
ifest as external deviation of the nose. e classify the deviated
nose into three basic types: caudal septal deviations, concave
dorsal deformities, and concave/convex dorsal deformities.
4. Restoration of long-term support with buttressing caudal septal
batten or dorsal spreader grafts
5. Outfracture or submucous resection of hypertrophied antero-
inferior turbinates, if necessary, for correction of the deviated
septum
6. Precisely planned and executed external percutaneous
osteotomies
61.7.7 Inferior Turbinoplasty
In patients with symptomatic nasal airway obstruction caused
by inferior turbinate hypertrophy that is refractory to medical
management, an inferior turbinoplasty is performed. This can be
done by turbinate outfracture, submucous morselization of the

i i n e e i ed e
• Type I: Caudal septal deviation
Straight septal tilt
Concave deformity (C-shaped)
S-shaped deformity
• Type II: Concave dorsal deformity
C-shaped dorsal deformity
Reverse C-shaped dorsal deformity
• Type III: Concave/convex dorsal deformity (S-shaped)

Correction of the deviated nose is based on the following

principles:
1. The open approach to expose all deviated structures
2. Release of all mucoperichondrial attachments to the septum,
especially the deviated part
3. Straightening of the entire septum while maintaining a 10-mm
caudal and dorsal L-strut
Fig. 61.41 Cartilage harvest technique. (1) A No. 15 blade scalpel
is used to incise the septal perichondrium, exposing the distinct
bluish-gray underlying cartilage. A Cottle elevator is used to create a
submucoperichondrial plane posteriorly to the perpendicular plate of
the ethmoid (2) down to the nasal floor (3) and across the face of the
septum (4 ).

931
 X Rhinoplasty
Fig. 61.42 When harvesting septal cartilage, it is necessary to
preserve an L-strut with 10 mm of dorsal septum and 10 mm of caudal
septum retained to support the lower nasal vault.
Fig. 61.43 Inferior turbinoplasty can be done by turbinate outfracture, submucous morselization of the turbinate bone, or submucous resection of
the anterior one-third to one-half of the inferior turbinate.
932
turbinate bone, or submucous resection of the anterior one-third
to one-half of the inferior turbinate. The submucous resection
is done by developing medial mucoperiosteal flaps, exposing
the conchal bone using a Cottle elevator, and sharply resecting
the proper amount. The flaps are replaced after this resection
without the need for suture repair (Fig. 61.43). It is important to
note that the extent of the conchal bone resection is limited to
the anterior portion. This is done mainly to avoid complications
of bleeding if the posterior portion is resected.
61.7.8 Cephalic Trim
In cases in which the tip is boxy or bulbous and requires better
refinement and definition, when the tip-defining points need
medialization, or when rotation of the tip is desired, a cephalic
trim is performed. This is done by using a caliper to measure
along the caudal margin of the LLC to preserve a 6 mm rim strip.
After this is demarcated, the cephalic portion of the middle and
lateral crura is resected (Fig. 61.44). The cartilage is preserved
for possible use later in the case.
61.7.9 Lower Lateral Crural
Turnover Flap
A lower lateral crural turnover flap is another useful technique to
address peridomal fullness while providing additional support
to the lateral crusra of the LLCs. It is beneficial for deformities,
weakness, and collapse of the lateral crura and can also be used

to improve lateral crural strength during tip reshaping. However,
there must be sufficient lower lateral crura to leave a 6-mm rim
strip. It can be used in combination with other external valve and
alar arch supporting techniques.
A horizontal line that bisects the cephalic aspect of the lower
lateral crus from the 6-mm rim strip is marked with methylene
blue. The cephalic aspect is dissected from the underlying ves-
tibular skin inferiorly to this horizontal line, and then the line
is scored with a o. 15 blade. ext, 2-mm full-thickness cuts at
the medial and lateral ends of the horizontal line are made. The
flap is turned over, and its caudal edge is secured with multiple
horizontal mattress sutures (Fig. 61.45).
61.7.10 Autospreader Flaps
Reduction of the nasal dorsum may compromise the internal
nasal valves. Even a slight decrease in the angle between the ULC
and the septum can lead to a significant increase in nasal airway
resistance. Patients who have a high, narrow dorsum, a weak
middle vault, short nasal bones, or a positive Cottle test preop-
eratively are at risk for developing postoperative internal nasal
valve dysfunction and, consequently, nasal airway obstruction.
Fig. 61.44 The cephalic trim is first marked using a caliper to measure
along the caudal margin of the lower lateral cartilage to preserve a
6-mm rim strip. After this is demarcated, the cephalic portion of the
middle and lateral crura is resected.
61 Primary Rhinoplasty
In these cases, the use of autospreader flaps fashioned from the
dorsal aspects of the ULCs can maintain patency of the internal
nasal valves while preserving the dorsal aesthetic lines (Fig. 61.46).
After component dorsal hump reduction has been performed, the
overprojecting dorsal aspect of the ULCs is incised, leaving the
underlying mucoperichondrium intact. This dorsal portion of the
ULC is then rotated internally approximately 90 to lie between
the septum and the medial edge of the ULCs, supported as a flap
by its attachment to the mucoperichondrium. The new dorsal
edges of the ULCs are then sutured with 5–0 polydioxanone
suture (PDS) at the midline to the rotated autospreader flaps and
secured along the septum.
Limitations using this technique include patients with a devi-
ated dorsal septum or asymmetric dorsal aesthetic lines. Spreader
grafts are indicated in these cases.
61.7.11 Spreader Grafts
Spreader grafts can be used to help stent open the internal valve,
stabilize the septum, and preserve the dorsal aesthetic lines (Fig.
61.47). These grafts usually are obtained from septal cartilage
and are designed to measure approximately 25 to 30 mm by 3
mm. Their cephalic ends can be trimmed obliquely to fit snugly
underneath the bony dorsum, and their caudal ends can be placed
either at the septal angle (if lengthening of the nose is not desired)
or extending past it (if lengthening is desired). Furthermore, the
grafts can be placed flush with the anterior septum or slightly
recessed. Placing the grafts flush with the septum will create a
wider- and flatter-appearing dorsum, while recessing the grafts
slightly will create a more rounded dorsum. e secure the grafts
with 5–0 PDS in a horizontal mattress fashion.
Fig. 61.45 Demonstration of the lower lateral crural turnover flap:
The cephalic aspect of the lateral crus is dissected from the underlying
vestibular skin inferiorly. A No. 15 blade is used to score the cartilage,
and 2-mm full-thickness cuts are made at the medial and lateral
ends of the horizontal line. The flap is turned over while maintaining
a minimum of a 6-mm width, and its caudal edge is secured with
multiple horizontal mattress sutures. (Reproduced with permission
from Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP.
Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr
Surg. 2009; 123:1830-1841.)
933
 X Rhinoplasty
Fig. 61.46 Demonstration of the autospreader flap. The dorsal portion
of the upper lateral cartilage is rotated internally approximately 90°
to lie between the septum and the medial edge of the upper lateral
cartilages, supported as a flap by its attachment to the mucoperi-
chondrium. The new dorsal edges of the upper lateral cartilages are
then sutured at the midline to the rotated autospreader flaps with 5–0
polydioxanone suture and secured along the septum.
61.7.12 i di i n
Altering Tip Projection
It is important to recognize the factors that contribute to tip pro-
jection in situ before embarking on a discussion on how precisely
to alter tip projection. The following are key anatomic elements
affecting tip projection:
1. The length and strength of the LLCs
2. The fibrous connections between the ULCs and LLCs (and
septum)
3. The abutment of the cartilages with the piriform aperture
4. The anterior septal angle
Alteration of any of these anatomic structures can result in
incremental changes in tip projection.
A graduated approach to tip projection is predicated on precise,
incremental, nondestructive changes made to the tip complex,
934
Fig. 61.47 Spreader grafts approximately 25 to 30 mm are placed along
the dorsal septum and sutured in place to help stent open the internal
valve, stabilize the septum, and preserve the dorsal aesthetic lines.
beginning with placement of a columellar strut graft, proceeding
with suture modification, and finishing with the use of tip grafts.
The algorithm begins with placement of a columellar strut graft.
This strut is usually fashioned from septal cartilage and measures
approximately 25 4 mm. It can be placed in a fixed (secured
to the anterior maxilla) or a floating (not secured to the max-
illa) fashion. This strut not only controls the columellar profile,
but also bolsters tip projection and unifies the tip complex. The
strut is placed by dissecting a pocket between the medial crura.
A double-pronged hook is then used to retract the middle crura
gently anteriorly to set the desired projection and symmetry. The
strut is positioned in the pocket, and a 25-gauge needle is used to
stabilize this configuration. Most struts are left floating on a soft
tissue pad between the base of the pocket and the nasal spine.
Medial crural sutures are placed in horizontal mattress fashion to
secure the complex. Further medial crural sutures can be placed
more caudally on the medial crura to control flaring, if necessary.
The next step in altering tip projection involves suture tech-
niques, which can increase tip projection by 1 to 2 mm. Suture
techniques are ideal for controlling cartilage in a precise, nonde-
structive fashion. Although the choice of a particular suture mate-
rial is surgeon dependent, the underlying premise is to choose a
material that one can easily work with and will hold the cartilage
in its altered position long enough to allow the natural fibrosis
to solidify the result. Although many suture techniques can be
performed in both open and closed rhinoplasty (with cartilage

delivery), we find them easier to place using the open technique
because it affords greater visualization and ease of placement.
e commonly use four suture techniques to alter projection and
shape the nasal tip:
1. Medial crural
2. Medial crural-septal
3. Interdomal
4. Transdomal
Medial crural sutures serve to unify the medial crura of the LLCs
and are frequently used in conjunction with a columellar strut
(to help stabilize the strut) (Fig. 61.48). They can also be used to
reduce flaring of the footplates of the medial crura or to decrease
the angle of divergence between the middle crura, thereby effect-
ing an increase in projection, albeit to a limited degree. e gener-
ally use 5–0 PDS in horizontal mattress fashion for this technique;
however, the suture choice can vary by individual preference.
Interdomal sutures are placed through the medial walls of the
domes in a mattress fashion and tied to narrow the interdomal
distance (Fig. 61.49). This results in both an increase in tip refine-
ment and an increase in projection.
Transdomal sutures are placed across the dome in mattress
fashion to narrow the arch of the dome and create more tip
definition (Fig. 61.50). Local anesthetic can be used to hydrodis-
sect a plane between the cartilaginous dome and the adherent
underlying mucoperichondrium to help prevent inadvertent
incorporation of the vestibular lining into the suture bite. e
Fig. 61.48 The medial crural suture.
Fig. 61.49 The interdomal suture.
61 Primary Rhinoplasty
generally use 5–0 PDS in horizontal mattress fashion, placing the
knots on the medial aspect of the domes. These sutures can be
made asymmetric to correct anatomic asymmetries if necessary.
It is important, however, to prevent overtightening of this suture,
which can result in an unnaturally sharp tip-defining point.
If more tip projection or definition is desired after the maneu-
vers just described, tip grafts may be used. e find it easier to
place these grafts using the open approach because it allows
direct visualization and precise placement and facilitates subse-
quent manipulation if necessary. It should be noted that grafts,
in general, have a tendency to become visible, so their use is
reserved only for the patient in whom the prior, more predictable
methods do not result in satisfactory tip projection. There are two
general types of tip grafts:
1. Onlay tip grafts
2. Infratip lobular grafts
The onlay tip graft can be fashioned from any type of cartilage,
although we find that the cartilage obtained from the cephalic
trim harvest works exceptionally well. This graft is placed in a
position overlying the domes and fixed in place (Fig. 61.51). e
generally use 5–0 PDS for this, with the knots positioned under-
neath the dome.
The infratip lobular graft is positioned with its superior margin
overlying the dome and tip-defining points and extending infe-
riorly a variable distance, usually 10 to 12 mm (Fig. 61.51). It is
usually shield-shaped and has rounded graft edges to avoid a
935
 X Rhinoplasty
visible and palpable stepoff. This graft increases infratip lobular
definition and projection and is secured with interrupted 5–0 PDS.
hen trying to decrease nasal tip projection, once again it is
important to realize the anatomic factors that contribute to tip pro-
jection. If the support derived from the fibroelastic and ligamen-
tous attachments is disrupted, tip projection becomes primarily
dependent on the length and strength of the LLCs. Therefore, in
the open approach, if the skin envelope has been undermined and
these fibroelastic tissues have been severed, the primary means
of decreasing tip projection lies in altering these LLCs. This may
include techniques such as transection, setback, and resuturing of
the medial or lateral crura. Deprojection by affecting the medial
crura will slightly rotate the tip complex caudally, whereas affect-
ing the lateral crura will slightly rotate the tip cephalically. It is
also important to recognize that if the tip projection is decreased
significantly, alar flaring or columellar bowing may result, which
would necessitate correction (Fig. 61.52).
Altering Tip Rotation
Using the nasofacial analysis techniques described, rotation is
evaluated by the nasolabial angle. This angle, found by measur-
ing the angle between a line coursing through the most anterior
and posterior edges of the nostril and a plumb line dropped
perpendicular to the natural horizontal facial plane, should be
between 95 and 100 in women and between 90 and 95 in
men, as previously discussed.
Fig. 61.50 The transdomal suture.
Fig. 61.51 The onlay tip graft (left) and the infratip lobule graft (right).
936
To alter tip rotation, the extrinsic forces holding the tip at its
current angle must be released. This is generally done by severing
the connection between the LLC and ULC. This frequently takes the
form of a cephalic trim, as described previously. Furthermore, the
fibrous attachments of the medial crura and the caudal septum
can be transected to release tension on the nasal tip and allow
more cephalad rotation. This is generally achieved by resecting a
variable amount of the caudal septum (Fig. 61.53).
Depending on the amount of tip rotation, it may be necessary to
perform a limited resection of the nasal mucosa and membranous
septum to maintain proper nasal balance and harmony. After the
tip is rotated, its position is maintained with suture techniques
(medial crural septal sutures) and/or a columellar strut or septal
extension graft.
61.7.13 Alar Rims
Alar contour grafts are used as a simple and effective method to
correct and prevent alar notching or retraction. A subcutaneous
pocket below the infracartilaginous incision and parallel to the
alar rim is created with dissection scissors. The pocket should
span the length of the deformity and extend 3 mm to each side of
it. An alar contour graft is typically 3 10 mm, but it may be need
to be larger, depending on the desired effect (Fig. 61.54).
61.7.14 Lateral Crural Strut Grafts
Lateral crural strut grafts are used to support weak lateral crura,
prevent collapse of the external nasal valve, address malposition
of the lateral crura, or increase tip projection. The vestibular skin
is dissected from the deep surface of the posterior surface of the
lateral crus. If the intention is to bolster or straighten the lateral
crus, the strut graft is simply placed behind the lateral crus and
fixed in position with 5–0 PDS horizontal mattress sutures (Fig.
61.55).
If caudal repositioning of the lateral crus is intended, the lateral
crus is separated from the accessory cartilages. A subcutaneous
pocket below and adjacent to the accessory cartilages is dissected
posteriorly to the piriform aperture. To correct malposition of the
lateral crura, the pocket is dissected below the infracartilaginous
incision and parallel to the alar rim. A 4 25 mm lateral crural
strut graft is placed in the pocket and rests on the piriform aper-
ture posteriorly. The anterior aspect of the graft is placed deep to
the lateral crus and secured with two or three 5–0 PDS horizontal
mattress sutures.
Fig. 61.52 If the tip projection is decreased significantly, alar flaring or
columellar bowing may result, which will necessitate correction.

61.7.15 Correcting the Alar–Columellar
Relationship
Class I Deformity
hen the patient has a class I deformity, or when the long axis–
columellar rim distance (BC in Fig. 61.26) is greater than 2 mm
and the alar rim–long axis distance (AB in Fig. 61.26) is normal,
this is an example of a true hanging columella. Correcting this
involves resecting either the caudal septum, the caudal portion
of the medial crus, the caudal portion of the middle crus, or a
combination of these depending on which is responsible for the
deformity (Fig. 61.56).
Class II Deformity
A class II deformity, or a retracted ala (AB greater than 2 mm,
BC less than 2 mm), is treated in several ways. One method is
to insert an elliptically shaped composite graft from an access
incision made in the vestibular skin. The graft is made slightly
larger than is needed to compensate for secondary contraction.
If the retraction is mild and there is no tissue deficiency present,
an alternative technique can be used where the lateral crura are
detached from the accessory chain and repositioned inferiorly.
A final method is to place an alar contour graft (nonanatomic
Fig. 61.53 Cephalic rotation of the tip can be achieved by cephalic trim of the lower lateral cartilages as well as resection of the caudal septum.
Fig. 61.54 Alar contour grafts.
61 Primary Rhinoplasty
position) in a pocket created along the vestibular rim to displace
the ala inferiorly (Fig. 61.57).
Class III Deformity
A class III deformity is a combination of a class I and class II
deformity and is therefore corrected with a combination of the
two procedures (Fig. 61.58).
Class IV Deformity
A class IV deformity is a hanging ala (AB less than 1 mm, BC less
than 2 mm). This is usually treated with an elliptical excision of
vestibular skin (Fig. 61.59). Care is taken to avoid overresection
of skin in this maneuver because an abnormal, rolled-in appear-
ance of the alar rim can result.
Class V Deformity
A class V deformity is a retracted columella (AB less than 2 mm,
BC less than 1 mm). The treatment of choice for this deformity
is placement of a columellar strut, which is positioned more
caudally to extend the caudal dimension of the columella. A
septal extension graft and a columellar onlay graft are additional
options to address a retracted columella (Fig. 61.60).
Fig. 61.55 The lateral crural strut graft.
937
 X Rhinoplasty

Fig. 61.56 Class I deformity and methods for correction.

Class VI Deformity A lateral osteotomy may be performed as low-to-high, low-

A class VI deformity is a combination of class IV and class V and
is treated with a combination of the techniques described (Fig.
61.61).
61.7.16 Osteotomies
Osteotomies are a powerful technique in rhinoplasty. The indi-
cations to perform osteotomies, regardless of technique, are as
follows:
• To narrow the lateral walls of the nose
• To close an open-roof deformity (after dorsal hump reduction)
• To create symmetry by straightening the nasal bony framework
Contraindications to osteotomies can include patients with
short nasal bones; elderly patients with thin, fragile nasal bones;
and patients with heavy eyeglasses. There are several osteotomy
techniques, including medial, lateral, transverse, or a combination
of these. Furthermore, they can be performed through either an
external or an internal approach.
to-low, or double-level (Fig. 61.62). They may be combined with
medial, transverse, or greenstick fractures of the upper bony seg-
ment as well. Regardless of the technique used in performing the
lateral osteotomy, it is important to maintain a smooth fracture
line by staying low along the bony vault, thereby preventing the
potential for a step-off deformity. The cephalic margin of the oste-
otomy should not be higher than the intercanthal line (the level of
the medial canthi); the thick nasal bones above this level increases
the technical difficulty, and it is possible to cause iatrogenic injury
to the lacrimal system (with resultant epiphora).
A low-to-high osteotomy is generally used to correct a small
open roof deformity or to mobilize a medium-to-wide nasal base.
It begins low at the piriform aperture and ends high medially on
the dorsum. The nasal bones are then greensticked to medial-
ize them, with predictable fracture patterns obtained based on
nasal bone thickness. Occasionally, a separate superior oblique
osteotomy is necessary to mobilize thicker nasal bones enough
to be greensticked. A low-to-low osteotomy is generally a more
powerful technique in that it results in more medial movement
of the nasal bones and therefore is classically used when there
is a large open-roof deformity or if a wide bony base requires

938

Fig. 61.57 Class II deformity and methods for correction.
correction. It starts low along the piriform aperture and continues
low along the base of the bony vault to end in a lateral position
along the dorsum near the intercanthal line. As there is more bone
between the cephalic aspect of this osteotomy and the midline,
this type of osteotomy technique is frequently accompanied by
a medial osteotomy to mobilize the nasal bones better to achieve
the desired result.
e have refined our preferred technique of external perforated
lateral osteotomies, which has proved to be well controlled, pre-
dictable, and reproducible. Furthermore, there are certain unique
advantages to this technique based on the preservation of the
periosteal attachments, namely:
• Decreased amount of dead space
61 Primary Rhinoplasty
• Reduced subluxation and subsequent airway compromise
• Greater overall stability after positioning
The technique is as follows:
1. Inject both intranasally and along the lateral nasal sidewalls
with 2 mL of 1 lidocaine with 1:100,000 epinephrine, allowing
5 to 7 minutes for the hemostatic process to take effect.
2. Introduce a sharp 2-mm osteotome percutaneously on the mid-
portion of the bony nasal pyramid at the level of the inferior
orbital rim and nasofacial junction. It must be held at a plane
parallel to the surface of the maxilla.
3. To avoid injury to the angular artery, sweep the osteotome down
the lateral nasal sidewall in a subperiosteal plane.
939
 X Rhinoplasty
Fig. 61.58 Class III deformity.
Fig. 61.60 Class V deformity and methods for correction.
4. Position the osteotome at an angle such that one edge is in con-
tact with the bone and strike with the mallet (Fig. 61.63). The
endpoints are a change in the feel and sound at that location.
5. Extend the osteotomy in an inferior, superior, and superi-
or-oblique manner at the level of the piriform. Leave a 2-mm
gap between individual osteotomies (Fig. 61.64).
6. Perform the same procedure on the contralateral nasal wall.
7. After the osteotomies are completed, use gentle pressure
between the thumb and forefinger to perform a greenstick
fracture of the nasal bones to position them in the desired
location.
940
Fig. 61.59 Class IV deformity and methods for correction.
Fig. 61.61 Class VI deformity.
8. Cover with flesh-colored Steri-Strips (3M, St. Paul, M ) and
apply a dorsal compression splint (Denver splint), which is kept
in place for 7 days to minimize postoperative edema (Fig. 61.65).
Medial osteotomies are used to facilitate medial positioning
of the nasal bones (Fig. 61.66). They are generally indicated in
patients with thick nasal bones or a wide bony base to achieve a
more predictable result, because greenstick fractures in these sub-
groups can sometimes be difficult and can lead to unpredictable
fracture patterns. Medial osteotomies can be used in conjunction
with lateral osteotomies; however, it is not necessary to use both
 61 Primary Rhinoplasty

Fig. 61.62 Schematic depiction of lateral low-to-low, low-to-high, and double level osteotomies.

Fig. 61.63 Most efficient cutting angle of the osteotome. Fig. 61.64 Lateral percutaneous low-to-low osteotomy.

Fig. 61.65 Application of Steri-Strips and a dorsal compression splint (Denver splint).

941
 X Rhinoplasty

types in all cases. hen both techniques are used, the medial a malleable metal splint is applied over the dorsum (Fig. 61.69).
osteotomy is usually performed first because doing so makes it A drip pad is fashioned from a 2 2 gauze and secured under
technically easier to perform subsequent lateral osteotomies. the nose with 0.5-inch paper tape. The throat pack is removed,
Although the cant of the medial osteotomy can be varied (such and the oropharynx and stomach are carefully suctioned to help
as medial oblique, paramedian, or transverse), for the reasons evacuate any blood, which may result in postoperative nausea and
just stated, the cephalic margin should not cross the intercanthal vomiting.
line. After the medial and lateral osteotomies are created, the
nasal bones are greensticked, as described earlier, to the desired
position.
61.7.18 Alar Base Surgery
Occasionally, a double-level lateral osteotomy is needed to In cases in which alar base surgery is necessary, it is generally
correct lateral wall convexities that are too great to be corrected performed after closure of the transcolumellar and infracarti-
with a standard single-level lateral osteotomy or when significant laginous incisions but before intranasal and external splints are
lateral nasal wall asymmetries exist (Fig. 61.67). This is done by placed.
first making the upper (more medial) lateral osteotomy along the Analysis of the alar base was discussed earlier in the chapter.
nasomaxillary suture line. The lower (more lateral) of the two is Based on proper and precise nasofacial analysis, alar base abnor-
then created in standard low-to-low fashion. malities may be diagnosed, which may include wide or excessive
Regardless of the operative technique, there are potential com- nostril sills, a wide alar base, asymmetric or malpositioned alar
plications associated with osteotomies (Table 61.4). bases, or any combination of these.
ide nostril sills, or alar flaring, are a relatively common prob-
lem. This is corrected by performing a small crescentic resection
61.7.17 Closure of the alar base, making sure to avoid extending the incision into
After excellent hemostasis is achieved and the wound is irrigated
to remove any excess debris, the skin envelope is redraped. If the
patient has thick skin, and especially if the patient is a woman,
we may choose to place a single 6–0 polyglycolic acid (Vicryl,
ohnson ohnson, Somerville, ) suture from the dermis
(underside of the skin envelope) to the underlying cartilaginous
framework in an attempt to recreate a supratip break.
The transcolumellar incision is then closed using 6–0 nylon
suture in simple interrupted fashion, making sure the coaptation
of the incision margins is precise (Fig. 61.68). The stairstepping
of the original incision facilitates accurate closure. The infracarti-
laginous incisions are reapproximated using 5–0 chromic suture
in a simple interrupted fashion. e take special care to prevent
overbiting with the suture, which can create contour irregularities
and notching, especially in the soft triangle area.
If septal work has been performed, we place intranasal Silastic
(Dow Corning, Midland, MI) splints coated with antistaphylo-
coccal antibiotic ointment. These are secured with a transseptal
3–0 nylon suture. The nasal dorsum is then carefully taped, and

Fig. 61.66 Medial osteotomies. Fig. 61.67 Double-level osteotomy.

942
 61 Primary Rhinoplasty

Table 61.4 Potential complications of lateral nasal osteotomies

Infections Operative trauma Cosmetic problems

• Local • Hemorrhage (hematoma, ecchymosis) • Excessive narrowing or convexity

Abscess • Edema • Insufficient mobilization of lateral bony walls
Cellulitis • Nasal cyst formation • Unstable bony pyramid
Granuloma • Anosmia • Redundant soft tissue
• Systemic • Arteriovenous fistula • Stairstep deformity
• Intracranial • Epiphora • Nasal bone asymmetry
• Canalicular bleeding
• Neuromuscular injury
• Intracranial injury

the actual vestibule (Fig. 61.70). The incision is placed approxi-
mately 1 to 2 mm above the true alar base. The soft tissue at the
base is mobilized with judicious use of electrocautery and then
transposed medially to the desired aesthetic endpoint, where it
is sutured in place. e suture using the halving principle in this
region because the interior incision is shorter than the exterior
incision.
A wide alar base is corrected in a similar fashion; however,
the crescentic excision assumes a more wedge-type geometry
and may include a small portion of the nostril sill (Fig. 61.71). If
a transcolumellar incision was used at the start, it is crucial that
the alar base excision stay within 3 mm of the lateral alar groove,
because the blood supply to the nasal tip can be jeopardized if the
lateral nasal artery is inadvertently injured.
Although some have advocated suture techniques for narrow-
ing the nasal base, we generally accomplish this with excisional
techniques, as just described.
61.8 Postoperative Management
All preoperative and postoperative instructions are given to
the patients in writing before as well as on the day of surgery.
Postoperatively, we routinely prescribe the following:
• Methylprednisolone (Medrol Dosepak, Upjohn, alamazoo,
MI) for 7 days (to minimize postoperative edema)
• Hydrocodone/acetaminophen 5:500 for postoperative pain
every 4 to 6 hours as needed

Fig. 61.68 Closure of the transcolumellar incision.

Fig. 61.69 If septal work has been performed, intranasal Silastic splints coated with antistaphylococcal antibiotic ointment are placed and secured
with a transseptal 3–0 nylon suture. The nasal dorsum is then carefully taped, and a malleable metal splint is applied over the dorsum.

943
 X Rhinoplasty
Fig. 61.70 Wide nostril sill, or alar flaring, is corrected by performing
a small crescentic resection of the alar base, making sure to avoid
extending the incision into the vestibule.
• ormal nasal saline solution for postoperative nasal congestion
• Antibacterial ointment to incisions three times daily
The patient is instructed to keep the head of the bed elevated
at an angle of 45 beginning immediately after surgery to help
minimize postoperative swelling. Cool compresses are used
periorbitally during the day for the first 48 hours. Antibacterial
ointment is applied three times daily to the incisions after gentle
cleaning with a half-strength hydrogen peroxide–saline solution.
The patient is instructed to change the drip pad under the nose
as necessary until the drainage stops, at which time the pad and
tape can be discontinued. Any manipulation of the nose, including
rubbing, blotting, or blowing, is discouraged for the first 3 weeks
postoperatively. Sneezing should be done through the mouth
during this time. It is imperative to keep the nasal splint dry, and
the patient’s hair should be washed as in a beauty salon, with the
patient leaning the head backward over the sink.
e maintain our patients on a liquid diet on the day of surgery,
which is subsequently advanced the following day to a soft regular
diet. Any foods that require excessive lip movements, such as
eating apples or corn on the cob, should be avoided for 2 weeks
after surgery.
During the first 2 weeks, nasal congestion may be minimized by
the use of normal saline nasal spray and over-the-counter nasal
decongestant sprays such as Afrin (oxymetazoline). However,
the use of Afrin should be limited because cessation can cause
rebound nasal congestion. If patients have difficulty with the
passage of air through the intranasal splints, they are encouraged
to breathe through their mouth. If the patient is very congested,
in-office suctioning may be warranted.
e ask the patient to return on postoperative day 5 to 7, at
which time the sutures and nasal splints are removed. The nose
(especially the tip) may appear swollen and turned up, and the
tip may feel numb, but the patient is reassured that this is to
944
Fig. 61.71 A wide alar base is corrected in a similar fashion to alar
flaring, but the crescentic excision assumes a more wedgelike geome-
try and may include a small portion of the nostril sill.
be expected and will resolve with time, with normal sensation
returning within 3 to 6 months. The patient cannot let anything,
including eyeglasses, rest on the nose for at least 4 weeks. Glasses
should be taped to the forehead. Contacts can be worn as soon as
the swelling has diminished enough to allow easy insertion (usu-
ally less than 5 to 7 days postoperatively). Patients are instructed
to avoid direct sunlight and to wear sunscreen of SPF 30 or higher
to prevent possible hyperpigmentation of the scar.
e ask our patients to restrict strenuous activity that increases
their heart rate (above 100 beats/min) or blood pressure for 3
weeks after surgery. After that, they can gradually resume normal
activity. Obviously, any contact sports or activities that may cause
direct trauma to the nose are prohibited for at least 4 weeks after
surgery. Although some patients’ noses look excellent within 6 to
8 weeks, some may remain swollen for up to 1 year, but after 3 to
4 weeks such swelling will generally not be obvious to anyone but
the patient.
After the first postoperative visit (within the first week), we
ask the patient to return to the clinic at 3 and 8 weeks after the
operation. e continue to follow the patient 3, 6, and 12 months
after surgery, and then annually thereafter.
61.9 Outcomes
Although it is difficult to determine an exact revision rate fol-
lowing primary rhinoplasty, a survey of plastic surgeons and
otolaryngologists revealed that 58 of those surveyed cited their
revision rate less than 5 . This survey also revealed that the open
approach was preferred by 73 compared with 20 preferring
the closed approach for revision rhinoplasty.
In the senior author’s practice, approximately one in 25 primary
rhinoplasty patients requires revision. The most frequent reasons
for reoperation include further tip refinement or correction of
tip asymmetries (lower third), polly beak or pinched supratip

deformity (middle third), and excessive dorsal reduction or dorsal
irregularities (upper third).
Functionally, continued nasal airway obstruction after primary
rhinoplasty has, in our experience, usually been from excessive nar-
rowing of the internal valve (without placement of spreader grafts).
e used to see this more frequently when we performed more
aggressive resection of the transverse processes of the ULCs. Once
we adopted the component dorsal hump reduction technique with
preservation of the ULCs, the incidence of internal valve obstruction
decreased and the need for spreader grafts greatly diminished.
61.10 Results
61.10.1 Patient Example 1
The healthy 24-year-old woman shown in Fig. 61.72 presented
for cosmetic rhinoplasty without nasal airway obstruction. She
was unhappy with the appearance of her boxy tip and desired
correction. The frontal view demonstrates adequate dorsal
aesthetic lines, but asymmetric fullness of her supratip. Her left
LLC segment is more obliquely rotated than the right LLC. She
has excess lateral alar convexity with preoperative alar notching.
Operative Goals
1. Drastically refine the tip and narrow the tip-defining points.
2. Correct the lateral alar convexity and alar notching.
Surgical Plan
1. Open approach with transcolumellar stairstep incision connect-
ed to bilateral infracartilaginous incisions
Fig. 61.72 Patient example 1, preoperative. (Reproduced with permis-
sion from Rohrich, RJ, Adams WP Jr. The boxy nasal tip: classification
and management based on alar cartilage suturing techniques. Plast
Reconstr Surg. 2001; 107:1849-1863.)
61 Primary Rhinoplasty
2. Cephalic trim of lateral and middle crura leaving a 6-mm rim
strip
3. Medial crural, interdomal, and transdomal suturing
4. Bilateral alar contour grafts to correct lateral alar convexity and
prevent alar notching
This surgical plan is shown in Fig. 61.73.
Results
Comparison of preoperative and 15-month postoperative views
(Fig. 61.74) demonstrates improvement of dorsal aesthetic lines
and correction of her boxy tip. She has dramatic tip refinement,
with reduction of supratip fullness and narrowed tip-defining
points. Placement of alar contour grafts has corrected the lateral
alar convexity and prevented alar notching.
61.10.2 Patient Example 2
The healthy 24-year-old woman shown in Fig. 61.75 had aes-
thetic as well as functional concerns. Aesthetically, she did not
like her dorsal nasal contour and boxy, asymmetrical nasal tip.
Functionally, she complained of left nasal airway obstruction.
The lateral view demonstrates a slight dorsal hump, supratip
fullness, decreased tip projection, and a columellar–labial angle
Fig. 61.73 Patient 1, surgical plan. (Reproduced with permission from
Rohrich, RJ, Adams WP Jr. The boxy nasal tip: classification and man-
agement based on alar cartilage suturing techniques. Plast Reconstr
Surg. 2001; 107:1849-1863.)
945
 X Rhinoplasty

a b c d

e f g h

i j k l
Fig. 61.74 Patient example 1. (a,c,e,g,i,k) Preoperative and (b,d,f,h,j,l) 15 months postoperative. (Reproduced with permission from Rohrich,
RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg. 2001;
107:1849-1863.)

of 100 . Her basal view confirms an asymmetrical tip with left- Operative Goals
sided alar collapse. The left LLC is concave; the right is convex.
Her intranasal examination revealed left-sided deflection of the 1. Remove the small dorsal hump.
caudal septum. 2. Decrease the tip rotation.
3. Correct the tip asymmetry.

946

Fig. 61.75 Patient example 2, preoperative. (Reproduced with permis-
sion from Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter
JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr
Surg. 2009; 123:1830-1841.)
4. Refine the tip and reestablish tip-defining points.
5. Correct the left external nasal valve collapse and concave left
LLC.
6. Prevent postoperative alar retraction.
Surgical Plan
1. Open approach with transcolumellar stairstep incision connect-
ed to bilateral infracartilaginous incisions
2. Component reduction of dorsum (2 mm)
3. Caudal septal resection with medial crural setback sutures to
decrease tip rotation
4. Septal cartilage harvest leaving a 10-mm L-strut
5. Left lower lateral crural turnover flap to correct concave left LLC
6. Right cephalic trim leaving a 6-mm rim strip
7. Bilateral spreader grafts
8. Medial crural, interdomal, and transdomal suturing
9. Columellar strut
10. Lateral osteotomies (external perforated)
11. Bilateral alar contour grafts to prevent alar retraction
This surgical plan is shown in Fig. 61.76.
Results
Comparison of the patient’s preoperative and 12-month postoper-
ative appearance (Fig. 61.77) demonstrates a straight dorsum and
a unified tip complex with correction of her tip asymmetry. The
lateral view confirms the straight dorsal profile with a supratip
break, normal tip projection, and a nasolabial angle of 95 . There is
61 Primary Rhinoplasty
Fig. 61.76 Patient 2, surgical plan. LLC, lower lateral cartilage.
(Reproduced with permission from Janis JE, Trussler A, Ghavami A,
Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open
rhinoplasty. Plast Reconstr Surg. 2009; 123:1830-1841.)
an improved alar–columellar relationship. The basal view confirms
correction of her tip asymmetry and shows restoration of the
columellar–infratip lobular relationship. The left-sided external
valve collapse was corrected with the lower lateral crural turnover
flap, while alar contour grafts prevent postoperative alar retraction.
61.10.3 Patient Example 3
The healthy 41-year-old woman with Fitzpatrick type III thick
nasal skin shown in Fig. 61.78 presented for cosmetic rhinoplasty
without nasal airway obstruction. She was unhappy with the
appearance of her dorsal hump and unrefined tip. This patient
demonstrates the classic Middle Eastern nasal morphology. The
frontal view demonstrates nasal deviation and a plunging tip
with infralobular deficiency. Her lateral view demonstrates a
large dorsal hump and a severely underprojected, underrotated,
amorphous, and plunging tip as well as absence of a supratip
break. She has an alar–columellar discrepancy with a retracted
columella. Her basal view demonstrates nostril–tip imbalance
with short nostrils. Intranasal examination was normal. Her
dynamic examination revealed a hyperdynamic tip. Following
primary rhinoplasty, she requested a more dramatic change
in her tip, and this required a secondary soft tissue debulking
operation.
947
 X Rhinoplasty

a b c d

e f g h

i j k l
Fig. 61.77 Patient example 2, (a,c,e,g,i,k) Preoperative and (b,d,f,h,j,l) 12 months postoperative. (Reproduced with permission from Janis
JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;
123:1830-1841.)

Operative Goals Surgical Plan

1. Remove the large dorsal hump. 1. Open approach with transcolumellar stairstep incision connect-
2. Correct the nasal deviation. ed to bilateral infracartilaginous incisions
3. Refine the tip and reestablish the tip-defining points (note thick 2. Component reduction of dorsum (5 mm)
skin). 3. Anterior septal angle reduction
4. Drastically improve the tip rotation and projection.

948
 61 Primary Rhinoplasty

4. Septal harvest (for cartilage grafting purposes) with 10-mm

L-strut
5. Bilateral spreader grafts
6. Cephalic trim leaving a 6-mm rim strip
7. Columellar strut graft with medial crural septal sutures
8. Medial crural, interdomal, and transdomal suturing
9. Combined infralobular and onlay tip graft
10. Lateral osteotomies (external perforated)

This surgical plan is shown in Fig. 61.79.

Results
Comparison views of preoperative and 2-year postoperative
appearance (Fig. 61.80) demonstrate a more balanced nose
after reduction of the dorsum and refinement of the tip
including improved tip rotation, projection, and definition. The
drastic improvement in overall nasal tip definition, including
enhancement of the supratip and infratip, required a secondary
operation with more soft tissue debulking and visible onlay
Fig. 61.78 Patient example 4, preoperative. (Reproduced with
tip graft replacement secondary to early graft resorption. The permission from Rohrich RJ, Ghavami A. Rhinoplasty for Middle
necessity for secondary tip refinement or soft tissue debulking is Eastern noses. Plast Reconstr Surg. 2009; 123:1343-1354.)
not uncommon in the Middle Eastern population and should be
discussed during the initial informed consent.

61.11 Concluding Thoughts

Success in primary rhinoplasty is predicated on accurate preop-
erative analysis and clinical diagnosis, identification of both the
patient’s expectations and the surgeon’s goals, and a thorough
review of the plan of care and expected postoperative recovery.
Intraoperatively, adequate anatomic exposure of the nasal
deformity, preservation and restoration of the normal anatomy,
correction of the deformity using incremental control, mainte-
nance and restoration of the nasal airway, and recognition of
the dynamic interplay between these maneuvers will optimize
outcomes and lead to a successful experience for both the patient
and the rhinoplasty surgeon alike.

Clinical Caveats
• The key to a successful outcome begins with proper patient
selection.
• A thorough understanding of normal and abnormal nasal
anatomy is paramount.
• Accurate, precise, and complete nasofacial analysis is manda-
tory to help plan the operation.
• Full and complete disclosure of all risks and benefits, includ-
ing financial responsibilities, must be performed to both the
surgeon’s and the patient’s satisfaction. There is no substitute
for an informed patient.
• The surgeon should never enter the operating room without
a well-thought-out plan.
• The type of incision used is far less important than the
correction of the underlying problem. Choose appropriately
according to the deformity and your own experience.
• If performing an open approach through a transcolumellar Fig. 61.79 Patient 4, surgical plan. (Reproduced with permission
incision, one must avoid excessively debulking the tip and from Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses.
Plast Reconstr Surg. 2009; 123:1343-1354.)

949
 X Rhinoplasty

a b

c d e f

g h
Fig. 61.80 Patient example 4. (a,c,e,g) Preoperative and (b,d,f,h) 2 years postoperative. (Reproduced with permission from Rohrich RJ, Ghavami
A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009; 123:1343-1354.)

maintain alar base incisions at least 3 mm inferior to the alar
groove to preserve blood supply to the tip.
• The procedure should proceed in an organized, stepwise
fashion from skin to skin, without rushing. Iatrogenic injuries
are difficult to correct.
• The dorsal reduction should always be performed before
harvesting septal cartilage, so that the 10-mm L-strut is
maintained.
• The dorsum should be reduced in component fashion to
prevent an inverted-V deformity.
• The surgeon should attempt to preserve the transverse
processes of the ULCs.
• Tip modifications should be performed using a graduated
approach.
• All incisions must be closed meticulously.
• The postoperative splints/tapes should be positioned care-
fully to prevent iatrogenic deformity.
• The postoperative course should be reviewed with the patient
and family before and after the operation.

950

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62 Tip Grafting for Nasal Contouring
Jeffrey T. Steitz and Dean M. Toriumi
Abstract
Management of the tip in rhinoplasty is a challenging endeavor
that is managed in a variety of ways including cephalic trim,
dome sutures, and tip grafting, among others. All surgical
principles should build off a strong, stable nasal base to maintain
tip projection and rotation. Once base stability has been estab-
lished, tip grafting can be used to increase projection, reorient
malpositioned lower lateral cartilages, and create favorable tip
contour. Multiple techniques can be utilized, including shield
tip grafts and lateral crural strut grafts. Revision surgery may
require autologous cartilage harvest, which can complicate the
operation but, when the right material is selected, can create
astounding results.
Keywords
rhinoplasty, tip grafting, tip contouring, shield graft, lateral
crural strut graft
62.1 Introduction
asal tip contouring is perhaps the most difficult rhinoplasty
skill to master. Seemingly isolated maneuvers can simulta-
neously affect multiple parameters on both the anterior and
lateral views. The degree of difficulty is compounded by the
relentless contraction of the skin–soft tissue envelope and the
resultant potential for late complications. Early techniques in
tip rhinoplasty were primarily reductive. The lower lateral car-
tilages (LLCs) were trimmed, scored, or divided to create smaller,
albeit weakened, noses. Current techniques in tip rhinoplasty
emphasize conservative LLC excision, suture reshaping, cartilage
repositioning, and cartilage grafting.
One of the earliest reports of nasal tip cartilage grafting was
by Peer in 1945. Through his histologic studies of grafts, he
refuted the prevailing belief that septal cartilage was resorbed
after transplantation, and he specifically described lengthening a
retracted columella with septal cartilage. Hage in 1964 detailed
the correction of dynamic alar collapse using auricular cartilage
through, presciently, an open transcolumellar approach. Modern
tip grafting techniques were first described by Sheen after he
keenly observed that polly-beak deformities resulted from an
overreduced nasal structure that was unable to accommodate a
large skin–soft tissue envelope; his solution was to augment the
tip with cartilage grafts placed through an endonasal approach.
These techniques were later popularized through the external
approach by Johnson and Toriumi.
Tip grafting is often performed in conjunction with conservative
reduction of the LLCs and suture contouring. Grafting significantly
increases surgical complexity and the potential for postoperative
complications and, thus, should not be used indiscriminately. A
62 Tip Grafting for Nasal Contouring
graded surgical algorithm may effect modest tip changes, such as
narrowing and slight increases in projection, with conservative
cartilage trimming and suture reshaping alone. Tip grafting can
be used for greater changes, and grafting alone can lengthen
or enhance the projection of a short nose, straighten a severely
crooked tip, and reposition retracted alae. hen used properly,
cartilage grafting is a powerful tool for nasal tip contouring.
62.2 Indications and
Contraindications
Indications for tip grafting in primary rhinoplasty include the
increase of tip projection, prevention of postoperative loss of tip
projection, nasal lengthening, straightening of tip deviations, and
correction of cephalically positioned LLCs. Mild increases in tip
projection may be successfully achieved with suture contouring
(such as dome-binding sutures, lateral crural steal, and so on);
increases greater than 1 or 2 mm frequently require tip grafts.
The degree of augmentation and refinement, the anatomy of the
existing nasal framework, and the skin thickness will further
dictate the type of tip grafting employed.
Patients with weak LLCs, short medial crura, and a deficient
caudal septum are at risk for postoperative loss of tip projection.
Extended columellar struts, caudal septal extension grafts, and
caudal septal replacement grafts can each be used to stabilize the
tip. These same grafts can also be used to lengthen short noses and
correct persistent caudal septal deviations. Costal cartilage may
be needed when lengthening a short nose to withstand the force
applied by the stretched, contracting skin–soft tissue envelope.
Cephalically positioned LLCs are another indication for grafting
techniques. Aesthetically, cephalically positioned cartilages con-
tribute to tip bulbosity, the “parentheses” tip deformity, and alar
retraction. Functionally, they facilitate lateral wall collapse and
decrease nasal valve patency. After dissection from both the nasal
skin and vestibular mucosa, only very strong, flat lateral crura
permit suture repositioning alone. Most cartilages lack adequate
strength to support the lateral wall and will require placement
of lateral crural strut grafts to prevent postoperative alar collapse
and retraction.
o absolute contraindications to tip grafting exist, although
grafting is sometimes unnecessary. Primary rhinoplasty patients
with adequate projection, proper rotation, and minimal tip bul-
bosity may successfully be treated with conservative trimming
of the cephalic lateral crura and suture contouring. Overly long
noses may be better addressed by setting the medial crura back
on the caudal septum in a tongue-and-groove fashion. Desired
aesthetic changes must be balanced against the increased risk of
complications posed by grafting.
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62.3 Pertinent Anatomy

The nasal tip proper is one of the nine aesthetic subunits of the
nose. ithin the context of nasal tip contouring, the term tip
more accurately reflects the lower third of the nose, specifically
the tip, ala, soft tissue triangle, and columellar subunits. The
transition points between these subunits contribute substan-
tially to tip highlights and shadows.
The external appearance of the nasal tip is dictated primarily
by the anatomy of the LLCs and the caudal septum. Projection
and rotation are the primary metrics analyzed when viewing the
tip profile. Other important parameters are the alar–columellar
relationship, the columellar–lobular angle or double break, and
the supratip break. Ideal tip projection has been quantified by
assorted mathematical equations and anatomic relationships. et Fig. 62.1 (a) Anterior view highlighting ideal tip contours. There is a
adequate projection is often best determined by simple observa- horizontal ellipse at the tip, highlighting ideal underlying structure.
There is a subtle shadow in the supratip with a smooth transition from
tion of each patient’s anatomy particularly dorsal height, nasal tip lobule to alar lobule. (b) Lateral view shows the smooth transition
length, and chin projection. Ideal rotation in men is approximately from tip lobule to alar lobule.
90 to 100 , compared to 100 to 120 in women. The perceived
rotation is affected by the position and contour of the nasolabial
angle. A gentle curve is desirable; a sharp transition makes the
tip and alae isolates the tip with shadows and creates the “paren-
angle appear more acute and unnatural.
theses” deformity; this may be caused by bulbous or cephalically
The alar–columellar relationship can significantly affect the per-
positioned LLCs. An unnatural, single midline tip highlight may be
ceived harmony of the tip profile. Alar retraction creates a snarled
seen in patients whose domes have been pinched together. On the
appearance that mars an appropriately projected and rotated tip.
basal view, a pinched tip will exhibit marked alar concavity.
Approximately 2 to 4 mm of columellar show is generally consid-
Overall tip shape and size are crucial to tip aesthetics. A bulbous
ered aesthetic. Greater show may result from alar retraction or a
tip interrupts a smooth brow-to-tip aesthetic line. Bulbosity may
hanging columella; less show may be caused by hanging alae or
result from both enlarged and cephalically positioned lateral
retracted columella. The alar rim contour should approximate a
crura. The ideal lateral crural position can range from 35 to 45
gentle curve. hereas alar retraction is characterized by a more
off the midline; more simply, they should point toward the lateral
uniform arc of elevation, alar notching describes an acute, focal
canthus as opposed to the medial canthus.
retraction that interrupts the ideal contour.
Even after a cephalic trim is performed, cephalically positioned
The double break and supratip break are other important
lateral crura can leave residual tip fullness that tends to obliterate
components of an aesthetic tip. The double break is formed by
the subtle sidewall inflection at the confluence of the sidewall, tip,
the natural divergence of the intermediate crura. The cephalic
and ala.
break point corresponds to the tip-defining points on the anterior
The relationship of the infratip lobule to the ala is another
view and represents the transition from the domes to the lateral
important component of the anterior view, and the ideal contour
crura. The caudal break point represents the initial divergence of
is a gently curving V, or gull in flight. Prominence of the infratip
the medial crura into the domes and can be difficult to appreciate
lobule, tip rotation, and alar position all contribute to this contour.
on anterior view. The area between these two points forms the
It is exaggerated by a prominent, hanging infratip lobule and
infratip lobule. The transition from the tip-defining point to the
reduced by a hidden, flattened infratip lobule. An underrotated
dorsum forms the supratip break. The dome height over the
tip also creates an unsightly shadow at the nasolabial angle.
anterior septal angle and the skin thickness draping over it create
the break. A 1- or 2-mm supratip break is especially desirable in
women, whereas men may tolerate less or no supratip break.
The tip profile is primarily a two-dimensional relief against a
62.4 Preoperative Assessment
uniform background; subtle shadows and highlights compose the The surgeon begins the preoperative assessment by eliciting the
anterior view. hen using a single midline light source, the tip patient’s functional and aesthetic concerns. Understanding the
highlight predominates. Ideally, it is a horizontally oriented ellipse patient’s surgical goals is crucial to a successful surgeon-patient
formed by the divergence of the intermediate crura and the paired relationship. Some patients request correction of obvious defor-
domes. The paired tip-defining points are more prominent when mities, such as a dorsal hump or bulbous tip, whereas others
two light sources are used. The average width between tip-de- provide annotated photographs detailing a multitude of changes.
fining points is reportedly 8 mm, although this distance should Some want to address a single deformity, such as male patient
be individualized based on overall facial width, base width, and who wants a less bulbous tip but is unconcerned with a slight
cultural norms (Fig. 62.1). dorsal convexity. Ethnic patients may ask for subtle changes that
Cephalic to the tip highlight there should be a subtle shadow maintain their ethnicity, or they may desire a more refined nose.
that represents the supratip break. Greater supratip breaks cast Identifying patients with unachievable aims or goals beyond
darker shadows. The tip highlight should gradually transition to the surgeon’s aesthetic range is paramount. Patients with goals
the alae without a deep shadow. A concave transition between the that are unattainable rarely have body dysmorphic disorder;

954

they more commonly request changes that are not anatomically
feasible. For instance, a finite reduction is achievable in a patient
with thick skin, a large dorsal hump, and overprojected nasal tip
without developing a polly beak deformity; however, a small,
petite nose is unrealistic. Other patients may desire changes that
are displeasing to the surgeon’s aesthetic sensibilities, such as a
scooped dorsum or arched alae. These goals may be surgically
attainable, and the patient may indeed be happy postoperatively.
However, a dissatisfied patient is both unhappy and aesthetically
worse. All of these patients are poor candidates, and the surgeon
should politely decline to operate.
62.4.1 Patient History
The patient’s past surgical history should be obtained. The
timing and number of prior septoplasties, rhinoplasties, and
cartilage-harvesting procedures are recorded. Proper preopera-
tive counseling requires that the surgeon be aware of available
grafting material and whether alloplastic implants or injectable
fillers have been used previously. In the case of previous inject-
able filler, it is important to know the material injected and the
frequency with which it was performed. Additionally, many
patients with previous filler to the nose may have intermittent
inflammatory change of the overlying skin, which may not be
evident on the day of examination. It is important to elicit this
history, as it may indicate the presence of chronic infection/
inflammation that may increase risk of postoperative infection.
The patient’s past medical history should also be elicited, partic-
ularly rhinologic complaints such as nasal obstruction, congestion,
epistaxis, and rhinorrhea. Patients with allergic rhinitis should be
counseled that medical intervention will be necessary to alleviate
their symptoms rather than surgery. A history of bleeding diathe-
ses, asthma, chronic obstructive pulmonary disease, diabetes, and
immune disorders is also important, because these will have an
impact on intraoperative management and postoperative healing.
The patient’s medication usage should be recorded, particularly
nasal decongestant sprays.
For most primary and secondary rhinoplasties, smoking is not
a contraindication, although the increased risk of infection, tissue
necrosis, and prolonged healing should be discussed. Complex
revisions of skin–soft tissue envelopes damaged by infection,
fillers, or alloplastic implants are at a much higher risk for com-
plications and should be delayed until the patient stops smoking
completely. Ideally, all patients should quit smoking 6 to 8 weeks
before surgery.
62.4.2 Physical Examination
The physical examination begins with visual inspection of the
anterior, lateral, and basal views. The external manifestations of
various anatomic irregularities were discussed in the previous
section. Palpation helps to assess the strength of the LLCs and
caudal septum. In revision patients, palpation will aid in differ-
entiating soft tissue from structural abnormalities and assessing
the elasticity of damaged skin.
Anterior rhinoscopy with a nasal speculum can identify caudal
septal deviations, internal nasal valve collapse, and inferior tur-
binate hypertrophy. It is prudent to perform nasal endoscopy in
any patient who complains of nasal obstruction. A rigid 0 scope
62 Tip Grafting for Nasal Contouring
can be introduced under direct visualization or with a camera and
monitor. The presence of a septal perforation, synechiae, polyps,
concha bullosa, or mucopurulent drainage necessitates additional
rhinologic workup.
62.4.3 Photography and Imaging
Photography is an integral component of the rhinoplasty con-
sultation. Standard views include anterior, lateral, oblique, and
basal views. Photographs are taken with two umbrella lights,
each positioned behind the camera at a 45 angle to the patient.
An anterior photograph with a single midline umbrella light
positioned behind the camera improves the contrast between
light and shadow and provides better visualization of nasal con-
tours. Additional views include close-ups of all standard views,
an inspiratory basal view to assess external valve collapse, and
smile views. Patients with vertically oriented smiles (that is, the
corner of the mouth goes up instead of moving laterally) who
will be undergoing placement of an extended columellar strut
graft or caudal septal replacement graft with fixation to the nasal
spine may develop a transverse upper lip crease when they smile.
Imaging software is an excellent tool for demonstrating
operative goals. Modified photographs can help patients com-
municate their goals more effectively and provide the surgeon
with a visual surgical template. It is imperative, however, that
realistic imaging of an obtainable outcome be shown. In the senior
author’s practice, preoperative digital imaging is performed, and
copies of these simulated results are provided for the patient to
take home. He or she is encouraged to review the photographs
and schedule another visit if modifications or clarification is
necessary. However, producing virtual results with the patient
present should be performed only after considerable experience,
because it requires deft use of the software and knowledge of
what is surgically achievable. Likewise, photo imaging should not
be performed by ancillary staff, who may not have knowledge
of realistically achievable results. If used properly, photographic
imaging can be a powerful tool in the surgical practice.
62.5 Preoperative Planning,
Including Markings
Patients are positioned supine on the operating room table, with
the head supported by a foam pillow. Operative anterior, lateral,
and basal photographs are taken after intubation.
Convexities and concavities are marked before local anesthetic
is injected, so that deformities can continue to be identified
despite the inevitable edema from the injection and operative
manipulation (Fig. 62.2). Local injection of the tip, nasal spine,
dorsum, sidewalls, septum, and vestibular mucosa incision lines
is then performed with 1 lidocaine with 1:100,000 epinephrine.
Vigorous injection of the septum facilitates hydrodissection of the
mucoperichondrial flaps.
An inverted-V incision is outlined midway between the supe-
rior extent of the columella and the medial crural footplates. A
straight-line columellar incision should be avoided to prevent scar
contracture and columellar notching. In patients whose noses will
be deprojected, the incision should be outlined slightly higher to
accommodate its eventual inferior movement.
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62.6 Operative Technique
62.6.1 Incision and Dissection
The various benefits and drawbacks of endonasal and open
rhinoplasty are a frequent topic of debate. Many advanced tip
grafting techniques require suture fixation and are best accom-
plished by the open approach. Flap elevation and closure warrant
close attention and meticulous technique.
The anterior columellar portion of the incision is made with a
No. 11 blade. For precise incision placement, the blade is moved
in a sawing motion. The lateral limbs are incised very superficially
to avoid transecting the medial crura. The vestibular portion of
the columellar incision is more easily completed with a o. 15
blade. Grasping and turning the tip with the left hand exposes the
columella. The incision is extended up toward the vestibular apex,
but not blindly into it.
The marginal incisions are performed next. Using a wide
double-pronged skin hook, the lateral crura are exposed. Gentle
palpation with the scalpel can help identify the caudal edges of
the lateral crura. The incision is then performed from lateral to
medial but is stopped short of the vestibular mucosa beneath
Fig. 62.2 Preoperative markings are performed prior to injection of
local anesthetic. This particular patient has marked bulbosity in the
tip with pinching in the left middle vault and subtle asymmetry of the
nasal bones.
956
the dome. At this point the marginal incision has not yet been
connected to the columellar incision.
Elevation of the skin–soft tissue envelope over the medial crura
begins using Converse scissors, exerc ising care to avoid transect-
ing the medial crura. As the dissection approaches the intermedi-
ate crura, it is important to dissect within the supraperichondrial
plane. This plane is often identified by its wispy connective tissue
and lack of bleeding.
Once the skin flap has been elevated over the intermediate crura,
the marginal incisions can be completed. A wide double-pronged
skin hook is used to expose the vestibular apex, and the incision
is completed with the Converse scissors. Direct visualization
permits precise incision placement. Dissection over the domes
is facilitated by simultaneous caudal LLC retraction and cephalad
skin flap retraction. Careful dissection over the lateral crura
ensures that the caudal margin is not inadvertently transected.
Dissection continues in the supraperichondrial plane onto the
anterior septal angle and over the upper lateral cartilages (ULCs);
a Converse retractor facilitates visualization beneath the flap.
Once the rhinion is encountered, the nasal bone periosteum is
incised with the sharp edge of a oseph periosteal elevator. The
periosteum is raised off the nasal bones with the oseph elevator.
62.6.2 Septal Cartilage Harvest
Septal cartilage is the first choice for grafting material because
of its location, strength, and flexibility. There are multiple
approaches for septal cartilage harvest; the choice depends on
the work to be undertaken. A illian incision may be used for
rhinoplasties in which repositioning of the tip, columella, or
nasal base is not necessary. If more extensive work is needed and
the nose requires shortening, lengthening, rotation, or deprojec-
tion, dissection between the medial crura to expose the caudal
septum may be beneficial. The interdomal space is divided,
and dissection is carried onto the anterior and posterior septal
angles; extended dissection requires division of the ULCs from
the dorsal septum. Entering the interdomal space and separating
the ULCs allow maximal septal exposure and precise control of
nasal base and tip position.
Mucoperichondrial flap dissection in the subperichondrial
plane ensures a relatively bloodless dissection. The proper plane
is entered by scoring the septum with a o. 15 blade and then
dissecting the flap with a Freer elevator. Dissection is carried back
to the bony–cartilaginous junction bilaterally. If the bony septum
is deviated, flap elevation continues posteriorly and the deviated
portion is resected.
In harvesting septal cartilage, it is important to leave a 1- to
1.5-cm L-strut intact to provide nasal support. Additional cartilage
may be left beneath the keystone area of the ULCs to ensure dorsal
support, particularly in patients with short nasal bones. Careful
dissection of posterior septal cartilage between the perpendicular
plate of the ethmoid bone and the vomer will ensure maximal
length to the septal graft (Fig. 62.3).
62.6.3 Costal Cartilage Harvest
Details of costal cartilage harvesting and carving are presented
in Chapter 63 . It is worth reiterating, however, that postoperative
warping can be avoided by early and sequential intraoperative

graft carving. Somewhat counterintuitively, bent pieces are
often preferred to straight pieces, because the warping has com-
menced in the operating room and can be used to the surgeon’s
advantage.
62.6.4 Nasal Base Stabilization
The nasal base is the foundation of the lower third of the nose and
maintains tip position; anatomically, it is composed of the caudal
septum and its soft tissue attachments to the LLCs. Stabilization
of the nasal base is a prerequisite for tip contouring. A weak
nasal base requires overcorrection of projection and rotation
in anticipation of postoperative loss of projection. Consistent
results require precise intraoperative tip positioning on a stable
base that is resistant to postoperative skin–soft tissue envelope
contraction.
A graduated approach to nasal base stabilization is prudent.
Patients at risk for postoperative loss of tip projection are those
with weak LLCs, a short caudal septum, and short medial crura.
The nasal base of patients with long, strong medial crura can be
stabilized with a columellar strut placed into a pocket dissected
between the medial crura. In patients requiring rotation or short-
ening, the medial crura can be fixed to the overly long, midline
caudal septum in a tongue-and-groove fashion.
Patients requiring nasal lengthening or significant projection
need strong support to resist the skin–soft tissue envelope
contractile forces. Lengthening is accomplished with a caudal
septal extension or replacement graft (Fig. 62.4). Caudal septal
Fig. 62.3 Harvested septal cartilage.
62 Tip Grafting for Nasal Contouring
extension grafts can be placed end to end or overlapped, depend-
ing on the position of the caudal septum. End-to-end grafts are
stabilized with two sets of bilateral splinting grafts sutured with
5–0 polydioxanone sutures (PDS) or with extended spreader
grafts. A slightly deviated caudal septum can be lengthened with
an overlapping graft if the caudal margin of the graft is midline.
The graft is secured with horizontal mattress 5–0 PDS. The over-
lapping cephalic edge of the graft is beveled so that the airway is
not obstructed. End-to-end grafts are preferred because they are
less likely to cause deviation or airway obstruction.
Patients with a severe caudal septal deviation, deficient septum,
or nasal cant may benefit from a caudal septal replacement graft
(Fig. 62.5, Fig. 62.6). In these cases, the caudal septum is removed
while a strong dorsal strut is left intact. Spreader grafts are inserted
up to the osteocartilaginous junction and extend beyond the end
of the dorsal strut to stabilize the caudal septal replacement graft.
Dissection is carried down through the interdomal space onto the
nasal spine. After removal of the caudal septum, a straight 5-mm
osteotome is used to make a notch in the nasal spine and set the
midline of the nasal base (Fig. 62.7). Creation of a wedge-shaped
notch acts as a graft fixation point and allows precise and stable
graft placement. The nasal spine may not be centered, such as in
deviated noses, and the notch may need to be set off of the nasal
spine midline. Before graft placement, two 4–0 PDS sutures are
placed through the periosteum on each side of the notch and left
untied. If no tissue is available for suture placement, a hole can be
drilled through the nasal spine with a 16-gauge needle. Once the
graft is placed within the notch, the suture is passed back through
the graft and tied.
Cartilage from the septum or rib is preferred for caudal septal
replacement and extension grafts. Equivalent strength with auric-
ular cartilage requires thicker grafts, which can excessively widen
the columella and block the airway. Costal cartilage is strong
enough to resist postoperative contractile forces in complex revi-
sions where scarred skin–soft tissue envelopes need lengthening
and projection.
62.6.5 Tip Projection
Multiple techniques are available to increase tip projection.
Minor increases in projection can be obtained with suture
contouring alone. Dome-binding sutures can be placed within
the native domes or used to recruit lateral crura (Fig. 62.8). The
lower lateral cartilages may also be advanced on a stable nasal
base and fixed with transeptal 4–0 plain gut sutures. This tech-
nique will blunt the nasolabial angle, which may or may not be a
beneficial change. hen these techniques prove insufficient, tip
grafting is required.
Mild increases (1 or 2 mm) in tip projection can be attained
with tip onlay grafts. These grafts are trimmed into a rectangular
or elliptical shape to simulate the ideal tip highlight and are
sutured directly over the domes in a horizontal orientation (Fig.
62.9). Any type of cartilage may be used, although the cephalic
trim of the lateral crura is ideal for mild increases, because its soft
edge blends easily with the native cartilages. For greater increases
in projection, thicker or multiple pieces of septal cartilage or soft
tissue may be necessary.
Larger increases in projection can be obtained with shield
tip grafts. The graft shape simulates the divergent intermediate
crura and paired tip-defining points. Beveled edges facilitate graft
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Fig. 62.4 Surgeon’s view showing a caudal septal extension graft Fig. 62.5 Caudal septal replacement graft prior to implantation. Graft
fixated with extended spreader grafts. was created from septal cartilage graft.

Fig. 62.7 5-mm osteotome creating a notch in the anterior nasal

Fig. 62.6 Caudal septal replacement graft fixated in place to the spine. Osteotomy may be performed off midline depending on
anterior nasal spine and spreader grafts. whether or not deviation of the nasal base is present preoperatively.

958

Fig. 62.8 Rendering of dome sutures and caudal septal extension graft
for nasal tip contouring. This is generally reserved for patients with
inherently strong and caudally oriented lower lateral cartilages.
camouflage. The shield tip graft is sutured to the intermediate
crura and projects above the domes (Fig. 62.10, Fig. 62.11). The
additional projection carries an increased risk of graft visibility,
particularly in patients with thin skin. However, the graft’s lead-
ing edge stretches and thus refines the thick-skinned tip. Slight
graft flexion, often caused by compression from the skin–soft
tissue envelope, helps preserve the double break. Support grafts
(cap or buttress grafts) can be placed behind the shield graft to
resist excessive cephalic pressure.
Smoothing the transition from the shield graft to the lateral
crura is crucial to preserving a smooth tip–alar lobule junction
and preventing shadows that isolate the tip. Lateral crural grafts
extend from the existing LLCs to the posterosuperior aspect of the
shield graft and are secured with 6–0 PDS. They are used primarily
when the shield graft projects more than 3 mm above the existing
dome structures.
Skin thickness dictates the amount of camouflage necessary to
prevent graft visibility. Thick skin may require none, whereas thin
skin requires several layers. Perichondrium is an excellent tissue for
this purpose, especially thick, fibrous, costal perichondrium. Gently
crushed septal cartilage, auricular cartilage, or scar tissue is also
useful. These materials can be sutured over or around the leading
edge of the shield graft to prevent graft visibility (Fig. 62.12).
Greater tip projection increases the distance between the domes
and anterior septal angle, thus increasing the supratip break. The
visible supratip break reflects the skin thickness draped over this
height. In a projected tip on a stable base, 4 to 6 mm between the
dome and the anterior septal angle is appropriate for thin skin,
whereas 8 to 12 mm may be needed for thick skin. Too large a
supratip break may appear as a scooped dorsum or mild saddle
deformity. Supratip grafts can be sutured to the cartilaginous
dorsum to ease the transition and improve the overall nasal profile.
62.6.6 Tip Rotation
Smaller degrees of tip rotation can be achieved simply by placing
a columellar strut and dome-binding sutures. This maneuver
62 Tip Grafting for Nasal Contouring
Fig. 62.9 Soft tissue grafting to the nasal tip assists in maintaining a
higher orientation of the caudal margin of the lateral crus (in compari-
son to the cephalic margin) as well as camouflage.
will increase tip projection and often produce moderate tip rota-
tion; the amount of rotation depends on the prominence of the
caudal septum and its contribution to the ptotic tip. Trimming
the caudal septum can result in tip rotation but is unreliable. Tip
rotation can also be achieved by shortening the lateral crura or
by performing a lateral crural division and overlay (the lateral
crural steal technique described by ridel and colleagues).
Alternatively, tip rotation can be controlled by setting the medial
crura into position about the native or extended caudal septum.
hen excessive nasal length is caused by a redundant caudal
septum, tip rotation can be achieved by dissecting between the
medial crura and suturing them to the existing caudal septum.
This maneuver will result in shortening of the nose and rotation
of the nasal tip. The caudal septum is not trimmed but rather used
as a fixation point to create tip rotation. The degree of rotation
can be increased by moving the domes more cephalad than the
lower segment of the medial crura. Once rotation is achieved
using this method, there may be redundancy of the lateral crura
that may require dissection of the lateral crura and repositioning.
Maneuvers used to rotate and project the tip may also flatten the
infratip lobule. Lack of a double break on tip profile will give the
nose an unnatural, beaklike appearance. Infratip grafts can be
sutured to the medial crura to recreate the ideal contour.
62.6.7 i e nemen
Tip refinement refers to the overall size, shape, and definition
of the tip. The shape and width of the domes and the size and
position of the lateral crura determine whether the tip is
aesthetically pleasing. Large lateral crura should be trimmed
cephalically; leaving behind 8 to 10 mm of width is advisable,
although the precise amount resected depends on the shape and
intrinsic strength of the cartilages. Dome-binding sutures refine
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Fig. 62.10 Anterior view of a shield tip graft (prior to placement of

additional grafts). Fig. 62.11 Basal view of a shield tip graft.

and narrow the tip. Residual tip bulbosity after trimming and
suture contouring is often caused by cephalically oriented lateral
crura or residual deformity of the lateral crura. Dome-binding
sutures may also deform the lateral crura by leaving an unnat-
ural bulge lateral to the dome sutures or near the alar groove.
Lateral crural strut grafts can be used effectively to reposition
the LLCs, refine the tip, and enlarge the nasal airway. Lateral
crural strut grafts are sutured to the undersurface of the lateral
crura to position the cartilages in a flatter, stiffer orientation; they
can then be effectively narrowed without bulging laterally (Fig.
62.13). The lateral crura are freed from the underlying vestibular
mucosa (Fig. 62.14, Fig. 62.15, Fig. 62.16); local anesthetic is
injected to facilitate the dissection. Septal cartilage is strong and
flexible but not always available. The strength of costal cartilage
permits reduced graft thickness at the expense of increased tip
rigidity. Auricular cartilage is often too thick for this application.
Grafts are generally 1 to 1.5 mm thick, 5 mm wide, and 25 to 30
mm long, although the exact length depends on the degree of
airway collapse and alar retraction.
The position of the domes can be altered with lateral crural
strut grafts (Fig. 62.17). This technique is applied primarily in an
overprojected nose to decrease tip projection and counterrotate
the tip. Precise positioning of the medial graft edge creates a new
tip-defining point along the intermediate crura or medial to the
original dome. Positioning the lateral crural strut graft medially
moves the old dome lateral to the new one and deprojects and Fig. 62.12 Shield tip graft with soft tissue camouflage and articulated
counterrotates the tip. The new dome’s position is fixed by placing rim grafts.

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Fig. 62.13 Basal view of lateral crural strut grafts prior to repositioning
into a caudally oriented pocket. Note the flattening of the lateral crus. Fig. 62.14 Anterior view of released lateral crura.

Fig. 62.15 Basal view of released lateral crura. Fig. 62.16 Surgeon’s view of released lateral crura.

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transdomal sutures of 5–0 PDS through the medial margin of the
graft and native LLCs; the suture is tied between the new domes
to hide the suture knot. A limited increase in tip projection can
be obtained by moving the medial margin of the lateral crural
strut graft lateral to the existing dome. Tip projection is more
commonly increased by advancing the nasal base on a stable strut
or extension graft or with a shield tip graft.
Cephalically oriented lateral crura can be repositioned once lat-
eral crural strut grafts are in place. A pocket is dissected caudally
in the alar skin–soft tissue envelope with Converse scissors. The
pocket is typically placed just caudal to the alar groove. Placement
of the strut graft within this pocket will decrease the cephalic
tip bulbosity and improve retracted alae. Precise placement of
the pockets is critical to producing symmetrical alar margins
and nostrils. If the nostril shapes or alar margins are asymmet-
ric preoperatively, the two pocket locations must be altered to
compensate for these differences. It is also paramount to leave
the remainder of the alar lobule, caudal to the placement of the
pocket, undissected to allow precise placement of the strut graft
with minimal mobility. A common mistake is placement of the
pocket at the caudal margin of the ala similar to the placement of
an alar rim graft. This can cause visibility of the graft, distortion
of the alar margin, and minimal improvement in lateral wall
collapse. Repositioning of the lateral crura with lateral crural strut
grafts increases the need for alar base reduction due to increased
alar flare.
In complex revision cases, the native domes and lateral crura
may be severely deformed by scar tissue, multiple grafts, and
overresection. If no usable intermediate or lateral crura exist, new
ones can be shaped from lateral crural replacement grafts.
Lateral crural replacement grafts are sutured to the caudal
septal extension or caudal septal replacement graft (Fig. 62.18).
Soft, flexible tissue is ideal for the lateral crural replacement grafts.
Thin septal cartilage, scar tissue, and rib perichondrium are good
options, although a remnant lateral crural graft with attached scar
tissue is ideal because of its flexibility and strength. Lateral crural
strut grafts can be sutured to the lateral aspect of the lateral crural
replacement grafts to provide lateral wall support. They should
measure 25 to 32 mm in length depending on the size of the nose
and the amount of lateral wall support needed. Ideal lateral crural
strut grafts are slightly curved, and the concave side is oriented
toward the nasal airway to ensure airway patency. Once the
Fig. 62.17 Artistic rendering of the creation of a new dome utilizing
lateral crural release and lateral crural strut graft.
962
lateral crural strut grafts are in place, domes can be created by
placing 5–0 PDS dome sutures bilaterally.
62.6.8 Nostril Reshaping
In addition to base reduction techniques, nostrils can be reshaped
with grafting. Lateral crural repositioning is perhaps the most
powerful method of pulling down retracted alae and recreating
nostril shape on anterior view. Lateral crural overresection
in traditional reductive rhinoplasties often led to alar collapse
that isolated the tip in circumferential shadows. Alar retraction
exaggerates the gull in flight contour on anterior view and
contributes to the abnormal alar–columellar relationship on
profile. As previously described, lateral crural strut grafts can
be used to reposition the alae more caudally. It is essential to
make the pockets for the repositioning caudally and down to
the piriform aperture to ensure adequate alar movement. hen
moving the ala caudally, the pocket created for the lateral crura
should be even more caudal and closer to the alar margin. Often
this maneuver will result in increased alar flare, which must be
addressed with alar base reductions.
Further improvement in nostril shape can be obtained with
alar rim grafts. These can help recreate and support the tip–alar
transition and correct alar concavities. Alar rim grafts are typi-
cally 2 to 3 mm wide and 12 to 15 mm long. A pocket is carefully
dissected caudal to the marginal incision, and the graft is slid
into the pocket (Fig. 62.19, Fig. 62.20). It is held in place with a
single 6–0 poliglecaprone (Monocryl, ohnson ohnson, ew
Brunswick, ) suture (Fig. 62.21). The medial graft edge should
be gently crushed with Adson-Brown forceps to prevent visibility.
Alar rim grafts help correct the alar concavities seen on the basal
view and create a smooth transition from tip lobule to alar lobule.
62.6.9 Closure
Closure begins by reapproximating the skin flap with a single
deep 6–0 Monocryl suture. The marginal incisions are then care-
fully approximated with 5–0 chromic gut; poor reapproximation
can lead to the development of vestibular webs and nasal valve
stenosis. The columellar skin is closed with 7–0 nylon vertical
mattress sutures placed perpendicular to the incision line apices.
Precise closure at the columellar edge is crucial to prevent visible
contour irregularities. The spaces in between are then filled with
Fig. 62.18 Artistic rendering of lateral crural replacement grafts.
 62 Tip Grafting for Nasal Contouring

Fig. 62.19 Developing a pocket for alar rim graft with Converse scis-
sors. Creation of a tight pocket allows for easy placement of rim graft.

Fig. 62.20 Placement of rim graft into pocket.

vertical mattress or simple interrupted sutures, depending on

the amount of eversion needed. The vestibular portion of the
columellar incision is closed with single interrupted 6–0 fast-
absorbing gut sutures. Meticulous technique helps to camou-
flage the scar.
Lateral wall splints fashioned from 0.25-mm bivalve septal
splints facilitate integration of lateral crural struts. The bivalve
septal splint is cut in half and the edges trimmed. One piece is
placed intranasally and the other across the sidewall and ala.
The splints are sutured in place with a single 3–0 nylon suture
placed through-and-through the sidewall, and the knot is tied
intranasally. To account for the lateral wall edema and prevent
skin ulceration or necrosis, the knot should be loose enough to
allow passage of a needle-holder tip. Vestibular splints, also
fashioned from 0.25-mm bivalve septal splints, may be placed to
stent constricted airways and to help preserve the lateral position
of lateral wall grafts.
A narrow strip of nonadherent gauze is placed over the dorsum
from the radix to the supratip. The nose is then taped with 0.25-
inch reinforced paper tape, and a thermoplastic cast is applied to
the dorsum. Bacitracin is applied to all suture lines. A gauze drip
pad is placed across the nose. onadherent gauze and a transpar-
Fig. 62.21 Fixation of rim graft. ent dressing are used to cover the chest incision at the harvest site.

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62.7 Postoperative Care
A broad-spectrum antibiotic is prescribed postoperatively for up
to 2 weeks. Patients are encouraged to take acetaminophen for
pain, although hydrocodone/acetaminophen pills are prescribed
for more severe pain. Vestibular splints are removed at the
earliest on postoperative day 1 but may be left in place for up
to 1 week. The columellar sutures, nasal cast, and lateral wall
splints are removed on postoperative day 7. Alar base reduction
sutures are removed on postoperative day 14. Patients return to
the office for two additional visits the first month, monthly for
the next two visits, and then bimonthly for two visits. Long-term
follow-up beyond this period is highly encouraged, as patients
are counseled that the nose is 30 healed at 1 year and 40
healed at 2 years.
Correction of minor asymmetries with compression maneuvers
can begin 3 weeks after surgery. Patients are directed to apply
pressure to specific areas for 1 minute 10 times daily. If costal car-
tilage is harvested, silicone sheeting is provided for chest incisions
3 weeks after surgery. Patients are instructed to tape the sheeting
over the scar nightly and clean it with alcohol in the morning;
sheets are changed monthly.
alking may begin on postoperative day 1, but patients are
asked to refrain from strenuous physical activity for 6 weeks.
Swimming is restricted for 4 weeks; afterward patients may swim
only in chlorinated pools for the next 2 months. Patients may wear
glasses while their cast is still in place. Thereafter, patients are
asked to bring glasses to the office so that their resting position on
the nasal bridge can be assessed.
62.8 Problems and Complications
The most common complication after surgery is residual
asymmetries, especially in difficult revisions or congenital or
traumatic cases. The likelihood that asymmetries may develop is
strongly correlated with the patient’s skin thickness. Thick skin
remains edematous for much longer after surgery and will tend
to hide many irregularities; even minor irregularities will show
through thin skin.
ostril asymmetry can be one of the most difficult problems to
correct in revision patients. Preference is given to aligning nostrils
on anterior view. An appropriate alar–columellar relationship on
lateral view is the next goal in nostril reshaping. Symmetry on
the basal view is the most difficult to achieve, but fortunately the
least visible.
Additional complications include bleeding, infection, and
scarring. Epistaxis is uncommon after surgery and can often be
treated with oxymetazoline spray. Recalcitrant bleeding may
require application of hemostatic agents, packing, or operative
intervention. The risk of infection is very low but increases
substantially in patients who have had multiple procedures. Any
suspicion of nasal cellulitis should be treated quickly and aggres-
sively. A low threshold for incision and drainage in the operating
room is prudent, since chronic abscesses can smolder and destroy
nasal cartilage grafts or, in the worst cases, irreparably damage
the skin envelope.
964
Careful attention to closure of the transcolumellar incision
can maximize scar camouflage. Poor scars can be treated with
dermabrasion or revision. Improper closure of marginal and
intracartilaginous incisions can lead to vestibular scarring. Even
the smallest scars or webs can compromise the internal nasal
valve and drastically decrease nasal airflow. Repair often requires
placement of an auricular composite graft.
Base reduction and chest incisions can be especially trouble-
some, particularly in thick-skinned ethnic patients, such as Asians
and mestizos. Silicone sheeting, steroid injections, and dermabra-
sion can all be used to improve the appearance of hypertrophic
scars.
62.9 Results
The 28-year-old woman shown in Fig. 62.22 requested nasal
refinement. She reported nasal dyspnea at rest and during
exercise. On anterior view, she had a narrow dorsum and lateral
wall pinching, with slight bulbosity in the nasal tip (Fig. 62.22,
Fig. 62.23). On lateral view, she had a small dorsal hump, an
underprojected tip, and a deep radix (Fig. 62.24, Fig. 63.25).
Additionally, she had a slightly underprojected chin. On basal
view, she had short, flared medial crura, a wide columella, and
a trapezoidal configuration secondary to her wide tip and lateral
wall collapse (Fig. 62.26). She also exhibited moderately severe
external valve collapse on inspiration (Fig. 62.27).
62.9.1 Surgical Plan
Correction of the patient’s nasal airway obstruction required
repositioning the cephalically oriented lateral crura. A small
caudal septal extension graft was placed to support the nasal
base. Spreader grafts were placed to correct the middle vault
pinching (Fig. 62.28). The lateral crura were dissected from the
vestibular skin and supported with lateral crural strut grafts
(Fig. 62.29). The lateral crura were then positioned caudally to
correct the cephalically oriented cartilages (Fig. 62.30). A small,
soft cartilage graft was placed over the domes to provide some
additional tip projection and narrowing (Fig. 62.31). A medium
extended anatomic Silastic chin implant was also inserted
through a small submental incision.
62.9.2 Surgical Steps
The rhinoplasty worksheet demonstrates the maneuvers per-
formed during her surgery (Fig. 62.32):
1. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
2. Open septoplasty and septal cartilage harvest
3. Bilateral spreader grafts
4. Caudal septal extension graft end-to-end with caudal septum
5. Bilateral lateral crural strut grafts, dome sutures, and lateral
crura caudal repositioning
6. Soft cartilage placed over domes
7. Soft tissue placed where necessary to camouflage tip grafting
 62 Tip Grafting for Nasal Contouring

Fig. 62.22 Case study, preoperative anterior view. Fig. 62.23 Preoperative close-up anterior view.

Fig. 62.24 Preoperative lateral view. Fig. 62.25 Preoperative close-up lateral view.

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Fig. 62.26 Preoperative basal view. Fig. 62.27 Preoperative basal view during inspiration.

Fig. 62.28 Intraoperative view of spreader grafts and caudal septal

extension graft.

62.9.3 Result
Five years postoperatively, the patient has smooth brow-tip
aesthetic lines, improved dorsal width, and a narrower tip (Fig.
62.33, Fig. 62.34). She no longer has a parentheses shape to her
nasal tip, and the shadowing of her tip is more favorable. On
lateral view, she has a smooth dorsum, increased projection, and
an improved nasolabial angle (Fig. 62.35, Fig. 62.36). The basal
view reveals a triangular configuration, lateral wall support, and Fig. 62.29 Intraoperative view of lateral crural strut grafts prior to
repositioning.
increased nostril size (Fig. 63.37).

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 62 Tip Grafting for Nasal Contouring

Fig. 62.30 Intraoperative view of lateral crural strut graft after Fig. 62.31 Intraoperative view of tip after soft tissue grafting placed
repositioning. for camouflage.

Fig. 62.32 Rhinoplasty worksheet.

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Fig. 62.33 Postoperative anterior view. Fig. 62.34 Postoperative close-up anterior view.

62.10 Concluding Thoughts

Grafting for nasal tip contouring is a difficult endeavor but can
provide dramatic improvements in both aesthetics and func-
tional outcomes. Patients must be carefully selected and coun-
seled regarding expected outcomes and postoperative course.
Although it is difficult to master the proper techniques for tip
grafting, the results can be very rewarding.

Clinical Caveats
• Understanding ideal aesthetic tip contour is essential in
primary and revision rhinoplasty to maximize aesthetic and
functional outcomes.
• Patients with strong, caudally oriented lateral crura can be
managed with less aggressive techniques utilizing dome
sutures and less cartilage grafting due to the inherent
strength of the LLCs.
• Patients with weak, cephalically oriented lateral crura must
be managed more aggressively and often require reposition-
ing of the lateral crura into a more caudal pocket with strong
lateral crural strut grafts.
• Shield tip grafting is another powerful means of improving
tip projection and definition. Care must be taken to prevent
long-term visibility, and some patients with very thin skin are
not candidates for this type of grafting.
Fig. 62.35 Postoperative lateral view.

968
 62 Tip Grafting for Nasal Contouring

Fig. 62.36 Postoperative close-up lateral view. Fig. 62.37 Postoperative basal view.

Suggested Reading
[1] Daniel R . The nasal tip: anatomy and aesthetics. Plast Reconstr Surg
1992;89(2):216–224
2 Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr
Surg 2000;105(3):1140–1151, discussion 1152–1153
3 DeRosa , Toriumi DM. Toriumi’s approach. In: Gunter R Rohrich R , Adams R,
eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St. Louis, MO:
uality Medical Publishing; 2007
4 DeRosa , atson D, Toriumi DM. Structural grafting in secondary rhinoplasty.
In: Gunter R Rohrich R , Adams R, eds. Dallas Rhinoplasty: Nasal Surgery by
the Masters, 2nd ed. St. Louis: uality Medical Publishing; 2007
5 Sheen H. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg
2000;105(5):1820–1852, discussion 1853
6 Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, PA: B Saunders;
1996
[7] Toriumi DM. Structure approach in rhinoplasty. Facial Plast Surg Clin North Am
2005;13(1):93–113
[8] Toriumi DM, Checcone MA. ew concepts in nasal tip contouring. Facial Plast
Surg Clin North Am 2009;17(1):55–90, vi
[9] Toriumi DM. ew concepts in nasal tip contouring. Arch Facial Plast Surg
2006;8(3):156–185

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63 Asian Rhinoplasty
Jeffrey T. Steitz, Sheena Samra, and Dean M. Toriumi
Abstract
ith the substantial increase in Asian rhinoplasty over the past
decade, surgical approach has evolved and a wide variety of
techniques are utilized. Dorsal augmentation with alloplasts has
exploded in the estern Hemisphere, which has also increased
the amount of revision procedures required, given the popularity
of Silastic implants and their associated extrusion rates. Herein
we discuss the intricacies of Asian rhinoplasty, specifically in
regard to dorsal augmentation and tip reconstruction.
Keywords
Asian rhinoplasty, reconstructive rhinoplasty, costal cartilage
graft, structural rhinoplasty, dorsal augmentation
63.1 Indications and
Contraindications
Rhinoplasty in the Asian population has dramatically increased
over the past two decades and is one of the most common facial
plastic procedures in that population. The impressive increase
in popularity is largely due to improvement in social acceptance
of aesthetic plastic surgery and an explosion in pop culture and
social media platforms. Rhinoplasty in the Asian population is
largely a procedure of augmentation rather than reduction.
Asia contains a wide variety of ethnicities and cultures. It is
important for the surgeon who performs rhinoplasty in the Asian
population to understand these regional differences and tailor the
surgery towards the patient’s specific desires. The term Asian
rhinoplasty typically refers to East Asian patients, originating
primarily from China, Hong ong, apan, and the oreas. These
patients typically present for augmentation rhinoplasty due to an
underprojected nasal bridge and tip, wide nasal base, and thick,
sebaceous skin. In contrast to the Eastern region, the southern and
western parts of Asia have a stark contrast in nasal anatomy. These
regions comprise primarily Iran, Iraq, atar, Saudi Arabia, Turkey,
and United Arab Emirates as well as India, Pakistan, Afghanistan,
and many others. In general, patients of these regions tend to
have larger, overprojected noses with dorsal humps and medi-
um-thickness skin. These operations tend to be more reductive
in nature. Finally, in northern parts of Asia it is more common to
see noses similar to those of Eastern European descent in Russia.
Overall, there are a wide variety of Asian noses. The terminol-
ogy used frequently refers to patients of Eastern Asian descent,
and that will be the focus of this chapter.
63.2 Pertinent Anatomy
Anatomic descriptions in the plastic surgical literature, such as
high dorsum and low radix, traditionally refer to the ideal
970
Caucasian (European) nose. However, this custom does not mean
that characteristics described for a Caucasian individual’s nose
are the universal aesthetic ideal. Cultural norms and preferences
dictate aesthetics: the model Asian nose differs from the model
Caucasian nose. Most Asian patients would like a higher nasal
dorsum and more projected nasal tip, keeping a natural look.
The Asian nose typically has a low radix, low dorsum, and
broad, underprojected tip. Thick, sebaceous skin contributes to a
round tip with poor definition and blunted soft tissue triangles.
The columella is commonly retracted. Asian patients frequently
exhibit an acute nasolabial angle and retrusive premaxilla.
Cartilages within the Asian nose tend to be weak, especially
the caudal septum, which is typically cranially positioned. The
cartilaginous septum is frequently very small, necessitating the
harvest of cartilage from a secondary location. The nasal bones
trend toward being shorter than in other ethnic groups, which
contribute to the small cartilaginous septum, as short nasal bones
are usually accompanied by a prominent perpendicular plate. This
does, however leave a larger amount of ethmoid bone, which may
be used as grafting material. Skin elasticity should be assessed,
and patients may be instructed to perform stretching exercises in
an attempt to accommodate larger augmentation grafts.
63.3 Preoperative Assessment
The surgeon elicits specific reasons for seeking rhinoplasty at
the initial consultation and reviews the patient’s cosmetic and
functional concerns. It is vitally important to understand an
Asian patient’s aesthetic goals. The majority of Asian patients
request cosmetic enhancements that preserve their unique
ethnic characteristics; occasionally patients will seek a more
estern or northern European standard. Fastidious patients
may voice their concerns using accurate terminology, whereas
others will have difficulty identifying features they like and
dislike. For the latter, photographs of desirable noses will help to
focus the conversation.
Computer imaging is particularly helpful in these situations.
A consensus can quickly be reached based on the visuals, and
imaging facilitates discussion of realistically achievable results.
Imaging can demonstrate realistic, balanced results that will help
the patient and surgeon develop an appropriate surgical plan.
Some patients express the desire to maintain their ethnicity, yet
present photographs of a Caucasian person’s nose. In the senior
author’s practice, Asian patients frequently provide photographs
of Asian actresses, many of whom who have undergone prior
augmentation rhinoplasties, rendering their nose more estern.
Patients who request revision procedures must be screened
for prior implants. Alloplastic implants are frequently used in
Asia for augmentation rhinoplasty, particularly silicone L-strut
implants. Implants can damage skin, particularly of the dorsum,
leaving it thin, irregular, and telangiectatic. Silicone L-strut
implants may also thin the tip skin, because the implant genu

is the point of greatest tension. Implant removal frequently
requires replacement with an autologous costal cartilage graft.
This greatly increases the complexity of surgery and must be
fully discussed with the patient. Porous polyethylene, polytetra-
fluoroethylene (PTFE), and extended PTFE are also seen, though
less commonly than silicone in the Asian population. These
grafts tend to integrate more with the surrounding skin and
soft tissue envelope, leaving a significant amount of fibrosis and
contracture. In addition to implants, nonsurgical rhinoplasty is
gaining in popularity, and many patients are having filler placed
into the soft tissues of the nose. In Asian patients, this is most
frequently performed to the radix, bridge, and nasal tip. This
can lead to vascular compromise, infections, and scarring and
must be managed very carefully. Hyaluronic acid fillers may be
reversed preoperatively or removed intraoperatively. Calcium
hydroxyapatite fillers tend to integrate more with the surround-
ing tissues and are usually more difficult to remove, especially
if injected into a subdermal plane. Intraoperative removal of
filler close to the dermis may compromise the vascularity of the
nasal tip, and this should frequently be assessed during and after
removal. Patients with previous implants or filler injections are
at much higher risk of infection and must be counseled properly
regarding their risk.
The potential use of autologous grafting materials such as
auricular or costal cartilage must be discussed with the patient
preoperatively. If harvesting of costal cartilage is anticipated,
knowledge of prior breast augmentation is important for both
operative counseling and intraoperative technique. The scar from
inframammary implant placement or breast reduction may be
useful for costal cartilage harvest if it is still located within the
inframammary fold.
The risks of costal cartilage harvesting and implantation should
be carefully explained to the patient. In addition to the standard
risks of pneumothorax, scarring, and graft warping, the patient
should understand that he or she will have increased nasal stiff-
ness postoperatively. This will soften over time, but the nose will
always remain more rigid than it was preoperatively. Chest pain
may range from nonexistent to moderate for 3 or 4 days postoper-
atively. Discomfort when lifting heavy objects may persist for 1 to
2 months before it subsides completely. Dorsal augmentation with
costal cartilage in Asian patients stretches skin near the medial
canthus, and changes to the epicanthal fold may occur.
63.4 Preoperative Planning
The septum is unlikely to provide sufficient grafting material for
Asian patients undergoing augmentation rhinoplasty; invariably,
auricular or costal cartilage harvest is necessary.
Multiple factors must be considered when designing the inci-
sion for costal cartilage harvest. The senior author preferentially
harvests the seventh rib, as it allows for the straightest segment
of rib. The incision must be placed below the inframammary fold
at the superior border of the seventh rib, but incisions can be kept
shorter than 12 mm, which often heals with minimal scarring. If
the incision is larger and made at the inframmary fold, the fifth,
sixth, and seventh ribs may all be harvested through the same
incision when additional grafting material is needed. Fifth-rib
harvest can be more difficult, because it requires dissecting under
63 Asian Rhinoplasty
the breast tissue in women and through the pectoralis muscle in
men, either of which also makes harvest more painful. The fifth
rib has a more continuous curve than the sixth rib, making it
difficult to harvest a long, straight segment. Seventh-rib harvest
is generally safer, especially laterally, as this segment of rib does
not typically overly the pleura. There can be some destabilization
of the rib cage depending on the eighth rib’s attachment to the
sternum. If destabilization occurs, this can often increase postop-
erative pain. Removal may cause a slight but noticeable depression
and can potentially produce a less stable rib cage.
In women the incision is ideally placed in the inframammary
fold. The right side of the chest is preferred for a right-handed
surgeon; thus the patient’s rib pain will not be confused with
cardiac pain. In larger-breasted women, an incision can easily be
hidden in the inframammary fold. If future breast augmentation
is a consideration, the incision should be made lower to anticipate
the new inframammary fold. In some women the incision should
be placed slightly more laterally so that it is not visible when the
woman is wearing a dress with a low neckline. In patients with
breast implants, the inferior extent of the breast pocket must be
determined before the incision is made to prevent implant injury
or violation of the implant capsule.
The size of the incision depends on a number of factors.
Asian patients scar poorly on the chest, so incision length and
placement are critical to a favorable outcome. Muscular or obese
patients and those with pectus excavatum require larger incisions
to accommodate the greater depth of dissection needed; in thin
patients with superficial ribs, smaller incisions are required.
Longer incisions are necessary for harvesting longer pieces of rib.
Incisions as small as 1.2 cm can be used to harvest 4 or 5 cm of rib
in patients with the appropriate chest characteristics. Harvesting
rib through a small incision is more difficult and time consuming
but is a cosmetically superior approach. Surgeons with less expe-
rience harvesting costal cartilage should use a larger incision to
avoid damaging the pleura.
63.5 Operative Technique
The procedure is typically performed with the patient under
general anesthesia in the supine position; the patient’s head is
placed on a small soft support. e prefer to use general anes-
thesia with endotracheal intubation to protect the airway from
blood that may drip down to the larynx during the septoplasty
portion of the operation. e typically prepare the ear in case
additional cartilage is needed. ith secondary rhinoplasty or
augmentation rhinoplasty, we also prepare the chest to allow
costal cartilage harvesting if needed.
Typically the operation is longer than a standard septorhino-
plasty, so care must be taken to mobilize the extremities at least
once every hour, place sequential compression devices on the
extremities, and make sure there is no compression of the lower
lip underneath the endotracheal tube to prevent pressure necrosis.
63.5.1 Harvest of Costal Cartilage
Graft warping is a potential complication when using costal
cartilage, but the risk can be mitigated with meticulous tech-
nique. Early graft harvest and sequential carving allow time for
971
 X Rhinoplasty
bending and warping tendencies to present and be managed
intraoperatively.
Costal cartilage can often be harvested before opening the nose
in Asian patients because of the insufficient septal cartilage and
the obvious need for grafting material to augment the nose. Before
the skin incision is made, the costal cartilage is palpated with a
27-gauge needle to assess for calcification. If the palpated rib
contains excessive calcification, then surgical planning is directed
toward the next most appropriate rib. This is especially helpful
when making small incisions ( 2–3 cm), as selection of the
proper rib is critical prior to making the incision. Some surgeons
use preoperative imaging to assess for calcifications, but in our
experience this has largely become unnecessary thanks to the
accuracy of needle palpation. The skin is then incised with a o.
15 blade, and the subcutaneous fat is sharply dissected. Ragnell or
Senn retractors are used to expose the muscular fascia. Frequent
palpation with a 27-gauge needle ensures a proper trajectory of
dissection and identifies the bony–cartilaginous junction. The
rectus sheath and pectoral fascia fuse to form the fascial sheath
above the sixth rib. A cruciate incision is made through the fascia,
and any muscle is bluntly dissected to expose the rib. Blunt dis-
section minimizes bleeding and postoperative pain.
The thick, fibrous rib perichondrium is excellent material for
camouflaging grafts, especially when performing tip grafting and
dorsal augmentation. The outer layer of rib perichondrium may
be excised initially or removed once the rib is harvested. Larger
sheets can often be harvested by excising the perichondrium first.
The perichondrium is incised with a o. 15C scalpel; the smaller
profile of the o. 15C blade permits greater visualization through
a small incision. The perichondrium is then elevated from lateral
to medial with a Freer elevator, and the pedicle is divided with
scissors after sufficient material has been raised.
Shallow transverse incisions are made with a o. 15C scalpel
near the bony–cartilaginous junction and as far medial as the
patient’s needs dictate. Leaving a thin rim of cartilage at the
bony junction allows sharp edges to be rounded after the rib is
removed. The incisions should be superficial to avoid violating
the inner perichondrium and pleura. Costal dissection is easily
performed with the sharp end of the Freer elevator. ounger
patients have soft, white costal cartilage, whereas older patients
have yellow-brown cartilage with varying amounts of calcifica-
tion. Often there are islands of calcification at the rib periphery,
and dissection must proceed around them. Rarely is the entire
segment calcified and unusable.
hen freeing the perichondrium from the superior and inferior
edges of the rib, it is best to err slightly into the rib itself. Leaving
a thin cuff of cartilage helps prevent inadvertent transection of
the often-attenuated deep perichondrium. There is frequently
an interchondral joint between the sixth and seventh ribs near
the rib genu. The attachment may be fibrous, a synovial joint,
or a solid cartilaginous connection that requires division with
a Freer elevator. After the rib has been dissected circumferen-
tially, the Freer elevator is used to elevate the rib bluntly off the
deep perichondrium. The undersurface of the rib and the deep
perichondrial sleeve can be viewed directly to ensure that the
pleura is not violated. Significant resistance in trying to elevate
the rib bluntly often indicates incomplete dissection at one of the
corners, especially medially, where the rib is thicker. Care must
be taken when elevating an older, more brittle rib to ensure that
972
it does not fracture. After the rib is freed, a double-pronged skin
hook facilitates removal from the pocket. The medial and lateral
rib edges are trimmed and smoothed with Takahashi forceps. The
inner perichondrial sleeve is inspected and irrigated with saline
solution; a Valsalva maneuver performed by the anesthesiologist
confirms pleural integrity. The rib is placed in an antibiotic-
infused saline solution.
Carving often begins after opening of the nose. Carving is best
performed on a flat carving block with a o. 10 blade. Toothed
forceps provide a secure grasp of the rib; nontoothed forceps may
eject grafts off the carving block. Carving the rib into three seg-
ments maximizes the number of useable grafts. The thickness of
each segment varies according to the patient’s needs. The central
portion of rib often warps least. Outer segments have a fibrous
component that causes greater warping in younger patients but
helps maintain graft integrity in older, more brittle ribs. The
segments are thinned initially and placed back into the antibiot-
ic-infused saline solution.
Final cuts are made just before the grafts are placed. Carving
the grafts in this manner allows warping tendencies to manifest
intraoperatively and to be used for curved grafts. For example,
dorsal grafts placed concave side down will lie flat after skin–soft
tissue envelope compression, whereas lateral crural strut grafts
can be placed convex side up to support the airway better. Older
calcified rib is more difficult to harvest, carve, and suture but
maintains the distinct advantage of warping very little. ounger
cartilage is easy to carve and suture but can warp dramatically
and is less predictable.
Incision Closure
Careful closure of the chest incision minimizes scarring and
visibility of the scar. Unused pieces of costal cartilage can be
placed back within the perichondrial sleeve for potential use if a
minor revision is needed at a later time. Alternatively, we prefer
to bank the leftover, usable cartilage in an incision behind the
postauricular hairline. This is generally well tolerated, requiring
a less than 1-cm incision, and offers the additional benefit of ease
of harvest at a later date. The muscular fascia over the costal car-
tilage harvest is closed with 3–0 polydioxanone sutures (PDS),
and breast tissue or subcutaneous fat is closed with 4–0 PDS. The
breast is pushed medially and inferiorly in women to assess for
puckering, which represents improper dermal tethering to the
deep closure. The epidermal edges in small incisions are often
damaged by retraction. A o. 15 blade can be used to trim the
wound edge up to, but not around, the incision apex; trimming
circumferentially elongates the incision. The skin is then closed
deeply with 5–0 poliglecaprone (Monocryl, ohnson ohnson,
ew Brunswick, ) and a subcuticular 6–0 Monocryl. Any area
where the skin is not adequately reapproximated and everted
can be closed with a 5–0 fast-absorbing gut suture. Skin adhesive
is then placed over the closure. Local anesthetic is injected after
closure is completed. This can be done with 0.25 bupivacaine
mixed with liposomal bupivacaine for most effective pain relief.
63.5.2 Harvest of Auricular Cartilage
Auricular cartilage is easily harvested through a postauricular
incision placed on the pinna above the postauricular crease. This

incision placement ensures that scars will not be visible and pre-
vents blunting of the postauricular sulcus. The incision is carried
down onto the posterior perichondrium, which may be harvested
or left in situ (Fig. 63.1). The entire conchal bowl can be harvested
without changing the external auricular appearance; violation of
the antihelix, however, will cause a cosmetic deformity.
Transauricular needles can help demarcate the area to be har-
vested. The cartilage is incised with a o. 15 blade and bluntly
dissected from the anterior perichondrium with a Freer elevator.
Hemostasis of the anterior skin–perichondrial flap is obtained
with bipolar cautery; judicious use prevents damage to the
flap. The skin incision is closed deeply with 6–0 Monocryl and
superficially with 5–0 fast-absorbing gut suture. A Penrose drain
is trimmed and left exiting the inferior extent of the incision if
needed. A cotton bolster coated in antibiotic ointment is sutured
through and through the conchal bowl with 3–0 nylon; the poste-
rior bolster can be lassoed within the suture loop.
63.5.3 Elevation of the Skin Flap for an
External Rhinoplasty Approach
Details regarding the incision and dissection are discussed in
Chapter 61. Asian patients frequently require increased projec-
tion, and it may be prudent to place the transcolumellar incision
slightly lower to accommodate eventual superior movement of
the scar.
63.5.4 Dorsal Augmentation
Most Asian rhinoplasties require dorsal augmentation, although
some patients may present with dorsal humps that require
reduction, especially Asian patients from the southern and
western parts of the continent. The cartilaginous convexity is
first reduced with a o. 15 blade. If a bony component of the
hump exists, the cephalic extent of the reduction is perforated
with a 2-mm straight osteotome placed perpendicular to the
nasal bones (Fig. 63.2). This maneuver creates a weak point for
the 12-mm Rubin osteotome to exit through and counteracts the
Fig. 63.1 Conchal cartilage harvest via a postauricular approach.
63 Asian Rhinoplasty
tendency for overreduction. Reduction of the dorsal hump often
creates an open roof deformity that requires lateral osteotomies
to close. High–low–high lateral osteotomies are performed with
a 3-mm straight osteotome. Intermediate osteotomies are rarely
needed, except for an extremely wide dorsum.
Thoughtful graft selection for dorsal augmentation can help
minimize postoperative complications. Septal cartilage is often
preferred over auricular or costal cartilage for dorsal augmentation,
because it does not curl or warp. The cartilage may be overlapped,
and a double-layered septal cartilage augmentation graft may be
used. This, combined with soft tissue such as temporalis fascia,
can be an excellent choice for dorsal augmentation. Unfortunately,
the septum is often insufficiently thick or is depleted, making
it necessary to harvest auricular or costal cartilage. Auricular
cartilage can curl at the edges and create a deformity when used
for dorsal augmentation. The costal cartilage of older patients is
typically brown and more calcified and brittle; although carving
and suturing are more difficult, older costal cartilage warps less.
Conversely, younger costal cartilage is white, softer, and easier to
carve, but warps more (Fig. 63.3, Fig. 63.4).
Dorsal grafts are carved into a canoe shape: flat or slightly
concave on the undersurface, gently rounded on the edges, and
tapered at both the caudal and cephalic ends (Fig. 63.5). The
specific dimensions depend on the needs of the patient.
Ideally the dorsal graft is slightly curved so the graft can be
set into position with the concave surface facing downward. This
orientation protects against any chance that the graft will curve
upward, leaving the patient with a prominence in the supratip
and radix.
Graft edges often need camouflaging to prevent visible postop-
erative step-offs, especially in thin-skinned patients. Dorsal pal-
pation is critical, since intraoperative edema will obscure minor
irregularities. Perichondrium can be sutured along the graft edge
with 6–0 Monocryl. Alternatively, the entire graft can be covered
in perichondrium.
Graft size and placement are individualized for each patient.
Greater dorsal augmentation creates a narrowing effect on the
frontal view that must be balanced with anticipated changes to
Fig. 63.2 Lateral view of a 2-mm osteotome showing the trajectory
used for delineating superior aspect of hump reduction. Osteotome
is then inserted underneath skin–soft tissue envelope to create
osteotomy.
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 X Rhinoplasty
Fig. 63.3 Costal cartilage harvested from 17-year-old Asian female
patient. Note the white color and absence of calcifications.
Fig. 63.5 Carved dorsal augmentation graft prior to implantation.
the tip. Asian patients frequently have wide tips that resist sig-
nificant narrowing and necessitate restrained dorsal narrowing to
preserve tip–dorsum harmony.
The radix of Caucasian/European individuals commonly lies
between the superior lash line and the upper lid crease, whereas
the radix of Asian patients typically lies at the midpupillary level.
Dorsal graft placement thus depends on the degree of ethnic char-
acteristics the patient wishes to maintain, which is ascertained in
the preoperative visit and confirmed with preoperative computer
imaging.
In primary augmentation rhinoplasties, dissection of a narrow
dorsal pocket facilitates tight graft placement. For grafts extend-
ing over the bony dorsum, graft adherence can be improved by
roughly rasping the dorsum and suturing perichondrium to
the graft’s undersurface. This will create a bone–perichondrial
interface that promotes graft adhesion in the early postoperative
period. The graft can be secured caudally to the middle vault with
5–0 PDS.
In complex revisions, the L-strut may need to be reconstructed.
After the dorsal component of the L-strut is built with extended
spreader grafts and a septal extension graft, a separate dorsal graft
can be placed on top of the stable middle vault. Placing the dorsal
graft on top of extended spreader grafts permits minor movement
independent of the L-strut.
Removal of large alloplastic implants in patients undergoing
revision procedures requires wider dissection and often results
974
Fig. 63.4 Costal cartilage harvested from 55-year-old Asian male patient.
Note the yellow-brown discoloration and presence of calcifications.
Fig. 63.6 Kirschner wire (0.35 mm) for fixation of dorsal augmentation
graft. This is removed on postoperative day 7.
in a large pocket. Grafts can be sutured to adjacent soft tissue
or transcutaneously using 6–0 Monocryl. In the rare patient in
whom graft stability cannot be obtained with suture fixation, a
transcutaneous threaded irschner wire can be drilled through
the dorsal graft and into the underlying nasal bone (Fig. 63.6). On
postoperative day 7, the wire can be removed in the office with
little patient discomfort.
63.5.5 Tip Contouring
The tip in Asian patients is often bulbous, underprojected, and
lacking in definition. Frequently used techniques include cephalic
trim of the lateral crura, dome binding and interdomal sutures,
and shield tip grafting with lateral crural grafts. Repositioning of
the lateral crura is seldom performed, because it can accentuate
the hanging ala and alar flare commonly found in Asian patients.
Slightly increased projection may be obtained with onlay tip
grafts in selected Asian patients with thin skin. These rectangular
or elliptical grafts are sutured horizontally over the domes with
6–0 Monocryl to simulate the natural horizontal tip highlight. Soft
cartilage, such as auricular or trimmed lower lateral cartilage, is
ideal for this purpose, and approximately 1 to 2 mm of increased
projection can be achieved.
Thick-skinned patients frequently require shield tip grafts with
lateral crural grafts to increase projection, stretch the skin, and

refine the tip. The shape of the shield graft simulates the divergent
medial crura and domes. Shield grafts are sutured to the medial
crura with 6–0 Monocryl. Large grafts, creating substantial
increases in projection (greater than 2 mm), are often supported
with buttress grafts and/or lateral crural grafts. Both grafts
maintain postoperative tip projection by preventing cephalic
rotation of the shield graft once the skin–soft tissue envelope
is sutured closed. Lateral crural grafts are sutured on top of the
native lateral crura, whereas lateral crural strut grafts are sutured
to the undersurface of the lateral crura. In addition to supporting
the shield graft, lateral crural grafts smooth the transition from
the tip to the alae and preserve the natural tip–alar highlight (Fig.
63.7, Fig. 63.8). Shield tip grafts can be carved from any type of
cartilage, although stronger septal and costal cartilage is preferred
to weaker, more flexible auricular cartilage.
Tip refinement can often be obtained with dome binding and
interdomal sutures. hen a shield tip graft is used, the tip width
is set by the leading edge of the graft. Soft tissue or perichondrium
can be placed over and around the tip graft to provide additional
camouflage.
eak alae can be supported with alar rim grafts. Rim grafts are
thin, sliver-shaped grafts inserted into pockets dissected caudal to
the marginal incision. They are secured with a single 6–0 Monocryl
suture, and the medial edge of the graft is crushed with Adson-
Brown forceps to prevent visibility within the tip. Articular alar
rim grafts are sutured to the lateral edges of the shield tip graft and
then advanced into the marginal incision pockets. Alar rim grafts
help form a triangular base by straightening concave alae and
camouflage shield tip grafts. Correcting alar concavities eliminates
shadows that isolate the tip and interrupt the tip–alar highlight.
The transcolumellar incision is closed deeply with a single 6–0
Monocryl to align and reduce tension on the skin edges. The skin is
Fig. 63.7 Anterior view of shield tip graft with lateral crural grafts.
63 Asian Rhinoplasty
then closed with interrupted vertical mattress 7–0 nylon sutures
oriented perpendicular to the incision. The marginal incisions are
closed with 5–0 chromic gut, and the septal mucoperichondrial
flaps are reapproximated with a 5–0 plain gut quilting suture.
63.5.6 Reduction of the Alar Base
Alar base reduction, if necessary, is the final step during rhino-
plasty. Different intraoperative maneuvers have variable effects
on the final alar position. For example, increasing tip projection
decreases flare, whereas lateral crural repositioning increases
flare. Regardless, Asian patients may benefit from some form
of base reduction. The degree of flare, nostril size, and native
alar/sill anatomy determine incision placement. Base reduction
incisions made across the nostril sill are at a high risk for visible
scarring. These patients are better candidates for external alar
reductions unless the nostrils are very large. Patients should be
counseled preoperatively that their thick, sebaceous skin makes
them more likely to scar unfavorably.
The amount to be resected is first outlined with a marking pen.
Conservative excisions are preferable, because additional ala can
be excised postoperatively at a later time. The ala is excised with
a o. 11 blade. The incision is closed deeply with a single 6–0
Monocryl suture, and the skin is closed with interrupted vertical
mattress 7–0 nylon sutures and simple 6–0 fast-absorbing gut
sutures. Meticulous technique is necessary to prevent visible
scarring.
63.6 Problems and Complications
Close postoperative follow-up is important after augmentation
rhinoplasty to monitor the dorsal graft. Mild graft warping
Fig. 63.8 Basal view of shield tip graft.
975
 X Rhinoplasty

or shifting can be treated with nasal compression exercises
for 1 minute 10 times daily until the graft position stabilizes.
Severe warping or migration necessitates operative revision.
Severe warping usually manifests within the first 3 months
postoperatively.
Dorsal irregularities are often camouflaged by thick skin in
Asian patients. Small visible bumps can be treated with a needle
shave in the office. The area to be treated is first marked and then
injected with a local anesthetic. A 16-gauge needle is inserted,
and the bump is rasped with the needle’s bevel. Depressions,
unfortunately, cannot be treated in this manner. Revision surgery
is often needed to fill the depression with cartilage or soft tissue
grafts.
ide, underprojected tips are susceptible to postoperative
loss of projection if not properly stabilized. Correction requires
operative revision to stabilize the nasal base. Grafting material is
needed to place a caudal septal extension or replacement graft to
which the lower lateral cartilages can be secured.
The thick skin of many Asian patients can cause prolonged
postoperative edema. This can be especially problematic in the
supratip area, where edema can lead to scar formation and create
a polly-beak deformity. Edema that has persisted 4 weeks after
surgery can be treated with nightly nasal taping. Recalcitrant
edema can be treated with injections of 0.2 to 0.3 mL triamcino-
lone acetonide 10 mg/mL.
Pneumothorax can occur during rib graft harvest. Meticulous
technique, especially blunt dissection within the perichondrial
sleeve, is the best defense against this morbid complication. If a
pleural tear is discovered intraoperatively, a red rubber catheter
can be inserted into the defect. The wound should then be closed
with the catheter in place. After closure, a Valsalva maneuver can
be performed as the catheter is withdrawn to remove as much
air as possible. A postoperative chest radiograph can confirm the
presence of any residual pneumothorax and help to determine
whether chest tube placement is necessary.
Scarring of the columella, alar base, and chest is more common
in thick-skinned Asian patients. Asian patients in particular scar
poorly on the chest. Three weeks after surgery, patients are given
Silastic (Dow Corning, Midland, MI) sheeting to place on their
incisions each night. The compression from the Silastic is thought
to enhance the scar’s appearance. Triamcinolone acetonide injec-
tions can also be used to treat hypertrophic scarring.
used to avoid harvesting costal cartilage, but this patient did not
want artificial material used in her nose. The dorsal graft was
used to raise her dorsum and produce a narrowing effect on
frontal view. A caudal septal extension graft stabilized the nasal
base. A shield tip graft was used to project and narrow the tip.
Surgical Steps
The patient’s rhinoplasty worksheet illustrates the steps per-
formed during the surgery (Fig. 63.10).
1. Right inframammary fold incision and sixth-rib harvest
2. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
3. Open septoplasty and septal cartilage harvest
4. Costal cartilage spreader grafts
5. Caudal septal extension graft placed end to end and secured
with extended spreader grafts and bilateral splinting grafts (Fig.
63.11)
6. Costal cartilage tip graft and lateral crural grafts covered in
perichondrium
7. Bilateral alar rim grafts
8. Costal cartilage dorsal graft covered with perichondrium and
crushed cartilage (Fig. 63.12)
9. Supratip graft
10. Bilateral alar batten grafts
11. Bilateral alar base reductions
Results
One year postoperatively (Fig. 63.13), the patient has a narrower
dorsum and a narrower and more refined tip. The lateral view
reveals increased dorsal height and tip projection. Her nasal
starting point is close to her midpupillary line. The basal view
shows increased projection and a more refined tip.

63.7 Results
63.7.1 Case 1
The 28-year-old woman shown in Fig. 63.9 requested rhino-
plasty. On anterior view, she had an amorphous tip. On lateral
view, she had a low dorsum and an underprojected tip. Intranasal
examination revealed a right septal spur.

Surgical Plan
The plan for this patient was to perform an augmentation
rhinoplasty. She had a low, wide dorsum that is typical in the
Asian patient. Costal cartilage was harvested to obtain material
for dorsal augmentation. An alloplastic implant could have been Fig. 63.9 Preoperative photoarray for case 1.

976
 63 Asian Rhinoplasty

Fig. 63.10 Rhinoplasty worksheet for case 1.

Fig. 63.11 Intraoperative view of extended spreader grafts with caudal septal extension graft.

977
 X Rhinoplasty

Fig. 63.12 Intraoperative view of dorsal augmentation graft.

a b

c d e f

g h i j
Fig. 63.13 (a,c,e,g,i) Pre- and (b,d,f,h,j) postoperative photoarray for case 1.

978

Fig. 63.14 Preoperative photoarray for case 2.
Fig. 63.15 Rhinoplasty worksheet for case 2.
63 Asian Rhinoplasty
63.7.2 Case 2
The 28-year-old woman (Fig. 63.14) requested correction of her
nasal deformity. She had no nasal obstruction. On anterior view,
she had a wide dorsum, tip, and nasal base. On lateral view, she
had a low radix, a very low dorsum, and an underprojected tip.
The basal view revealed a wide, underprojected tip.
Surgical Plan
The plan for this patient was to perform an augmentation rhino-
plasty. She did not want an alloplastic implant, so costal cartilage
was harvested. Two ribs were needed in this patient: a very large
dorsal graft to augment her flat dorsum and the other rib graft
for the septal extension graft and tip grafts. An extended colu-
mellar strut was used to stabilize the nasal base. A notch carved
in the strut’s base was integrated with the nasal spine to prevent
movement. The strut was further stabilized with thin splinting
grafts overlapping the caudal septum. To keep the dorsal graft
midline, it was notched and integrated with the columellar strut.
This maneuver is frequently unnecessary, because the dorsal
979
 X Rhinoplasty

graft can be sutured to the upper lateral cartilages. A shield tip
graft and lateral crural grafts were used to provide tip projection
and contour.
Surgical Steps
This patient’s rhinoplasty worksheet illustrates the surgical
steps performed (Fig. 63.15).
1. Right inframammary incision and harvesting of the sixth and
seventh ribs
2. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
3. Septoplasty and septal cartilage harvest
4. Caudal septal extension graft sutured to nasal spine (Fig. 63.16)
5. Hole drilled in nasal spine with a 16-gauge needle
6. Caudal septal extension graft secured to caudal septum with
bilateral splinting grafts
7. Bilateral alar batten grafts
8. Shield tip graft and lateral crural grafts (Fig. 63.17)
9. Costal cartilage dorsal graft covered in perichondrium (Fig.
63.18)
10. otch carved in caudal aspect of dorsal graft and integrated with
caudal septal extension graft (Fig. 63.19)
11. Crushed cartilage and perichondrium placed over tip graft
12. Supratip graft placed
Results
Six months postoperatively, the patient has a narrower dorsum
and tip. On lateral view, she has increased dorsal height and tip
projection. The basal view reveals her increased tip projection
(Fig. 63.20).
63.8 Concluding Thoughts
Asian patients requesting rhinoplasty frequently require
increasing nasal tip projection or augmenting the nasal dorsum.
They tend to have weak lower lateral cartilages and lack nasal

Fig. 63.16 Intraoperative view of extended caudal septal extension graft and fixation to the nasal spine.

Fig. 63.17 Intraoperative view of shield tip graft with lateral crural extensions.

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 63 Asian Rhinoplasty

Fig. 63.18 Dorsal augmentation graft with perichondrium to allow for fixation superiorly.

a b
Fig. 63.19 (a) Dorsal augmentation graft fixated to septal extension graft; (b) shield tip graft with lateral crural grafts.

tip support. Reductive methods may further decrease nasal
tip support and leave the patient with inadequate refinement.
Structural grafting can improve tip support and tip definition.
Increasing the dorsal height can improve nasal dorsal definition
and create a narrowing effect. Structural grafting may require
harvesting ear cartilage or costal cartilage. Most Asian patients
have inadequate septal cartilage for grafting purposes. Costal
cartilage will provide more than enough material for grafting
but does require more advanced techniques. Management of the
Asian patient requires clear communication to ensure that the
patient and physician agree on the intended aesthetic changes.

981
 X Rhinoplasty

a b

c d e f

g h i j
Fig. 63.20 (a,c,e,g,h) Pre- and (b,d,f,h,j) postoperative photoarray for case 2.

Clinical Caveats
Suggested Reading
[1] DeRosa , Toriumi DM. The Asian nose. In Gunter P, Rohrich R , Adams P, eds.
• Requests for cosmetic procedures are increasing in Asian Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St. Louis, MO: uality
patients; rhinoplasty is the most commonly requested. Medical Publishing; 2007
• Clear operative goals are necessary for patient satisfaction. 2 Lopez MA, Shah AR, estine G, O’Grady , Toriumi DM. Analysis of the
• Careful planning of the chest incision for costal cartilage physical properties of costal cartilage in a porcine model. Arch Facial Plast Surg
harvest minimizes morbidity. 2007;9(1):35–39
3 Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37(2):335–352
• Early and sequential costal cartilage carving allows warping 4 Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am
tendencies to manifest intraoperatively. 2007;15(3):293–307, v
• Knowledge of cartilage curvatures is essential for proper
graft selection and usage.
• Stable dorsal graft placement prevents postoperative graft
migration.
• Base reduction is frequently necessary in Asian patients.
• Close postoperative follow-up is necessary for optimal results.

982

64 Ethnic Rhinoplasty
Ashkan Ghavami and Sean Y. Saadat
Abstract
This chapter discusses the important considerations a surgeon
must take into account when performing rhinoplasty on an
ethnic or non-Caucasian patient. Beauty standards have long
been based off of Caucasian ideals, but with increasing levels of
globalization unlike any other time in human history, surgeons
are being faced with a more diverse patient population with a
wide range of aesthetic goals that vary based on their own ethnic
origin as well as specific preferences. This chapter discusses
important preoperative considerations that must be made when
assessing a non-Caucasian patient. The rhinoplasty surgeon
must utilize numerous surgical techniques to execute natural,
yet effective reshaping in Middle Eastern, African, and Hispanic
patients. The goal of this chapter is to delineate the variations
in morphologic preoperative presentation and the plethora of
dynamic surgical techniques available to perform a racially
congruent and aesthetically pleasing rhinoplasty.
Keywords
ethnic rhinoplasty, rhinoplasty, surgical technique, aesthetic
surgery, African nose, Middle Eastern nose, Hispanic rhinoplasty,
facial cosmetic surgery
64.1 Introduction
For hundreds of years now, beauty standards around the globe
have been described in ways that are centered around Caucasian
European aesthetic principles. Of late, the concepts surround-
ing beauty have quickly evolved in complexity as the world
increasingly respects and appreciates the differences in physical
features of differing ethnicities and cultural backgrounds. These
trends have begun to grow exponentially with the powerful,
ever-present force of social media. Much of social media is
centered on beauty: makeup, plastic surgery (surgical and non-
surgical), and fitness. Despite the falsity of images manipulated
by Facetune (Lightricks, erusalem, Israel) or Photoshop (Adobe
Systems, San ose, CA), prospective patients make use of these
images as a tool in communicating desired results. This places
extra challenges on plastic surgeons to communicate effectively
with their patients and, if selected, execute the surgery with
optimal technique and accuracy.
hen it comes to the nose, specifically, these trends have
become extremely relevant, not just in the world of aesthetic sur-
gery but even in areas such as makeup, hair care, and the overall
beauty industry, as ethnic groups have begun to create a stronger
global presence and obtain more of a seat at the table of human
influence. For example, nasal makeup contouring is one of the
quintessential trends on social media, with makeup shades mar-
keted to all skin color shades and hues. There is, thus, a blending
64 Ethnic Rhinoplasty
of ethnic beauty standards in the global landscape that is being
led by a strong social media influence.
The term ethnic rhinoplasty describes a surgical approach
that is taken to construct a nose that is aligned with the standards
of beauty specific to that patient’s own ethnicity. ot to say that
only descendants of white Europeans have been getting cosmetic
rhinoplasties since the practice became popular, but until recently,
many surgeons have approached rhinoplasty using beauty ideals
that did not take into account the patient’s ethnicity and the
differences in facial morphology that come with it.
This is why we often see patients of nonwhite ethnicities pre-
senting with very unnatural or ethnically incongruent -appear-
ing noses and other features. A perfect example of this would be
the late Michael ackson. The physical transformation undergone
by the ing of Pop from his childhood years to the time imme-
diately prior to his passing is one of the most dramatic examples
of racial incongruence of our time. In addition to the anatomic
incongruity, there is a subset of patients who specifically want to
move away from their ethnic origins. This places further demands
on plastic surgeons with respect to patient selection and psycho-
logical ramifications.
It is important to remember that the nose, although just one
part of the human face, is in many ways the most important piece
of the puzzle that together creates true facial beauty. The nose is
in the center of the face and establishes harmony between the
upper face and lower face. If nasal shape and proportion are not
aesthetically appropriate, it can create a complete disharmony of
the patient’s facial features. This can lead to an overly operated
look that does not coincide with any cultural standard of beauty.
Although ethnic rhinoplasty is a recently coined term, it has
been practiced by many surgeons throughout history. hether
Sushruta in 500 BC, who operated on noses with Indian aesthetic
ideals in mind, or John Roe in 1999, who pioneered operations on
what he called the Irish pug nose, it has always been important
to keep the patient’s ethnicity in mind when planning to alter
their features for the purpose of improving their overall aesthetic.
For the purpose of this chapter, we have divided ethnic rhino-
plasty techniques into three separate subgroups based on ethnic
origin: Middle Eastern, African American, and Hispanic. Asian
rhinoplasty is covered in Chapter 63.
64.2 Middle Eastern
64.2.1 Introduction
The term Middle Eastern is often unclear when relating to
ethnic origins, because the nations that constitute this specific
ethnicity are not always clear. The term, however. most often
refers to people of Arabic, Turkish, orth African, or Persian
descent. Further clarifications and delineations have been made,
such as that of Bizrah, who divided the Middle Eastern popu-
lation into the Middle East, orth African, Gulf, and non-Gulf
983
 X Rhinoplasty
regions. The Gulf regions consist mainly of the nations that
surround the Persian Gulf, such as Saudi Arabia, the United Arab
Emirates, uwait, Iran, and Oman. The non-Gulf countries are
not as clean-cut in their definition, but for the purpose of this
chapter we will consider the following nations in our discussion:
Syria, Turkey, Lebanon, Egypt, and Morocco. Lastly, anthropolo-
gists would consider countries such as Iran and adjacent states as
Near Eastern. Further detail is beyond the scope of this chapter.
The distinctions between subgroups are important not only for
geographic reasons but also because the nasal form and expecta-
tions differ accordingly. Most of those regions with large dorsal
humps seek out dorsal hump reduction and stable cephalad
rotation of their nasal tip, whereas those in the Arab nations and
in orth Africa may require more cartilage frame augmentation
with thick skin debulking and alar base reduction. This is very
important to consider when operating on individuals of Middle
Eastern origin, as aesthetic outcomes are certain to be judged
not just by the patients, but also by their community and family.
Interestingly, there are further subsets in countries such as Iran,
Lebanon, and other nations with younger populations who may
request a more dramatic or esternized appearance. Those same
groups, when residing in the United States, seek out a more natu-
ral look with lesser magnitudes of dorsal reduction, curved dorsal
profile, tip rotation, and narrowing.
All Middle Eastern groups have a large percentage of their fellow
countrymen and women migrating or already migrated for two
generations to Europe, the United States, and Canada. All surgeons
interested in becoming rhinoplasty experts should become com-
fortable delivering desired results in function and aesthetics to
these groups of patients, who seek out rhinoplasty often as young
as 14 and 15 years old. In Iran, the most notorious of the Middle
Eastern countries when it comes to rhinoplasty, it is estimated that
each year there are about 200,000 rhinoplasties performed in a
population of 77 million individuals. The United States is estimated
to see about 221,000 rhinoplasties in a population of 330 million.
This means that per capita, Iranians undergo four times as many
rhinoplasties as Americans do on a yearly basis.
In many Middle Eastern nations, rhinoplasties are often seen as
a coming of age gift, especially for young women. This is because
the classic Middle Eastern nose is often notable for its large dorsal
hump, high radix, and bulbous ptotic tip. The young patients will
present to a plastic surgeon’s office with their parents (often the
mother) with clear expectation of a specific rhinoplasty result in
mind. This activity has been even more propagated by social media
and the current global youth (Millennials and younger) culture of
selfies, self-focus, low attention span, and general impatience.
64.2.2 Preoperative Evaluation and
Anatomic Assessment
As with any aesthetic procedure, a proper preoperative assess-
ment is key to both understanding the patient’s native anatomy
as well as surveying the desired and expected outcome. At the
first consult, it is important that the surgeon elicit the reasons
for the patient wanting a rhinoplasty. In the Middle Eastern
population, it is not uncommon that a younger teenage patient
presents with a parent or parents who have convinced them that
this is something that is required as a traditional rite of passage
984
to adulthood. This paradigm is shifting, however, and the senior
author has witnessed more autonomy in younger patients, with
many presenting after they have completed college or are at the
beginning of their chosen career paths.
The Middle Eastern nose is anatomically very distinct from
that of any other ethnic group. Bearing individual similarities to
the African, Hispanic, and Caucasian noses, the Middle Eastern
nose frequently demonstrates a combination of a high dorsum, a
dependent or ill-defined nasal tip, a deviated nasal septum, and
thick skin–soft tissue envelope. There is, however, a spectrum,
not unlike that seen in the Hispanic nose, in which features
can include a thin skin envelope with a more dominant bone–
cartilage frame, and those more mixed in origin from Arab or orth
African genetics demonstrating a thicker skin envelope, wide alar
base, and weak frame. By and large, Middle Eastern patients have
Fitzpatrick type III–IV skin and tend to have moderate to thick,
sebaceous skin, specifically at the nasal tip and nostrils. As in
any ethnicity, however, the more important consideration is not
the thickness of the skin but rather the elasticity. Both thick and
thin skin can be nonelastic, not responding ideally to reductive or
augmentative maneuvers.
64.2.3 Characteristics of the
Middle Eastern Nose
The following characteristics of the Middle Eastern nose are
illustrated in Fig. 64.1.
• Skin either thick or thin, and noncontractile
Thick, sebaceous tip and alar skin (fibrofatty soft tissue
envelope), especially at the tip and supratip
Thin skin (usually dorsally) that can reveal significant
osseous changes, especially at the rhinion; thin skin in tip/
soft triangle facets can serve as pitfalls during nasal tip
maneuvers.
• Significant dorsal hump: bony and cartilaginous
• Overprojecting radix; shallow high radix
• ide bony and middle nasal vaults: wide dorsal aesthetic
lines (increasing or unmasked by dorsal reduction)
• asal deviation: septal deviation common and commonly
visible externally
• Poorly defined, bulbous and/or boxy nasal tip
• Tip projection:
Underprojected nasal tip, caudally displaced (insufficient
medial crura)
ote: tip overprojection with long lower lateral and long
medial crura
• Droopy nasal tip with very acute nasolabial (and columellar–
labial) angle
• Cephalically and vertically malpositioned lower lateral crura
• Hyperdynamic nasal tip (hyperactive depressor septi nasi
muscle)
• Dominant lower lateral crura and insufficient middle and
medial crura
• ostril–tip imbalance
• ostril asymmetries with flaring and/or excess sill

Fig. 64.1 Classic Middle Eastern nasal features and preoperative nasal measurements. The classic Middle Eastern nose is depicted in this image with
the traditional characteristics that lead a high percentage of Middle Eastern people to seek out rhinoplasties.
Fig. 64.2 Measurements of Middle Eastern nasal features compared
with conventional ideals. (a) The traditional nasofrontal angle is
known to be about 150°. The Middle Eastern population is known
for a radix that is overprojected, leading to a blunted nasofrontal
angle. (b) The nasolabial angle cannot be too narrow or overrotated,
and 90–100° is most appropriately requested in this ethnic group.
Recurrent tip ptosis is a frequent concern of Middle Eastern patients.
64 Ethnic Rhinoplasty
64.2.4 Technical Steps
After elevation of the soft tissue envelope, the first component
to address is reduction of the dorsal hump. In the Middle Eastern
population, the nasal dorsum is often wide and overprojected.
It is made up of the paired nasal bones, ascending maxillary
processes, septal excess, and upper lateral cartilages (ULCs). It
is a common pitfall for surgeons to overresect the dorsal hump,
leading to a ski jump appearance to the nose, an increase in
perceived dorsal length, and an ethnically incongruent result.
The senior author has noted instances of this in which an
improperly shaped dorsal septal graft, polytetrafluoroethylene
(PTFE; Gore-Tex, Implantech, Ventura, CA), or even a diced carti-
lage fascia graft (DCFG) was placed by necessity when avoidance
would have been the prudent route.
An incremental component dorsal technique is preferred in
dorsal height reduction for Middle Eastern patients. It is also not
uncommon for Middle Eastern patients to have an overprojected
radix, which is why burring or rasping of the radix is often required
to establish a proper dorsal height set point, a proper nasofrontal
angle, and finally an appropriate nasolabial angle (Fig. 64.2).
A component dorsal hump reduction is often necessary in order
to correct a significant open roof deformity. Osteotomies, along
with spreader grafts or flaps, are also common maneuvers required
in most Middle Eastern noses. Dorsal width is addressed by per-
forming osteotomies, using a low-to-low percutaneous technique
in a orientation, because the bony width commonly begins at
the ascending maxillary process (Fig. 64.3). The reason the senior
author prefers a low osteotomy technique is because it helps to
avoid creating any visible bony stepoffs or creating unbalanced
dorsal aesthetic lines. It is very common to perform unilateral or
bilateral double-level osteotomies, which we believe is best accom-
plished with a percutaneous technique, introducing the osteotome
through a single stab incision and sweeping it along the outline of
the intended curve, making intermittent breaks around the area to
985
 X Rhinoplasty
Fig. 64.3 Osteotomies are performed in low–low “J-shaped” fashion
to address the dorsal width beginning at the maxillary process and
allow for a natural curvilinear line that mimics native bony anatomy.
A double level is often needed to further improve the stepoff.
Fig. 64.5 Intraoperative photo of auto spreader flaps. This technique
allows for smooth dorsal aesthetic contour lines and functional airway
tension and will leave more septal cartilage available to use as other
grafts. The bending medially of the upper lateral cartilages (ULCs) with-
out scoring allows for a springlike effect and, when secured, provides
tensioning of the midvault cartilage and superficial musculoaponeurotic
system (SMAS). The ULCs are held in caudal tension while suturing so
that the tension is set in two axes and pulls the nasal SMAS accordingly.
be mobilized, similar to the perforations around a postage stamp.
This effect of the bones creates a more customized curvilinear
takeoff from the ascending process of the maxilla (Fig. 64.4).
Once the dorsal hump has been addressed, the next step is cor-
rection of any septal deviation, which is often present in Middle
Eastern patients despite a negative history of nasal trauma. A
986
Fig. 64.4 (a) Percutaneous osteotomy involves creating “postage
stamp” perforations on the bones through a single stab incision. (b)
Manipulating the mobilized bone controls the nasal bone width.
septoplasty is indicated both in correction of the septal deviation as
well as for cartilage harvest for grafting purposes. A classic L-strut
technique is used for the septoplasty, leaving at least a 1 1-cm
(preferably 1.5-cm or greater) L-strut in place for proper structural
support. The strongest component of septal cartilage should then
be used primarily for spreader grafts and lateral crural strut grafts.
Many patients with large dorsal humps also have a tilted or C- or
S-shaped septum. Commonly the caudal septum is deviated off of
the anterior nasal spine and nasomaxillary crest. The nasomaxil-
lary crest itself may also be shifted along with the deviation (often
left). All these components and septal, vomerine spurs must be
addressed thoroughly for proper correction of external asymmetry
and improvement of internal nasal airway function.
The role of true spreader grafts has recently been a topic of
debate where many are now advocating for using autospreader
flaps in place of septal cartilage. The autospreader flap technique
was developed using the dorsal segments of the redundant upper
lateral cartilages after component reduction, turning them inward
toward the septum (Fig. 64.5). The springlike effect that occurs
from turning the cartilages inward provides a strong support for

the internal valve angle. e prefer at least a 4-mm segment so
that after bending medially, a 2 2-mm spring is created. Scoring
is not recommended. However, multiple horizontal mattress and
simple sutures are required to avoid convexities and irregularities.
The septum–spreader flap construct should be seamless to avoid
postoperative midvault asymmetries. In many cases, however,
spreader grafts may still be indicated to provide adequate support
and even to improve external contour of the dorsal aesthetic lines.
Most importantly, if the open roof extends cephalad enough to
leave a space between the cephalically attenuated upper lateral
cartilage and nasal bones, then a spreader graft will be necessary.
e advocate strongly for use of either spreader graft or spreader
flap unless a very minimal alteration is made to the nasal bones
and frame dorsally or laterally. In that case a simple reapproxi-
mation of the upper lateral cartilages with possible trimming and
proper tension setting of the ULC and nasal superficial muscu-
loaponeurotic system (SMAS) is established (Fig. 64.6).
It is also our contention that spreader techniques in and of
themselves do not improve nasal airway but rather the tension
and tautness created between the SMAS, ULCs, and midline struc-
tures. The midvault may also still require a lower lateral cartilage
(LLC) strut or a batten-type technique for proper dynamic airway
function.
The nasal tip in Middle Eastern patients can provide a complex
challenge with respect to the soft tissue:cartilage ratio. Middle
Eastern patients often present with an ill-defined nasal tip that
is bulbous or boxy with overlying thick skin, mandating more
aggressive tip modification using reductive and augmentative
techniques in conjunction to create a strong underlying support for
the newly sculpted nasal tip. A stepwise approach is encouraged
when reconstructing the nasal tip, beginning with placement of a
columellar strut, medial crural/graft sutures, transdomal sutures,
interdomal sutures, tip grafting, and soft tissue facet treatment.
The soft triangle facets should be supported using a soft triangle
tension graft (Fig. 64.7). Highly morselized cartilage grafts (via
Fig. 64.6 Sutures are used in a horizontal mattress fashion spanning across the upper lateral cartilages in order to narrow and refine the contour of
the nasal midvault.
64 Ethnic Rhinoplasty
syringe injection) can further support the soft tissue facets or
smooth dorsal irregularities in moderate to thick skin noses. The
soft tissue facet has more recently been a focal point for experts
globally, as attention must be paid to a smooth alar rim–to-tip
transition. A notch, irregularity, or exaggeration of the soft tissue
facets postoperatively can detract from the natural appearance of
the final contours. Alar contour grafts are utilized as well in more
than 75 of primary and secondary cases and are a staple in all
rhinoplasties regardless of the ethnic background.
After tip modification is done, it is important to assess the result
by redraping the soft tissue and then appropriately thinning the
fibrofatty layer in patients with thicker skin. Thick skin will often
thwart attempts at final tip refinement outcomes, which is why
selective defatting is indicated in a majority of Middle Eastern
patients who present with thick, sebaceous, inelastic skin. The
fibrofatty layer is conservatively and electively reduced and can
include fibrous fat, nasal SMAS, and sometimes scar from fillers.
As a counterpoint, highly visible tip onlay grafts must be
selected very carefully or not at all. Cephalic remnants or morse-
lized thin grafts are preferred, if indicated, as long-term visibility
can be an unsightly issue. Tip suturing techniques are always the
first choice in the algorithmic approach.
The lower lateral crus is often long and dominates the weaker,
thinner medial crus, creating a nasal tripod imbalance. This can
lead to postoperative polly-beak formation and tip ptosis recur-
rence, which are the more common reasons for revisions in Middle
Eastern patients. The positioning of the tripod and rebalancing,
which involves positioning the domes and central tripod axis
biomechanically anterior to the anterior septal angle. Improper
tip complex position and/or inadequate septal angle and caudal
reduction will make these sequelae more likely.
The convexity and width of the LLC in these patients allows use
of the LLC turnover flap technique. This will correct concavities,
irregularities, and convexities of the LLC along with creating a
stronger bilaminate support to the alar rim. This can be combined
987
 X Rhinoplasty
with a caudal repositioning and further posterolateral support
(via batten or short strut; Fig. 64.8).
The tension that is created in the LLC through tip suturing medi-
ally and the strength created by bilamination or strut support, as
Fig. 64.7 (a) The nose is composed of several aesthetic subunits that
are all individually addressed in cosmetic rhinoplasty. The nasal soft
triangle, located at the medial portion of the ala, is very prone to
notching when the marginal incision is made too close to the exterior.
Such issues are easily addressed using morselized cartilage grafts
placed directly into the space. (b) The soft triangle (ST) tension graft
(first presented by the senior author in 2013) is usually derived from
the cephalic remnant and is malleable to provide tension and control
of the domes and fill the soft tissue facets. (c) The ST tension graft
provides a stenting of the facets and maintains an open angle of the
domes as well as fills dead space in the facets.
Fig. 64.9 True transection of the lower lateral cartilage (LLC) with a long strut graft attached. (a) Location of transection. (b) Transection corrects
convexities and concavities, and a strut provides further support and strength. This allows for repositioning of the lateral crus of the LLC in patients
with vertical displacement of the cartilage.
988
well as nonanatomic soft tissue facet and alar rim grafting, all
serve to establish a natural and strong transition from alar rim to
the reshaped tip. Any deviation away from this in appearance will
set back the result to a classic 1980s nose job look, which many
modern Middle Eastern patients want to avoid at all costs.
True transection of the middle lateral cartilage (MLC) and/
or the LLC with strut support may be necessary (Fig. 64.9). The
lower lateral crura can be vertically oriented in these patients,
and repositioning with strut support will address many factors
such as alar strength (external valve sufficiency). Lower lateral
crural transection also provides a powerful method for increasing
rotation in a very ptotic tip. It is important, however, to pay close
attention so as not to make a sharp supratip break or overrated
nasal tip, because the result can quickly become ethnically incon-
gruent. Although some Middle Eastern patients may request this,
the surgeon should consider carefully the reputation that will be
linked to overoperated nasal contours in the community.
Fig. 64.8 Transection of the lower lateral cartilage with placement
of a strut graft extension and caudal repositioning of the accessory
piece can be helpful when addressing nasal tripod imbalance and a
malpositioned tip.

There is also often hypertrophy of the depressor septi nasi
muscle, which leads to a ptotic and hyperdynamic nasal tip, which
is also exaggerated in appearance by already present tip ptosis
and a short upper lip length. Transection and/or excision of this
muscle can help to improve upper lip length as well as decrease
dynamic deformity of the nasal tip postoperatively. However, the
open approach with inter–medial crural dissection, by its nature,
will disassociate the depressor muscle adequately in most cases.
Placement of a columellar strut graft will further ensure contin-
ued depressor inactivity.
Lastly, alar flare and excess nostril sill should be differentiated.
The first requires lateral alar bulk/flare excision through eir
excision, whereas the latter necessitates sill excision. Often a
combination of the two techniques is required. It is critical not
to perform these maneuvers if in doubt and to be very judicious,
as this is one of the few irreversible moves in rhinoplasty. Alar
base modification will be addressed in more detail in the African
rhinoplasty section.
Tip Shaping Highlight
• Define the nasal tip through controlled, cartilage-preserv-
ing techniques (use flaps instead of large grafts whenever
possible).
• Avoid overcorrection of the nasolabial angle and excessive
nasal tip rotation.
• Address tip underprojection and definition by establishing
ideal rotation and insufficient middle/medial crura.
• Recognize length/strength discrepancies between the lower
lateral and medial crura.
• Address the soft tissue facets for proper alar rim–to-tip
contour transition.
• Address the hyperdynamic tip.
• Avoid tip ptosis recurrence and/or polly-beak formation
through proper nasal tripod position.
• Address alar base through sill and/or alar flare reduction.
• Correct nostril asymmetries.
64.2.5 Case 1 Example
The 17-year-old Lebanese-Armenian patient shown in Fig.
64.10a–d desired an overall smaller nose with particular empha-
sis on lifting her tip and reducing her hump so as not to exaggerate
when smiling. She stressed the importance of a natural nasal
appearance and a minimal dorsal curve that is near-straight.
Evaluation
Her nasal skin was overall thin. She had a significant dorsal
hump and droopy tip which was worst when smiling. The nasal
tip was bulbous and asymmetric. Alar base asymmetry but lack
of excess sill or flare was noted. Her septum was of a C configu-
ration and deviated to the left with right turbinate compensated
hypertrophy.
Surgical Technique
• Dorsal hump reduction with spreader grafts placement
• - or hockey stick–configured percutaneous osteotomies
64 Ethnic Rhinoplasty
• Bulbous tip reshaping and narrowing
• Droopy tip correction with overall nasal length reduction and
subtle cephalad tip rotation
Tip shaping was accomplished with suturing techniques, soft
triangle tension graft, and small alar contour grafts. A minimal
cephalic trim was performed.
Result
One year postoperatively (Fig. 64.10e–h), she was happy with
her outcome and had improved nasal breathing.
64.3 African
64.3.1 Introduction
The African nose, much like the Middle Eastern, is both complex
and unique in its structural composition and therefore requires
extensive understanding from the point of the surgeon who
hopes to accurately sculpt a result that is congruent with the
patient’s ethnic features. Rhinoplasty has been gaining popular-
ity among the African American population, likely correlating
with the surgical world’s improved understanding of surgical
approaches to create results that are more in line with a more
natural appearance post rhinoplasty. It should be stressed, how-
ever, that this is still one of the most complex of morphologies
to modify effectively without creating a need for a future, more
complex revision.
To achieve aesthetically appropriate outcomes in patients
of African ancestry, the rhinoplasty surgeon must have a clear
understanding of the desired standards of beauty and the unique
anatomic characteristics of the African nose. Even more than that
of Middle Eastern populations, the African nose presents with a
wide range of anatomic variations and a very specific relationship
of the nose to the greater context of the African facial aesthetic.
However, unlike Middle Eastern and Hispanic noses, the tenets
are a bit more focused and a high percentage of this population
requires a few classic techniques to be performed. Those are
principally the following:
• Osteotomies
• Dorsal augmentation (rib graft, DCFG)
• Septal angle and caudal septal augmentation (septal extension
graft, extended spreader grafts, vs. large columellar strut graft)
• Tip projection and judicious narrowing
• LLC strengthening (lateral tripod strength with support)
• Alar base narrowing (interalar distance and/or alar flare
reduction)
• Soft tissue envelope thinning
hen evaluating a patient of African descent for a rhinoplasty,
the surgeon must inquire about the motivation for seeking oper-
ative correction. Historically, beauty standards have often been
tailored to Caucasian standards of beauty, which may have caused
a misunderstanding of the ideals required when referring to
beauty among any other ethnic population, most notably in those
of African descent. A surgeon must understand the patient’s goals
prior to surgery and make it known that ethnically incongruent
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 X Rhinoplasty
Fig. 64.10 (a,b,c,d) This 17-year-old Lebanese-Armenian patient desired an overall smaller nose with particular emphasis on lifting her tip and
reducing her hump so as not to exaggerate when smiling. She stressed the importance of a “natural” nasal appearance and minimal dorsal curve that
is near-straight. (e,f,g,h) She is seen 1 year postoperatively and is happy with her outcome and has improved nasal breathing.
results will lead to a distortion of the nasofacial aesthetic harmony
rather than improvement. There is a subset of patients who will
request an exaggerated change in their nasal appearance that may
be difficult to obtain without risking an overoperated appearance,
even regardless of racial incongruity. For example, alar notching
can be significant, as can excessive alar base resection leading to
a triangulation of the overall nasal shape with effacement of the
natural curvilinear transition at the alar–cheek junction.
Regardless of the patient’s ethnicity, nasofacial harmony should
always be the goal outcome with any rhinoplasty patient, and
understanding the patient’s ethnic standard of beauty and indi-
vidual anatomic variations is key to a desired surgical outcome
(Fig. 64.11).
64.3.2 Preoperative Evaluation and
Anatomic Assessment
The African American nose, although showing a great deal of
variation between individual patients, is often characterized by a
wide, low dorsum, broad and underprojected tip, a thick bulbous
tip, a short columellar complex, excessive alar flaring, and nasal
bones that are often wider than the interalar distance. The wide
range of variation in the African patient population is attributed
to the varying regional differences and historic influences of
multiple cultural backgrounds within the African continent. For
example, the northeast African countries are often characterized
990
with noses that closely resemble the Middle Eastern nose, with a
higher dorsal hump and more ptotic and hyperdynamic tip com-
plex. In contrast, the nasal complexes of northwestern African
descendants often more closely resemble that of the Hispanic
ethnic nasal morphologies.
A very crucial difference in the African face that sets them
apart from other ethnic groups is the presence of bimaxillary pro-
trusion, leading to a perceived decrease in nasal projection. It is
important, however, as stated by Byrd, that the ideal nasal length
must be measured from the radix to the tip-defining points and
should approximate the distance from the stomion to the menton.
The nasal length measurement should be derived from a clinical
examination and a profile view of the patient rather than a frontal
view.
asal projection is defined as the distance from the alar–cheek
junction to the nasal tip. In the Caucasian patient this is approx-
imately 0.67 times the ideal nasal length, whereas in the African
American patient this distance is shorter and is approximately 0.5
times the nasal length.
hen further compared with the Caucasian ideal in a study
by Porter and Olson, the African study population demonstrated
a decreased columella–lobule ratio, greater variability in the
nasal base shape, an alar base width wider than the intercanthal
distance, a smaller nasolabial angle, and an increased nasofacial
angle. Consideration of these differences is key to producing an
ethnically congruent result in any rhinoplasty patient of African
descent.

Fig. 64.11 Classic African nasal traits and postoperative goals.
Another important concept is proper nasal alignment in the
African rhinoplasty patient. The ideal nasal alignment is a lateral
attachment of the ala to the cheek that lies within a vertical line
drawn through the medial canthus. asal features can be improved
without altering ethnic appearance by bringing the elements of
the nose closer to this boundary. Given the differences relative to
the Caucasian standard and the variability of the features of the
African American nose, an appreciation of and sensitivity toward
African American nasofacial aesthetics is essential for obtaining
consistent aesthetic results in this patient population. As in any
rhinoplasty, it is important to perform preoperative anatomic
analysis in a stepwise fashion to determine the best method of
approach (Fig. 64.12).
Skin
The skin, especially in the tip area, is notably thicker, sebaceous,
and relatively inelastic in the African American patient com-
pared to the Caucasian, leading to a poorly defined, flattened,
and bulbous tip. The skin memory is significant in these patients.
The fibrofatty layer underlying the skin of the nasal tip often
measures 2 to 4 mm in thickness and is relatively inelastic in
64 Ethnic Rhinoplasty
nature, which leads to obscuring of any underlying cartilage
framework. The fibrofatty tissue should be selectively defatted,
particularly over the domal highlights. In the rare occasion,
however, when thin skin is present, less extensive maneuvers
are warranted, particularly at the tip complex. In addition, the
soft tissue facets must be supported. An articulating alar contour
graft, in which the graft is sutured to the lateral domes instead
of free-floating in a soft tissue pocket, is a powerful maneuver.
A larger than normal alar contour graft or a tripod-secured
one will help avoid an unnatural notching or retraction in the
soft tissue facet. Retraction in this region is due to the need for
significant tip projection as well as caudal augmentation. There
is a demand on the skin to stretch in every dimension, and its
weakest transition point is the facet. Therefore, rigidity and
framework need to be added in this region to prevent buckling,
notching, and retraction. A soft triangle tension graft may also
serve useful in addition to the maneuvers just described.
Alar Cartilages
Initially, alar cartilages in the African population were thought
to be weak and thin; hence their inability to support the thick
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Fig. 64.12 Characteristics of the African nose and underlying fibrofatty tissue and ligaments. Selective defatting of the nasal tip is key to achieving a
more refined result in these patients.
fibrofatty overlying skin, as represented by the classically
underprojected and bulbous tip. It was not until recently that
studies have shown the size of the alar cartilages of the African
population to actually bear great similarity to those of the
Caucasian population, with the difference being in the obtuse
angle between the lateral and medial crura and a space filled
with a great deal of fibrofatty tissue. The nasal spine has also
been found to be often underdeveloped along with insufficient
medial crura, all leading to the lack of tip projection in this pop-
ulation of individuals. Septal extension grafts with or without
extended spreader grafts are often required to add both septal
angle projection and caudal framework.
The alar cartilages are commonly weak, and turnover tech-
niques and flaps are not sufficient to counteract the heavy soft
tissue. Formal LLC strut grafts are necessary in most cases. These
can be accompanied with transection and caudal transposition,
usually with posterolateral alar margin pocket insertion. This
reinforces the tripod and aids in overall tip and nasal projection
as well.
Alar Base
Alar base abnormalities in the African American patient can be
defined as one of three entities:
1. Increased interalar distance (excess sill), with the alar bases be-
ing lateral to the medial canthal lines
992
2. Excessive alar flaring, which is characterized by a portion of the
ala extending lateral to the alar attachment of the cheek (more
than 2 mm)
3. A combination of alar flaring and increased interalar distance,
making the correction more challenging
The columella is short and rounded and often hidden on the
profile view by heavy overlying alar rims. Strong alar contour
grafts (typically secured and fixated to the domal elements)
establish an elongation of the nostril apices and can help modify
horizontal large nostrils into narrower taller ones that are directed
more vertically and have a teardrop shape. This is one of the most
rewarding maneuvers for which this patient population will be
very grateful.
Nasal Pyramid
The average African patient will present with a nasal bony
pyramid that is widened with a dorsum that is low and broad
and nasal bones that are often similar in their height and width.
The classically deepened nasofrontal angle also exaggerates
the already present flattened look of the overall nose. This is
where the bimaxillary protrusion seen in the African population
also contributes to flattening the appearance of the nose, as it
causes a further decrease in nasal tip projection. Augmentation
of the maxilla and/or periapical area near the piriform aperture
with fat grafts and/or morselized cartilage will go a long way in

establishing overall nasal projection. Proper preoperative assess-
ment is crucial in order to determine the length of the nasal
bones, whether osteotomies are indicated, and whether dorsal
augmentation alone would be better to improve the appearance
of projection.
A very important concept in performing rhinoplasty on this
population is that the bony base in Africans is often wider than
that in Caucasians. This is important when considering narrowing
of the nasal base in these patients because aggressive narrowing
can lead to an appearance of increased interpupillary distance and
disruption of the patient’s nasofacial harmony. A classic stigma
of an overoperated black nose is a narrow, pencil-like dorsum.
By performing a judicious osteotomy and combining with either
radix or full dorsal augmentation, nasal narrowing and height will
synergistically be improved. See the following section for dorsal
augmentation nuances.
64.3.3 Technical Steps
As in any other rhinoplasty, the operation should begin with
meticulous dissection and elevation of the soft tissue envelope
using a transcolumellar incision extended into bilateral infra-
cartilaginous incisions along the caudal edge of the lower lateral
cartilages. The soft tissue should be left on the skin envelope and
the dissection carried subchondrially whenever possible. The
open approach is optimal for the African population because
the soft tissue envelope in this population can often skew pre-
operative anatomic assessments and hide the true underlying
framework of the patient’s nasal complex. Furthermore, frame-
work augmentation requires careful and precise suture fixation
in multiple anatomical regions.
The soft tissue dissection is best done in a subperichondrial
plane by dissecting from inferior to superior and medial to lat-
eral, to expose the most lateral aspect of the alar cartilages last.
Once elevated, the soft tissue is retracted and nasal framework
is assessed. The entire nasal complex must be assessed together,
since any adjustment to tip will affect the dorsal appearance and
vice versa. Dorsal augmentation and osteotomies are typically
performed first, but the surgeon may need to revisit the dorsum
to perform further alterations after tip alterations are complete.
Commonly this comes in the form of more radix augmentation
and/or supratip augmentation to reestablish an appropriate dorsal
profile and dorsum-to-tip transition.
Most patients of African descent will require some form of
dorsal augmentation, but rasping is often necessary to remove
irregularities and create a smooth bed on which to place any
dorsal augmentative grafts. If there is a dorsal hump that is not too
cephalad, then it can be kept and augmented with separate radix
and dorsal septal angle DCFG or a single DCFG graft that is left
bulkier at the radix. Regardless of the method, any form of dorsal
augmentation should be suture-secured at three points to skin or
bone (with bony drill hole using an awl or drill) cephalad and two
points to the ULCs caudally. In cases of significant augmentation
(more than 10 mm, a formal rib (fresh or fresh-frozen cadaveric)
should be carved and secured with a DCFG or fascial sleeve overlay
or wrap. The augmentation, when indicated, is performed after all
septal cartilage is harvested and can be performed either before
or after tip position is optimized. The senior author prefers to aug-
ment the dorsum and do all cephalic and bony manipulation first,
64 Ethnic Rhinoplasty
then determine tip projection. Tip projection using tripod struts
and onlay grafts can be more easily adjusted, while osseous width
and dorsal height cannot without obtaining more significant graft
sources.
Septal cartilage is harvested from the anterior septal angle by
separating the septum from the ULCs and then dissecting apart
the medial crura. Once the cartilage is harvested, this is when
the osteotomies may often be performed when indicated prior to
moving onto the nasal tip restructuring.
In the African patient, tip work should focus mainly on
increasing tip projection, as the nasal tip in this population is
often heavily underprojected with minimal baseline support.
Initially, a columellar strut is placed between the medial crura,
which are often weak and short. The strut graft provides an initial
structural support to make up for the weak medial crus. African
patients typically present with a retracted columella in addition
to decreased projection, which is why a columellar strut is key to
creating an ideal end result.
Suture techniques are essential in increasing tip projection in
the African rhinoplasty. Excessive steal effect and warping or
weakening of the LLC or MC are avoided by LLC strut reinforce-
ment with or without repositioning of the native LLC. Suture
techniques are often combined with an infratip lobular and/or
onlay-type graft and, at times, even multiple layers of onlay grafts
when indicated. The heavier soft tissue sleeve necessitates thicker
and more rigid tip grafts than in most Middle Eastern or Hispanic
patients. Traditionally larger-sized shield grafts still do well in this
ethnic nasal type, but facet support is still imperative.
Once the ideal tip projection is achieved, the soft tissue enve-
lope is then defatted in order to decrease the weight of the skin
on the new nasal framework and improve resulting tip projection
and definition. The surgeon must take close care when defatting
the soft tissue envelope to preserve the subdermal plexus and
prevent postoperative tip necrosis due to vascular compromise,
although this complication is rare.
Temporal mastoid or (if harvesting rib) rectus fascia is often used
in conjunction with diced cartilage (conchal preferred), which has
been shown to have a more permanent and augmentative effect
than just using either of them by itself. The senior author has had
considerable success with minimally morselized and shaped one-
piece conchal dorsal grafting (with perichondrium attached) with
fascial overlay in black patients. The soft tissue characteristics
lend themselves to not always having to wrap fully, as in classic
DCFG techniques, and not always having to extend from radix to
supratip (Fig. 64.13).
Once the ideal nasal framework is achieved, the skin is redraped
and incisions are closely reapproximated using a series of external
sutures. It is at this time that the alar complex is assessed and
alar base or sill resections are performed for further refinement.
An excess of alar flaring is defined by the alar rims falling more
than 2 mm outside of the medial canthal lines. In order to correct
flaring, alar base resections are performed using extreme care to
maintain the lower incision precisely within the alar–cheek junc-
tion. The incision must also be carried medially into the nostril to
prevent any alar notching.
Alar nostril sill excisions are often indicated in this population
when there is an increased interalar distance. The technique
used is the alar nostril sill resection, which helps to decrease the
interalar distance and give a more refined appearance to the final
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Fig. 64.13 Diced cartilage fascia graft (DCFG) types. (a) DCFG full wrap extending from radix to midvault and supratip. Note: This can also consist of
a perichondrially preserved single unit of conchal cartilage with only edges beveled and/or morselized. Both techniques are fixated at three points.
(b) DCFG only in radix, which can be with fascial overlay or free diced or fully morselized cartilage. (c) Combination of both techniques as indicated by
the anatomical end points.

result. The medial aspect is always incised first and an incremen-
tal lateral incision/excision is carried second to avoid excess skin
removal. More skin can always be trimmed and refined, but it
cannot be put back if excess is removed. It is important to use a
curvilinear angle, which will avoid excess pulling of the alar soft
tissue and a triangular/unnatural alar cheek junction (Fig. 64.14).
This patient population is often subject to prolonged postoper-
ative edema because of the thick and sebaceous nature of the soft
tissue envelope. This is why prolonged postoperative taping can
help to decrease this swelling and lead more quickly to a refined
final result. Silicone sheeting can also be used for up to 3 months
for thick-skinned patients in order to accelerate the resolution of
postoperative edema. Postoperative protocols are listed nearer to
the end of each chapter.
64.3.4 Case 2 Example
The 28-year-old African American woman shown in Fig. 64.15a–c
did not like her wide, flat nose and lack of tip projection. She
emphasized the lack of tip refinement as well as her nose being
too close to her face. She also disliked her nostril flaring but did
not want an awkward or overly narrowed nostril appearance.
She was wary of looking unnatural or overdone.
Evaluation
• Thick skin and soft tissue
• ide asymmetric dorsum and tip
• Underprojected tip with mild alar retraction and excess nos-
tril show
• Excess alar flare and interalar (sill) distance
• Bilateral turbinate hypertrophy and mild left septal tilt/
deviation
• Large left vomerine spicule
Surgical Technique
• Lateral low-to-low percutaneous osteotomies
• Internal medial osteotomies
• o dorsal reduction except to roughen the dorsal surface for
receiving the DCFG
• Minimal cephalic trim
• Lower lateral crural strut grafts after transection and caudal
transposition of the lower lateral crura
• Pocket placement of the LLC/strut constructs
• Large columellar strut graft and tip shaping sutures
• Ear cartilage conchal graft harvest for diced cartilage grafting
• Onlay tip graft, shield graft, soft triangle tension graft as well
as articulating alar contour grafts
• Alar base eir and sill reduction performed incrementally
with a tailored cut-as-you-go approach.
Results
The patient appears postoperatively in Fig. 64.15d–f.
64.4 Hispanic
64.4.1 Introduction
Much like the African American population, the Hispanic patient
population has become an increasingly large group seeking
rhinoplasty. By 2050 it is projected that the Hispanic population
will actually surpass Caucasians as the largest ethnic group in
the United States. This steady increase in Hispanic patients has
led to a greater understanding of the anatomic differences and
approaches required for a rhinoplasty surgeon when operating
on a Hispanic nose.

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 64 Ethnic Rhinoplasty

Fig. 64.14 (a) Nasal sill and (b) alar base resection techniques.

hat makes the Hispanic nose so unique compared to postoperative beauty ideals can be dramatically different. This
other ethnicities is that there is often a misconception among chapter will define the differences between the two Hispanic
American plastic surgeons about what the classic Hispanic nasal subgroups and the unique surgical considerations that must be
appearance actually is. The term “Hispanic” is often misinter- taken into account, both for operative approach as well as for
preted specifically from Latin America, but that would actually outcome, in order to achieve an appropriately racially congruent
constitute individuals of Latino origin. Hispanic ethnicity result.
implies that that the individual is of Spanish origin (from either
Spain or Latin America) with varying degrees of ative Central/
South American descent; such a combination is referred to as
64.4.2 Preoperative Evaluation and
mestizo. This is where many surgeons who have not had much Anatomic Assessment
exposure to Hispanic patients often mistakenly assume that the
For the purpose of classification, there are four different
patient’s anatomy mustclosely resemble that of the ative South
types of noses among the Hispanic ethnicity that should be
American.
considered to properly guide a surgeon’s approach to a rhi-
This distinction is an important one, because depending on
noplasty. Conceptually, the spectrum (not unlike the Middle
degree of ethnic influence between Spanish, or Castilian, and
Eastern nose) ranges from a dominant cartilage/bone frame
ative Central/South American, the anatomic differences and

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with thinner soft tissue to one with weak soft cartilaginous Thus, there is a great deal of diversity within the Hispanic
framework. Daniel has described and delineated this range as ethnicity when it comes to nasal structure and anatomic classifi-
follows: cation. e will simplify these the subgroups as follows:

• Type I consists of a profile with normal radix height, high
bridge, and normal tip projection and is often referred to as a
Castilian nose.
• Type II consists of low radix height, near-normal bridge, and
dependent tip. It is a new designation and one extremely
important to the diagnosis, because minimal dorsal reduction
can lead to major secondary problems.
• Type III consists of a broad base, thick skin, and wide tip, with
its strongest expression in the mestizo nose.
• Type IV is similar to the Chata nose, with predominant African
features, not represented in this classification. This type pres-
ents more often on the East Coast of the United States because
of a large number of Hispanics from the Caribbean who reside
there and have some African ethnic roots in their background.
• Type I: Castilian
• Type II: Mexican-American
• Type III: Mestizo
• Type IV: Creole
hat is important to note about the Hispanic nose is that each
of these subgroups requires a different surgical approach and
technique, which is why it is imperative to understand specific
morphological nuances. For example, in the mestizo-type nose
there is often need for a greater level of tip augmentation, since
one of the unique factors of this nasal complex is a consistent lack
of tip projection at baseline.
The Castilian nose, as previously discussed, requires a com-
pletely different operative approach, because the European

Fig. 64.15 (a,b,c) This 28-year-old African American woman did not like her wide, flat nose and lack of tip projection. She emphasized the lack of tip
refinement as well as her nose being too close to her face. She also disliked her nostril flaring but did not want an awkward or overly narrowed nostril
appearance. She was wary of looking “unnatural or overdone.” (d,e,f) Postoperative views.

996

influence in this subgroup has led to noses that often have a dorsal
hump, which patients desire to have reduced with normal or even
overprojection of the nasal tip. This would require a more reduc-
tive technique to refine the appearance of the nasal complex, as
opposed to augmentation. The nasal skin envelope is often thin.
See Fig. 64.16 for a depiction of the differences in cartilage-to–
soft tissue ratio.
The Mexican-American and Creole subtypes are unique
themselves because they are more a mix of multiple ethnicities
with a predominance of Hispanic features. These patients require
meticulous preoperative assessment because they arguably have
the least standardized nasal anatomy thanks to the multiethnic
influence in their anatomic development.
64.4.3 Technical Steps
Type I (Castilian)
The common triad of concern in these patients is large dorsal
hump; long, ptotic nasal tip; and lack of tip refinement. In order
to address these specific issues, a straightforward component
dorsal hump reduction is performed with preservation of
the upper lateral crura. If the open roof is very cephalad, then
ULC length may be insufficient, and true spreader grafts will
be required. The radix can be high and shallow, and, as in the
Middle Eastern nose, deepening of the radix will enhance the
orbital appearance, allowing for a more feminine nasofacial
Fig. 64.16 Variations of the classic Hispanic nasal anatomy displaying
a spectrum of soft tissue–to-cartilage ratio. The Castilian represents
a strong osseocartilaginous frame and thinner skin sleeve, while the
Chata is the furthest on the spectrum, with a reverse osseocartilagi-
nous-to–soft tissue relationship.
64 Ethnic Rhinoplasty
contour. Osteotomy is indicated in a low-to-low with a “J” exten-
sion to close the open roof and optimize and medialize the dorsal
aesthetic contour lines. Medial osteotomies are necessary when
the cephalad nasal bones are very thick.
For the nasal tip, a combination of appropriate tip-shaping
sutures as well as tensioning of the alar rim and LLC are neces-
sary. Creating tautness, strength, and convexity correction in the
LLC requires bilamination with a turnover or strut when thin or
persistently convex. If the LLCs are inherently stout, then minimal
cephalic trim with alar rim graft support and a soft triangle ten-
sion graft may be all that is necessary. Avoiding LLC tensioning
and treatment can create contour issues along with weakness of
the external valve/alar arch due to the anteromedially directed
steal that tip suturing can produce.
Overall, the Castilian nose can be addressed very similarly to
the classical Middle Eastern nose, which makes geographic sense
since the Spaniards were under Moorish rule for over 500 years.
The primary goal in these patients should be to achieve a smaller
nose by performing a functional reductive operation without
overresection, which would lead to an overly operated, ethnically
incongruent result with dynamic collapse problems.
Type II (Mexican-American)
Among this specific subtype, the challenge exists mostly in
the rhinion/radix region because of the extremely delicate
balance between reduction of the dorsal hump, coupled with
a low radix that can often require augmentation using grafting
techniques. The skin at the rhinion region is often very thin, so
grafts must be placed with care as not to become visible with
surface irregularities. Any partial-length graft is also likely
to be visible through the skin where the junction between
the graft and dorsum occurs, which is why full-length grafts
are much more effective and aesthetically acceptable in this
patient population. In addition, camouflage with flattened fas-
cial (blanket) or highly morselized cartilage covered with soft
tissue onlay can be done.
For augmentation of the radix, the author prefers to use diced
cartilage grafting from the concha, rather than use of an intact
onlay graft. The diced graft allows the scraps of cartilage that go
unused after septal or conchal harvest to be used for a productive
purpose. The cartilage is preferably wrapped in temporal fascia
or topped with a fascial onlay (from mastoid or temple) to pre-
vent reabsorption and migration of the graft material. In a few
instances where the overlying skin envelope is thicker, the diced
cartilage graft may be placed without any facial wrap, although
resorption of the graft may be more likely with eventual loss of
any augmentation. The author prefers cartilage-only augmenta-
tion to be reserved for the radix.
For the nasal tip, overly exaggerated modification is to be
avoided; hence the author prefers to use mainly tip suture
techniques to reposition and contour the shape of the domes
and tension the LLC without soft support using soft triangle
grafting and alar contour grafts. A strong columellar strut graft
is mandatory if projection is to be increased and maintained in
the long term. In addition to tip suturing, the thickness of the
tip skin will determine the dimensions and thickness of any
tip grafts.
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Type III (Mestizo) of the Hispanic nasal type, a lateral soft tissue pocket with LLC
strut insertion will provide lateral two-thirds alar arch support.
ust as the Castilian nose can be related to the Middle Eastern
This will lead to a more natural alar base and nostril soft tissue
nose when discussing operative approaches, the Type III or mes-
reduction. The anterior third of the tip/alae and soft tissue facets is
tizo subgroup rhinoplasty is very closely related to that of the
supported by soft triangle grafting with modified shield (infratip
African subgroup. Thus, the mestizo nose requires the addition
lobule) onlay grafting and, almost always, alar contour grafts. The
of sturdy cartilage grafts with LLC thickening and repositioning
plethora of cartilage relocation, strut and support grafts, along
more caudally. This often necessitates transection, LLC strut
with dorsal augmentation and narrowing, will provide an unop-
underlay, and repositioning caudally to lateral fibrofatty tissue
erated but appropriate change in the amorphous nasal contour to
or in a formal alar rim soft tissue pocket. The senior author pre-
that of a refined one.
fers creation of a lateral pocket in most cases, as this maneuver
allows for more rigidity and support to the alar rim along its full
length. This provides more support to reduce the alar base via a 64.4.4 Case 3 Example
eir/sill combination technique, without an unnatural buckling
or contour in the lateral third of the alar arch. It is critical to The 22-year-old Mexican-American woman shown in Fig.
establish adequate tip projection and overall nasal lengthening. 64.17a–d had thin skin and desired a refined, smaller nose and
Commonly a large columellar strut graft is sufficient. However, reduction of her dorsal hump as well as tip refinement.
if the overall nasal length is short, then a septal extension graft,
either end to end or with extended spreader grafts, is required Evaluation
to lengthen the septum proper. e do not prefer a tongue-and-
groove-type technique in which the medial crura are secured to • Thin skin with underlying cartilage frame highly visible
the septum or septal extension graft. This rigidity is unnatural • High dorsal hump, mostly bony
and can be uncomfortable for many patients. It is extremely • eak medial crura and wide flat tip complex
important, when performing the myriad of lower third and tip
• Soft triangle facets pronounced
complex maneuvers, to keep in mind the patient’s overall facial
aesthetic, as overrotation of the tip or overresection of the base
• Asymmetric nasal bones and mild left septal deviation with
left nasomaxillary crest spiculization
can lead to an overly operated appearance.
Volume reduction of the nasal tip soft tissue can be done by
direct excision of subcutaneous tissue from the lobule, wide skin Surgical Technique
undermining to allow for a lateral shift of the lobular skin, and
incremental stepwise alar base/sill wedge excisions with precise • Component (incremental) dorsal hump reduction with auto-
reapproximation. A poorly performed alar base excision with spreader flaps
overresection or improper incision placement will result in an • Low to low with medial extended osteotomies
awkward redraping of the alar base soft tissues and alar–cheek • Minimal cephalic trim
region. This can be a devastating complication for these patients,
• Columellar strut graft to stretch and strengthen medial crura
as these scars are both incredibly obvious even to the untrained
anteriorly
eye and also very difficult to correct.
• Lateral crural tensioning with asymmetric transdomal and
interdomal suture placement
Type IV • Soft tissue facet graft
The final Hispanic subtype, or chata -type nose, is extremely
• Finely placed cartilage paste via syringe injection at rhinion
similar to the thickest African type of nose, with a very amorphous and soft tissue facets prior to final skin and lining suture
overall nasal contour with flat and wide frame and overlaying closure
inelastic, sebaceous, thick nasal skin sleeve. The most funda-
mental concept to remember when performing rhinoplasty on
the classic chata patient is the global nasal rebalancing between Results
heavy dominant soft tissue forces and weak frame: dorsal aug- As shown in Fig. 64.17e–h, 13 months postop she was very
mentation, increase in tip projection and columellar lengthening, pleased with the natural result.
tip definition, alar rim rigidity, and alar base narrowing may all
be necessary. Techniques will center around maneuvers that
those of African origins often require. The thick, noncontractile 64.5 Postoperative Care
soft tissue needs selective debulking, while the frame from radix
In any ethnicity, the postoperative care for a rhinoplasty patient
to caudal and anterior septum needs lengthening and support.
should remain fairly consistent while providing tasks for patients
Since the skin and soft tissue will not retract predictably and
to be involved proactively in their healing. Immediately postop-
shrink, more rigid and extensive frame and tip augmentation is
eratively, icing can alleviate and prevent a great deal of swelling
required to imprint against the skin from beneath it.
from forming and leading to increased discomfort for the patient.
The inherent position of the LLC is often not conducive to
Patients should always be counseled prior to undergoing rhino-
proper nasal reshaping, and transection with large strut grafts is
plasty that postoperative swelling will continue to subside over
often needed. As with the wider-spectrum, flat Mexican variation

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Fig. 64.17 (a,b,c,d) This 22-year-old Mexican-American woman had thin skin and desired a refined, smaller nose and reduction of her dorsal hump as
well as tip refinement. (e,f,g,h) She is 13 months postop and very pleased with the natural result
the course of one year and, in some cases, up to 18 months or
longer. The radix and tip complex regions are the last for edema
to resolve, particularly if multiple maneuvers are employed.
Especially in multicultural nasal types, where soft tissue is
often very dense and inelastic, there may be a predisposition to
more edema as the soft tissue sticks to the restructured frame.
Sometimes intralesional dilute triamcinolone injections into the
tip or other areas of persistent edema can be very helpful in these
cases. It is imperative that these patients and their families know
what to expect. It is not uncommon for patients to return early
and be impatient with the somewhat slow process, complaining
that those around them are criticizing their results. Constant
reassurance from the surgeon and properly trained staff is key. It
is helpful to have one designated staff member assigned to that
patient, including the patient coordinator.
Patients will often mistakenly believe that they will be com-
pletely in love with their results within days or weeks. Social media
has confused patients, as many immediate postoperative results
are shown without long-term ones or a depiction of the process
through time. This has improved somewhat as of late, as more
surgeons are showing long-term and intermediate-time-frame
results along with education. As an interesting aside, patients
who have their surgery filmed or photographed will see how the
general shape is intraop, before edema and ecchymosis really set
64 Ethnic Rhinoplasty
in (when the surgery is not prolonged and surgery is performed
meticulously and cleanly). This, however, must be mitigated with
the proper counseling, as patients are often concerned and disap-
pointed with the result after splints are removed at the 1-week
mark, given the level of edema that makes their nose look, at
times, even larger than what it was preoperatively.
The senior author prefers an Aquaplast (Patterson Medical,
Mendota Heights, M ) splint, which molds easily over the side-
walls. It is removed along with internal Doyle splints and sutures
at 6–7 days postoperative. Turbinoplasty with outfracture and/or
minimal conchal bone excision can result in slight postoperative
bleeding and oozing. Formal partial turbinectomies of the inferior
turbinate can result in more epistaxis. Intraoperative judicious
cauterization (fulguration of the submucosa) can aid in limiting
this. In addition, surgical and antibiotic ointment placed against
the raw turbinate mucosa and in the dead space of the soft tissue
facets are also helpful.
The nose should be thoroughly irrigated with saline irrigation
for up to 3 months postoperatively. This will help to ensure the
patient is able to breathe well through the healing process and
will continue to eliminate any exuded nasal lining, or crusting.
The incisions should also be kept moist, especially while sutures
remain in place for 1 week postoperatively, using antibiotic oint-
ment applied with a cotton tip applicator.
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Pain is often more of an issue when patients have undergone
osteotomies with their rhinoplasty, so proper medication should
be provided to prevent undue discomfort. It is best to counsel
patients to stay away from narcotic medications as much as pos-
sible, given the negative side effect profile, but at times the pain is
too great and narcotics must be taken. It is wise to have patients
take acetaminophen around the clock starting from the day of
surgery in order to give a base line level of pain control. Ibuprofen
should be avoided for the first 2 to 3 days postoperatively, given
the potential increased bleeding risk and continued risk of devel-
oping septal hematoma, but many authors are now describing
allowing patients to begin ibuprofen therapy on postoperative
day 2 or 3, given that true increased risk of bleeding has yet to be
concretely proven in any studies. Ibuprofen or other nonsteroidal
anti-inflammatory drugs ( SAIDs) can also help to mitigate a
great deal of the discomfort from the peak of inflammation on
postoperative day 3, but ultimately this decision must remain in
the hands of the surgeon.
At 1 week, splints and sutures are removed and the external
nasal splint is removed as well. Patients must continue to take
great care of the nose to prevent any trauma, given that the bones
will continue to be unstable for 6 to 8 weeks and any cartilage
grafting has yet to set and heal in this time frame as well. Patients
will often describe that their nose feels firmer than before, which
is to be expected. This is a result of both postoperative inflam-
mation and any augmentative grafting that has increased the
nasal tip support framework. The nose will likely remain firmer
permanently, although some degree of softening does definitely
occur with time.
64.6 Concluding Thoughts
The concepts and techniques that are necessary to perform an
aesthetic rhinoplasty properly on a patient of any ethnic origin
must culminate in nasofacial harmony, regardless of the specific
ethnic origin. hile some ethnicities demonstrate thick skin,
weak broad cartilage frame, and a low/wide dorsum, it is incorrect
to assume that this is the sin qua non of an ethnic rhinoplasty.
Multicultural rhinoplasty is, perhaps, a better term. This would
delineate that a spectrum of morphology is present ranging
Clinical Caveats
• It is critical preoperatively to evaluate and understand the
dynamic interactions and limitations of the skin and soft
tissue envelope as well as the internal nasal lining. Controlling
the unpredictability of the frame-soft tissue ratio is a key
factor in successful outcomes.
• Proper evaluation of the skin and soft tissue variations and
the planned preoperative preparation (if applicable), intra-
operative techniques, and postoperative regimen should be
discussed with the patient.
• The specific aesthetic goals should be discussed in detail with
the patient. Preferences with regard to desired curvature
or straightness to the dorsal profile line, nostril shaping,
animated nasal features patient dislikes, and degree of tip
modification are some examples of common specificities that
patients give their preferences on. The degree of judicious
dorsal reduction or augmentation should be incremental and
include continual assessment and reassessment of dorsum to
tip relationship.
• Nasal airway analysis must be comprehensive, and changes to
nasal width, external and internal valves should be addressed.
It is not uncommon that narrowing excessive nasal width can
compromise the airway, as can nasal tip narrowing. Spreader
grafts and flaps should be considered in every case, particu-
larly when larger degrees of modification are to be employed.
• Thick-skinned amorphous nasal types invariably have a weak
cartilage frame and require addition of cartilage from septum
and often distant sources such as ear or rib cartilage. The rhi-
noplasty surgeon should feel comfortable in acquiring these
donor sites.
• Septal extension grafts that lengthen the central L-frame of
the nose are often required in wide, short, less projected
ethnic nasal types. Increasing nasal length as well as height
with dorsal augmentation are cornerstones of proper surgical
treatment and are the foundation of a positive aesthetic
outcome.
• Once the dorsal height and nasal length are established, the
tip complex shape and its relationship to the alar rim and
dorsum can be modified. This will commonly require lower